Anterior Skull Base Meningioma: Surgical approach and complication avoidance

Background: Endoscopic endonasal approach (EEA) and keyhole transcranial approaches are being increasingly used in anterior skull base meningioma (ASBM) surgery. Objective: We compare tumor resection rates and complication profiles of EEA and supraorbital key hole approach (SOKHA) against conventional transcranial approaches (TCA). Methods: Fifty-four patients with ASBM [olfactory groove (OGM), n=19 and planum sphenoidale/tuberculum sellae (PS/TSM), n=35) operated at a single centre over 7 years were retrospectively analyzed. Results: The overall rate of GTR was higher in OGM (15/19, 78.9%) than PS-TSM group (23/35, 65.7%, p=0.37). GTR rate with OGM was 90% and 75% with TCA and EEA. Death (n=1) following medical complication (TCA) and CSF leak requiring re-exploration (n=2, one each in TCA and EEA) accounted for the major complications in OGM. For the PS/TSM group, the GTR rates were 73.3% (n=11/15), 53.8% (n=7/13) and 71.4% (n=5/7) with TCA, EEA and SOKHA respectively. Seven patients (20%) of PS-TSM developed major postoperative complications including 4 deaths (one each in TCA, SOKHA and 2 in EEA group) and 3 visual deteriorations. Direct and indirect vascular complications were common in lesser invasive approaches to PS-TSM especially if the tumor has encased intracranial arteries. Conclusions: No single approach is applicable to all ASBMs. TCA is still the best approach to obtain GTR but has tissue trauma related problems. SOKHA may be a good alternative to TCA in selected PS-TSMs while EEA may be an alternate option in some OGMs. A meticulous patient selection is needed to derive reported results of EEA for PS-TSM.

Multiple meningiomas

Multiple meningiomas are rare conditions that refer to the presentation of two or more meningiomas, simultaneous or not, without the association of neurofibromatosis. We report a case of a 83-year-old woman with a clinical presentation of loss of right visual acuity. After imaging exams, she was diagnosed with three meningiomas, located in the olfactory groove, left temporal-parietal convexity and parasagittal. In addition, a comprehensive review of the literature on pathophysiology, histology, risk factors, clinical presentation, and treatment of multiple meningiomas was carried out, in order to highlight the peculiarities of this condition and to associate it with our reported case. Therefore, this article made it possible to compare the characteristics presented in this patient with general aspects of the conditions reported in the literature review.

Surgical Treatment for Olfactory Groove Meningiomas: A Meta-Analysis of the Literature

Background Surgical resection of olfactory groove meningiomas (OGMs) is challenging and lots of surgical approaches can be chosen. We conducted a systematic review and meta-analysis of the studies investigating surgical resection of OGMs to better understand the surgical treatment of OGMs.Methods PubMed, Embase and Cochrane Library were used to search the studies reporting treatment outcomes of surgery for patients with OGMs. The final eligible studies were assessed using the Oxford Center for Evidence Based Medicine for level of evidence. Relevant parameters were extracted to perform descriptive and/or quantitative analyses.Results A total of 42 studies including 1673 patients were included in this systematic review (8 level 3 studies and 34 level 4 studies). Surgeries through transcranial approaches (TCAs) and endoscopic endonasal approach (EEA) were done on 1596 and 77 patients, respectively. Based on a random effects model, rates of gross total resection (GTR) and cerebrospinal fluid (CSF) leak were determined to be 92.4% (CI: 88.6-95.5%) and 5.9% (95% CI: 3.4-9%), respectively. The mortality following surgery was 1.6% (95% CI: 0.9-2.5%) under a fixed effects model. Through subgroup analyses, TCAs were found to be more favorable in GTR and CSF leakage compared to EEA. Besides, anterolateral TCA was associated with better control of CSF leakage than anterior TCA. Conclusion Surgical treatment is capable of achieving GTR in the vast majority of patients with OGMs and postoperative mortality is under well control. Transcranial approach allows a better chance of GTR and better control of CSF leak in comparison to EEA. In comparison to anterior TCA, anterolateral TCA is associated less mortality. However, low evidence level and significant heterogeneity of the included studies prevent the formation of more solid conclusions.

A rare autopsy case of pentalogy of Cantrell with tetralogy of Fallot and olfactory bulb agenesis

Introduction/Objective Pentalogy of Cantrell is an uncommon congenital disorder characterized by sternal, diaphragmatic, pericardial, intracardiac and supraumbilical abdominal or chest wall defects. It is usually associated with other abnormalities and thus poses a therapeutic challenge, with a high mortality rate despite early diagnosis. Methods/Case Report This is an autopsy case of a 1 day old, former 37-week-old male infant with a prenatal diagnosis of incomplete pentalogy of Cantrell including omphalocele, ectopia cordis, pleural effusions, cardiac anomalies and polyhydramnios who was delivered via elective cesarean section. Maternal history included tobacco use during pregnancy, multiple psychiatric disorders, and a family history of an unbalanced translocation. The infant required intubation, ventilation, and chest tube insertion at birth due to respiratory distress. He also developed pneumoperitoneum which had to be decompressed. Within 24 hours the infant passed, despite advanced care. On autopsy, external examination showed central and peripheral cyanosis and a large omphalocele containing the heart, parts of the liver and intestines. Initial internal examination revealed a hypoplastic left lung, anterior diaphragmatic defect and absence of the pericardium. Organ dissection post-fixation showed an overriding aorta, pulmonic stenosis, subaortic valve ventricular septal defect and right ventricular hypertrophy, all components of tetralogy of Fallot. On brain examination, the olfactory groove and bulb were both absent. Examination of the placenta and 3 vessel cord revealed no abnormalities. Chromosomal microarray analysis on cord blood was normal. Conclusion The spectrum of defects seen in this disease complex has been postulated to be due to failure of differentiation or migration of mesenchymal structures during embryonic development but ultimately, this entity is not well understood. Identifying various disease associations through autopsies can help to establish possible etiologies, and options for therapeutic interventions or screening.

Two-step staged resection of giant olfactory groove meningiomas

Background The surgical treatment of giant olfactory groove meningiomas (OGMs) with marked perilesional brain oedema is still a surgical challenge. After tumour resection, increase of brain oedema may occur causing dramatic neurological deterioration and even death of the patient. The objective of this paper is to describe surgical features of a two-step staged resection of these tumours performed to counter increase of postoperative brain oedema. Methods This two-step staged resection procedure was carried out in a consecutive series of 19 patients harbouring giant OGMs. As first step, a bifrontal craniectomy was performed followed by a right-sided interhemispherical approach. About 80% of the tumour mass was resected leaving behind a shell-shaped tumour remnant. In the second step, carried out after the patients’ recovery from the first surgery and decline of oedema, the remaining part of the tumour was removed completely followed by duro- and cranioplasty. Results Ten patients recovered quickly from first surgery and the second operation was performed after a mean of 12.4 days. In eight patients, the second operation was carried out later between day 25 and 68 due to surgery-related complications, development of a trigeminal zoster, or to a persisting frontal brain oedema. Mean follow-up was 49.3 months and all but one patient had a good outcome regardless of surgery-related complications. Conclusions Our results suggest that a two-step staged resection of giant OGMs minimizes the increase of postoperative brain oedema as far as possible and translates into lower morbidity and mortality.

Olfactory groove meningioma with a 10-year history of smell loss and olfactory recovery after surgery

A rare cause of olfactory impairment is olfactory groove meningiomas with insidious onset of non-specific symptoms like headache, olfactory dysfunction, psychiatric symptoms such as depression, personality changes, declining cognitive function, visual disturbances or seizures. A common complication of surgery is loss of olfactory function. Still, the preservation of olfactory function should be attempted as olfactory loss often has a severe negative impact on quality of life. This report describes a woman with an olfactory groove meningioma and a 10-year history of olfactory impairment. It includes preoperatively and postoperatively extended olfactory testing, a neurosurgical approach to preserve the olfactory function and postoperative olfactory rehabilitation. After rehabilitation, the patient regained a normal olfactory function, even though the right-sided olfactory nerve could not be preserved during surgery. The case demonstrates the importance of performing neuroimaging in selected patients with olfactory loss and a method for preserving and potentially improving postoperative olfactory function.

Smell loss as initial symptom of olfactory groove meningioma

Approximately 20% of the general population suffer from olfactory dysfunction (OD). Until today, olfactory function (OF) receives less attention than other human senses despite its significance for quality of life. The main causes of OD are upper respiratory tract infections, traumatic brain injuries and sinonasal diseases. Here, we report the case of a 28-year-old woman, who started to suffer from OD during pregnancy. Smell loss was attributed to pregnancy-induced rhinitis and initiated no further examinations. Nevertheless, OD persisted post partum and undulating headache occurred 1 year later. Only after visual impairment and one more year passing by, diagnosis of olfactory groove meningioma was made using MRI. With this case report, we want to highlight the importance of the symptom of smell loss. Patients reporting OD should undergo thorough anamnesis, endoscopy of the nasal cavity, psychophysical smell testing and radiographic imaging in unclear cases to determine diagnosis.