Giant anterior clinoidal meningiomas: surgical technique and outcomes

Clinical article

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Surgery for giant anterior clinoidal meningiomas that invade vital neurovascular structures surrounding the anterior clinoid process is challenging. The authors present their skull base technique for the treatment of giant anterior clinoidal meningiomas, defined here as globular tumors with a maximum diameter of 5 cm or larger, centered around the anterior clinoid process, which is usually hyperostotic.


Between 2000 and 2010, the authors performed 23 surgeries in 22 patients with giant anterior clinoidal meningiomas. They used a skull base approach with extradural unroofing of the optic canal, extradural clinoidectomy (Dolenc technique), transdural debulking of the tumor, early optic nerve decompression, and early identification and control of key neurovascular structures.


The mean age at surgery was 53.8 years. The mean tumor diameter was 59.2 mm (range 50–85 mm) with cavernous sinus involvement in 59.1% (13 of 22 patients). The tumor involved the prechiasmatic segment of the optic nerve in all patients, invaded the optic canal in 77.3% (17 of 22 patients), and caused visual impairment in 86.4% (19 of 22 patients). Total resection (Simpson Grade I or II) was achieved in 30.4% of surgeries (7 of 23); subtotal and partial resections were each achieved in 34.8% of surgeries (8 of 23). The main factor precluding total removal was cavernous sinus involvement. There were no deaths. The mean Glasgow Outcome Scale score was 4.8 (median 5) at a mean of 56 months of follow-up. Vision improved in 66.7% (12 of 18 patients) with consecutive neuroophthalmological examinations, was stable in 22.2% (4 of 18), and deteriorated in 11.1% (2 of 18). New deficits in cranial nerve III or IV remained after 8.7% of surgeries (2 of 23).


This modified surgical protocol has provided both a good extent of resection and a good neurological and visual outcome in patients with giant anterior clinoidal meningiomas.

Abbreviations used in this paper:AChA = anterior choroidal artery; ACP = anterior clinoid process; CN = cranial nerve; FSR = fractionated stereotactic radiotherapy; GOS = Glasgow Outcome Scale; GTR = gross-total resection; ICA = internal carotid artery; ICH = intracerebral hemorrhage; MCA = middle cerebral artery; PCA = posterior cerebral artery.

Article Information

Address correspondence to: Sergey Spektor, M.D., Ph.D., Department of Neurosurgery, Hebrew University-Hadassah Medical Center, POB 12000, Jerusalem, Israel 91120. email:

Please include this information when citing this paper: published online August 17, 2012; DOI: 10.3171/2012.7.JNS111675.

© AANS, except where prohibited by US copyright law.



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    Extradural exposure of the optic canal. After a left-sided craniotomy, the frontal dura (FD) is elevated, exposing the orbital roof (OR) and falciform ligament (FL), which covers the optic nerve. R = retractor blade; SOC = superior wall of the optic canal.

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    Exposure after extradural anterior clinoidectomy. Upper: Cadaver dissection of the right side demonstrating the surgical anatomy after extradural unroofing of the optic canal and extradural clinoidectomy. The optic nerve (ON) has been exposed. The clinoidal segment of the ICA is inferior and lateral to the optic nerve; the oculomotor nerve is seen lateral to the ICA en route from the lateral wall of the cavernous sinus (LCSW) into the superior orbital fissure (SOF). Lower: Intraoperative photograph of the right side demonstrating the preserved extradural neurovascular anatomy, which is not violated by the intradural tumor. This cornerstone of well-preserved anatomy serves as the starting point of a “roadmap” for safer tumor resection. DCR = distal carotid ring; OC = optic canal; T = tumor; III = oculomotor nerve.

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    Graph showing the craniotomies and extradural skull base procedures performed in 22 patients.

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    Case 3. Images obtained in a 41-year-old woman with a giant clinoidal meningioma. The patient had presented with headaches, cognitive deficit, and visual complaints. A–E: Computed tomography scans (A and B) and MRI studies (C–E) demonstrating a giant (63-mm) right clinoidal meningioma. F: Postoperative CT scan showing that GTR was achieved after extradural unroofing of the optic canal and extradural clinoidectomy. G–L: Follow-up MRI studies obtained 8.3 years after surgery, showing no residual tumor. The patient is doing well (GOS Score 5), and her vision has improved.

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    Bar graph showing the extent of resection and cavernous sinus involvement in 23 surgeries for removal of giant clinoidal meningiomas. CS = cavernous sinus.

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    Bar graph showing the number of surgical complications after 23 surgeries for removal of giant clinoidal meningiomas.

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    Bar graph showing the number of new CN deficits after 23 surgeries for removal of giant clinoidal meningiomas.


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