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

OBJECTIVEHyperostosing 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.METHODSThis 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.RESULTSThe 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%).CONCLUSIONSResection 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.

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Transcavernous Approach for Gross Total Resection of a Dumbbell-Shaped Giant Trigeminal Schwannoma

Journal of Neurological Surgery Part B Skull Base ◽

10.1055/s-0041-1729995 ◽

2021 ◽

Author(s):

Sima Sayyahmelli ◽

Emel Avci ◽

Burak Ozaydin ◽

Mustafa K. Başkaya

Keyword(s):

Skull Base ◽

Cavernous Sinus ◽

Tumor Resection ◽

Mass Effect ◽

World Health ◽

Gross Total Resection ◽

Petrous Apex ◽

Total Resection ◽

Who Grade ◽

Trigeminal Schwannoma

AbstractTrigeminal schwannomas are rare nerve sheet tumors that represent the second most common intracranial site of occurrence after vestibular nerve origins. Microsurgical resection of giant dumbbell-shaped trigeminal schwannomas often requires complex skull base approaches. The extradural transcavernous approach is effective for the resection of these giant tumors involving the cavernous sinus.The patient is a 72-year-old man with headache, dizziness, imbalance, and cognitive decline. Neurological examination revealed left-sided sixth nerve palsy, a diminished corneal reflex, and wasting of temporalis muscle. Magnetic resonance imaging (MRI) showed a giant homogeneously enhancing dumbbell-shaped extra-axial mass centered within the left cavernous sinus, Meckel's cave, and the petrous apex, with extension to the cerebellopontine angle. There was a significant mass effect on the brain stem causing hydrocephalus. Computed tomography (CT) scan showed erosion of the petrous apex resulting in partial anterior autopetrosectomy (Figs. 1 and 2).The decision was made to proceed with tumor resection using a transcavernous approach. Gross total resection was achieved. The surgery and postoperative course were uneventful, and the patient woke up the same as in the preoperative period. MRI confirmed gross total resection of the tumor. The histopathology was a trigeminal schwannoma, World Health Organization (WHO) grade I. The patient continues to do well without any recurrence at 15-month follow-up.This video demonstrates important steps of the microsurgical skull base techniques for resection of these challenging tumors.The link to the video can be found at https://youtu.be/TMK5363836M

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Ependymomas in infancy: underlying genetic alterations, histological features, and clinical outcome

Child s Nervous System ◽

10.1007/s00381-020-04655-x ◽

2020 ◽

Vol 36 (11) ◽

pp. 2693-2700

Author(s):

Stephanie T. Jünger ◽

Felipe Andreiuolo ◽

Martin Mynarek ◽

Evelyn Dörner ◽

Anja zur Mühlen ◽

...

Keyword(s):

Posterior Fossa ◽

Genetic Alterations ◽

Gross Total Resection ◽

Older Children ◽

Total Resection ◽

Who Grade ◽

Chromosome 1Q ◽

Stable Genome ◽

1Q Gain

Abstract Introduction Young age is an adverse prognostic factor in children with ependymomas. Treatment of these infants is challenging since beneficial therapeutic options are limited. As ependymomas are considered a biologically heterogeneous group, we aimed to characterize infant ependymomas with regard to their histological and genetic features. Materials and methods We analyzed 28 ependymomas occurring in children younger than 18 months at diagnosis enrolled into the HIT2000-E protocols with the aim to postpone irradiation until the age of 18 months if possible. All cases underwent neuropathological review, including immunohistochemical characterization. Genome-wide copy number alterations (CNA) were assessed by molecular inversion probe assays, and RELA and YAP1 fusions were detected by RT-PCR and sequencing. Results All infant ependymomas were anaplastic (WHO grade III). Twenty-one (75%) cases were located in the posterior fossa. Gross total resection was accomplished in 12 (57%) of these cases. All posterior fossa tumors showed loss of H3-K27me3 characteristic of PFA ependymomas. CNA analysis showed a stable genome in all cases with lack of chromosome 1q gain, an adverse prognostic marker in PFA ependymomas of older children. However, after a median follow-up of 5.4 years, 15 (71%) relapsed, and 9 (43%) died. Seven ependymomas (25%) occurred in the supratentorial region. Gross total resection could be achieved in only two of these cases. Four tumors carried C11orf95-RELA fusions, and two cases had typical YAP1-MAMLD1 fusions (one case was not analyzable). The RELA-fused cases did not display CDKN2A loss as an adverse indicator of prognosis in this disease entity. Although three infants (43%) with supratentorial ependymomas relapsed, all patients survived (median follow-up, 8.0 years). Conclusion Infant ependymomas seem to fall into three biological entities, with supratentorial tumors carrying RELA or YAP fusions and PFA posterior fossa ependymomas. The latter showed a poor outcome even though chromosome 1q gain was absent.

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Microsurgical resection of giant T11/T12 conus cauda equine schwannoma

Bosnian Journal of Basic Medical Sciences ◽

10.17305/bjbms.2020.5153 ◽

2020 ◽

Author(s):

Alisa Arnautovic ◽

Mirza Pojskic ◽

Kenan Arnautovic

Keyword(s):

Motor Evoked Potentials ◽

Tumor Resection ◽

Cauda Equina ◽

Sensory Nerve ◽

Gross Total Resection ◽

Nerve Roots ◽

Total Resection ◽

Who Grade ◽

Extramedullary Tumor ◽

Microsurgical Resection

In this video, we highlight the anatomy involved with microsurgical resection of a giant T11/T12 conus cauda equine schwannoma. Spinal schwannoma remains the third most common intradural spinal tumor. Tumors undergoing gross total resection usually do not recur. To our knowledge, this is the first video case report of giant cauda equina schwannoma resection. A 55-year-old female presented with paraparesis and urinary retention. Lumbar spine MRI revealed contrast-enhancing intradural extramedullary tumor at the T11/T12 level. Surgery was performed in a prone position with intraoperative neurophysiology monitoring (somatosensory and motor evoked potentials - SSEP and MEP). T11/T12 laminectomies were performed. After opening the dura and arachnoid, the tumor was found covered with cauda equina nerve roots. We delineated the inferior pole of the tumor, followed by opening of the capsule and debulking the tumor. Subsequently, the cranial pole was dissected from the corresponding cauda equina nerve roots. Finally, the tumor nerve origin was identified and divided after nerve stimulation confirmed the tumor arose from a sensory nerve root. The tumor was removed; histological analysis revealed a schwannoma (WHO Grade I). Postoperative MRI revealed complete resection. The patient fully recovered her neurological function. This case highlights the importance of careful microsurgical technique and gross total resection of the tumor in the view of favorable postoperative neurological recovery of the patient. Intraoperative use of ultrasound is helpful to delineate preoperatively tumor extension and confirm postoperative tumor resection.

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Dynamic changes in magnetic resonance imaging appearance of dysembryoplastic neuroepithelial tumor with or without malignant transformation

Journal of Neurosurgery Pediatrics ◽

10.3171/2013.1.peds11449 ◽

2013 ◽

Vol 11 (5) ◽

pp. 518-525 ◽

Cited By ~ 15

Author(s):

Yui Mano ◽

Toshihiro Kumabe ◽

Ichiyo Shibahara ◽

Ryuta Saito ◽

Yukihiko Sonoda ◽

...

Keyword(s):

Malignant Transformation ◽

Gross Total Resection ◽

Subtotal Resection ◽

Dysembryoplastic Neuroepithelial Tumor ◽

Total Resection ◽

Who Grade ◽

Adjuvant Radiochemotherapy ◽

First Case ◽

Complex Forms

Dysembryoplastic neuroepithelial tumors (DNETs) have conventionally been regarded as benign and stable tumors and considered curable with surgery without adjunctive therapy. Recently, recurrent DNETs with or without malignant transformation have been described. The authors report 2 unusual cases of DNET: 1) an enlarging lesion that developed an enhancing component over the natural course of 4 years, and 2) a recurrent DNET that developed an enhancing component 10–11 years after gross-total resection. The patient in the first case was treated with subtotal resection and adjuvant radiochemotherapy; histological examination of the tumor led to the diagnosis of DNET, WHO Grade I, for the nonenhancing component and anaplastic oligodendroglioma, WHO Grade III, for the enhancing component. The patient in the second case was treated with repeat gross-total resection; the original tumor had been histologically diagnosed as DNET, and the nonenhancing and enhancing components of the recurrent tumor were diagnosed as simple and complex forms of DNET, respectively. These and previous reports suggest an aggressive subtype of DNETs. If follow-up MRI reveals progressive behavior, resection should be performed without delay. Additional radiochemotherapy is needed if the histological diagnosis demonstrates malignant transformation.

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Petroclival Meningiomas: Factors Determining the Choice of Approach

Journal of Neurological Surgery Part B Skull Base ◽

10.1055/s-0037-1608654 ◽

2017 ◽

Vol 79 (04) ◽

pp. 367-378 ◽

Cited By ~ 3

Author(s):

Gustavo Isolan ◽

Sâmia Wayhs ◽

Guilherme Lepski ◽

Leandro Dini ◽

Joel Lavinsky

Keyword(s):

Tumor Progression ◽

Cranial Nerve ◽

Tumor Resection ◽

Retrosigmoid Approach ◽

University Hospital ◽

Gross Total Resection ◽

Middle Fossa ◽

Total Resection ◽

Petroclival Meningiomas

Objectives To review a surgical series of petroclival meningiomas and the factors considered in the choice of approach. Design Retrospective review. Setting The study was conducted in a university hospital in southern Brazil. Participants Twenty-two patients with petroclival meningioma originating from the upper two-thirds of the clivus medial to the fifth cranial nerve. Main Outcome Measures Gross-total resection, mortality, major morbidity, new cranial nerve deficits and tumor progression or recurrence. Results Retrosigmoid approach was used in tumors <3 cm and in those at or below the internal auditory meatus. Posterior petrosectomy was performed for tumors extending into the middle fossa. Gross-total resection was performed in 11 patients (50%). The mean follow-up time was 32 months (6–75 months). There were four cases of tumor progression or recurrence, which were treated with radiosurgery. Conclusions Resection of petroclival meningiomas remains challenging. In most cases, the retrosigmoid approach was sufficient, without affecting the degree of tumor resection. Petrosal approaches were reserved for patients with tumor extension into the middle fossa.

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High Cervical Ependymoma Resection: 2-Dimensional Operative Video

Operative Neurosurgery ◽

10.1093/ons/opy184 ◽

2018 ◽

Vol 16 (4) ◽

pp. 516-517

Author(s):

Simone E Dekker ◽

Chad A Glenn ◽

Thomas A Ostergard ◽

Brian D Rothstein ◽

Nicholas C Bambakidis

Keyword(s):

High Speed ◽

Treatment Options ◽

Tumor Resection ◽

Postoperative Management ◽

Skin Incision ◽

Gross Total Resection ◽

Total Resection ◽

Who Grade ◽

Postoperative Mri ◽

High Cervical

Abstract This operative video illustrates resection of a cervical ependymoma in a 40-yr-old female with numbness of upper and lower extremities and ataxia. Magnetic resonance imaging (MRI) demonstrated an enhancing intramedullary intradural spinal mass at C2-3. The patient underwent a posterior cervical laminoplasty for tumor resection. This video highlights the natural history of this disease, treatment options, surgical procedure, potential risks and complications, and postoperative management of ependymomas. A posterior midline skin incision was made from the inion to the level of C4 which exposed the posterolateral elements of C1-3. C2 and C3 lamina were removed as a single piece using the high-speed drill. A C1 laminectomy was then also performed to provide adequate superior exposure. The dura was opened widely in the midline. Careful midline myelotomy was then performed overlying the tumor. The tumor is noted to be densely adherent to the surrounding spinal cord. Gross total resection was completed using ultrasonic aspiration and microdissection. The dura was closed in a watertight fashion followed by a synthetic dural sealant. The bony elements of C2, C3 were then reconstructed using osteoplastic laminoplasty, titanium miniplates, and screws at C2-3. The wound was closed in multiple layers using sutures. Specimens were sent for frozen and permanent pathological analysis, eventually demonstrating WHO grade II ependymoma. There were no complications. Postoperative MRI demonstrated gross total resection. The patient had an uneventful postoperative course. The strength was at baseline at long term follow-up, with small sensory deficit.

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Infratentorial choroid plexus tumors in children

Child s Nervous System ◽

10.1007/s00381-020-04532-7 ◽

2020 ◽

Vol 36 (8) ◽

pp. 1761-1766 ◽

Cited By ~ 1

Author(s):

S. Joy Trybula ◽

Constantine Karras ◽

Robin M. Bowman ◽

Tord D. Alden ◽

Arthur J. DiPatri ◽

...

Keyword(s):

Adjuvant Therapy ◽

Choroid Plexus ◽

Surgical Resection ◽

Fourth Ventricle ◽

Gross Total Resection ◽

Incomplete Resection ◽

Total Resection ◽

Who Grade ◽

Choroid Plexus Tumors

Abstract Objective Choroid plexus tumors (CPTs) are rare pediatric intracranial neoplasms, and mostly occur in the lateral ventricle. CPTs located in the infratentorial location are considered to be rare in the pediatric population. We present a series of eight patients treated in the last decade at our institution focusing on clinical presentations and their outcome after excision. Methods We performed an institutional retrospective review of patients who underwent surgical resection of infratentorial CPTs during the period from 2008 to 2017. Patients’ charts were reviewed for demographic data, clinical presentation, surgical treatment, and follow-up. Results There were eight patients (6 females and 2 males), with mean age for the cohort at presentation was 9.0 years. They represent 75% of 12 CPTs of all locations treated at the same period in our institution. These 8 infratentorial CPTs were in the fourth ventricle in seven, and in the cerebellopontine angle (CPA) in one. Seven patients had choroid plexus papillomas (WHO grade I) and 1 had an atypical choroid plexus papilloma (WHO grade II). Gross total resection was attempted in all patients. However, two of 3 patients with fourth ventricle floor invasion had subtotal resection with a thin layer of tumor left on the floor. The remaining 6 had a gross total resection. Six patients with preoperative hydrocephalus had a perioperative external ventricular drainage but none required permanent shunting after tumor resection. None showed recurrence/tumor progression without adjuvant therapy during the follow-up period of 20 months to 11 years. Conclusion Infratentorial dominance among pediatric CPTs in this series contradicts previous reports. Infratentorial CPTs are amenable to surgical resection. Unresected small residuals due to invasion to the fourth ventricle floor showed no regrowth during 2 to 3 years follow-up without adjuvant therapy. However, these patients with incomplete resection need watchful observations.

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The impact of authors’ medical specialty on publication patterns and published results of adjuvant radiotherapy for WHO grade 2 meningiomas—a systematic review

Acta Neurochirurgica ◽

10.1007/s00701-021-04797-0 ◽

2021 ◽

Author(s):

Per Sveino Strand ◽

Ole Solheim

Keyword(s):

Systematic Review ◽

Adjuvant Radiotherapy ◽

Gross Total Resection ◽

Radiation Oncologist ◽

Total Resection ◽

Who Grade ◽

Significant Difference ◽

The Impact

Abstract Background The role of adjuvant radiotherapy after gross total resection (GTR) of WHO grade 2 meningioma remains unclear, and conflicting results have been published. We hypothesized that authors’ medical specialties could be associated with reported findings on the role of adjuvant radiotherapy after GTR of WHO grade 2 meningiomas. Method A systematic review was conducted in Embase and Medline databases, in addition to screening of all relevant bibliographies. Articles including patients aged 18 years or older, with histologically confirmed WHO grade 2 meningioma, were included. We extracted data on medical subspecialties using the author list. We registered study design, median follow-up, number of included patients, WHO classification in use, and years of study inclusion. Results Thirty-seven relevant studies were identified, where 34 (92%) were retrospective cohort studies, two studies (5%) were systematic reviews, and one study (3%) was a meta-analysis. If the last author was a radiation-oncologist, the study was more likely to favor adjuvant radiotherapy, and if a neurosurgeon was last author, the study was more likely to not advocate adjuvant radiotherapy (p=0.009). There was no significant association between study result and whether the study was published in a neurosurgical or oncological journal (p=0.802). There was no significant difference in follow-up time, years of inclusion, or number of included patients between studies favoring or not favoring adjuvant radiotherapy. Conclusions In this systematic review of the literature, we found that if a radiation-oncologist was the last author of the study, the study was more likely to favor adjuvant radiotherapy after gross total resection of WHO grade 2 meningioma. Clinicians and researchers should be aware of a possible genealogy bias in the neuro-oncological literature.

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Posterior fossa tumors in children, Histopathology &extent of excision as prognostic factors

Al-Kitab Journal for Pure Sciences ◽

10.32441/kjps.03.02.p9 ◽

2020 ◽

Vol 3 (2) ◽

pp. 108-119

Author(s):

Manna Ramadan ◽

Shaswar Ali

Keyword(s):

Posterior Fossa ◽

Tumor Resection ◽

Choroid Plexus Papilloma ◽

Surgical Techniques ◽

Gross Total Resection ◽

Diagnostic Tools ◽

Subtotal Resection ◽

Posterior Fossa Tumors ◽

Total Resection

The Posterior fossa is the commonest site of primary intracranial tumors in children, for the last two decades the over-all survival and 5-years progression-free survival of children with posterior fossa tumors (PFT) like Medulloblastoma& Ependymomas has been doubled due to the improvement in the diagnostic tools and the advances in the surgical techniques approaching total or near total resection. The aim of the study is to find the relation of histopathology and the extent of excision with mortality and survival. A total of twenty eight cases with Histologically (26 cases) and two cases radiologically (CT-scan and MRI) confirmed pediatric posterior fossa tumors treated in Erbil Teaching Hospital between,Jan.2013 and Dec.2015 were included in the study As a result the twenty-eight pediatric patients were included in the study, mean age was (8 years),16 boys and 12 girls, mean follow-up period was 14 months,11 cases had Medulloblastoma (39%), 5 cases had Ependymoma (18%), 9 cases had Astrocytoma(32%) , 2 cases had Brainstem mass (7%) and one case had Choroid plexus papilloma (4%).Tumor resection was performed in 26 patients, Twenty cases had total resection (77%), and six Pts .had subtotal resection (23%), two cases without surgery During the follow-up period out of the 20 cases that had total resection nineteen are still alive(95%) and only one died (5%),six cases that had Subtotal resection; four of them are dead (67%) and only two cases are still alive(33%). Two cases that had no surgery both of them are dead (100%).Eleven cases of Medulloblastoma 8 of them had gross total resection and three of them had subtotal resection, 9 of them still alive (82%) and two are dead (18%). Nine Pts of Astrocytoma, 8 of them had total resection and one subtotal; eight of them are still .)alive (89%) and only one died (11%Five pts with Ependymoma, three had total resection and two had subtotal resection,three are still alive (60%) and two dead (40%). Two cases of Brainstem mass not operated and both are dead, One case of Choroid papilloma totally resected & still alive. In conclusion treatment of posterior fossa tumors in children with surgery yields long survival rates, children with gross total resection or a near total resection had better outcome. Histopathology subtypes of the tumors were associated with a favorable outcome for Astrocytoma which has less mortality and better survival rate than others

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Recurrent Sphenocavernous Meningioma

Journal of Neurological Surgery Part B Skull Base ◽

10.1055/s-0041-1725941 ◽

2021 ◽

Author(s):

Mizuho Inoue ◽

Mohamed Labib ◽

Alexander Yang ◽

A. Samy Youssef

Keyword(s):

Tumor Resection ◽

Intensity Modulated Radiotherapy ◽

Residual Tumor ◽

World Health ◽

Neurological Deficits ◽

Falciform Ligament ◽

Total Resection ◽

Anterior Clinoid Process ◽

Who Grade ◽

Health Organization

AbstractA case of a recurrent sphenocavernous meningioma is presented. The patient is a 42-year-old male who presented with an episode of transient right-sided numbness. A magnetic resonance imaging (MRI) revealed a large left sphenocavernous meningioma. The patient underwent a frontotemporal craniotomy for tumor resection. Near total resection was achieved with minimal residual in the left cavernous sinus (CS) and orbital apex. The pathology was consistent with meningioma, World Health Organization (WHO) grade I. A follow-up MRI was done 9 months after surgery and showed a growth of the residual tumor, which was treated with intensity modulated radiotherapy. Tumor growth was detected on serial imaging over a 4-year period. Surgical resection was offered. A left frontotemporal craniotomy with pretemporal transcavernous approach was performed. The bone flap was reopened and the dura was opened in a Y-shaped fashion. The roof of the optic canal was drilled off, and the falciform ligament was opened to decompress the optic nerve. The tumor was disconnected from the anterior clinoid region (the anterior clinoid process was eroded by the tumor) and reflected off the wall of the lateral CS. Tumor was adherent to the V2 fascicles (the lateral CS wall was resected in the first surgery) and was sharply dissected off. Gross total resection was achieved. The pathology was consistent with meningioma, WHO grade I. The patient had an unremarkable postoperative course without any new neurological deficits.The link to the video can be found at: https://youtu.be/KVBVw_86JqM.

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