Bilateral sphenoorbital hyperostotic meningiomas with proptosis and visual impairment: A therapeutic challenge. Report of three patients and review of the literature

Staged Resection of Difficult-to-Treat Intracranial Meningiomas: A Systematic Review of the Indications, Surgical Approaches, and Postoperative Outcomes

Introduction  Meningiomas-the most common extra-axial tumors-are benign, slow-growing dural-based lesions that can involve multiple cranial fossae and can progress insidiously for years until coming to clinical attention secondary to compression of adjacent neurovascular structures. For complex, multicompartmental lesions, multistaged surgeries have been increasingly shown to enhance maximal safe resection while minimizing adverse sequela. Here, we systematically review the extant literature to highlight the merits of staged resection. Methods  PubMed, Scopus, and Web of Science databases were queried to identify articles reporting resections of intracranial meningiomas using a multistaged approach, and articles were screened for possible inclusion in a systematic process performed by two authors. Results  Of 118 identified studies, 36 describing 169 patients (mean age 42.6 ± 21.3 years) met inclusion/exclusion criteria. Petroclival lesions comprised 57% of cases, with the most common indications for a multistaged approach being large size, close approximation of critical neurovascular structures, minimization of brain retraction, identification and ligation of deep vessels feeding the tumor, and resection of residual tumor found on postoperative imaging. Most second-stage surgeries occurred within 3 months of the index surgery. Few complications were reported and multistaged resections appeared to be well tolerated overall. Conclusions  Current literature suggests multistaged approaches for meningioma resection are well-tolerated. However, there is insufficient comparative evidence to draw definitive conclusions about its advantages over an unstaged approach. There are similarly insufficient data to generate an evidence-based decision-making framework for when a staged approach should be employed. This highlights the need for collaborative efforts among skull base surgeons to establish an evidentiary to support the use of staged approaches and to outline those indications that merit such an approach.

Surgical Treatment of Spheno-Orbital Meningiomas: A Systematic Review and Meta-Analysis of Surgical Techniques and Outcomes

BACKGROUND

Spheno-orbital meningiomas (SOMs) are rare tumors arising from the meninges surrounding the sphenoid bone and orbital structures. Surgical resection is the primary treatment approach for SOMs. Several surgical approaches have been described during the decades, including microsurgical transcranial (MTAs), endoscopic endonasal (EEAs), endoscopic transorbital (ETOAs), and combined approaches, and the choice of surgical approach remains a topic of debate.

PURPOSE

This systematic review and meta-analysis aim to compare the clinical and surgical outcomes of different surgical approaches used for the treatment of SOMs, discussing surgical techniques, outcomes, and factors influencing surgical decision making.

METHODS

A comprehensive literature review of the databases PubMed, Ovid MEDLINE, and Ovid EMBASE was conducted for articles published on the role of surgery for the treatment of SOMs until 2023. The systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. Meta-analysis was performed to estimate pooled event rates and assess heterogeneity. Fixed- and random-effects were used to assess 95% confidential intervals (CIs) of presenting symptoms, outcomes, and complications.

RESULTS

A total of 59 studies comprising 1903 patients were included in the systematic review and meta-analysis. Gross total resection (GTR) rates ranged from 23.5% for ETOAs to 59.8% for MTAs. Overall recurrence rate after surgery was 20.7%. Progression-free survival (PFS) rates at 5 and 10 years were 75.5% and 49.1%, respectively. Visual acuity and proptosis improvement rates were 57.5% and 79.3%, respectively. Postoperative cranial nerve (CN) focal deficits were observed in 20.6% of cases. The overall cerebro-spinal fluid (CSF) leak rate was 3.9%, and other complications occurred in 13.9% of cases. MTAs showed the highest GTR rates (59.8%, 95%CI = 49.5-70.2%; p = 0.001) but were associated with increased CN deficits (21.0%, 95%CI = 14.5-27.6%). ETOAs had the lowest GTR rates (23.5%, 95%CI = 0.0-52.5%; p = 0.001), while combined ETOA and EEA had the highest CSF leak rates (20.3%, 95%CI = 0.0-46.7%; p = 0.551). ETOAs were associated with better proptosis improvement (79.4%, 95%CI = 57.3-100%; p = 0.002), while anatomical class I lesions were associated with better visual acuity (71.5%, 95%CI = 63.7-79.4; p = 0.003) and proptosis (60.1%, 95%CI = 38.0-82.2; p = 0.001) recovery. No significant differences were found in PFS rates between surgical approaches.

CONCLUSION

Surgical treatment of SOMs aims to preserve visual function and improve proptosis. Different surgical approaches offer varying rates of GTR, complications, and functional outcomes. A multidisciplinary approach involving a skull base team is crucial for optimizing patient outcomes.

Patient-specific implants for reconstruction of orbit and skull following resection of spheno-orbital meningiomas: A two-implant concept

INTRODUCTION

The surgical treatment of spheno-orbital meningioma (SOM) is challenging. In addition to anatomical constraints that lead to a difficult resection, the reconstruction of the resulting defect is demanding. Uniform recommendations concerning the best reconstruction technique are not available in the existing literature. We propose a novel two-piece concept for reconstructing post-ablative defects using patient-specific implants.

MATERIAL AND METHODS

Between 2018 and 2021, seven patients underwent SOM resection using two digitally planned patient-specific implants for orbit and skull reconstruction. To analyze the accuracy of the reconstruction, preoperative plans were merged with postoperative data sets. The clinical outcome was evaluated by comparing the pre- and postoperative exophthalmos index (EI).

RESULTS

In all cases, adequate reconstruction and a satisfactory match between the final implant position and preoperative planning were achieved. The EI was reduced in all cases from a mean of 1.27 to 1.09 (p = 0.003).

CONCLUSIONS

The proposed concept of a two-piece reconstruction after SOM resection is an excellent way to manage the concern around post-ablative defects. The current technical conditions allow for a precise, safe, and predictable reconstruction.

Spheno-Orbital Meningioma and Vision Impairment-Case Report and Review of the Literature

(1) Background: Spheno-orbital meningioma (SOM) is a very rare subtype of meningioma which arises from the sphenoid ridge with an orbital extension. It exhibits intraosseous tumor growth with hyperostosis and a widespread soft-tissue growth at the dura. The intra-orbital invasion results in painless proptosis and slowly progressing visual impairment. (2) Methods: We present a case of a 46-year-old woman with SOM and compressive optic nerve neuropathy related to it. Her corrected distance visual acuity (CDVA) was decreased to 20/100, she had extensive visual field (VF) scotoma, dyschromatopsia, impaired pattern-reversal visual-evoked potential (PVEP), and decreased thicknesses of the retinal nerve fiber layer (RNFL) and ganglion cell complex (GCC), measured with the swept-source optical coherence tomography (SS-OCT), and a pale optic nerve disc in her left eye. Brain CT and MRI showed a lesion at the base of the anterior cranial fossa, involving the sphenoid wing and orbit. Pterional craniotomy and a partial removal of the tumor at the base of the skull and in the left orbit with the resection of the lesional dura mater and bony defect reconstruction were performed. (3) Results: The histological examination revealed meningothelial meningioma (WHO G1). Decreased CDVA and VF defects completely recovered, and the color vision score and PVEP improved following the surgery, but RNFL and GCC remained impaired. No tumor recurrence was observed at a follow-up of 78 months. (4) Conclusions: Optic nerve dysfunction has the capacity to improve once the compression has been relieved despite the presence of the structural features of optic nerve atrophy.

Surgical Treatment of Recurrent Spheno-Orbital Meningioma

OBJECTIVE

The extensive bone infiltration and carpet-like growth characteristics of spheno-orbital meningioma (SOM) make it hard to remove entirely, and recurrence and proptosis are the main reasons for reoperation. The authors report 20 cases of surgical treatment for recurrence of SOM, including surgical technique and symptom improvement.

METHODS

The clinical data and follow-up results of 20 cases of recurrent SOM at our institution from 2000 to 2017 were retrospectively analyzed.

RESULTS

All of the 20 patients with recurrence had received at least one operation before admission, with a mean age of 56 years and 70% female. The mean follow-up time was 36 months (1-72 months). All patients mainly showed symptoms such as proptosis and headache, and were found to be affected by supraorbital fissure during the operation. In 17 patients with recurrence, the affected sphenoid wing became tumor-like hyperplasia. Patients with extraocular muscle involvement have obvious protrusion and are often accompanied by diplopia. After surgical removal of the tumor, the symptoms of proptosis in 19 patients were significantly improved. During the follow-up, only 3 cases of proptosis recurred. After 15 patients underwent Simpson grade IV resection, 4 patients (27%) relapsed again. Five patients underwent Simpson III resection, and only 1 patient (20%) had tumor recurrence 18th months after surgery, and no proptosis recurred.

CONCLUSIONS

The complete surgical removal of recurrent SOM is practically impossible. The main direction of surgical treatment should be to improve the symptoms of proptosis.

Transorbital Endoscopic Surgery for Sphenoid Wing Meningioma: Long-Term Outcomes and Surgical Technique

Sphenoid wing meningiomas are benign tumors that can result in proptosis, visual impairment, and pain. Traditional open surgical approaches are associated with significant morbidity. Transorbital endoscopic surgery has been developed as a minimally invasive approach to gain access to these tumors and address the main presenting symptoms. Case series reporting transorbital endoscopic resection of sphenoid wing meningiomas using combined endonasal, pre-caruncular, and extended superior eyelid approaches have demonstrated stable and/or improved short- and medium-term visual outcomes. Earlier medial optic nerve decompression appears to result in more favorable long-term visual outcomes. Transorbital endoscopic surgery therefore represents an emerging minimally invasive alternative to deal with these challenging lesions.

Challenging the osseous component of sphenoorbital meningiomas

BACKGROUND

Intraosseous growth is a unique feature of sphenoorbital meningiomas (SOM). Its close relation to neurovascular structures limits complete surgical resection and possibly contributes to the high recurrence rate.

OBJECTIVE

To evaluate the growth behavior of intraosseous remnants and develop a protocol for precise intraoperative visualization of intraosseous SOM.

METHODS

We included 31 patients operated for SOM from 2004 to 2017. The growth velocity of the intraosseous tumor component was volumetrically calculated in 20 cases. To improve accuracy of image guidance, we implemented a specialized bone surface-based registration algorithm. For intraoperative bone visualization, we included CT in multimodality continuous image guidance in 23 patients. The extent of resection (EOR) was compared with a standard MR-only navigation group (n = 8).

RESULTS

In 11/20 cases (55%), a progressive regrowth of the intraosseous SOM remnant was noted during a mean follow-up of 52 months (range 20-132 months). We observed a mean increase of 6.2 cm3 (range 0.2-23.7 cm3) per patient and side during the follow-up period. Bone surface-based registration was significantly more accurate than skin surface-based registration (mean 0.7 ± 0.4 mm and 1.9 ± 0.7 mm, p < 0.001). The EOR of the intraosseous component was significantly higher using CT + MRI navigation compared with controls (96% vs. 81%, p = 0.044).

CONCLUSION

Quantitative assessment of the biological behavior of intraosseous remnants revealed a continuous slow growth rate independent of the soft tumor component of more than half of SOM. According to our data, application of a multimodal image guidance provided high accuracy and significantly increased the resection rate of the intraosseous component of SOM.

Spheno-Orbital Meningiomas: A 16-Year Surgical Experience

OBJECTIVE

To examine the efficacy of spheno-orbital meningioma (SOM) resection aimed at symptomatic improvement, rather than gross total resection, followed by radiation therapy for recurrence.

METHODS

A retrospective review of all patients having undergone resection between 2000 and 2016 was performed. Demographics, operative details, postoperative outcomes, recurrence rates, and radiation treatment plans were analyzed. Statistical analysis was performed to assess for factors affecting recurrence (Fisher exact and Student t test), changes in exophthalmos index (EI) (Student t test), and progression-free survival (Kaplan-Meier and log rank).

RESULTS

Twenty-five patients were included; 92% of participants were women. Mean age was 51 years. World Health Organization grades were I (n = 21) and II (n = 4). Simpson grades were I (n = 14), II (n = 3), and IV (n = 8). Mean follow-up time was 44.8 months. Proptosis was significantly improved at the 3- to 6-month postoperative visit (mean ΔEI, 0.15; P < 0.05) and at last follow-up (mean ΔEI, 0.13; P < 0.05). Visual acuity was either improved or stable in 18 of 19 patients. There were 12 recurrences; mean time to recurrence was 21.8 months. Increased recurrence rate was significantly associated with younger age. Eight patients received fractionated radiation at time of recurrence. To date, all treated patients are progression free.

CONCLUSIONS

Among this cohort, surgery provided a lasting improvement in proptosis and improved or stabilized visual deficits. Surgery followed by radiation at recurrence provided excellent tumor control and lends credence to the growing body of literature demonstrating effective control of subtotally resected skull base meningiomas.

Petroclival meningiomas: Magnetic resonance imaging factors predict tumor resectability and clinical outcome

OBJECTIVE

Despite advances in skull base surgery, surgical removal of petroclival meningiomas (PCM) still poses a considerable neurosurgical challenge with regard to postoperative morbidity and the patients' long-term outcome. Knowledge of imaging features for PCM that might help to predict common risk factors encountered with tumor resection preoperatively is limited. The aim of this study was to clarify whether MRI features of PCM might predict tumor resectability and clinical outcome.

METHODS

A retrospective analysis of 18 cases of PCM treated surgically in our department between 2007 and 2013 was performed. Following radiological tumor features were compared to the extent of tumor resection and the patients' outcome: a) tumor diameter, b) calcification, c) tumor margin towards the brainstem, d) presence of an arachnoidal cleavage plane, e) brainstem edema, f) brainstem compression and g) tumor signal intensity on T2WI.

RESULTS

There was an excellent correlation between tumor resectability and preoperative findings with regard to the presence or absence of an arachnoidal cleavage plane and an irregular tumor margin towards the brainstem. Additionally, the presence of brainstem edema was significantly related to surgical morbidity, whereas a high tumor intensity on T2WI correlated significantly with soft tumor consistency and/or vascularity encountered during surgery.

CONCLUSION

As demonstrated in our series, PCM with an irregular tumor margin and absence of an arachnoidal plane towards the brainstem should be considered a high-risk group. In these cases, especially when additional brainstem edema is present, limited resection of tumor may be aspired to avoid postoperative morbidity.