Management of Planum/Olfactory Meningiomas: Predicting Symptoms and Postoperative Complications

Surgical Management and Outcome of the Planum Sphenoidale Meningioma: A Single-Center Strobe Compliant Study

BACKGROUND

The resection of the jugum (planum) sphenoidale meningioma (JSM) is challenging, and there is a scarcity of available data in the literature. This study aimed to describe the surgical management and long-term outcome of jugum sphenoidale meningioma.

METHODS

This was a retrospective, single-center, cohort study of 91 JSM patients treated in our department from 2005 to 2022. All the included patients have undergone surgical treatment. Clinical, radiologic, and surgical data were extracted with specific attention to the age at onset, family history, duration from symptoms to diagnosis, clinical presentation, quality of excision, recurrence, and treatment outcome.

RESULTS

WHO grade I and grade II meningioma were 83.5% (n = 76) and 16.5% (n = 15) respectively. Fronto-lateral 42.9% (n = 39) and pterional approaches 57.1% (n = 52) were the 2 major surgical approaches used for the management of planum sphenoidale meningioma. Twelve patients needed emergency surgical treatment at admission: 4 (4.4%) External CSF Shunt and 8 (8.8%) VP-Shunt. We have found a statistically significant (P = 0.032) association between the quality of excision and the risk of recurrence. The GTR (Hazard ratio = 1) of the planum meningioma protects the patient from recurrence within 60 months of follow-up. Postoperative complications encountered were CSF-Leak in 2.2%, Meningitis 4.4%, surgical site infection 2.2%, and surgical site hematoma 3.3%. The overall postoperative favorable outcome was 68.1% (n = 62).

CONCLUSIONS

The pterional approach has allowed the achievement of GTR for jugum sphenoidale meningioma with protective odds from recurrence risk.

Clinical tool for prognostication of discharge outcomes following craniotomy for meningioma

BACKGROUND

Patients' comorbidities might affect the immediate postoperative morbidity and discharge disposition after surgical resection of intracranial meningioma.

OBJECTIVE

To study the impact of comorbidities on outcomes and provide a web-based application to predict time to favorable discharge.

METHODS

A retrospective review of the prospectively collected national inpatient sample (NIS) database was conducted for the years 2009-2013. Time to favorable discharge was defined as hospital length of stay (LOS). A favorable discharge was defined as a discharge to home and a non-home discharge destination was defined as an unfavorable discharge. Cox proportional hazards model was built. Full model for time to discharge and separate reduced models were built.

RESULTS

Of 10,757 patients who underwent surgery for meningioma, 6554 (60%) had a favorable discharge. The median hospital LOS was 3 days (interquartile range [IQR] 2-5). In the full model, several clinical and socioeconomic factors were associated with a higher likelihood of unfavorable discharge. In the reduced model, 13 modifiable comorbidities were negatively associated with a favorable discharge except for drug abuse and obesity, which are not associated with discharge. Both models accurately predicted time to favorable discharge (c-index:0.68-0.71).

CONCLUSION

We developed a web application using robust prognostic model that accurately predicts time to favorable discharge after surgery for meningioma. Using this tool will allow physicians to calculate individual patient discharge probabilities based on their individual comorbidities and provide an opportunity to timely risk stratify and address some of the modifiable factors prior to surgery.

Surgical Morbidity in Relation to the Surgical Approach for Olfactory Groove Meningiomas-A Pooled Analysis of 1016 Patients and Proposal of a New Reporting System

Background: There is currently no consensus in the field regarding whether a frontal or lateral approach is superior for microsurgical resection of olfactory groove meningiomas (OGM). Due to the lack of uniformity in classifying lesions and inherent differences in reporting outcomes after varying operative approaches, the best practice for approaching these lesions is yet to be determined. Objective: This study aimed to assess various surgical approaches undertaken for OGMs, investigate procedural aspects influencing the extent of resection, and analyze the respective complication rate associated with each approach. We performed a comprehensive literature review of presenting signs and symptoms in OGM patients, their surgical management, and the reported surgical outcomes. To address the lack of uniform data reporting across studies and to take more recent translational studies into account, we developed a new classification system for OGMs that can remedy the existing deficiencies in comparability of reporting. Methods: We conducted a PRISMA-guided literature search for surgical reports on OGMs published in the MRI era using broad search terms such as 'olfactory groove meningioma' and 'surgery', which yielded 20,672 results. After title screening and removal of duplicates, we assessed 871 studies on the specific surgical management of olfactory groove meningiomas. Following the application of exclusion criteria and abstract screening, a set of 27 studies was chosen for the final analysis of a pooled cohort of these reported patient outcomes. Results: The final twenty-seven studies included in our in-depth analysis identified a total of 1016 individual patients who underwent open microsurgical resection of OGMs. The approaches used included: pterional/unilateral, bifrontal with variations, and anterior interhemispheric approaches. Across all studies, gross total resection (Simpson Grades I or II) was achieved in 91.4% of cases, and subtotal resection (Grades III and IV) was reported in 8.6% of cases. A cumulative twenty-seven percent of surgical OGM patients sustained some form of complications. Minor issues accounted for 22.2% (CSF leak, seizures, infection, transient cranial nerve palsies, hydrocephalus), whereas major issues comprised 4.7% (hemorrhage, ischemic infarct, malignant cerebral edema). We then examined the correlation between these complications and the surgical approach chosen. Among pooled cohort of 426 patients who underwent unilateral approaches, 14% experienced minor complications, and 2.1% experienced major complications. For the mixed cohort of 410 patients who underwent bifrontal approaches, 24.6% experienced minor complications, and 7% experienced major complications. Conclusions: Unilateral approaches appear to have lower complication rates for the resection of OGMs compared to bilateral approaches. However, the extent of resection is not uniformly reported, making it difficult to identify differences. The use of an improved preoperative classification and scoring system can help establish a more coherent system to select the most suitable approach and to uniformly report surgical outcomes, such as EOR and complication rates specific to a given OGM and its surgical approach.

The Surgical Risk Factors of Giant Intracranial Meningiomas: A Multi-Centric Retrospective Analysis of Large Case Serie

Giant intracranial meningiomas (GIMs) are a subgroup of meningiomas with huge dimensions with a maximum diameter of more than 5 cm. The mechanisms by which a meningioma can grow to be defined as a “giant” are unknown, and the biological, radiological profile and the different outcomes are poorly investigated. We performed a multi-centric retrospective study of a series of surgically treated patients suffering from intracranial meningioma. All the patients were assigned on the grounds of the preoperative imaging to giant and medium/large meningioma groups with a cut-off of 5 cm. We investigated whether the presence of large diameter and peritumoral brain edema (PBE) on radiological diagnosis indicates different mortality rates, grading, characteristics, and outcomes in a multi-variate analysis. We found a higher risk of developing complications for GIMs (29.9% versus 14.8%; p < 0.01). The direct proportional relationship between PBE volume and tumor volume was present only in the medium/large group (Pearson correlation with p < 0.01) and not in the GIM group (p = 0.47). In conclusion, GIMs have a higher risk of developing complications in the postoperative phase than medium/large meningioma without higher risk of mortality and recurrence.

Comparison of Three Surgical Approaches for Frontobasal Meningiomas: Purely Endoscopic Endonasal, Purely Microscopic Bifrontal Transcranial, and Combined Endoscopic and Microscopic Supraorbital Transciliary Approaches

ABSTRACT

Surgical removal of frontobasal meningiomas (FBMs) can be achieved using different techniques, including endoscopic, transcranial, and combined approaches. The advantages and disadvantages of the outcomes of these approaches should be compared to provide the most convenient surgical treatment to the patient. This study aimed to compare 3 surgical approaches for FBMsin terms of outcomes and determine the superiority of each on the basis of anatomical, surgical, and clinical efficacy. Systematic review was performed to identify studies comparing techniques for the surgical removal of FBMs. Each group included 13 patients; 39 patients with FBMshad undergone surgery. These groups were endoscopic endonasal approach (EEA), microscopic bifrontal transcranial approach (MTA), and endoscopic plus microscopic combined supraorbital transciliary approach (STA) groups. Data on the demographics of patient population, pre- and post-operative neurological examination, tumor properties, imaging studies, and surgical complications were extracted. The mean age at the time of surgery for the patient population was 53.2 years. Among the groups, no statistically significant differences were observed with regard to sex (P = 0.582). The mean follow-up time was 56.7 months. A statistically significant difference was observed in the mean tumor volume among the groups; the MTA group showed the highest mean tumor volume. However, no significant difference was found in the mean tumor volume between EEA and STA groups. Regarding operation duration, the STA group had the shortest operation time (mean = 281.5 minutes), whereas the average surgical duration in MTA group was the longest (mean = 443.8 minutes). The average bleeding volume was highest in the MTA group (mean = 746.2 ml) and lowest in the EEA group (mean = 320.8 ml). Tumor removal was incomplete in three patients (two in the EEA group and one in the MTA group). Recurrence was detected in two cases. One patient with recurrence was operated using the endoscopic surgical approach, whereas the other patient underwent the microscopic bifrontal approach. Post-operative hyposmia/anosmia or decreased olfactory function was the most common complication observed in 5 patients, 2 patients each in the EEA and MTA groups and one in the STA group. The second most common complication was wound infection in one patient in the MTA group and two patients in the STA group (7.7%). Both cerebrospinal fluid (CSF) leakage and meningitis were present in two patients (5.1%), one patient each from the EEA and STA groups. Pre-operative visual disturbances were reported in 13 patients (33.3%), all of which resolved post-operatively No statistical differences were found among the groups. Mortality occurred in a patient in the MTA group (2.6%) caused by cardiac arrest on post-operative day 1. This is the first study comparing the surgical outcomes of three surgical approaches for FBMs. Although recent literature suggests that both endoscopic and transcranial approaches have their own advantages and disadvantages, the authors showed that none of the surgical approaches have obvious superiority over the others with regard to outcomes. Thus, the selection of the ideal surgical approach should be based on surgical experience and tumor characteristics.

Endoscopic endonasal approaches for the management of skull base meningiomas: selection criteria and clinical outcomes

BACKGROUND

Meningiomas are the most common primary intracranial tumor, arising from different locations, including the skull base. Despite advances in adjuvant treatments, surgical resection remains the main and best treatment for meningiomas. New surgical strategies, such as the endoscopic endonasal approach, have greatly contributed in achieving maximum and total safe resection, preserving the patient's neurological function.

METHODS

Based on the senior authors large experience and a review of the current literature, we have compiled this paper.

RESULTS

We review the surgical technique used at our institution and the most relevant aspects of patient selection when considering resecting a skull base meningioma using the the EEA. Further consideration is given to some skull base meningiomas arising from specific locations with some case examples.

CONCLUSIONS

The EEA is not an ideal approach for every skull base meningioma. Careful evaluation of the neurovascular structures surrounding the tumor is imperative to select the appropriate surgical corridor for a safe resection. Nevertheless, for appropriately selected cases, the endoscopic technique is a very valuable tool with some evidences of being superior to the microscopic transcranial approach. A dual-trained surgeon, in both endoscopic and transcranial approaches, is the best alternative to achieve the best patient outcome.

Phantosmia and Dysgeusia following Endoscopic Transcribriform Approaches to Olfactory Groove Meningiomas

The endoscopic, endonasal transcribriform approach (EETA) is an important technique used to directly access the anterior skull base and is increasingly being used in the management of olfactory groove meningiomas (OGMs). As this approach requires removal of the cribriform plate and olfactory epithelium en route to the tumor, patients are anosmic postoperatively. Here, we report the development of phantosmia and dysgeusia in two patients who underwent EETAs for OGMs, which has not yet been reported in the literature. We hypothesize that phantosmia and dysgeusia may result from aberrant neuronal signals or misinterpretation centrally from the remaining distal portions of the olfactory and taste pathways. Since EETAs are newer than traditional open craniotomy-based techniques, reporting these outcomes will be important to appropriately counsel patients preoperatively.

Predictors of Acute Vertebrobasilar Vasospasm following Tumor Resection in the Foramen Magnum Region

Objective

Cerebral vasospasm can occur after skull base tumor removal. Few studies concentrated on the posterior circulation vasospasm after tumor resection in the posterior fossa. We aimed to identify the risk factors associated with postoperative vertebrobasilar vasospasm after tumor resection in the foramen magnum.

Methods

We retrospectively reviewed the data of 62 patients with tumors in the foramen magnum at our institution from January 2010 to January 2015. The demographic data, tumor features, surgical characteristics were collected. Vertebrobasilar vasospasm was evaluated by bedside transcranial Doppler before surgery and on postoperative day 1, 3, 7. Univariate and multivariate analyses were performed to determine the predictors of postoperative vasospasm in the posterior circulation.

Results

Vertebrobasilar vasospasm was detected in 28 (53.8%) of the 62 patients at a mean time of 3.5 days after surgery. There were 5 (8%) patients with severe vasospasm according to the grading criteria. Age, tumor type, tumor size, vertebral artery encasement, and surgical time were significantly related to vasospasm in the univariate analysis. Further multivariate analysis demonstrated that only age and vertebral artery encasement were independent risk factors predicting the occurrence of postoperative vertebrobasilar vasospasm.

Conclusions

The incidence of acute vertebrobasilar vasospasm is not uncommon after foramen magnum tumor resection. Age and vertebral artery encasement are significantly correlated with postoperative vasospasm. Close monitoring of vasospasm should be given to patients with younger age and the presence of vertebral artery encasement on the preoperative imaging to facilitate early diagnosis and intervention.

Endoscopic Endonasal Approach for Olfactory Groove Meningiomas: Operative Technique and Nuances

Olfactory groove meningiomas represent approximately 10% of all intracranial meningiomas. Because these tumors originate at the ventral skull base, the endonasal route provides direct access to the tumor blood supply for early devascularization and removal of the underlying hyperostotic bone at the cranial base. In carefully selected patients, these tumors can be totally removed without additional brain retraction or manipulation. In this report, we describe the surgical technique and operative nuances for removal of olfactory groove meningiomas using the endoscopic endonasal approach, and also discuss the indications, limitations, complication avoidance and management, and postoperative care.