Neurosurgery Blog


Daily bibliographic review of the Neurosurgery Department. La Fe University Hospital. Valencia, Spain

Birth desires and intentions of women diagnosed with a meningioma

Petroclival meningioma outcomes

J Neurosurg 122:1151–1156, 2015

To the authors’ knowledge, no previous study has examined the impact of meningioma diagnosis on women’s birth desires and intentions. In an exploratory study, the authors surveyed women affected by meningioma to determine their attitudes toward childbearing and the influences, including physician recommendations, on this major life decision and compared their responses to those of women in the general population.

Methods Meningioma survivors from the Meningioma Mommas online support group participated in an online survey that included questions on their birth desires and intentions, whether the risk of disease recurrence influenced their reproductive decisions, and risks communicated to them by their physicians. Using chi-square and rank-sum tests, the authors compared the survey participants’ responses with those of the general population as assessed by the 2006– 2010 National Survey of Family Growth. Logistic regression was used to adjust for differences in age, race, ethnicity, education, parity, pregnancy status, and infertility status in these populations.

Results Respondents with meningioma were more likely than those in the general population to report wanting a baby (70% vs 54%, respectively), intending to have a baby (27% vs 12%, respectively), and being very sure about this intention (10% vs 2%, respectively). More than half (32 of 61) of the women of childbearing age reported being advised by a physician about potential risk factors for recurrence of the meningioma, and pregnancy was the most commonly cited risk factor (26 of 61). The most common factor influencing birth desires and intentions was risk of the meningioma returning and requiring more treatment, which was reported by nearly two-thirds of the women in their childbearing years.

Conclusions A majority of the meningioma survivors of childbearing age who completed the survey reported a desire for children, although concern about the risk of meningioma recurrence was an important factor for these women when making reproductive decisions. Physicians are in a position to educate their patients on potential risk factors for recurrence and to provide contact information for services such as counseling and family planning.

Stereotactic Radiosurgery for Intracranial Meningiomas: Current Concepts and Future Perspectives

Stereotactic Radiosurgery for Intracranial Meningiomas- Current Concepts and Future Perspectives

Neurosurgery 76:362–371, 2015

Meningiomas are among the most common adult brain tumors. Although the optimal management of meningiomas would provide complete elimination of the lesion, this cannot always be accomplished safely through resection. Therefore, other therapeutic modalities, such as stereotactic radiosurgery (as primary or adjunctive therapy), have emerged.

In the current review, we have provided an overview of the historical outcomes of various radiosurgical modalities applied in the management of meningiomas. Furthermore, we provide a discussion on key factors (eg World Health Organization grade, lesion size, and lesion location) that affect tumor control and adverse event rates. We discuss recent changes in our understanding of meningiomas, based on molecular and genetic markers, and how these will change our perspective on the management of meningiomas.

We conclude by outlining the areas in which knowledge gaps persist and provide suggestions as to how these can be addressed.

An evidence-based treatment algorithm for the management of WHO Grade II and III meningiomas

Management of WHO Grade II and III meningiomas

Neurosurg Focus 38 (3):E3, 2015

The management of WHO Grade II “atypical” meningiomas (AMs) and Grade III “malignant” meningiomas (MMs) remains controversial and under-investigated in prospective studies. The roles of surgery, radiation therapy, radiosurgery, and chemotherapy have been incompletely delineated. This has left physicians to decipher how they should treat patients on a case-by-case basis.

In this study, the authors review the English-language literature on the management and clinical outcomes associated with AMs and MMs diagnosed using the WHO 2000/2007 grading criteria. Twenty-two studies for AMs and 7 studies for MMs were examined in detail. The authors examined clinical decision points using the literature and concepts from evidence-based medicine.

Acknowledging the retrospective nature of the studies concerning AM and MM, the authors did find evidence for the following clinical strategies: 1) maximal safe resection of AM and MM; 2) active surveillance after gross-total resection of AM; 3) adjuvant radiation therapy after subtotal resection of AM, especially in the absence of putative radioresistant features; and 4) adjuvant radiation therapy after resection of MM.

Gamma Knife radiosurgery for meningiomas arising from the tentorium

Gamma Knife radiosurgery for meningiomas arising from the tentorium- a 22-year experienceJ Neurooncol (2015) 121:129–134

In order to evaluate long term clinical and imaging outcomes, the authors retrospectively reviewed our 22-year experience using stereotactic radiosurgery (SRS) for tentorial meningiomas.

Thirty-nine patients with tentorial meningiomas underwent SRS using various Gamma Knife technologies between 1988 and 2010. The most common presenting symptoms were headache, dizziness or disequilibrium, and ataxia. The median tumor volume was 4.6 cm3 (range 0.5–36.6 cm3) and the median radiation dose to the tumor margin was 14 Gy (range 8.9–18 Gy). The median follow-up period was 41 months (range 6–183 months).

At the last imaging follow-up, tumor volumes decreased in 22 patients (57 %), remained stable in 13 patients (33 %), and increased in 4 patients (10 %). The progression-free survival after SRS was 97 % at 1 year, and 92 % at 5 years. At the last clinical followup, 35 patients (90 %) showed no change in symptoms, 1 patient (2 %) showed improvement of their neurologic symptom, and 3 patients (8 %) demonstrated worsening symptoms. The rate of symptom worsening after SRS was 5 % at 1 year, and 10 % at 5 years. Asymptomatic peritumoral edema after SRS occurred in 2 patients (5 %). Symptomatic adverse radiation effect developed in 2 patients (5 %).

SRS for tentorial meningiomas provided long-term effective tumor control and a low risk of radiation related complications.

Surgery of Intradural Extramedullary Tumors: Retrospective Analysis of 107 Cases

Intradural extramedullary tumors

Neurosurgery 75:509–514, 2014

Intradural extramedullary tumors (IDEMTs) are uncommon lesions that cause pain and neurological deficits.

OBJECTIVE: To evaluate the effects of surgery for IDEMTs.

METHODS: This cohort study recruited all patients operated on for IDEMTs at the Department of Neurology and Psychiatry of Sapienza University of Rome from January 2003 to January 2013. The analysis was conducted on clinical records evaluation over a 1-year follow-up. The Graphic Rating Scale was used to assess pain. Neurological deficits were detected through neurological examination. Quality of life was evaluated with the EuroQol (EQ-5D). Statistical interpretation of the data was performed with SPSS version 19 software.

RESULTS: One hundred seven patients were recruited. Three were lost to follow-up. Patients reported lower level of pain 1 year after surgery (before surgery, 6.05; after surgery, 3.65). Mean comparison showed a significant decrease of 22.400 (P , .001). Ninety-two patients (88.5%) were neurologically asymptomatic 1 year after surgery. Only 12 patients (11.5%) presented with a deficit, with a global decrease of 39% (x2 = 27.6; P, .005). The quality of life in patients was middle to high (mean rating of EQ-5D visual analog score, 61.78%). The lowest levels of quality of life were found in patients with sphincter dysfunctions (mean, 33.4).

CONCLUSION: Surgery for IDEMTs has a good outcome. Patients reported lower levels of pain and a drastic reduction in neurological symptoms 1 year after surgery. The quality of life is middle to high. It is influenced mainly by the neurological outcome.

Endoscopic endonasal surgery for olfactory groove meningiomas: outcomes and limitations in 50 patients

Endoscopic endonasal surgery for olfactory groove meningiomas- outcomes and limitations in 50 patients

Neurosurg Focus 37 (4):E8, 2014

Recently, endoscopic endonasal surgery (EES) has been introduced in the management of skull base tumors, with constantly improving outcomes and increasing indications. The authors retrospectively reviewed the effectiveness of EES in the management of olfactory groove meningiomas.

Methods. Between February 2003 and December 2012, 50 patients (64% female) with olfactory groove meningiomas underwent EES at the University of Pittsburgh Medical Center. The authors present the results of EES and analyze the resection rates, clinical outcome, complications, and limitations of this approach.

Results. Forty-four patients presented with primary tumors, whereas six were previously treated elsewhere. The patients’ mean age was 57.1 years (range 27–88 years). Clinical presentation included altered mental status (36%), visual loss (30%), headache (24%), and seizures (20%). The mean maximum tumor diameter was 41.6 mm (range 18–80 mm). All patients underwent EES, which was performed in stages in 18 giant tumors. Complete tumor resection (Simpson Grade I) was achieved in 66.7% of the 45 patients in whom it was the goal, and 13 (28.9%) had neartotal resection (> 95% of the tumor). Tumor size, calcification, and absence of cortical cuff from vasculature were significant factors that influenced the degree of resection (p = 0.002, p = 0.024, and p = 0.028, respectively). Tumor residual was usually at the most lateral and anterior tumor margins. Following EES, mental status was improved or normalized in 77.8% of the cases, vision was improved or restored in 86.7%, and headaches resolved in 83.3%. There was no postoperative deterioration of presenting symptoms. Complications were increased in tumors > 40 mm and included CSF leakage (30%), which was significantly associated with lobular tumor configuration (p = 0.048); pulmonary embolism/deep vein thrombosis, more commonly in elderly patients (20%); sinus infections (10%); and delayed abscess months or years after EES (6%). One patient had an intraoperative vascular injury resulting in transient hemiparesis (2%). There were no perioperative deaths. During a mean follow-up period of 32 months (median 22 months, range 1–115 months), 1 patient underwent repeat EES for tumor regrowth.

Conclusions. Endoscopic endonasal surgery has shown good clinical outcomes regardless of patient age, previous treatment, or tumor characteristics. Tumor size > 40 mm, calcification, and absence of cortical vascular cuff limit GTR with EES; in addition, large tumors are associated with increased postoperative complications. Significant lateral and anterior dural involvement may represent indications for using traditional craniotomies for the management of these tumors. Postoperative CSF leakage remains a problem that necessitates innovations in EES reconstruction techniques.

Back pain in patients with degenerative spine disease and intradural spinal tumor: what to treat? when to treat?

Intradural tumorEur Spine J (2014) 23:821–829

Back pain is common in industrialized countries and one of the most frequent causes of work incapacity. Successful treatment is, therefore, not only important for improving the symptoms and the quality of life of these patients but also for socioeconomic reasons. Back pain is frequently caused by degenerative spine disease. Intradural spinal tumors are rare with an annual incidence of 2–4/1,00,000 and are mostly associated with neurological deficits and radicular and nocturnal pain. Back pain is not commonly described as a concomitant symptom, such that in patients with both a tumor and degenerative spine disease, any back pain is typically attributed to the degeneration rather than the tumor.

Objective The aim of the present retrospective investigation was to study and analyze the impact of microsurgery on back/neck pain in patients with intradural spinal tumor in the presence of degenerative spinal disease in adjacent spinal segments.

Methods Fifty-eight consecutive patients underwent microsurgical, intradural tumor surgery using a standardized protocol assisted by multimodal intraoperative neuromonitoring. Clinical symptoms, complications and surgery characteristics were documented. Standardized questionnaires were used to measure outcome from the surgeon’s and the patient’s perspectives (Spine Tango Registry and Core Outcome Measures Index). Follow-up included clinical and neuroradiological examinations 6 weeks, 3 months and 1 year postoperatively.

Results Back/neck pain as a leading symptom and coexisting degenerative spine disease was present in 27/58 (47 %) of the tumor patients, and these comprised to group under study. Patients underwent tumor surgery only, without addressing the degenerative spinal disease. Remission rate after tumor removal was 85 %. There were no major surgical complications. Back/neck pain as the leading symptom was eradicated in 67 % of patients. There were 7 % of patients who required further invasive therapy for their degenerative spinal disease.

Conclusions Intradural spinal tumor surgery improves back/neck pain in patients with coexisting severe degenerative spinal disease. Intradural spinal tumors seem to be the only cause of back/neck pain more often than appreciated. In these patients suffering from both pathologies, there is a higher risk of surgical overtreatment than undertreatment. Therefore, elaborate clinical and radiological examinations should be performed preoperatively and the indication for stabilization/fusion should be discussed carefully in patients foreseen for first time intradural tumor surgery.


True petroclival meningiomas

True petroclival meningiomas- results of surgical management

J Neurosurg 120:40–51, 2014

The relentless natural progression of petroclival meningiomas mandates their treatment. The management of these tumors, however, is challenging. Among the issues debated are goals of treatment, outcomes, and quality of life, appropriate extent of surgical removal, the role of skull base approaches, and the efficacy of combined decompressive surgery and radiosurgery. The authors report on the outcome in a series of patients treated with the goal of total removal.

Methods. The authors conducted a retrospective analysis of 64 cases of petroclival meningiomas operated on by the senior author (O.A.) from 1988 to 2012, strictly defined as those originating medial to the fifth cranial nerve on the upper two-thirds of the clivus. The patients’ average age was 49 years; the average tumor size (maximum diameter) was 35.48 ± 10.09 mm (with 59 tumors > 20 mm), and cavernous sinus extension was present in 39 patients. The mean duration of follow-up was 71.57 months (range 4–276 months).

Results. In 42 patients, the operative reports allowed the grading of resection. Grade I resection (tumor, dura, and bone) was achieved in 17 patients (40.4%); there was no recurrence in this group (p = 0.0045). Grade II (tumor, dura) was achieved in 15 patients (36%). There was a statistically significant difference in the rate of recurrence with respect to resection grade (Grades I and II vs other grades, p = 0.0052). In all patients, tumor removal was classified based on postoperative contrast-enhanced MRI, and gross-total resection (GTR) was considered to be achieved if there was no enhancement present; on this basis, GTR was achieved in 41 (64%) of 64 patients, with a significantly lower recurrence rate in these patients than in the group with residual enhancement (p = 0.00348). One patient died from pulmonary embolism after discharge. The mean Karnofsky Performance Status (KPS) score was 85.31 preoperatively (median 90) and improved on follow-up to 88, with 30 patients (47%) having an improved KPS score on follow-up. Three patients suffered a permanent deficit that significantly affected their KPS. Cerebrospinal fluid leak occurred in 8 patients (12.5%), with 2 of them requiring exploration. Eighty-nine percent of the patients had cranial nerve deficits on presentation; of the 54 patients with more than 2 months of follow-up, 21 (32.8%) had persisting cranial nerve deficits. The overall odds of permanent cranial nerve deficit of treated petroclival meningioma was 6.2%. There was no difference with respect to immediate postoperative cranial nerve deficit in patients who had GTR compared with those who had subtotal resection.

Conclusions. Total removal (Grade I or II resection) of petroclival meningiomas is achievable in 76.4% of cases and is facilitated by the use of skull base approaches, with good outcome and functional status. In cases in which circumstances prevent total removal, residual tumors can be followed until progression is evident, at which point further intervention can be planned.

Management of tuberculum and diaphragma sellae meningiomas


Neurosurg Focus 35 (6):E7, 2013

Tuberculum sellae meningiomas (TSMs) and diaphragma sellae meningiomas (DSMs) are challenging lesions to treat due to their proximity to neurovascular structures.

Methods. The authors reviewed the medical records of patients who underwent surgical excision of TSMs and DSMs from 1990 to 2013. They also describe the technical strategies used to minimize injury to the optic apparatus, vascular structures, and pituitary stalk.

Results. Twenty-four patients with TSM and 6 patients with DSM were included in the study. Seventy percent of the tumors were large (≥ 5 cm). The pterional approach was employed in most cases. Optic canal involvement was observed in 4 patients. Twenty-one patients (70%) had visual dysfunction before surgery. At follow-up (median 18 months), visual improvement was noted in 10 (47.6%) of 21 patients. Gross-total excision was achieved in 22 patients (91.6%) with TSM and 5 (83.3%) with DSM. At last follow-up, 28 patients (93.3%) had a Glasgow Outcome Scale score of 5. There were no deaths in this series.

Conclusions. Tuberculum and diaphragma sellae meningiomas present a unique subset of tumors due to their location. They can be safely excised with minimal morbidity and mortality using microsurgical techniques. Attention to technical details during surgery leads to greater respectability and superior visual outcome.

Effect of dural detachment on long-term tumor control for meningiomas treated using Simpson Grade IV resection

Effect of dural detachment on long-term tumor control for meningiomas treated using Simpson Grade IV resection

J Neurosurg 119:1373–1379, 2013

Meningiomas treated by subtotal or partial resection are associated with significantly shorter recurrencefree survival than those treated by gross-total resection. The Simpson grading system classifies incomplete resections into a single category, namely Simpson Grade IV, with wide variations in the volume and location of residual tumors, making it complicated to evaluate the achievement of surgical goals and predict the prognosis of these tumors. Authors of the present study investigated the factors related to necessity of retreatment and tried to identify any surgical nuances achievable with the aid of modern neurosurgical techniques for meningiomas treated using Simpson Grade IV resection.

Methods. This retrospective analysis included patients with WHO Grade I meningiomas treated using Simpson Grade IV resection as the initial therapy at the University of Tokyo Hospital between January 1995 and April 2010. Retreatment was defined as reresection or stereotactic radiosurgery due to postoperative tumor growth.

Results. A total of 38 patients were included in this study. Regrowth of residual tumor was observed in 22 patients with a mean follow-up period of 6.1 years. Retreatment was performed for 20 of these 22 tumors with regrowth. Risk factors related to significantly shorter retreatment-free survival were age younger than 50 years (p = 0.006), postresection tumor volume of 4 cm3 or more (p = 0.016), no dural detachment (p = 0.001), and skull base location (p = 0.016). Multivariate analysis revealed that no dural detachment (hazard ratio [HR] 6.42, 95% CI 1.41–45.0; p = 0.02) and skull base location (HR 11.6, 95% CI 2.18–218; p = 0.002) were independent risk factors for the necessity of early retreatment, whereas postresection tumor volume of 4 cm3 or more was not a statistically significant risk factor.

Conclusions. Compared with Simpson Grade I, II, and III resections, Simpson Grade IV resection includes highly heterogeneous tumors in terms of resection rate and location of the residual mass. Despite the difficulty in analyzing such diverse data, these results draw attention to the favorable effect of dural detachment (instead of maximizing the resection rate) on long-term tumor control. Surgical strategy with an emphasis on detaching the tumor from the affected dura might be another important option in resection of high-risk meningiomas not amenable to gross-total resection.

Anatomical variation of superior petrosal vein and its management during surgery for cerebellopontine angle meningiomas

Anatomical variation of superior petrosal vein and its management during surgery for cerebellopontine angle meningiomas

Acta Neurochir (2013) 155:1871–187

No systematic study is yet available that focuses on the surgical anatomy of the superior petrosal vein and its significance during surgery for cerebellopontine angle meningiomas. The aim of the present study was to examine the variation of the superior petrosal vein via the retrosigmoid suboccipital approach in relation to the tumor attachment of cerebellopontine angle meningiomas as well as postoperative complications related to venous occlusion.

Forty-three patients with cerebellopontine angle meningiomas were analyzed retrospectively. Based on the operative findings, the tumors were classified into four subtypes: the petroclival type, tentorial type, anterior petrous type, and posterior petrous type. According to a previous anatomical report, the superior petrosal veins were divided into three groups: Type I which emptied into the superior petrosal sinus above and lateral to the internal acoustic meatus, Type II which emptied between the lateral limit of the trigeminal nerve at Meckel’s cave and the medial limit of the facial nerve at the internal acoustic meatus, and Type III which emptied into the superior petrosal sinus above and medial to Meckel’s cave.

In both the petroclival and anterior petrous types, the most common vein was Type III which is the ideal vein for a retrosigmoid approach. In contrast, the Type II vein which is at high risk of being sacrificed during a suprameatal approach procedure was most frequent in posterior petrous type, in which the superior petrosal vein was not largely an obstacle. Intraoperative sacrificing of veins was associated with a significantly higher rate of venous-related phenomena, while venous complications occurred even in cases where the superior petrosal vein was absent or compressed by the tumor.

The variation in the superior petrosal vein appeared to differ among the tumor attachment subtypes, which could permit a satisfactory surgical exposure without dividing the superior petrosal vein. In cases where the superior petrosal vein was previously occluded, other bridging veins could correspond with implications for the crucial venous drainage system, and should thus be identified and protected whenever possible.

The Mirroring Technique: A Navigation-Based Method for Reconstructing a Symmetrical Orbit and Cranial Vault

Mirroring technique

Neurosurgery 73[ONS Suppl 1]:ons24–ons29, 2013

The reconstruction of orbital structures and the cranial vault curvature can be challenging after trauma or wide resections for tumors. Sophisticated methods have been developed recently, but these are resource- and time-consuming.

OBJECTIVE: We report the mirroring technique, which is an effective and costless application for navigation-guided reconstruction procedures.

METHODS: At the time of the reconstruction, high-resolution images are reloaded while forcing a left-right axial flip. The pointer subsequently enables a virtual 3- dimensional projection of the position of the contralateral normal anatomy.

RESULTS: This method was applied successfully in 2 cases of en plaque sphenoid wing meningiomas with secondary exophthalmia.

CONCLUSION: The mirroring technique represents an accurate method of outlining the contralateral normal anatomy onto the pathological side based on navigation guidance.


Surgical management and outcomes of petroclival meningiomas: a single-center case series of 259 patients

Petroclival meningioma outcomes

Acta Neurochir (2013) 155:1367–1383

Surgical management of petroclival meningiomas is challenging. Various and inconsistent outcome and prognostic factors of the lesions have been evaluated previously. In the present study, the surgical outcome, philosophy, and experience of petroclival meningiomas are detailed based on a large patient series.

Methods A series of 259 patients with petroclival meningiomas (70 males and 189 females) were surgically treated. Clinical charts and radiographs were reviewed. Follow-up results were evaluated.

Results The preoperative Karnofsky Performance Scale (KPS) score was 74.2±10.5. The mean tumor size was 4.3±1.0 cm. The gross total resection (GTR) rate was 52.5 %. During a mean follow-up period of 55.3 months, recurrence/progression (R/P) occurred in 11 patients. The recent KPS score was 78.4±22.7, it improved in 139 (57.2 %) patients and stabilized in 53 (21.8 %) patients, and 201 (82.7 %) patients lived independently. The risk factors affecting the KPS score included (but were not limited to) age≥60, preoperative KPS≤60, and brainstem edema. The adverse factors contributing to R/P-free survival included (but were not limited to) non-total resection and the absence of the subarachnoid space. The R/P-free survival rate was 94.5 % at 5 years and 91.2 % at 9 years. The overall survival rate was 94.7 % at 5 years and 94.7 % at 9 years.

Conclusions Favorable outcomes from petroclival meningiomas could be achieved by microsurgery. Neurological function and quality of life were prioritized, and GTR was attempted. Risk factors should be considered in surgical schemes, and tumor recurrence should be aggressively monitored and treated.

Endoscopic surgery for tuberculum sellae meningiomas: a systematic review and meta-analysis


Neurosurg Rev (2013) 36:349–359

Recent reports of surgical resection of tuberculum sellae meningiomas through an endoscopic endonasal approach (EEA) have provided an alternative to transcranial approaches in selected cases. However, these published reports have been limited by small sample size from single institutions.We performed a systematic review and metaanalysis to gain insight into potential limitations and benefits of EEA for tuberculum sellae meningiomas.

We performed a systematic review of the literature and analyzed pooled data for descriptive statistics on short-term morbidity and outcomes. We compared EEA to transcranial approaches reported during the same time-frame. Six studies (49 patients) met inclusion criteria for EEA. A pooled analysis of transcranial results reported during a similar time period yielded 11 studies (412 patients).

There were no differences in rate of gross total resection or peri-operative complications between the two groups. Although the EEA group was associated with higher rates of CSF leak (p<0.05; OR 3.9; 95 % CI 1.15, 15.75), EEA were also associated with significantly higher rates of post-operative visual improvement compared to transcranial approaches (p<0.05; OR 1.5; 95 % CI 1.18, 1.82). A systematic review of the small series of EEA for tuberculum sellae meningiomas published to date revealed similar extent of resection and morbidity, but increased post-operative visual improvement compared to transcranial approaches during a similar time period.

Long-term follow-up will be needed to define recurrence rates of EEA as compared to transcranial approaches. Cautious use of EEA for the removal of smaller tuberculum sellae meningiomas after formal endoscopic training may be warranted.

Modern surgical outcomes following surgery for sphenoid wing meningiomas

Sphenoid wing meningioma

J Neurosurg 119:86–93, 2013

Cushing and Eisenhardt were the first to describe sphenoid wing meningiomas in detail, categorizing globoid tumors into 3 groups: 1) medial; 2) middle; and 3) lateral. The authors review their experience with resection of sphenoid wing meningiomas at a single center, to examine whether this classification predicts clinical presentation and postsurgical outcome.

Methods. All patients undergoing resection of sphenoid wing meningioma at the authors’ institution over a 9-year period were identified. Clinical data were compared from patients with tumors arising at different points along the sphenoid wing to determine if these tumors behaved differently in terms of symptoms, radiographic characteristics, and postsurgical outcome.

Results. A total of 56 patients underwent microsurgical resection for sphenoid wing meningioma during this period. The rates of optic canal invasion (medial 50% vs middle 5% vs lateral 0%; p < 0.0001, chi-square test), supraclinoid internal carotid artery encasement (medial 32% vs middle 5% vs lateral 0%; p < 0.01, chi-square test), and middle cerebral artery encasement (medial 45% vs middle 24% vs lateral 0%; p < 0.01, chi-square test) were all highest with medial-third tumors. New or worsened neurological deficits occurred in 10 (19%) of 56 patients. Of all the imaging characteristics studied, only location of the tumor along the medial third of the sphenoid wing significantly predicted an increased rate of new or worsened neurological deficit (OR 2.7, p < 0.05).

Conclusions. The authors report outcomes in a large series of sphenoid wing meningiomas that were treated using modern surgical techniques.

Impact of anterior clinoidectomy on visual function after resection of meningiomas in and around the optic canal


Acta Neurochir (2013) 155:1293–1299

Meningiomas of the anterior and middle skull base frequently involve the optic nerve and cause progressive visual impairment. Surgical decompression of the optic nerve is the only option to preserve visual function. Depending on the invaded structures, optic nerve decompression can be part of a complete tumor removal or the main surgical intention in terms of local debulking. However, bony decompression of the optic canal including anterior clinoidectomy for optic nerve decompression is still a surgical maneuver under discussion.

Methods From 2006 to 2011, 46 consecutive patients with skull base meningiomas in and around the optic canal were operated. The pterional approachwas tailored for each patient. Resection included bony decompression of the optic canal with or without anterior clinoidectomy. Visual acuity and fields were evaluated pre- and postoperatively.

Results Fifty-three percent of patients underwent anterior clinoidectomy, 23 % optic canal unroofing, and 24 % any bony decompression. In 21 patients (46 %), gross total resection (GTR, Simpson grade I or II) was achieved, while 25 patients (54 %) received subtotal resection (STR, Simpson grade III or IV). Sixty-three percent of patients presented with preoperative visual impairment. Postoperative visual changes were significantly related to preoperative visual function. While all patients with normal preoperative vision remained unchanged, in patients with impaired vision, surgery caused improvement in 70%and deterioration in 10 % of patients (p<0.0001). In patients with anterior clinoidectomy, vision improved more frequently than without anterior clinoidectomy (p<0.05).

Conclusions Anterior clinoidectomy is safe and may improve visual outcome in meningiomas in and around the optic canal.

Clinical outcomes of tuberculum sellae meningiomas focusing on reversibility of postoperative visual function

Tuberculum Sellae Meningiomas

Acta Neurochir (2013) 155:25–31

Tuberculum sellae meningiomas present a special challenge because of their proximity to major arteries, visual pathways, and the hypothalamus. The aim of this study was to determine the prognostic determinants of clinical and visual outcomes of these tumors, focusing on the functional reversibility of an unserviceable eye after surgery.

Methods We retrospectively reviewed 86 patients on the basis of clinical and radiological factors that appeared to affect outcome. The visual acuity and visual fields were analyzed according to the visual impairment score (VIS). Unserviceable visual acuity included no perception of light (NPL), hand movement (HM), and counting fingers (CF). Ophthalmological functioning was tested in the preoperative period, the postoperative short-term period (≤2 weeks after surgery), and the postoperative long-term period (>6 months after surgery). Our own clinical outcome criteria including tumor control, visual improvement, and complications were used for evaluation.

Results Seventy-four of 86 patients (86 %) underwent total removal of the tumor. In three of these cases (3.4 %), recurrence developed. Thirty patients were classified into the “Excellent” group, 21 into the “Good” group, 20 into the “Fair” group, and 15 into the “Poor” group. In multivariate analysis, adhesion to optic nerve was an independent and significant predictor of clinical outcome. Favorable visual outcomes in both short- and long-term postoperative periods were achieved in 80.8%of cases. Preoperative and short-term visual outcomes were closely related to long-term visual outcome. Six of eight patients with preoperative CF status showed reversibility to a serviceable status after surgery. However, there was no conversion to serviceable status from NPL or HM.

Conclusions For patients with unilateral unserviceable visual function, maintenance of serviceable visual function on the opposite side might be more important. Of the patients with unserviceable visual function, careful surgery might be able to improve the visual function in CF eyes.

Factors affecting peritumoral brain edema in meningioma: special histological subtypes with prominently extensive edema

Peritumoral edema in meningioma

J Neurooncol (2013) 111:49–57

Various degrees of peritumoral brain edema (PTBE) are observed in patients with intracranial meningiomas. Factors affecting the occurrence of PTBE in intracranial meningioma were investigated.

PTBE was investigated retrospectively for 110 patients with primary intracranial meningiomas. Predictive factors related to PTBE were analyzed, for example patient age, sex, magnetic resonance imaging features (contrast enhancement, tumor shape, tumor location, tumor volume), angiographical features (tumor stain, pial–cortical arterial supply, venous obstruction), and histopathological features (histological subtypes, mindbomb homolog 1 labeling index (MIB1-LI)). Histological subtypes were classified into World Health Organization (WHO) grade I common type (meningothelial, transitional, fibrous), grade I uncommon type, and grade II and III types. The extent of PTBE was assessed by calculation of the edema index (EI).

PTBE was present in 53 cases (48 %). Male sex, heterogeneous enhancement, superficial location, tumor volume (≥10 cm3), remarkable tumor stain, pial supply, venous obstruction, malignant pathology, and MIB1-LI ≥4 % were correlated with PTBE in univariate analysis. Pial supply and remarkable tumor stain were correlated with PTBE in multivariate analysis. WHO grade I uncommon type had obviously higher EI than WHO grade I common type, and WHO grade II and III types (P<0.001). Seven cases with prominently high EI (EI ≥10) were all WHO grade I uncommon type, including angiomatous, microcystic, secretory, and lymphoplasmacyte-rich meningioma. Prominently extensive PTBE might indicate the presence of WHO grade I uncommon type meningioma.

Higher incidence of epilepsy in meningiomas located on the premotor cortex: a voxel-wise statistical analysis

Acta Neurochir (2012) 154:2241–2249

A substantial number of patients with brain tumors develop recurrent seizures, known as tumorassociated epilepsy. It is important to identify specific subgroups of brain tumor patients with higher incidences of epilepsy because a meta-analysis failed to certify the effectiveness of prophylactic anti-epileptic drugs (AEDs) to abort tumor-associated epilepsy as a whole.

Methods To investigate the relationship between tumor location and incidence of epilepsy, we performed voxel-wise comparison between 3D MRI scans obtained from patients with meningioma-associated epilepsy and those from control patients using spatial normalization techniques on neuroimaging data. Variables such as age, tumor size, the degree of edema, and pathological diagnosis were also compared between the two groups.

Results Our results showed the highest incidence of epilepsy when the tumor was located on the premotor cortex in the frontal lobe (Z-scores >2.0, Liebermeister’s quasi-exact test). The stepwise multiple regression analysis on the clinical data revealed that the tumor diameter (p<0.001) and the patient’s age (p=0.024) were positive and negative predictors, respectively, for the onset of epilepsy.

Conclusions The incidence of epilepsy was higher in meningiomas located on the premotor cortex than on the other cortex. Larger volume also contributed to the onset of epilepsy. We suggest that variations of epilepsy incidence dependent on tumor characteristics can be considered when treating tumor-associated epilepsy.

Meningiomas in Pregnancy

Neurosurgery 71:951–961, 2012

Dramatic growth of meningiomas is occasionally encountered during pregnancy. While cell proliferation is often assumed, hemodynamic changes have also been touted as a cause.

OBJECTIVE: We identified 17 meningiomas resected during pregnancy or within 3 weeks post-partum and characterized them to determine the cause of occasional rapid growth in pregnancy.

METHODS: Seventeen tumors were identified from searches at 4 university centers. All available clinical records, radiology images, and tissue specimens were reviewed, with immunohistochemical studies performed as needed.

RESULTS: Sixteen patients underwent tumor resection and 1 died of complications prior to surgery. Average patient age was 32 years. Nine experienced onset of symptoms in the third trimester or within 8 days post-partum. Principle physical findings included visual complaints (59%) and cranial nerve palsies (29%). Ten tumors (59%) were located in the skull base region. The Ki-67 labeling index was low (0.5-3.6%) in 11 of 13 benign (grade I) tumors and elevated (11-23.2%) in 3 of 4 atypical (grade II) meningiomas. Eight (50%) tumors featured hypervascularity with at least focal CD34- positive hemangioma-like microvasculature. Fourteen (82%) showed evidence of intraand/ or extracellular edema, 1 so extensive that its meningothelial nature was not apparent. Five tumors (29%) exhibited intratumoral hemorrhage and/or necrosis.

CONCLUSION: Our series suggests that pregnancy-associated meningiomas located in the skull base are likely to require surgical intervention for visual complaints and cranial nerve palsies. The rapid tumor growth is more often due to potentially reversible hemodynamic changes rather than hormone-induced cellular proliferation.

Neurosurgery Department. “La Fe” University Hospital. Valencia, Spain


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