Venous preservation–guided resection: a changing paradigm in parasagittal meningioma surgery

Clinical article

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Object

Surgical treatment of parasagittal meningiomas is challenging. Preserving the venous outflow is the key point, but this may preclude radical resection. Different surgical strategies have been proposed. To contribute to the debate on the optimal strategy for treating these tumors, a single-institutional, single-surgeon series of patients with parasagittal meningiomas was analyzed and the available literature reviewed.

Methods

Clinical charts of patients with parasagittal meningioma, managed at the University of Messina between 1988 and 2008, were retrospectively reviewed. A microsurgical resection, the goal of which was to preserve the venous outflow, was performed. Only if the superior sagittal sinus (SSS) was angiographically occluded, but if alternative venous outflow was clearly recognized, was the tumor resected, together with the sinus without further flow restoration. A MEDLINE review of the literature published between 1955 and 2011 was performed.

Results

Long-term follow-up (mean 80 months) data obtained in 67 patients with meningiomas involving the SSS were analyzed. The recurrence rate was 10.4%; the morbidity and mortality rates were 10.4% and 4.5%, respectively. The authors identified in the literature 19 relevant studies on this issue, and based on their review of the literature, there is no evidence that aggressive management offers an advantage in terms of recurrence rate.

Conclusions

Analysis of the data obtained in the 67 patients confirmed good outcome and long-term tumor control following a surgical strategy aimed to preserve venous outflow. These findings and the results of the authors' analysis of the literature emphasize that the goal of radical tumor resection should be balanced by an awareness of the increased surgical risk attendant on aggressive management of the SSS and bridging veins.

Abbreviations used in this paper:DSA = digital subtraction angiography; SRS = stereotactic radiosurgery; SSS = superior sagittal sinus.

Article Information

Address correspondence to: Alfredo Conti, M.D., Ph.D., Policlinico Universitario, Via Consolare Valeria 1, 98125, Messina, Italy. email: alfredo.conti@unime.it.

Please include this information when citing this paper: published online January 18, 2013; DOI: 10.3171/2012.11.JNS112011.

© AANS, except where prohibited by US copyright law.

Headings

Figures

  • View in gallery

    Studies obtained in a 73-year-old patient. A, E, and G: Left middle third of an SSS parasagittal meningioma. C: Sinus invasion Type VI with a clear alternative venous pathway as documented by preoperative DSA and MR angiography. Arrows show the pre- and posttumor veins forming an anastomotic circulation to allow venous outflow. B, F, and H: Postoperative MR images showing complete tumor removal. D: Three-month follow-up venous MR angiogram demonstrating preservation of bridging veins at the anterior and posterior poles of the tumor (arrows).

  • View in gallery

    Studies obtained in a 68-year-old patient. A, E, and G: Left anterior third of an SSS parasagittal meningioma. C: Sinus invasion Type III as documented on preoperative DSA and by intraoperative findings (data not shown). B, F, and H: Postoperative MR image showing complete removal. I: The integrity of bridging veins was carefully maintained during tumor resection. D: Three-month follow-up venous MR angiogram demonstrating the patency of the SSS and bridging veins.

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