Giant anterior clinoidal meningiomas: surgical technique and outcomes

Clinical article

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Object

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.

Methods

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.

Results

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).

Conclusions

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: spektor@hadassah.org.il.

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.

Headings

Figures

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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.

References

  • 1

    Abdel-Aziz KMFroelich SCDagnew EJean WBreneman JCZuccarello M: Large sphenoid wing meningiomas involving the cavernous sinus: conservative surgical strategies for better functional outcomes. Neurosurgery 54:137513842004

    • Search Google Scholar
    • Export Citation
  • 2

    Al-Mefty O: Clinoidal meningiomas. J Neurosurg 73:8408491990

  • 3

    Balasingam VNoguchi AMcMenomey SODelashaw JB Jr: Modified osteoplastic orbitozygomatic craniotomy. Technical note. J Neurosurg 102:9409442005

    • Search Google Scholar
    • Export Citation
  • 4

    Behari SGiri PJShukla DJain VKBanerji D: Surgical strategies for giant medial sphenoid wing meningiomas: a new scoring system for predicting extent of resection. Acta Neurochir (Wien) 150:8658772008

    • Search Google Scholar
    • Export Citation
  • 5

    Coscarella EBaşkaya MKMorcos JJ: An alternative extradural exposure to the anterior clinoid process: the superior orbital fissure as a surgical corridor. Neurosurgery 53:1621672003

    • Search Google Scholar
    • Export Citation
  • 6

    Cushing HEisenhardt L: Meningiomas: Their Classification Regional Behavior Life History and Surgical End Results Springfield, ILCharles C. Thomas1938

    • Search Google Scholar
    • Export Citation
  • 7

    Day JD: Cranial base surgical techniques for large sphenocavernous meningiomas: technical note. Neurosurgery 46:7547602000

  • 8

    De Jesús OToledo MM: Surgical management of meningioma en plaque of the sphenoid ridge. Surg Neurol 55:2652692001

  • 9

    Dolenc V: Direct microsurgical repair of intracavernous vascular lesions. J Neurosurg 58:8248311983

  • 10

    Goel AGupta SDesai K: New grading system to predict resectability of anterior clinoid meningiomas. Neurol Med Chir (Tokyo) 40:6106172000

    • Search Google Scholar
    • Export Citation
  • 11

    Iwai YYamanaka KIshiguro T: Gamma knife radiosurgery for the treatment of cavernous sinus meningiomas. Neurosurgery 52:5175242003

    • Search Google Scholar
    • Export Citation
  • 12

    Jennett BBond M: Assessment of outcome after severe brain damage. A practical scale. Lancet 1:4804841975

  • 13

    Lee JHJeun SSEvans JKosmorsky G: Surgical management of clinoidal meningiomas. Neurosurgery 48:101210212001

  • 14

    Lee JHSade BPark BJ: A surgical technique for the removal of clinoidal meningiomas. Neurosurgery 59:1 Suppl 1ONS108ONS1142006

  • 15

    Lee JYNiranjan AMcInerney JKondziolka DFlickinger JCLunsford LD: Stereotactic radiosurgery providing longterm tumor control of cavernous sinus meningiomas. J Neurosurg 97:65722002

    • Search Google Scholar
    • Export Citation
  • 16

    Lemole GM JrHenn JSZabramski JMSpetzler RF: Modifications to the orbitozygomatic approach. Technical note. J Neurosurg 99:9249302003

    • Search Google Scholar
    • Export Citation
  • 17

    Margalit NSLesser JBMoche JSen C: Meningiomas involving the optic nerve: technical aspects and outcomes for a series of 50 patients. Neurosurgery 53:5235332003

    • Search Google Scholar
    • Export Citation
  • 18

    Nakamura MRoser FJacobs CVorkapic PSamii M: Medial sphenoid wing meningiomas: clinical outcome and recurrence rate. Neurosurgery 58:6266392006

    • Search Google Scholar
    • Export Citation
  • 19

    Noguchi ABalasingam VShiokawa YMcMenomey SODelashaw JB Jr: Extradural anterior clinoidectomy. Technical note. J Neurosurg 102:9459502005

    • Search Google Scholar
    • Export Citation
  • 20

    Pamir MNBelirgen MOzduman KKiliç TOzek M: Anterior clinoidal meningiomas: analysis of 43 consecutive surgically treated cases. Acta Neurochir (Wien) 150:6256362008

    • Search Google Scholar
    • Export Citation
  • 21

    Perry ALouis DNScheithauer BWBudka Hvon Deimling AMeningiomas. Louis DNOhgaki HWiestler OD: WHO Classification of Tumors of the Central Nervous System LyonIARC Press2007. 164172

    • Search Google Scholar
    • Export Citation
  • 22

    Risi PUske Ade Tribolet N: Meningiomas involving the anterior clinoid process. Br J Neurosurg 8:2953051994

  • 23

    Roser FNakamura MJacobs CVorkapic PSamii M: Sphenoid wing meningiomas with osseous involvement. Surg Neurol 64:37432005

  • 24

    Russell SMBenjamin V: Medial sphenoid ridge meningiomas: classification, microsurgical anatomy, operative nuances, and long-term surgical outcome in 35 consecutive patients. Neurosurgery 62:3 Suppl 138502008

    • Search Google Scholar
    • Export Citation
  • 25

    Sekhar LNPatel SCusimano MWright DCSen CNBank WO: Surgical treatment of meningiomas involving the cavernous sinus: evolving ideas based on a ten year experience. Acta Neurochir Suppl 65:58621996

    • Search Google Scholar
    • Export Citation
  • 26

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

  • 27

    Tomasello Fde Divitiis OAngileri FFSalpietro FMd'Avella D: Large sphenocavernous meningiomas: is there still a role for the intradural approach via the pterional-transsylvian route?. Acta Neurochir (Wien) 145:2732822003

    • Search Google Scholar
    • Export Citation
  • 28

    van Loveren HRKeller JTel-Kalliny MScodary DJTew JM Jr: The Dolenc technique for cavernous sinus exploration (cadaveric prosection). Technical note. J Neurosurg 74:8378441991

    • Search Google Scholar
    • Export Citation
  • 29

    Yaşargil MG: Microneurosurgery StuttgartThieme1996. IVB:143

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