Papillary meningioma arising from the confluens sinuum with multidirectional extension through venous sinuses

Surgical Outcome of Torcula Herophili Meningioma: An Institutional Experience

INTRODUCTION

Resection of meningiomas (THMs) at the torcular Herophili poses challenges to surgeons due to complex regional anatomy. The current study aims to evaluate factors affecting the extent of resections, progression-free survival, and the role of radiation.

METHODS

We did a retrospective study of all the THM patients treated at our institute between May 1987 and June 2022. The demographic data, signs and symptoms, surgical notes, postoperative details, and radiotherapy were gathered retrospectively. Survival analysis was done with Kaplan-Meier tests along with predictors of the extent of resection as well as recurrence.

RESULTS

A total of 39 patients qualified to be included in the study, with 10 male patients (male:female 1:2.9) and an average age of 50.8 years. The average follow-up duration was 75.9 months. Simpson's grade 2 excision was achieved in 19 (48.7%) patients, followed by Simpson's grade 3 excision in 17 patients (43.6%). Progression-free survival in subtotal resection was 60 months, and 100 months in gross total resection. Statistically, the extent of the resection was determined by the involvement of sinuses/torcula and the number of quadrants involved around torcula. A total of 16 patients received radiosurgery for the residual or small reccurrence of the lesion. Follow-up revealed reccurrence in 5 cases.

CONCLUSIONS

Torcular meningiomas are relatively uncommon, described in few reports, and represent a therapeutic dilemma. Though some experts recommend complete removal of tumor and reconstruction of the sinus, others suggest maximum safe resection, followed by radiosurgery. The present study reflects reasonable control of the residual lesion with radiosurgery after maximum safe resection.

Torcular Meningioma with Multi-Venous Sinus Invasion: Compensatory Drainage Veins and Surgical Strategy

BACKGROUND

Torcular meningiomas involving major dural venous sinuses are rare entities and a great challenge for neurosurgeons. The deep knowledge of the patency of occlusion of the sinuses, the extent of the occlusion and potentially new developing of extra and intracranial collateral venous drainage as compensatory venous channels, are at the base of a correct operative strategy.

CASE DESCRIPTION

A 45-year-old woman presented with persistent headache. Magnetic resonance imaging of the brain and digital subtraction angiography demonstrated a huge torcular meningioma with complete multi-venous sinus occlusion and a wide venous network for brain and tumor drainage. In these rare cases, we have hypothesized the presence of venous drainage shared by the brain and the tumor, which could generate undesirable venous occlusion during operative resection. This could be a cause of the well-known surgical complications, such as brain swelling and hemorrhagic infarction.

CONCLUSIONS

We report our experience with a huge torcular meningioma with multi-venous sinus invasion and a literature review, with a special emphasis on compensatory drainage veins and surgical strategy.

Systematic Analysis of Outcomes for Surgical Resection and Radiotherapy in Patients with Papillary Meningioma

Introduction Papillary meningiomas (PMs) are characterized by their aggressive nature and high rate of recurrence. Due to their rarity, studies examining the relationship between treatment and clinical outcomes for this disease are limited. Gross total resection (GTR) with or without radiotherapy (RT) is considered the standard treatment; however, when GTR is not feasible, subtotal resection (STR) followed by RT may be an effective alternative. In this study, we analyzed the clinical outcomes in patients who either underwent GTR alone, GTR followed by RT, STR alone, or STR followed by RT. Methods A systematic analysis was performed to identify PM patients with sufficient follow-up and outcome data, as measured by recurrence. Patient data lacking extent of resection, follow-up, or recurrence information were excluded. Results A total of 29 patients with PM were treated with resections (23 GTRs and 6 STRs).The mean age and mean follow-up of patients in this study were 32.3 years and 42.1 months, respectively. Of these patients, 58.6% experienced recurrence. Overall, 47.8% of patients who underwent GTR experienced recurrence. These patients also demonstrated improved survival compared with STR. Among patients whose tumors were only partially excised, a recurrence rate of 83% was observed. Conclusion Our results confirm that GTR results in fewer recurrences compared with STR, supporting GTR as the treatment of choice for PM. Furthermore, GTR in conjunction with RT resulted in improved survival compared with GTR alone. When GTR was not feasible, STR with RT was associated with improved survival compared with STR alone. Future studies with more outcome data are needed to elucidate the optimal treatment for this rare disease.

Reversible non-thrombotic occlusion of the superior sagittal sinus caused by metastatic malignant lymphoma--case report

A 57-year-old female presented with intracranial hypertension secondary to non-thrombotic superior sagittal sinus occlusion manifesting as acute onset of headache, vomiting, and disorientation. She had a history of intrapelvic malignant lymphoma. Neuroimaging and tumor biopsy revealed that both the superior sagittal sinus and the straight sinus were occluded by metastatic deposits of malignant lymphoma. Her clinical symptoms were remarkably improved by irradiation and chemotherapy, and the affected sinuses were angiographically recanalized.

Ultrastructural examination is essential for diagnosis of papillary meningioma

AIMS

Papillary meningioma is a rare meningeal tumour. To date only a few cases have been reported and their immunohistochemical features have not been fully documented.

METHODS AND RESULTS

A 49-year-old woman presented with a 2-month history of headaches and memory disturbance. CT and MRI imaging showed an enhancing pineal mass with extension into the occipital lobes and invasion of the splenium. At surgery, the tumour was found to be tough and vascular with a well-defined capsule. No recurrence was noted 19 months after the operation. In another case a 44-year-old woman was admitted with 1-month history of headaches, poor memory, imbalance and diplopia. CT scan showed a large hyperdense, uniformly, enhancing mass within the middle cranial fossa at the petrous ridge. The tumour recurred 19 and 25 months after first resection. The histology of both tumours was similar. The neoplasms contained polygonal cells with a moderate amount of cytoplasm, rounded regular nuclei and distinct cell borders. The cells were arranged radially around the blood vessels (perivascular pattern) and a papillary pattern was seen only focally. Mitotic figures were moderately frequent. Immunohistochemistry showed that both tumours were immunoreactive to vimentin and NSE, whereas GFAP, CAM5.2, EMA, S100 protein and synaptophysin were negative. Electron microscopy revealed interdigitating cell processes, desmosomes and intermediate filaments.

CONCLUSIONS

The histological and immunohistochemical features of these two tumours are complex and difficult to interpret. Although papillary meningiomas were considered in our initial differential diagnosis, the final conclusion was possible only when the ultrastructural features were revealed.

Spontaneous peritumoral haemorrhage associated with sinus confluence meningioma: case report

BACKGROUND

Torcular or sinus confluence meningioma is rare and surgically formidable. This reported sinus confluence meningioma was associated with peritumoral intracerebral hemorrhage. The surgical strategy and the mechanism of peritumoral hemorrhage are discussed.

CASE DESCRIPTION

A 42-year-old woman presented with a history of headache, vomiting, and cerebellar dysfunction for 2 months. Plain computed tomography (CT) scan and magnetic resonance imaging (MRI) demonstrated a high-density mass in the torcular region involving both lateral sinuses. MR angiography demonstrated complete occlusion of the left lateral sinus and straight sinus and stenosis of the right lateral sinus. Two years after her first operation she experienced sudden headache and left upper quadrant hemianopsia. Plain CT scan and MRI showed a hyperintense tumor in the torcular region with an intracerebral hematoma in the right occipital lobe. An angiogram demonstrated occlusion of the caudal part of the superior sagittal sinus, bilateral transverse sinuses, and straight sinus. Gross total removal of the tumor was done along with the left lateral sinus through a suboccipital and a supratentorial occipital craniotomy in the first operation. The patient underwent total resection of the tumor at second operation through a bilateral occipital and suboccipital craniotomy along with resection of the dura including the confluence, the caudal part of the superior sagittal sinus, the right lateral sinus, and the straight sinus. The postoperative course was uneventful and postoperative MRI showed total removal of the tumor.

CONCLUSION

Sinus confluence meningioma may present with peritumoral hemorrhage. Radical removal may be possible when the sinus confluence is completely occluded and there is good collateral drainage.

Tentorial venous sinuses: an anatomic study

OBJECTIVE

Certain neurosurgical procedures require sectioning of the tentorium cerebelli. The presence of venous sinuses within the tentorium makes these procedures difficult. The aim of this study was to investigate the incidence, size, location, configuration, and pattern of venous drainage of these sinuses.

METHODS

The tentorium cerebelli was studied in 80 fresh cadavers. After the skull cap and the supratentorial portion of the brain were removed, the tentorium was inspected for the presence of venous sinuses. Their location, size, configuration, and pattern of venous drainage were noted. Subsequently, the infratentorial structures were removed via the tentorial incisura. The tentorial sinuses were again studied. In certain cases, the sinus was opened and a probe passed inside to confirm its presence.

RESULTS

The tentorium cerebelli was revealed to contain sinuses in 86% of the cadavers. These sinuses were classified into the following three types: Type I sinuses constituted 25% of the total and were most often located in the medial one-third of the tentorium. They were larger than the other types, frequently occurring with a branching "stag-horn" configuration and a tendency to drain into the straight sinus, the torcular herophili, and the medial one-third of the transverse sinus. Type II sinuses constituted 25% of the total and were most often located in the lateral one-third of the tentorium. They were smaller than the other types, and tended to drain into the duction of the transverse sinus and superior petrosal sinus and into the lateral one-third of the transverse sinus. Type III sinuses constituted 50% of the total and were located in the medial one-third of the tentorium. Their size ranged from small to medium. Unlike Type I sinuses, no branching pattern was observed. These sinuses tended to drain into the straight sinus, the torcular herophili, and the medial one-third of the transverse sinus. In the present study, the medial one-third of the tentorium was observed to be the most vascular part. No venous sinus was observed in the anterior part of the tentorium.

CONCLUSION

Venous sinuses are common in the tentorium cerebelli. In this study, they were observed in 86% of the cases. They can be classified into three types, based on their location, size, configuration, and pattern of drainage. The medial one-third of the tentorium is the most vascular part. A knowledge of these sinuses may be helpful while sectioning the tentorium. The importance of these sinuses in treating vascular and neoplastic diseases of the brain is highlighted. A brief review of the embryology of these sinuses is also presented.

Total resection of torcular herophili hemangiopericytoma with radial artery graft: case report

A case of recurrent hemangiopericytoma involving the torcular herophili is reported, with special reference to the reconstruction of the straight sinus with a radial artery graft. In preoperative investigations, the tumor was found invading the straight and transverse sinuses. The involved occipital superior sagittal sinus had been removed in the previous surgery. A collateral bypass was observed from the superior sagittal sinus to the straight sinus, and the veins of Rosenthal were not opacified, suggesting poor venous drainage from the deep venous system to the cavernous sinus. We considered it necessary to reconstruct the straight and right transverse sinuses to achieve total removal of the tumor. The affected sinuses were removed and were successfully reconstructed with a radial artery interposition graft between the straight and right transverse sinus. The postoperative course was good, and the bypass was patent on the postoperative angiogram. The details of the operative technique are described.

Primary papillary meningioma of the optic nerve sheath: a case of unique location and benign pathology

I report here a case of primary papillary meningioma of the optic nerve sheath which developed in the left eye of a 54-year-old woman over a period of 20 years. A review of 123 primary papillary meningiomas, including the current instance, disclosed that they tended to occur in young patients of both sexes at an average age of 35 years, with one-fourth of them occurring in the first two decades of life, and with a female/male ratio of 3:2. These meningiomas were most frequent in the supratentorial compartment of the cranial cavity, especially on the cerebral convexity and in the parasagittal region. They were uncommon subtentorially, intraspinally, and outside the central nervous system. Most reported papillary meningiomas were claimed to be malignant, but the tumor of this particular woman was benign pathologically and clinically.