Hyperostosing sphenoid wing meningiomas: surgical outcomes and strategy for bone resection and multidisciplinary orbital reconstruction

J Neurosurg 134:711–720, 2021

Hyperostosing sphenoid wing meningiomas cause bony hyperostosis that may extend into the orbit, resulting in proptosis, restriction of extraocular movements, and/or compressive optic neuropathy. The extent of bony removal necessary and the optimal reconstruction strategy to prevent enophthalmos is debated. Herein, the authors present their surgical outcomes and reconstruction results.

METHODS This is a retrospective review of 54 consecutive patients undergoing resection of sphenoid wing meningiomas associated with bony hyperostosis. The majority of cases were operated on by the senior author. Extent of tumor resection, volumetric bone resection, radiographic exophthalmos index, complications, and recurrence were analyzed.

RESULTS The median age of the cohort was 52.1 years, with women comprising 83% of patients. Proptosis was a presenting symptom in 74%, and 52% had decreased visual acuity. The WHO grade was I (85%) or II (15%). The median follow-up was 2.6 years. On volumetric analysis, a median 86% of hyperostotic bone was resected. Gross-total resection of the intracranial tumor was achieved in 43% and the orbital tumor in 27%, and of all intracranial and orbital components in 20%. Orbital reconstruction was performed in 96% of patients. Postoperative vision was stable or improved in 98% of patients and diplopia improved in 89%. Postoperative complications occurred in 44% of patients, and 26% of patients underwent additional surgery for complication management. The most frequent complications were medical complications and extraocular movement deficits. The median preoperative exophthalmos index was 1.26, which improved to 1.12 immediately postoperatively and to 1.09 at the 6-month follow-up (p < 0.001). Postoperatively, 18 patients (33%) underwent adjuvant radiotherapy after subtotal resection. Tumors recurred/progressed in 12 patients (22%).

CONCLUSIONS Resection of hyperostosing sphenoid wing meningiomas, particularly achieving gross-total resection of hyperostotic bone with a good aesthetic result, is challenging and associated with notable medical and ocular morbidity. Recurrence rates in this series are higher than previously reported. Nevertheless, the authors were able to attain improvement in proptosis and visual symptoms in the majority of patients by using a multidisciplinary approach.

Lateral Orbitotomy Approach for Lesions Involving the Middle Fossa

Neurosurgery 80:309–322, 2017

Classically used for treatment of orbital lesions,the lateral orbitotomy with cantholysis can be combined with a temporal craniectomy for lesions involving the middle cranial fossa.

OBJECTIVE: To present a single-center experience with the lateral orbitotomy approach for lesions involving the middle fossa.

METHODS: Twenty-five patients underwent lateral orbitotomies from April 2012 to July 2015. Excluding patients with solely intraorbital pathologies, 13 patients’clinical and radio- graphic records were retrospectively reviewed.

RESULTS: Signs/symptoms in the 13 patients (ages 28-81) included proptosis (69%), decreased visual acuity (31%), diplopia (54%), and afferent pupillary defect (69%). Pathologies were meningioma (8), esthesioneuroblastoma, lymphoma, chordoma, Ewing’s sarcoma, and squamous cell carcinoma. Surgical goals were maximal safe resection in 8 patients, palliative debulking in 3 patients, and cavernous sinus biopsy in 2 patients. In 8 patients for whom maximal resection was the goal, 2 had gross total resection, while 6 had near-total resection. All patients (3) for whom palliation was the goal had symptomatic improvement. Both cavernous sinus biopsies obtained diagnostic tissue without complications. All patients with proptosis (n = 9) and diplopia (n = 7), and 2 of 4 patients with decreased visual acuity had improvement in their symptoms. No patient reported worsening of their symptoms. Mean follow-up was 12 mo (2-30 mo). Complica- tions included oculorrhea (1), pseudomeningocele (2), transient ptosis (2), and forehead numbness (1).

CONCLUSION: The lateral orbitotomy is a promising approach for carefully selected lesions with involvement of both the lateral orbit and middle cranial fossa. It provides minimally invasive access for biopsy, decompression, or resection.

Internal and external spheno-orbital meningioma varieties: different outcomes and prognoses

SO Meningiomas

Acta Neurochir (2016) 158:1587–1596

Internal variation among spheno-orbital meningiomas  (SOM) is surgically challenging. Optic canal invasion  management is discussed.

Method This retrospective study includes 70 patients with  SOM who underwent surgery between 1995 and 2012.  Preoperative ophthalmological, neurological and aesthetic  clinical signs were collected. All patients benefitted from repeated  tomography and magnetic resonance imaging (MRI).  The surgical team consisted of a neurosurgeon and a plastic  surgeon. In the majority of cases, resection was followed by  bone reconstruction using an autologous iliac crest graft. The  extent of resection was evaluated on the dural and osseous  sides. Early clinical outcomes, long-term follow-up, recurrence  and adjuvant therapies were reported.

Results The mean age was 52 years old, and 91 % of the  patients were women. Initial symptoms primarily included  proptosis (65 %), decreased visual acuity (39 %) and soft  tissue tumefaction (16 %).We classified 40 cases as the internal  variety when considering the inner third of the greater  wing of the sphenoid, optic canal, anterior clinoid process or  cavernous sinus. The remaining cases were described as the  external variety. The complete resection rates for the internal  and external varieties were 12 % and 61 %, respectively  (P< 0.001). In total, 90% of cases were grade I meningiomas.  For grade I, we reported 30 % recurrence, and 50 % of these  cases recurred in the first 2 years. Grade II cases without early  adjuvant radiotherapy increased at 2 years.We did not observe  any difference in recurrence rate among grade I tumours with  or without tumour remnants. At the end of follow-up, visual  acuity was stabilised or increased in 88 % of patients. In addition,  14 % of patients experienced persistent pain at the  location of the iliac harvesting site.

Conclusions The internal SOM variety exhibited a reduced  total resection rate and a shorter progression-free survival  (PFS). Unroofing of the optic canal extended PFS. Among  grade I cases, the persistence of a negligible tumour remnant  did not alter the probability of recurrence. For superior grades,  radiotherapy must be administered in addition to surgery as  soon as possible. SOMs require prolonged follow-up.  Autologous iliac reconstruction is related to substantial morbidity  and could be replaced by prosthetic bone threedimensional  reconstruction.

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