Clinoidal meningiomas

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✓ Anterior clinoidal meningiomas are frequently grouped with suprasellar or sphenoid ridge meningiomas, masking their notorious association with a high mortality and morbidity rate, failure of total removal, and recurrence. To avoid injury to encased cerebral vessels, most surgeons are content with subtotal removal. Without total removal, however, recurrence is expected. Recent advances in cranial-base exposure and cavernous sinus surgery have facilitated radical total removal.

The author reports 24 cases operated on with vigorous attempts at total removal of the tumor with involved dura and bone. This experience has distinguished three groups (I, II, and III) which influence surgical difficulties, the success of total removal, and outcome. These subgroups relate to the presence of interfacing arachnoid membranes between the tumor and cerebral vessels. The presence or absence of arachnoid membranes depends on the origin of the tumor and its relation to the naked segment of carotid artery lying outside the carotid cistern. Total removal was impossible in the three patients in Group I, with postoperative death occurring in one patient and hemiplegia in another. Total removal was achieved in 18 of the 19 patients in Group II, with one death from pulmonary embolism. In the two patients in Group III, total removal without complications was easily achieved.

Article Information

Address reprint requests to: Ossama Al-Mefty, M.D., Department of Neurosurgery, University of Mississippi Medical Center, 2500 North State Street, Jackson, Mississippi 39216-4505.

© AANS, except where prohibited by US copyright law.

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Figures

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    Artist's drawing of a Group I meningioma. The tumor encases the carotid artery and its branches, with direct attachment to the adventitia. The optic nerve maintains an arachnoid plane from the chiasmatic cistern.

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    A Group I meningioma. Left: Preoperative computerized tomography appearance. During surgery, no arachnoid membrane was found and dissection of the middle cerebral and carotid arteries was impossible. Right: Lateral carotid arteriogram demonstrating narrowing of the carotid and middle cerebral arteries by the encasing tumor.

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    A Group II meningioma. Left: Artist's drawing showing the tumor encasing the carotid artery and its branches. An arachnoid membrane of the carotid cistern separates the tumor from the adventitia, rendering dissection possible. The optic nerve maintains an arachnoid membrane from the chiasmatic cistern. Right: Retouched operative photograph showing the optic nerve (II), the anterior cerebral artery (A1), the middle cerebral artery (M1), and part of the internal carotid artery (C) dissected free from the encasing tumor (T). Dissection continues on the proximal carotid artery and into the cavernous sinus. The dissection is relatively easy, owing to the presence of the arachnoid membrane of the carotid cistern. R = retractor on the frontal lobe.

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    A Group II meningioma. Computerized tomography scan (left) and arteriogram, anteroposterior view (right). Notice the arterial narrowing by the encasing tumor. Dissection and tumor removal were facilitated by the presence of an intervening arachnoid membrane.

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    A Group III meningioma. Left: Artist's drawing showing the tumor originating in the optic foramen. The tumor is small, separated from the carotid by the carotid cistern, but it extends into the optic canal. Right: Retouched operative photograph showing the carotid cistern intact. The tumor (T) is small and extends into the optic canal. II = optic nerve; C = carotid artery; R = retractor on the frontal lobe.

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    Computerized tomography scan of a Group III meningioma (arrow).

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    Contrast-enhanced computerized tomography scans of a patient with a Group II clinoidal meningioma. Left: Preoperative scan. Right: Scan obtained after total removal of the tumor including intracavernous and optic canal extensions. Notice the resection of the anterior clinoid.

References

  • 1.

    Adegbite ABKhan MIPaine KWEet al: The recurrence of intracranial meningiomas after surgical treatment. J Neurosurg 58:51561983Adegbite AB Khan MI Paine KWE et al: The recurrence of intracranial meningiomas after surgical treatment. J Neurosurg 58:51–56 1983

  • 2.

    Al-Mefty O: Supraorbital-pterional approach to skull base lesions. Neurosurgery 21:4744771987Al-Mefty O: Supraorbital-pterional approach to skull base lesions. Neurosurgery 21:474–477 1987

  • 3.

    Al-Mefty O: Surgery of the Cranial Base. Boston: Kluwer1988Al-Mefty O: Surgery of the Cranial Base. Boston: Kluwer 1988

  • 4.

    Al-Mefty OHoloubi ARifai Aet al: Microsurgical removal of suprasellar meningiomas. Neurosurgery 16:3643721985Al-Mefty O Holoubi A Rifai A et al: Microsurgical removal of suprasellar meningiomas. Neurosurgery 16:364–372 1985

  • 5.

    Al-Mefty OSmith RR: Surgery of tumors invading the cavernous sinus. Surg Neurol 30:3703811988Al-Mefty O Smith RR: Surgery of tumors invading the cavernous sinus. Surg Neurol 30:370–381 1988

  • 6.

    Andrews BTWilson CB: Suprasellar meningiomas: the effect of tumor location on postoperative visual outcome. J Neurosurg 69:5235281988Andrews BT Wilson CB: Suprasellar meningiomas: the effect of tumor location on postoperative visual outcome. J Neurosurg 69:523–528 1988

  • 7.

    Barbaro NMGutin PHWilson CBet al: Radiation therapy in the treatment of partially resected meningiomas. Neurosurgery 20:5255281987Barbaro NM Gutin PH Wilson CB et al: Radiation therapy in the treatment of partially resected meningiomas. Neurosurgery 20:525–528 1987

  • 8.

    Bergland RRay BS: The arterial supply of the human optic chiasm. J Neurosurg 31:3273341969Bergland R Ray BS: The arterial supply of the human optic chiasm. J Neurosurg 31:327–334 1969

  • 9.

    Bonnal JThibaut ABrotchi Jet al: Invading meningiomas of the sphenoid ridge. J Neurosurg 53:5875991980Bonnal J Thibaut A Brotchi J et al: Invading meningiomas of the sphenoid ridge. J Neurosurg 53:587–599 1980

  • 10.

    Bradac GBRiva ASchörner Wet al: Cavernous sinus meningiomas: an MRI study. Neuroradiology 29:5785811987Bradac GB Riva A Schörner W et al: Cavernous sinus meningiomas: an MRI study. Neuroradiology 29:578–581 1987

  • 11.

    Brihaye JBrihaye-van Geertruyden M: Management and surgical outcome of suprasellar meningiomas. Acta Neurochir Suppl 42:1241291988Brihaye J Brihaye-van Geertruyden M: Management and surgical outcome of suprasellar meningiomas. Acta Neurochir Suppl 42:124–129 1988

  • 12.

    Carella RJRansohoff JNewall J: Role of radiation therapy in the management of meningioma. Neurosurgery 10:3323391982Carella RJ Ransohoff J Newall J: Role of radiation therapy in the management of meningioma. Neurosurgery 10:332–339 1982

  • 13.

    Cioffi FABernini FPPunzo Aet al: Cavernous sinus meningiomas. Neurochirurgia 30:40471987Cioffi FA Bernini FP Punzo A et al: Cavernous sinus meningiomas. Neurochirurgia 30:40–47 1987

  • 14.

    Cook AW: Total removal of large global meningiomas at the medial aspect of the sphenoid ridge. Technical note. J Neurosurg 34:1071131971Cook AW: Total removal of large global meningiomas at the medial aspect of the sphenoid ridge. Technical note. J Neurosurg 34:107–113 1971

  • 15.

    Cophignon JLucena JClay Cet al: Limits to radical treatment of spheno-orbital meningiomas. Acta Neurochir Suppl 28:3753801979Cophignon J Lucena J Clay C et al: Limits to radical treatment of spheno-orbital meningiomas. Acta Neurochir Suppl 28:375–380 1979

  • 16.

    Craig WMGogela LJ: Meningioma of the optic foramen as a cause of slowly progressive blindness. J Neurosurg 7:44481950Craig WM Gogela LJ: Meningioma of the optic foramen as a cause of slowly progressive blindness. J Neurosurg 7:44–48 1950

  • 17.

    Cushing HEisenhardt L: Meningiomas. Their Classification Regional Behaviour Life History and Surgical End Results. Springfield, Ill: Charles C Thomas1938 pp 298319Cushing H Eisenhardt L: Meningiomas. Their Classification Regional Behaviour Life History and Surgical End Results. Springfield Ill: Charles C Thomas 1938 pp 298–319

  • 18.

    David MMahoudeau D: Les méningiomes de la petite aile du sphénoide (considerations anatomo-cliniques et thérapeutiques). Gaz Med France:1111301935David M Mahoudeau D: Les méningiomes de la petite aile du sphénoide (considerations anatomo-cliniques et thérapeutiques). Gaz Med France:111–130 1935

  • 19.

    Derome PJGuiot G: Bone problems in meningiomas invading the base of the skull. Clin Neurosurg 25:4354511978Derome PJ Guiot G: Bone problems in meningiomas invading the base of the skull. Clin Neurosurg 25:435–451 1978

  • 20.

    Dolenc VV: Anatomy and Surgery of the Cavernous Sinus. Wien: Springer-Verlag1989Dolenc VV: Anatomy and Surgery of the Cavernous Sinus. Wien: Springer-Verlag 1989

  • 21.

    Elsberg CADyke CG: Meningiomas attached to the medial part of the sphenoid ridge with syndrome of unilateral optic atrophy, defect in visual field of the same eye and changes in sella turcica and in shape of interpeduncular cistern after encephalography. Arch Ophthalmol 12:6446751934Elsberg CA Dyke CG: Meningiomas attached to the medial part of the sphenoid ridge with syndrome of unilateral optic atrophy defect in visual field of the same eye and changes in sella turcica and in shape of interpeduncular cistern after encephalography. Arch Ophthalmol 12:644–675 1934

  • 22.

    Fischer GFischer CMansuy L: Pronostic chirurgical des méningiomes de l'arête sphénoïdale. Neurochirurgie 19:3233461973Fischer G Fischer C Mansuy L: Pronostic chirurgical des méningiomes de l'arête sphénoïdale. Neurochirurgie 19:323–346 1973

  • 23.

    Fohanno DBitar A: Sphenoidal ridge meningioma. Adv Tech Stand Neurosurg 14:1371741986Fohanno D Bitar A: Sphenoidal ridge meningioma. Adv Tech Stand Neurosurg 14:137–174 1986

  • 24.

    Grant FC: Intracranial meningiomas. Surgical results. Surg Gynecol Obstet 85:4194311947Grant FC: Intracranial meningiomas. Surgical results. Surg Gynecol Obstet 85:419–431 1947

  • 25.

    Guthrie BLEbersold MJScheithauer BW: Neoplasms of the intracranial meninges in Youmans JR (ed): Neurological Surgeryed 3. Philadelphia: WB Saunders1990 Vol 5 pp 32503281Guthrie BL Ebersold MJ Scheithauer BW: Neoplasms of the intracranial meninges in Youmans JR (ed): Neurological Surgery ed 3. Philadelphia: WB Saunders 1990 Vol 5 pp 3250–3281

  • 26.

    Guyot JFVouyouklakis DPertuiset B: Méningiomes de l'arête sphénoïdale. A propos de 50 cas. Neurochirurgie 13:5715841967Guyot JF Vouyouklakis D Pertuiset B: Méningiomes de l'arête sphénoïdale. A propos de 50 cas. Neurochirurgie 13:571–584 1967

  • 27.

    Hakuba ALiu SSNishimura S: The orbitozygomatic infratemporal approach: a new surgical technique. Surg Neurol 26:2712761986Hakuba A Liu SS Nishimura S: The orbitozygomatic infratemporal approach: a new surgical technique. Surg Neurol 26:271–276 1986

  • 28.

    Holub K: Intrakranielle meningeome. Acta Neurochir 4:3554011956Holub K: Intrakranielle meningeome. Acta Neurochir 4:355–401 1956

  • 29.

    Jan MBazézé VSaudeau Det al: Devenir des méningiomes intracrâniens chez l'adulte. Etude rétrospective d'une série médico-chirurgicale de 161 méningiomes. Neurochirurgie 32:1291341986Jan M Bazézé V Saudeau D et al: Devenir des méningiomes intracrâniens chez l'adulte. Etude rétrospective d'une série médico-chirurgicale de 161 méningiomes. Neurochirurgie 32:129–134 1986

  • 30.

    Jefferson AAzzam N: The suprasellar meningiomas: a review of 19 years' experience. Acta Neurochir Suppl 28:3813841979Jefferson A Azzam N: The suprasellar meningiomas: a review of 19 years' experience. Acta Neurochir Suppl 28:381–384 1979

  • 31.

    Kempe LG: Operative Neurosurgery. New York: Springer-Verlag1968 Vol 1 pp 109118Kempe LG: Operative Neurosurgery. New York: Springer-Verlag 1968 Vol 1 pp 109–118

  • 32.

    Konovalov ANFedorov SNFaller TOet al: Experience in the treatment of the parasellar meningiomas. Acta Neurochir Suppl 28:3713721979Konovalov AN Fedorov SN Faller TO et al: Experience in the treatment of the parasellar meningiomas. Acta Neurochir Suppl 28:371–372 1979

  • 33.

    Koos WTKletter GSchuster Het al: Microsurgery of suprasellar meningiomas. Adv Neurosurg 2:62671975Koos WT Kletter G Schuster H et al: Microsurgery of suprasellar meningiomas. Adv Neurosurg 2:62–67 1975

  • 34.

    Lesoin FJomin MBouchez Bet al: Management of cavernous sinus meningiomas. Neurochirurgia 28:1951981985Lesoin F Jomin M Bouchez B et al: Management of cavernous sinus meningiomas. Neurochirurgia 28:195–198 1985

  • 35.

    MacCarty CSTaylor WF: Intracranial meningiomas: experiences at the Mayo Clinic. Neurol Med Chir 19:5695741979MacCarty CS Taylor WF: Intracranial meningiomas: experiences at the Mayo Clinic. Neurol Med Chir 19:569–574 1979

  • 36.

    Malis LI: Tumors of the parasellar region. Adv Neurol 15:2812991976Malis LI: Tumors of the parasellar region. Adv Neurol 15:281–299 1976

  • 37.

    Mirimanoff RODosoretz DELinggood RMet al: Meningioma: analysis of recurrence and progression following neurosurgical resection. J Neurosurg 62:18241985Mirimanoff RO Dosoretz DE Linggood RM et al: Meningioma: analysis of recurrence and progression following neurosurgical resection. J Neurosurg 62:18–24 1985

  • 38.

    Moritake KHanda HYamashita Jet al: STA-MCA anastomosis in patients with skull base tumours involving the internal carotid artery — haemodynamic assessment by ultrasonic Doppler flowmeter. Acta Neurochir 72:951101984Moritake K Handa H Yamashita J et al: STA-MCA anastomosis in patients with skull base tumours involving the internal carotid artery — haemodynamic assessment by ultrasonic Doppler flowmeter. Acta Neurochir 72:95–110 1984

  • 39.

    Ojemann RG: Meningiomas: clinical features and surgical management in Wilkins RHRengachary SS (eds): Neurosurgery. New York: McGraw-Hill1985 Vol 1 pp 635654Ojemann RG: Meningiomas: clinical features and surgical management in Wilkins RH Rengachary SS (eds): Neurosurgery. New York: McGraw-Hill 1985 Vol 1 pp 635–654

  • 40.

    Ojemann RG: Meningiomas of the basal parapituitary region: technical considerations. Clin Neurosurg 27:2332621980Ojemann RG: Meningiomas of the basal parapituitary region: technical considerations. Clin Neurosurg 27:233–262 1980

  • 41.

    Olivecrona H: The surgical treatment of intracranial tumors in Olivecrona HTönnis W (eds): Handbuch der Neurochirurgie. Berlin: Springer-Verlag1967 pp 1301Olivecrona H: The surgical treatment of intracranial tumors in Olivecrona H Tönnis W (eds): Handbuch der Neurochirurgie. Berlin: Springer-Verlag 1967 pp 1–301

  • 42.

    Pellerin PLesoin FDhellemmes Pet al: Usefulness of the orbitofrontomalar approach associated with bone reconstruction for frontotemporosphenoid meningiomas. Neurosurgery 15:7157181984Pellerin P Lesoin F Dhellemmes P et al: Usefulness of the orbitofrontomalar approach associated with bone reconstruction for frontotemporosphenoid meningiomas. Neurosurgery 15:715–718 1984

  • 43.

    Pertuiset BFarah SClayes Let al: Operability of intracranial meningiomas. Personal series of 353 cases. Acta Neurochir 76:2111985Pertuiset B Farah S Clayes L et al: Operability of intracranial meningiomas. Personal series of 353 cases. Acta Neurochir 76:2–11 1985

  • 44.

    Pompili ADerome PJVisot Aet al: Hyperostosing meningiomas of the sphenoid ridge — clinical features, surgical therapy, and long-term observations: review of 49 cases. Surg Neurol 17:4114161982Pompili A Derome PJ Visot A et al: Hyperostosing meningiomas of the sphenoid ridge — clinical features surgical therapy and long-term observations: review of 49 cases. Surg Neurol 17:411–416 1982

  • 45.

    Probst C: Possibilities and limitations of microsurgery in patients with meningiomas of the sellar region. Acta Neurochir 84:991021987Probst C: Possibilities and limitations of microsurgery in patients with meningiomas of the sellar region. Acta Neurochir 84:99–102 1987

  • 46.

    Sekhar LNSen CHJho HDet al: Surgical treatment of intracavernous neoplasms: a four-year experience. Neurosurgery 24:18301989Sekhar LN Sen CH Jho HD et al: Surgical treatment of intracavernous neoplasms: a four-year experience. Neurosurgery 24:18–30 1989

  • 47.

    Simpson D: The recurrence of intracranial meningiomas after surgical treatment. J Neurol Neurosurg Psychiatry 20:22391957Simpson D: The recurrence of intracranial meningiomas after surgical treatment. J Neurol Neurosurg Psychiatry 20:22–39 1957

  • 48.

    Skullerud KLöken AC: The prognosis in meningiomas. Acta Neuropathol 29:3373441974Skullerud K Löken AC: The prognosis in meningiomas. Acta Neuropathol 29:337–344 1974

  • 49.

    Stern WE: Meningiomas in the cranio-orbital junction. J Neurosurg 38:4284371973Stern WE: Meningiomas in the cranio-orbital junction. J Neurosurg 38:428–437 1973

  • 50.

    Sundt TM JrPiepgras DGMarsh WRet al: Saphenous vein bypass grafts for giant aneurysms and intracranial occlusive disease. J Neurosurg 65:4394501986Sundt TM Jr Piepgras DG Marsh WR et al: Saphenous vein bypass grafts for giant aneurysms and intracranial occlusive disease. J Neurosurg 65:439–450 1986

  • 51.

    Symon LRosenstein J: Surgical management of suprasellar meningioma. Part 1: The influence of tumor size, duration of symptoms, and microsurgery on surgical outcome in 101 consecutive cases. J Neurosurg 61:6336411984Symon L Rosenstein J: Surgical management of suprasellar meningioma. Part 1: The influence of tumor size duration of symptoms and microsurgery on surgical outcome in 101 consecutive cases. J Neurosurg 61:633–641 1984

  • 52.

    Ugrumov VMIgnatyeva GEOlushin VEet al: Parasellar meningiomas: diagnosis and possibility of surgical treatment according to the place of original growth. Acta Neurochir Suppl 28:3733741979Ugrumov VM Ignatyeva GE Olushin VE et al: Parasellar meningiomas: diagnosis and possibility of surgical treatment according to the place of original growth. Acta Neurochir Suppl 28:373–374 1979

  • 53.

    Uihlein AWeyand RD: Meningiomas of anterior clinoid process as a cause of unilateral loss of vision. Surgical considerations. Arch Ophthalmol 49:2612701953Uihlein A Weyand RD: Meningiomas of anterior clinoid process as a cause of unilateral loss of vision. Surgical considerations. Arch Ophthalmol 49:261–270 1953

  • 54.

    Waga SYamashita JHanda H: [Recurrence of meningiomas.] Neurol Med Chir 17:2032081977 (Jpn)Waga S Yamashita J Handa H: [Recurrence of meningiomas.] Neurol Med Chir 17:203–208 1977 (Jpn)

  • 55.

    Wara WMSheline GENewman Het al: Radiation therapy of meningiomas. AJR 123:4534581975Wara WM Sheline GE Newman H et al: Radiation therapy of meningiomas. AJR 123:453–458 1975

  • 56.

    Watts C: Sphenoid wing meningioma in Long DM (ed): Current Therapy in Neurological Surgery 1985–1986. Toronto: CV Mosby1985 pp 1416Watts C: Sphenoid wing meningioma in Long DM (ed): Current Therapy in Neurological Surgery 1985–1986.Toronto: CV Mosby 1985 pp 14–16

  • 57.

    Wilson WBGordon MLehman RAW: Meningiomas confined to the optic canal and foramina. Surg Neurol 12:21281979Wilson WB Gordon M Lehman RAW: Meningiomas confined to the optic canal and foramina. Surg Neurol 12:21–28 1979

  • 58.

    Yamashita JHanda HIwaki Ket al: Recurrence of intracranial meningiomas, with special reference to radiotherapy. Surg Neurol 14:33401980Yamashita J Handa H Iwaki K et al: Recurrence of intracranial meningiomas with special reference to radiotherapy. Surg Neurol 14:33–40 1980

  • 59.

    Yaşargil MG: Microneurosurgery. Stuttgart: Georg Thieme Verlag1984 Vol 1 pp 2632Yaşargil MG: Microneurosurgery. Stuttgart: Georg Thieme Verlag 1984 Vol 1 pp 26–32

  • 60.

    Yaşargil MGReichman MVKubik S: Preservation of the frontotemporal branch of the facial nerve using the interfascial temporalis flap for pterional craniotomy. Technical article. J Neurosurg 67:4634661987Yaşargil MG Reichman MV Kubik S: Preservation of the frontotemporal branch of the facial nerve using the interfascial temporalis flap for pterional craniotomy. Technical article. J Neurosurg 67:463–466 1987

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