Outcome of Tumor-Associated Proptosis in Patients With Spheno-Orbital Meningioma: Single-Center Experience and Systematic Review of the Literature

Reconstruction of orbital walls after resection of cranioorbital meningiomas: a systematic review and meta-analysis of individual patient data

Following meningioma removal, there are numerous methods available for reconstructing the orbital wall. This systematic review seeks to summarize the published data on the surgical treatment of cranioorbital meningiomas, and to analyze the effectiveness and safety of various techniques and materials used for the reconstruction of bony orbital walls. We conducted a search of the two databases and included original articles with a series of 10 or more cases. Descriptive statistics and meta-analysis of individual patient date were performed. The analysis included a total of 858 patients from 29 sources. No reconstruction of the orbital walls was performed in 525 patients (61.2%), while 333 observations (38.8%) involved resection followed by reconstruction. A relative improvement in eye position was achieved in 94.4% of cases with a 95% CI of (88.92%; 97.25%). However, normalization of eye position, regardless of reconstruction technique, was only present in 6.22% of cases with a 95% CI of (1.24%; 25.9%). The best results were observed with the use of autologous bone implants (64%, 95% CI [33.35%; 86.33%]) and titanium implants (55.78%, 95% CI [2.86%; 98.18%]). In cases of endoscopic resection and microsurgical resection without reconstruction, symmetrical eye position accounted for only 1.94% (95% CI [0%; 96.71%]) and 2.35% (95% CI [0.13%; 31.23%]), respectively. The frequency of normalization of eye position differed significantly (p < 0.01) among the subgroups. A total of 49 postoperative complications were registered, with wound infection (1.52%, 95% CI [0.86%; 2.65%]) and wound cerebrospinal fluid leak (1.32%, 95% CI [0.6%; 2.91%]) being the most frequent. No significant differences were found in the rates of complications among the different subgroups. One of the primary objectives of cranioorbital meningioma surgery is to correct the position of the eye. Simultaneous reconstruction of the bony orbital leads to better cosmetic outcomes. Postoperative complications did not depend on the reconstructive technique or the materials.

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.

Correspondence of Meningioma Orbital Grading and Clinicopathological Features among Indonesian Patients

BACKGROUND: Orbital meningiomas can cause visual disturbances, protrusion of the eyes, double vision, and optic nerve abnormalities that significantly decrease vision and eventually lead to blindness. To the best of our knowledge, data on the incidence and pathogenesis of orbital meningioma in Indonesia are non-existent. AIM: This study aimed to analyze the clinicopathological relationship with orbital meningioma grading. METHODS: It is a cross-sectional observational analysis on 44 orbital meningioma patients in Dr. Hasan Sadikin General Hospital and the National Eye Center, Cicendo Eye Hospital in 2017–2020. Chi-square analysis and logistic regression with statistical significance (p < 0.05) were engaged in the method. RESULTS: Orbital meningioma mostly occurred in women aged 30–44 years. Meningioma Grade I was dominated by meningothelial meningioma found in 14 (31.8%) patients, Grade II was atypical meningioma in 9 (20.9%) patients, and Grade III was anaplastic meningioma in 3 patients (6.8%). Clinical symptoms in the form of papillary atrophy (p = 0.046), visual acuity (p = 0.026), proptosis (p = 0.029), and hyperostosis (p = 0.024) were statistically significant and there was a significant difference between Grade I, Grade II, and Grade III using the Chi-square test. Logistic regression results showed that hyperostosis is significantly related to grading the orbital meningioma (p = 0.044) with an odds ratio of 0.206 (IK95% 0.04–0.955). CONCLUSION: Hyperostosis increases the grading of the orbital meningioma because it is related to the invasion of the tumor into the orbital bone and is a neoplastic process. The presence of hyperostosis which is more common in Grade III meningiomas can be used as one of the most important predictors of meningioma recurrence postoperatively. Nonetheless, our data add to the existing literature the potential points of anti-invasive adjuvant therapy attacks.

Fronto-Temporo-Orbito-Zygomatic Approach with Orbital Reconstruction in Lesions causing Unilateral Non-pulsating Proptosis

Background Unilateral non-pulsating proptosis can be caused by lesions with intraorbital extensions compressing the globe including sphenoid wing en plaque meningiomas and paranasal sinuses lesions.

Patients and Methods We operated on 20 patients with unilateral non-pulsating proptosis using fronto-temporo-orbito-zygomatic (FTOZ) approach with orbital reconstruction in six patients. Eighteen patients had sphenoid wing en plaque meningioma, 1 patient had paranasal sinuses fungal infection with intraorbital and intracranial extension, and 1 patient had frontal sinus dermoid with intraorbital extension.

Results Proptosis was corrected in 50% of the patients, improved in 25%, and remained stationary in 25%. Vision improved in three patients, remained stationary in three, and deteriorated in one patient. Two patients had temporary oculomotor ophthalmoplegia that resolved within 3 months.

Conclusion Although it is an invasive approach, FTOZ gives excellent exposure of the orbit and anterolateral skull base that allows the excision of intracranial lesions with orbital extension. If needed, the orbit could be reconstructed easily due to excellent exposure.

Surgical Management of Pre-Chiasmatic Intraorbital Optic Nerve Gliomas in Children after Loss of Visual Function—Resection from Bulbus to Chiasm

Optic pathway gliomas in children carry significant morbidity and therapeutic challenges. For the subgroup of pre-chiasmatic gliomas, intraorbital and intradural resection is a curative option after blindness. We present a two-center cohort using different surgical approaches. A retrospective analysis was performed, including 10 children. Mean age at surgery was 6.8 years. Interval between diagnosis and surgery was 1–74 (mean 24 ± 5.5, median 10) months. Indications for surgery were exophthalmos, pain, tumor progression, or a combination. Eight patients underwent an extradural trans-orbital-roof approach to resect the intra-orbital tumor, including the optic canal part plus intradural pre-chiasmatic resection. Gross total resection was achieved in 7/8, and none had a recurrence. One residual behind the bulbus showed progression, treated by chemotherapy. In two patients, a combined supra-orbital mini-craniotomy plus orbital frame osteotomy was used for intraorbital tumor resection + intradural pre-chiasmatic dissection. In these two patients, remnants of the optic nerve within the optic canal remained stable. No patient had a chiasmatic functional affection nor permanent oculomotor deficits. In selected patients, a surgical resection from bulb to chiasm ± removal of optic canal tumor was safe without long-term sequela and with an excellent cosmetic result. Surgery normalizes exophthalmos and provides an effective tumor control.

Tailored Anterior Clinoidectomy: Beyond the Intradural and Extradural Concepts

Anterior clinoidectomy (AC) is a key microsurgical step for the safe and successful management of parasellar pathologies that involve the anterior clinoid process (ACP) and the optic canal. Traditionally, extra and intradural ACs are performed separately according to the surgeon's experience or preference. The objective is to present and discuss the tailored AC concept through illustrative cases. We conducted a retrospective record review of three patients who underwent AC as a surgical step for the treatment of parasellar pathologies that involve the ACP and optic canal. A review of the relevant literature on AC was performed in the PubMed, LILACS, and SciELO databases.

In all three cases, the pterional craniotomy was the preferred approach for AC. Case 1, a 47-year-old female patient with type III anterior clinoidal meningioma, underwent a tailored intradural technique (optic canal unroofing) with total tumor resection and complete visual recovery. Case 2, a 63-year-old female patient with a complex type II anterior clinoidal meningioma with extensive hyperostosis of the ACP, underwent a hybrid AC technique with complete removal of the tumor and visual improvement. Case 3, a 62-year-old female, underwent a tailored intradural AC for clipping an incidental carotid-ophthalmic aneurysm.

Tailored AC aims to provide adequate exposure with less risk of neurovascular injury, allowing enough space to safely treat parasellar lesions. The type, size, and location of the lesion, as well as the surgeon’s experience, should always be considered for surgical planning.