Recent advances in cranial-base and cavernous sinus surgery have facilitated total removal, allowing respectable mortality and morbidity rates for these tumors.3,5,20,27,42,46 This report describes 24 cases of clinoidal meningiomas operated on over a period of 7 years, from November, 1981, to October, 1988, with vigorous attempts at total removal (including tumor, dura, and bone) during the first operation. According to the classification system of Simpson,47 the extent of tumor excision was either Grade I (complete macroscopic removal of the tumor, with excision of its dural attachment, and abnormal bone) or Grade II (complete macroscopic removal of the tumor and of its visible extensions, with coagulation of its dural attachment). Our experience with intraoperative anatomical observation led us to distinguish three categories of this tumor (Groups I, II, and III), each with a marked influence on the surgical difficulties, ability to achieve total removal, and outcome. These groups relate to the presence of interfacing arachnoid membranes between the tumor and the cerebral vessels. The presence or absence of this arachnoid membrane depends on the origin of the tumor and its relation to the small intradural carotid artery segment lying outside the carotid cistern.
The author is grateful to Julie Hipp for help in preparing the manuscript and to Michael P. Schenk for the drawings.
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