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A single centre’s experience of managing spheno-orbital meningiomas: lessons for recurrent tumour surgery

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Background Spheno-orbital meningiomas are complex tumours involving the sphenoid wing and orbit. Various surgical strategies are available but treatment remains challenging and patients often require more than one surgical procedure. This study evaluated whether smaller surgical approaches and newer reconstructive methods impacted the surgical and clinical outcomes of patients undergoing repeat surgery. Methods We retrospectively analysed the medical records of consecutive patients who underwent surgery for a spheno-orbital meningioma at a single tertiary centre between 2005 and 2016. We recorded procedural details and analysed complications, postoperative visual status and patient-reported cosmetic outcome. Results Thirty-four procedures were performed in 31 patients (M:F 12:22, median age 49 years) including 19 (56%) primary operations and 15 (44%) repeat procedures. Seven patients (20.5%) had a pterional craniotomy, 19 (56%) had a standard orbitozygomatic craniotomy and 8 (23.5%) underwent a modified mini-orbitozygomatic craniotomy. Calvarial reconstruction was required in 19 cases with a variety of techniques used including titanium mesh (63%), PEEK (26%) and split calvarial bone graft (5%). Total tumour resection (Simpson grade I–II) was significantly higher in patients undergoing primary surgery compared with those having repeat surgery (41% and 0%, respectively; p = 0.0036). Complications occurred in 14 cases (41%). Proptosis improved in all patients and visual acuity improved or remained stable in 93% of patients. Cosmetic outcome measures were obtained for 18 patients (1 = very poor; 5 = excellent): 1–2, 0%; 3, 33%; 4, 28%; 5, 39%. Tumour recurrence requiring further surgery occurred in four patients (12%). There was no significant difference in clinical outcomes between patients undergoing primary or repeat surgery. Conclusion Spheno-orbital meningiomas are highly complex tumours. Surgical approaches should be tailored to the patient but good clinical and cosmetic outcomes may be achieved with a smaller craniotomy and custom-made implants, irrespective of whether the operation is the patient’s first procedure.
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ORIGINAL ARTICLE - TUMOR - MENINGIOMA
A single centres experience of managing spheno-orbital
meningiomas: lessons for recurrent tumour surgery
Jonathan Shapey
1
&J. Jung
1
&K. Barkas
1,2
&R. Gullan
1
&S. Barazi
1
&R. Bentley
3
&C. Huppa
3
&N. W. Thomas
1
Received: 21 March 2019 / Accepted: 5 June 2019
#Springer-Verlag GmbH Austria, part of Springer Nature 2019
Abstract
Background Spheno-orbital meningiomas are complex tumours involving the sphenoid wing and orbit. Various surgical strat-
egies are available but treatment remains challenging and patients often require more than one surgical procedure. This study
evaluated whether smaller surgical approaches and newer reconstructive methods impacted the surgical and clinical outcomes of
patients undergoing repeat surgery.
Methods We retrospectively analysed the medical records of consecutive patients who underwent surgery for a spheno-orbital
meningioma at a single tertiary centre between 2005 and 2016. We recorded procedural details and analysed complications,
postoperative visual status and patient-reported cosmetic outcome.
Results Thirty-four procedures were performed in 31 patients (M:F 12:22, median age 49 years) including 19 (56%) primary
operations and 15 (44%) repeat procedures. Seven patients (20.5%) had a pterional craniotomy, 19 (56%) had a standard
orbitozygomatic craniotomy and 8 (23.5%) underwent a modified mini-orbitozygomatic craniotomy. Calvarial reconstruction
was required in 19 cases with a variety of techniques used including titanium mesh (63%), PEEK (26%) and split calvarial bone
graft (5%). Total tumour resection (Simpson grade III) was significantly higher in patients undergoing primary surgery com-
pared with those having repeat surgery (41% and 0%, respectively; p= 0.0036). Complications occurred in 14 cases (41%).
Proptosis improved in all patients and visual acuity improved or remained stable in 93% of patients. Cosmetic outcome measures
were obtained for 18 patients (1 = very poor; 5 = excellent): 12, 0%; 3, 33%; 4, 28%; 5, 39%. Tumour recurrence requiring
further surgery occurred in four patients (12%). There was no significant difference in clinical outcomes between patients
undergoing primary or repeat surgery.
Conclusion Spheno-orbital meningiomas are highly complex tumours. Surgical approaches should be tailored to the patient but
good clinical and cosmetic outcomes may be achieved with a smaller craniotomy and custom-made implants, irrespective of
whether the operation is the patients first procedure.
Keywords Meningioma .Spheno-orbital meningioma .Orbitozygomatic craniotomy .Visual outcome .Cosmetic outcome
Introduction
Spheno-orbital meningiomas arise from the greater sphenoid
wing with infiltrative tumour growth into the orbital bone.
Reactive hyperostosis may also occur in the greater or lesser
sphenoid wing, destroying the orbital wall and roof, implicat-
ing the middle cranial fossa, the optic canal and the clinoid
process. As a result, patients typically present with visual
symptoms and/or unilateral proptosis as a result of compres-
sion from the tumour or growth [14].
Due to the extensive tumour infiltration and bony destruc-
tion associated with these tumours, considerable drilling of the
skull base is often required to accomplish entire resection of the
tumour [5] and surgical reconstruction of the orbit may become
This article is part of the Topical Collection on Tumor - Meningioma
*Jonathan Shapey
jshapey@doctors.org.uk
1
Department of Neurosurgery, Kings College Hospital, London SE5
9RS, UK
2
Department of Neurosurgery, Hellenic Red Cross Hospital,
Athens, Greece
3
Department of Oral and Maxillofacial Surgery, KingsCollege
Hospital, London, UK
Acta Neurochirurgica
https://doi.org/10.1007/s00701-019-03977-3
necessary in order to protect the intracranial contents and re-
establish an aesthetic craniofacial silhouette [68]. Different
surgical and reconstructive strategies have been advocated for
patients with spheno-orbital meningioma [9,10] however there
is a paucity of high-quality studies to guide decision-making in
patients undergoing repeat surgery. Previous studies have often
excluded recurrent tumours making it difficult to determine best
practice in this difficult subgroup of patients, and this study
aims to address this knowledge gap.
During the studys period, the surgical management of
patients with spheno-orbital meningioma at our institution
evolved in line with surgical trends. In this study, we
assessed the surgical, visual and cosmetic outcomes of pa-
tients treated at a single tertiary neurosurgical centre over an
11-year period in order to determine the main factor whether
smaller surgical approaches using newer reconstructive
methods impacted the surgical and clinical outcomes of pa-
tients undergoing repeat surgery.
Methods
We retrospectively analysed the medical records of consecu-
tive patients who underwent surgery for a spheno-orbital me-
ningioma at Kings College Hospital, London, between
January 2005 and August 2016. All patients with a diagnosis
of a medial sphenoid wing meningioma or spheno-orbital me-
ningioma were identified from the hospitals operative data-
base and cross-referenced with data from the hospitalsclini-
cal coding department and pathology database. Patients with a
purely lateral sphenoid wing meningioma, not involving the
orbital structures, were excluded from the study.
The following data were collected for each patient: demo-
graphic features, presenting symptoms, previous surgical and
oncological treatments, preoperative radiological characteris-
tics of the tumour (incorporation of major vessels and cavern-
ous sinus involvement), WHO tumour grade, procedural de-
tails (including involvement of maxillofacial surgeons, inci-
sion type, craniotomy type, need for clinoidectomy, orbital
reconstruction and/or eye exenteration, Simpson grade
and type of cranioplasty [if applicable]), complications, sub-
sequent oncological treatments, visual and cosmetic out-
comes. Proptosis, visual acuity and diplopia were stratified
as improved, unchanged or reduced. Cosmetic outcome was
assessed by evaluating the patients postoperative imaging and
by collecting patient-reported outcome measures (PROM) via
telephone follow up using a five-point visual analogue scale to
assess their satisfaction with their postoperative appearance
(1 = very poor, 2 = poor, 3 = neutral, 4 = good, 5 = excellent).
Appropriate non-parametric statistical analyses (Fishersexact
test and Mann-Whitney Utest) were performed using the
GraphPad Prism software.
Results
Thirty-four procedures were performed in 31 patients during
the study period (M:F 12:22, median age 49 years [interquar-
tile range (IQR) 4458 years]) with surgery having previously
been undertaken in 15 cases (Table 1). Twenty-two patients
(71.0%) presented with visual symptoms, 13 of whom had no
other symptoms. Typical visual symptoms included loss of
visual acuity, proptosis and diplopia. Other associated symp-
toms included seizures, headaches, trigeminal pain, confusion
and incidental radiological growth. Radiological investiga-
tions demonstrated major arterial vessels either closely ad-
hered to, or incorporated within, 13 tumours, and 9 tumours
were associated with cavernous sinus involvement.
Twenty-four cases (70.6%) were performed jointly with the
units oral maxillofacial surgeons (OMFS), including 11 pri-
mary cases (57.9%) and 13 recurrent procedures (86.7%). A
pterional craniotomy was performed in 7 operations, a stan-
dard orbitozygomatic craniotomy (S-OZ) was performed in
19 cases and 8 patients underwent a modified mini-
orbitozygomatic craniotomy (MM-OZ) (Table 2,Fig.1).
With the exception of one patient, all pterional craniotomies
were performed using a standard unilateral curvilinear skin
incision whereas 78.9% of patients who underwent a S-OZ
craniotomy had a bicoronal skin incision, compared with
37.5% of patients undergoing a MM-OZ craniotomy. A tradi-
tional one-piece craniotomy was performed in all pterional
cases, in 53% of S-OZ and 62.5% of MM-OZ cases. A
clinoidectomy, orbital reconstruction and/or eye exenteration
was only performed when using either the S-OZ or MM-OZ
approach (Table 2). The following Simpson resection grades
were achieved in patients undergoing primary surgery: grade
I, 4 patients (21.1%); grade II, 4 patients (21.1%); grade III, 7
patients (36.8%); grade IV, 3 patients (15.8%); unknown, 1
patient (5.3%), whereas in patients having repeat surgery (n=
15), 14 patients (93.3%) had a Simpson grade III resection and
1 patient (6.7%) had a grade IV resection (Table 2). Total
tumour resection (Simpson III) was significantly higher in
patients undergoing primary surgery (p= 0.0036) but there
was no statistical difference in the degree of achieved tumour
resection in relation to the type of surgical approach (Table 3).
Final histological analysis confirmed WHO I tumours in 23
cases with WHO II atypical meningiomas confirmed in the
remaining 11 cases (Table 2).
No calvarial reconstruction was required following any
pterional craniotomy. In S-OZ cases, a single split calvarial
bone graft was used in one case (5.3%), titanium mesh was
used for calvarial reconstruction in 10 cases (52.6%), and a
customised PEEK cranioplasty implant used in 3 patients
(15.8%). No cranioplasty was required in 5 patients (26.3%)
who had a S-OZ craniotomy. In cases where a MM-OZ ap-
proach was used, 3 cases (37.5%) did not require cranioplasty,
2 patients (25%) had a titanium mesh cranioplasty, and 3
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patients (37.5%) had a PEEK customised implant (Table 3).
The first PEEK implant was used in 2014, following which it
became the reconstructive method of choice constituting 86%
of all implants used in the series in subsequent years (Fig. 2).
The choice of calvarial reconstruction was not influenced by
whether or not the patient had undergone previous surgery.
Surgical timings were available for 31 patients and were
measured from the start of anaesthetic induction. The median
length of surgery (including anaesthetic time) was 6 h, 45 min
(IQR 5 h, 57 min; 7 h 40 min) and was significantly shorter in
primary cases. The median duration of primary surgery was
6 h, 23 min (IQR 5 h, 38 min; 7 h, 7 min) compared with 7 h,
33 min (IQR 6 h, 29 min; 8 h, 4 min) when operating on
recurrent tumours (p= 0.0375). There was also a trend to-
wards shorter operations if no cranioplasty was required (me-
dian length of surgery, 6 h, 17 min [IQR 4 h, 56 min; 6 h,
35 min]) without the need for a cranioplasty compared with
6 h, 54 min (IQR 6 h, 18 min; 7 h, 46 min) with a cranioplasty
Table 1 Patient demographics,
presenting symptoms and tumour
features
Patient demographics n(%)
Patients 31
Procedures 34
Previous surgery 15
Sex M:F 12:22
Median age 49 years (IQR 4458 years)
Symptoms
Visual symptoms 22 (71.0)
Exclusively visual symptoms 13 (41.9)
Visual loss 13
Proptosis 13
Diplopia 6
Seizure 7 (34.0)
Headache 6 (19.4)
Trigeminal pain 3 (9.7)
Confusion/somnolence 3 (9.7)
Radiological growth (otherwise asymptomatic) 5 (16.1)
Radiological appearance
Major arterial vessel adhered to, or incorporated within, the tumour 13 (41.9)
Cavernous sinus involvement 9 (29.0)
Table 2 Surgical and
pathological details Primary surgery
n=19 (%)
Repeat surgery
n=15 (%)
Total
n=34 (%)
Surgical approach
Pterional craniotomy 6 (31.6) 1 (6.7) 7 (20.6)
Standard orbitozygomatic craniotomy 8 (42.1) 11 (73.3) 19 (55.9)
Modified mini-orbitozygomatic craniotomy 5 (26.3) 3 (20.0) 8 (23.5)
Simpson resection grade
I 4 (21.1)* 0* 4 (11.8)
II 4 (21.1)* 0* 4 (11.8)
III 7 (36.8) 14 (93.3) 21(61.8)
IV 3 (15.8) 1 (6.7) 4 (11.8)
Unknown 1 (5.3) 0 1 (2.9)
Histology
WHO grade I 14 (73.7) 9 (60.0) 23 (67.6)
WHO grade II 5 (26.3) 6 (40.0) 11 (32.4)
WHO grade III 0 0
*Significant difference in gross total resection (Simpson III) between primary and repeat surgery cases (p=
0.0036)
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(p= 0.13). The type of cranioplasty used did not significantly
alter the length of surgery.
Overall, surgical complications occurred in 14 cases
(41.2%) including one perioperative death (mortality rate of
3%) (Table 4). The single mortality occurred in a 61-year-old
gentleman who underwent primary surgery. A Simpson III
resection was achieved and his initial postoperative recovery
was uncomplicated. He remained mildly confused postopera-
tively so was transferred back to his local hospital to continue
his rehabilitation but suffered a fatal cardiac arrest 10 days
after surgery. There was no significant difference in the com-
plication rates between patients undergoing primary surgery
and repeat surgery (47.4% and 33.3%, respectively; p=
0.4953) or between the different surgical approaches
employed. In total, five patients (14.7%) suffered complica-
tions necessitating surgical intervention. Following
cranioplasty, there were no documented cases of pulsatile
enophthalmos but two patients developed visual deterioration
and a new cranial nerve palsy (6%). Three patients developed
a postoperative haematoma, including two cranioplasty cases,
with one cranioplasty and one non-cranioplasty patient requir-
ing the surgical evacuation of the haematoma.
Follow up data was available for 30 patients with a
median length of follow up 52 months (range 1 to
120 months) (Table 5). Four patients (11.8%) underwent
radiotherapy following their surgery and four patients
(11.8%) required further surgical treatment.
Postoperative visual outcomes were available in 28 pa-
tients (Table 5). Visual acuity improved in seven patients
(54%) who presented with visual loss and remained un-
changed in the other six patients. For those patients with
postoperative follow up data, vision improved or
remained unchanged in 92.9% and there was no signifi-
cant difference in visual outcome between patients having
primary or repeat surgery (Table 5). Three patients pre-
senting with diplopia experienced an improvement in their
symptoms (50%), and of the 13 patients with proptosis,
seven (53.5%) had complete resolution of their symptoms
and further 5 patients (38.5%) demonstrated an improve-
ment in the degree of proptosis (outcome for one patient
unknown). Two patients with normal visual acuity preop-
eratively deteriorated following the surgery and two other
patients experienced new diplopia, although one patient
had continued signs of improvement at the time of their
last follow up. Patient-reported cosmetic outcomes were
obtained in 18 patients. Good cosmetic results (score 3 to
5) were achieved in all cases with 66.7% of patients rating
their postoperative cosmetic appearance as good (27.8%)
or excellent (38.9%) (Table 5). Patient-reported cosmetic
outcome scores were not higher in patients undergoing
repeat surgery, and the type of cranioplasty used did not
affect the outcome.
Fig. 1 Line drawings illustrating the three approaches used in this series.
aPterional craniotomy. Principal burr hole is placed at the anatomical
keyhole (1), a depression at the junction of the superior orbital ridge,
zygomatic bone and superior temporal line; (2) standard pterional crani-
otomy; (3) superior temporal line; (4, dashed line) the anatomical pterion
defined as the junction of the frontal, parietal, temporal and sphenoid
bones. bStandard orbitozygomatic (S-OZ) craniotomy. First, a standard
pterional craniotomy (a) is performed. Following this, an orbitozygomatic
osteotomy is performed sequentially as numbered: (i) base of the zygo-
matic arch (1) extending to the lateral (2) and medial (3) zygoma; (ii) from
the orbital roof (4), lateral to supraorbital notch extending
inferoposteriorly to the superior orbital fissure; (iii) a final osteotomy
connecting the inferior and superior orbital fissures (5 and 6). c
Modified mini-orbitozygomatic (MM-OZ) craniotomy. A burr hole is
placed near the anatomical keyhole and a craniotomy is fashioned as
illustrated, incorporating an orbital cut through the superolateral part of
the orbit. As described by Lemole et al., this technique may be further
modified to a supraorbital or subtemporal approach depending on the
location of the meningioma
Acta Neurochir
Discussion
Surgical approach and calvarial reconstruction
Spheno-orbital meningiomas are complex and challenging tu-
mours that require careful preoperative planning and benefit
from a multidisciplinary approach involving neurosurgeons,
ophthalmologists, neuro-oncologists and oral and maxillofa-
cial surgeons. The orbitozygomatic (OZ) craniotomy remains
one of the most widely used and versatile approaches to the
skull base [11], and is typically the chosen approach for
spheno-orbital meningiomas. Compared with a pterional
craniotomy, a standard orbitozygomatic craniotomy (S-OZ)
increases exposure through the additional removal of the zy-
gomatic arch and orbital rim [12,13], and may be performed
as a one-piece [14,15] or two-piece craniotomy (Fig. 1)[16].
The perceived advantage of the two-piece technique is that it
produces a better view of the frontal lobes basal portions and
it may reduce the risk of enophthalmos and cosmetic defects
[17]. However, if complete resection of the zygoma is unlikely
to significantly improve the exposure of the target tumour, a
one-piece S-OZ may be successfully used to approach a
spheno-orbital meningioma. During the course of this study,
our approach to these tumours evolved and we now routinely
Table 3 Surgical details and clinical outcomes according to the surgical approach
Pterional craniotomy n= 7 Standard orbitozygomatic
craniotomy (S-OZ) n=19
Modified mini-orbitozygomatic
craniotomy (MM-OZ) n=8
Primary
surgery
n= 6 (%)
Repeat
surgery
n=1(%)
Tot a l
n=7(%)
Primary
surgery
n=8(%)
Repeat
surgery
n=11 (%)
Tot al
n=19 (%)
Primary
surgery
n= 5 (%)
Repeat
surgery
n= 3 (%)
Total
n= 8 (%)
Surgical details
Bicoronal incision 1 (16.7) 1 (100) 1 (14.3) 7 (87.5) 8 (72.7) 15 (78.9) 1 (20.0) 2 (66.7) 3 (37.5)
Craniotomy
One-piece 6 (100) 1 (100) 7 (100) 5 (62.5) 5 (45.5) 10 (52.6) 4 (80.0) 1 (33,3) 5 (62.5)
Two-piece 3 (37.5) 6 (54.5) 9 (47.4) 1 (20.0) 2 (66.7) 3 (37.5)
Clinoidectomy 2 (25.0) 1 (9.1) 3 (15.8) 1 (12.5)
Orbital reconstruction 6 (75.0) 6 (54.5) 12 (63.2) 1 (20.0) 3 (100) 4 (50.0)
Eye exenteration 3 (27.3) 3 (15.8)
Calvarial reconstruction
None 6 (100) 1 (100) 7 (100) 1 (12.5) 3 (27.3) 5 (26.3) 3 (60.0) 3 (37.5)
Split calvarial 1 (9.1) 1 (5.3)
Titanium mesh 5 (62.5) 5 (45.5) 10 (52.6) 1 (20.0) 1 (33.3) 2 (25.0)
PEEK 2 (25.0) 1 (9.1) 3 (15.8) 1 (20.0) 2 (66.7) 3 (37.5)
Simpson tumour resection grade
I 1 (12.5) 1 (5.3) 3 (60.0) 3 (37.5)
II 1 (16.7) 1 (14.3) 2 (25.0) 2 (10.5) 1 (20.0) 1 (12.5)
III 2 (33.3) 1 (100) 3 (42.9) 4 (50.0) 10 (90.9) 14 (73.7) 1 (20.0) 3 (100) 4 (50.0)
IV 3 (50.0) 3 (42.9) 1 (9.1) 1 (5.3)
Unknown 1 (12.5) 1 (5.3)
Visual outcome (visual acuity)
Improved 2 (25.0) 3 (27.3) 5 (26.3) 1 (20.0) 1 (33.3) 2 (25.0)
Unchanged 3 (50.0) 3 (42.9) 6 (75.0) 6 (54.5) 12 (63.2) 3 (60.0) 1 (33.3) 4 (50.0)
Reduced 1 (16.7) 1 (100) 2 (28.6)
Unknown 2 (33.3) 2 (28.6) 2 (18.2) 2 (10.5) 1 (20.0) 1 (33.3) 2 (25.0)
Cosmetic outcome
Very poor
Poor
Neutral 1 (16.7) 1 (14.3) 2 (25.0) 1 (9.1) 3 (15.8) 2 (66.7) 2 (25.0)
Good 2 (25.0) 1 (9.1) 3 (15.8) 1 (20.0) 1 (33.3) 2 (25.0)
Excellent 1 (16.7) 1 (14.3) 1 (12.5) 3 (27.3) 4 (21.1) 2 (40.0) 2 (25.0)
No outcome data 4 (66.7) 1 (100) 5 (71.4) 3 (37.5) 6 (54.5) 9 (47.4) 2 (40.0) 2 (25.0)
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Fig. 2 Left spheno-orbital me-
ningioma. abPreoperative
contrast-enhanced T1-weighted
MRI. Note the extensive tumour
present in the infratemporal fossa
(a) and the significant proptosis
(b); cdIntraoperative pictures.
Standard OZ performed through a
bicoronal incision; cexposure
prior to craniotomy; dcustom-
made PEEK cranioplasty secured
in place with temporalis sutured
to flap; efPostoperative
contrast-enhanced T1-weighted
MRI. Small residual en plaque
tumour seen in the middle fossa
dura but significant improvement
in proptosis achieved with a good
cosmetic result
Table 4 Perioperative
complications and morbidity Primary surgery
n=19 (%)
Repeat surgery
n=15 (%)
Total
n=34 (%)
Any complication 9 (47.4) 5 (33.3) 14 (41.2)
Complication type
Seizure 2 (10.5) 2 (13.3) 4 (11.8)
Haematoma 2 (10.5) 1 (6.7) 3 (8.8)
Requiring surgical evacuation 2 (10.5) 0 2 (5.9)
Oedema and raised ICP 2 (10.5) 0 2 (5.9)
Requiring surgical intervention 2 (10.5) 0 2 (5.9)
Infarct 2 (10.5) 1 (6.7) 3 (8.8)
CSF leak 2 (10.5) 0 2 (5.9)
Meningitis 1 (5.3) 2 (13.3) 3 (8.8)
New cranial nerve palsy 1 (5.3) 1 (6.7) 2 (5.9)
Death 1 (5.3) 0 1 (2.9)
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perform a one-piece modified mini-orbitozygomatic cranioto-
my (MM-OZ) as described by Lemole et al. through a unilat-
eral fronto-temporal skin incision [18]. By utilising a cutting
guide, an osteotomy can be taken through the body of the
zygoma and avoid the need for a zygomatic osteotomy. The
access is as good as the standard OZ approach and reduces the
operative time and a larger dissection.
There has been a considerable advancement in modern
cranioplasty techniques but calvarial reconstruction following
an orbitozygomatic craniotomy remains technically challeng-
ing. Successful cranioplasty aims to reconstruct the anatomy
of the skull and restore initial facial contours in order to
achieve a goodcosmetic result. Variousmaterials and methods
of cranioplasty have been described (Table 6)[19,20], and our
cranioplasty technique has also changed with experience. In
our series, all but one of the cases requiring primary
cranioplasty were performed using either a customised titani-
um mesh or polyetheretherketone (PEEK) implant.
Careful preoperative planning would identify the abnormal
bone using a CT scan obtained with a 0.625-mm slice thick-
ness. This enabled excellent visualisation, permitting us to
accurately estimate bone involvementtypically including
the calvarial and orbital roof regions. A 1-cm margin was then
used to design the implant which provides excellent access to
resect the affected dura. In cases where bony involvement was
more extensive than expected, further drilling was performed
but no additional cranioplasty was needed in any of the cases
as the infiltrated bone was usually at the sphenoid wing. If the
periorbital membrane was infiltrated with tumour then it was
resected and any frank infiltration tumour was removed.
Often, pedicled pericranial flaps were used over the deficient
dura, but we avoided the use of synthetic dural substitutes and
always reconstructed the orbital roof using a rigid material to
restore orbital volume and also to avoid hypoglobus.
Titanium lends itself to being an excellent graft material due
to its biocompatibility and its resistance to corrosion and me-
chanical forces [21]. We manufactured a customised graft be-
fore surgery using a preoperative CT scan, but titanium mesh
mayalternativelybemouldedintheatreduringsurgery.Newer
synthetic cranioplasty materials include hydroxyapatite, acrylic,
polymethylmethacrylate (PMMA) and polyetheretherketone
(PEEK) [19,20]. The main advantage of these synthetic mate-
rials is their radiolucency, partial elasticity and lack of heat
conductance, and the fact that they may be customised for each
individual patient using modern three-dimensional (3D) print-
ing technologies [19]. During the study period, our practice
Table 5 Clinical outcomes in patients undergoing primary and repeat surgery
Primary surgery n= 19 (%) Repeat surgery n=15(%) Totaln=34 (%)
Median length of follow up 40.5 months
(range 3120 months)
66.5 months
(range 1113 months)
52 months
(range 1120 months)
Tumour outcomes
Postoperative radiotherapy 1 (5.3) 3 (20.0) 4 (11.8)
Tumour recurrence requiring further surgery 2 (10.5) 2 (13.3) 4 (11.8)
Visual outcomes
Visual acuity (for all patients with available follow up data) n=16(%) n=12 (%) n=28(%)
Improved 3 (18.8) 4 (33.3) 7 (25.0)
Unchanged 12 (75.0) 7 (58.3) 19(67.9)
Reduced 1 (6.3) 1 (8.3) 2 (7.1)
Resolution of diplopia n= 4 (%) n=2(%) n=6(%)
Improved 2 (50.0) 1 (50.0) 3 (50.0)
Unchanged 1 (25.0) 0 1 (16.7)
Unknown 1 (25.0) 1 (50.0) 2 (33.3)
Resolution of proptosis n= 8 (%) n=5(%) n=13 (%)
Complete resolution 3 (37.5) 4 (80.0) 7 (53.8)
Improved 4 (50.0) 1 (20.0) 5 (38.5)
Unchanged 0 0 0
Unknown 1 (12.5) 0 1 (7.7)
Cosmetic outcome n=10 (%) n=8(%) n=18 (%)
Very poor 0 0 0
Poor 0 0 0
Neutral 3 (30.0) 3 (37.5) 6 (33.3)
Good 3 (30.0) 2 (25.0) 5 (27.8)
Excellent 4 (40.0) 3 (37.5) 7 (38.9)
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Table 6 Management of spheno-orbital meningiomasa summary of the literature. NA, not available; SCB, split calvarial bone; (P)MMA, (Poly)methyl methacrylate
Cases Simpson resection
III
Improved
vision
Improved
proptosis
CN
palsy
Morbidity
(mortality)
Cosmesis
(good)
Cranioplasty Material Adjuvant
therapy
Re-
growth
Follow
up
De Jesús and Toledo,
2001
6 83.3 50.0 100.0 NA NA NA NA NA 16.7 33.3 NA
Honeybul et al., 2001 15 40.0 NA 84.6 13.3 NA Mostly 100.0 NA NA NA NA
Sandalcioglu et al.,
2005
16 69.0 NA NA 12.5 25.0 NA 100.0 SCB 56.3 56.2 68.0
Bikmaz et al., 2007 17 82.3 70.0 100.0 5.9 29.0 NA 100.0 NA NA 7.1 36.0
Ringel et al., 2007 63 23.0 64.0 77.0 30.1 32.0 (3.2) NA NA PMMA NA 39.0 54.0
Mariniello et al., 2008 60 66.7 50.0 NA NA NA (3.3) NA NA NA 0.0 42.3 138.0
Cannon et al., 2009 12 66.7 16.6 50.0 16.7 16.6 NA 0.0 8.3 33.3 31.0
Franquet et al., 2009 23 69.6 NA 61.1 0.0 NA NA NA NA 13.0 NA NA
Shrivastava et al., 2005 25 70.0 87.0 96.0 8.0 16.0 NA 100.0 NA NA 8.0 5.0
Heufelder et al., 2009 21 33.3 76.0 94.4 23.8 4.7 85.0 100.0 SCB 9.5 39.0 65.6
Li et al., 2009 37 24.3 69.0 100.0 21.6 2.7 NA 16.2 NA NA 18.9 NA
Mirone et al., 2009 71 83.0 NA 87.0 4.2 NA NA 83.7 NA NA 5.0 76.8
Scarone et al., 2009 30 90.0 85.0 86.0 13.0 3.3 NA 0.0 NA 10.0 61.0
Civit et al., 2010 41 20.0 NA 87.0 9.0 10.4 NA 100.0 MMA NA NA NA
Honig et al., 2010 30 33.0 65.0 NA 0.0 63.1 NA 36.0 SCB 27.0 27.0 33.7
Oya et al., 2010 39 38.5 66.7 73.5 7.8 28.2 NA 0.0 NA 17.9 40.7
Schick 2010 77 54.5 30.8 78.8 3.0 26.0 Satisfied 5.2 SCB 11.7 12.9 57.9
Saeed et al., 2011 66 9.1 30.0 30.0 NA 16.6 NA NA SCB 22.7 17.0 102.0
Boari et al., 2013 40 56.0 66.7 92.5 5.0 17.5 NA 100.0 Titanium 45.0 10.0 72.6
Marcus et al., 2013 19 57.8 52.6 100.0 31.5 42.3 (5.3) NA 100.0 Titanium 10.5 10.5 60.0
Forster et al., 2014 18 72.2 NA 100.0 0.0 27.9 NA 72.2 Titanium NA 11.1 43.9
Talacchi et al., 2014 47 51.0 66.6 100.0 4.3 10.6 NA NA PMMA 10.6 29.7 52.0
Leroy et al., 2016 70 31.0 14.0 86.0 22.9 42.8 NA 100.0 Autograft 12.9 28.6 60.0
Terrier et al., 2016 130 40.0 44.5 32.5 16.1 17.6 49.6 62.0 Titanium 7.7 29.0 76.4
Freeman et al., 2017 25 68.0 16.0 86.4 8.0 24.0 NA 100.0 Titanium 32.0 48.0 44.8
Present study 34 24.0 54.0 85.0 6.5 41.2 (2.9) 66.7 55.9 SCB, Titanium,
PEEK
6.5 12.9 52.0
Acta Neurochir
evolved and it is now our preference to use custom-made PEEK
implants in patients undergoing surgery for spheno-orbital me-
ningioma because we believe this method provides better re-
sults including improved cosmetic outcome (Fig. 2).
All reconstructive methods and materials have their advan-
tages and disadvantages. The ability to restore with PEEK
allows for resection of the supraorbital bar and a more accurate
reconstruction. This affords excellent access from an anterior
approach to tumours affecting the superior orbital fissure and
optic foramen rather than from a more traditional lateral ap-
proach. The ability to reconstruct complex three-dimensional
defects with PEEK also gives reassurance that any size and
shape of the defect can be accurately restored. PEEK implants
are slightly more expensive than other materials but, in our
experience, PEEK cranioplasties handled better than titanium
mesh and could easily be drilled to provide additional fixation
points if required.
Tumour resection and recurrence
The surgical management of spheno-orbital meningiomas is
challenging because it is often very difficult to achieve a rad-
ical Simpson I resection due to the invasion of local structures
such as the cavernous sinus and surrounding dura.
Consequently, there is significant variation in the reported
Simpson resection grades achieved in spheno-orbital menin-
gioma surgery (Table 6)[14,2242]. Overall, in our series,
23.6% of patients had a Simpson grade I or II resection with a
Simpson grade III resection reported in the majority of pa-
tients (61.8%); however, total tumour resection (Simpson I
II) was significantly higher in patients undergoing primary
surgery (p= 0.0036). The choice of surgical approach did
not affect the degree of achieved surgical resection (Table 3).
The Simpson resection grade is based upon the surgeons
impression during surgery which is prone to inter-observer
variability and bias and may explain the comparatively higher
tumour recurrence rates in other series reporting a more radical
resection grade (Table 6)[30,34,38,42]. Nevertheless, it is
interesting to note that despite the lower resection grades
achieved in repeat surgeries, the rate of tumour recurrence
requiring further surgery in our study was comparatively low
(13.3%) and was not significantly different to that observed
following the primary surgery (10.5%). Furthermore, in com-
plex spheno-orbital meningiomas with cavernous sinus or or-
bital canal involvement, it is not always appropriate to aim for
an aggressive resection given the slow-growing nature of
these tumours and the potential morbidity attempting radical
resection could cause.
Complications
Like many other series, our results confirm that spheno-orbital
meningioma surgery is a high-risk procedure (Table 6).
Patients should therefore be counselled appropriately and time
should be taken to consider the aims of surgery with respect to
the patients age, symptoms and co-morbidities. We observed
an overall complication rate of 41% which, although high, is
similar to other published studies (Table 6)[29,31,33,37]. In
particular, several studies have highlighted the high risk of
developing a new cranial nerve palsy following surgery with
a reported complication rate of 331.5% [4,33,39,40]. In our
cohort, only two patients (5.9%) developed a new cranial
nerve palsy but other complications were more common
(Table 4). The choice of surgical approach and the presence
or absence of cranioplasty did not affect the complication rate,
and the complication rate was actually lower in patients un-
dergoing repeat surgery (not statistically significant).
Visual outcomes
Proptosis and visual loss are the most common clinical man-
ifestations of spheno-orbital meningiomas, but the degree of
visual improvement observed following surgery varies greatly
in the reported literature (Table 6)[1,2,4,23,24,33,36,42].
A wide variation in visual improvement has been recorded in
other studies (16.685%) [2,24,36,39], and it is likely that
the degree of the preoperative visual deficit has a significant
effect on postoperative recovery [36]. In our series, the degree
of proptosis improved in all patients and resolved completely
in a third of patients, diplopia improved in two-thirds of pa-
tients, and visual acuity improved (25.0%) or remained stable
(67.9%) in nearly all patients (Table 5). Most importantly, this
study demonstrated that recurrent tumour surgery was not
associated with worse clinical outcomes (Table 5)andthatin
selected patients, surgery via a minimal MM-OZ approach can
achieve comparable visual results (Table 3).
Choice of cranioplasty material and cosmetic
outcomes
Various materials may be used for cranial reconstruction
(Table 6), but there is no clear consensus if the choice of
material affects the patients final cosmetic result and evidence
relating to cosmetic outcome following repeat surgery is par-
ticularly scarce. In recent years, surgeons have preferred using
alloplastic materials for calvarial reconstruction. Earlier in our
series, we used mostly titanium mesh, either pre-fabricated
using the patients preoperative CTscan or moulded in theatre,
but over the last 5 years, we have favoured a customised
PEEK implant because we believed that this method provided
better cosmetic results (Fig. 2).
However, our results suggest that cosmetic outcomes are
not influenced by the choice of surgical approach or calvarial
reconstructive material (Table 3). Neither did repeat surgery
adversely affect the cosmetic outcome (Table 5). Two previ-
ous studies have attempted to assess cosmetic outcome in
Acta Neurochir
patients undergoing spheno-orbital meningioma surgery [4,
28], but no previous study has evaluated the cosmetic results
of PEEK cranioplasties in this patient population. Terrier et al.
and Heufelder et al. used general quality of life scores
(Glasgow Outcome Scale or SF36 questionnaire) to assess
reconstructive outcomes following surgery for spheno-
orbital meningiomas using the split calvarial bone graft and
titanium cranioplasties, respectively [4,28]. Our study is lim-
ited by small numbers but in 6 patients who received a PEEK
cranioplasty, 3 patients rated their cosmetic outcome as
good, 1 patients rated it excellent, and 2 patients were
neutral.
Limitations
This study is limited by the small number of patients however
spheno-orbital meningiomas are rare tumours, and this study
offers a practical illustration of neurosurgical practice at a
tertiary skull base centre. Despite its size, this study did con-
firm that repeat surgery is not associated with worse surgical,
visual or cosmetic outcomes. Analysis of cosmetic outcome
was also limited by the fact that several patients had moved
away from the area and, in the absence of up-to-date records, it
was not possible to trace these patients to conduct telephone
follow up. Nevertheless, our results suggest that, in selected
patients, surgery performed via a minimal MM-OZ approach
may offer comparable clinical outcomes but further work is
required to confirm which type of cranioplasty material offers
the best postoperative cosmetic outcome.
Conclusions
Spheno-orbital meningiomas are a highly complex and chal-
lenging entity that requires careful preoperative patient
counselling, multidisciplinary planning and long-term follow
up. Surgery is a high-risk procedure and thoughtful consider-
ation should be given to the aims of surgery in order to min-
imise morbidity. In our study, the predominant factor affecting
surgical and clinical outcomes was whether the patient was
undergoing primary or repeat surgery. The choice of surgical
approach and method of calvarial reconstruction did not affect
surgical or clinical outcomes. Surgical approaches to a
spheno-orbital meningioma should be tailored to the patient,
but we have demonstrated that good visual outcomes and
excellent cosmetic results may be achieved with a smaller
craniotomy and custom-made implants, irrespective of wheth-
er the operation is the patients first procedure.
Compliance with ethical standards
Conflict of interest The authors declare that they have no conflict of
interest.
Ethical approval All procedures performed were in accordance with the
ethical standards of the institutional research committee and with the
1964 Helsinki declaration and its later amendments or comparable ethical
standards.
Statement of informed consent This study was approved by the insti-
tutions research committee without the need for informed consent.
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Publishersnote Springer Nature remains neutral with regard to jurisdic-
tional claims in published maps and institutional affiliations.
Acta Neurochir
... been the most commonly used routes to reach this area. [5][6][7][8][9][10][11][12][13][14][15] In recent years, innovations in surgical techniques and implementation of new technologies have directed surgical treatment toward less invasiveness, with improvement of patients' outcome. 12,[16][17][18][19][20][21][22][23][24][25][26] Despite such advances, the best surgical corridor to approach the SOR is yet to be defined, with the intrinsic risk that each surgeon might perform only the surgical procedure he/she is more confident with. ...
... [5][6][7][8][9][10][11][12][13][14][15] In recent years, innovations in surgical techniques and implementation of new technologies have directed surgical treatment toward less invasiveness, with improvement of patients' outcome. 12,[16][17][18][19][20][21][22][23][24][25][26] Despite such advances, the best surgical corridor to approach the SOR is yet to be defined, with the intrinsic risk that each surgeon might perform only the surgical procedure he/she is more confident with. ...
... 7,[18][19][20]24,25,49 For many years, transcranial approaches (ie, SO, MPT, PT, and FTOZ) 6,7 have been considered the gold standard, and only in the past few years, endoscopic endonasal and transorbital approaches have been proposed for selected cases. 12,[18][19][20][22][23][24][25][26] Historically, MTAs were the first described approaches for treating SOR lesions. 6,7,11 As reported by others, the main limitation of MTAs is the exposure of the more medial anatomic structures of the SOR because of the hindrance of the temporal and frontal lobes. ...
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BACKGROUND The spheno-orbital region (SOR) is a complex anatomic area that can be accessed with different surgical approaches. OBJECTIVE To quantitatively compare, in a preclinical setting, microsurgical transcranial approaches (MTAs), endoscopic endonasal transpterygoid approach (EEA), and endoscopic transorbital approaches (ETOAs) to the SOR. METHODS These approaches were performed in 5 specimens: EEA, ETOAs (superior eyelid and inferolateral), anterolateral MTAs (supraorbital, minipterional, pterional, pterional-transzygomatic, and frontotemporal-orbitozygomatic), and lateral MTAs (subtemporal and subtemporal transzygomatic). All specimens underwent high-resolution computed tomography; an optic neuronavigation system with dedicated software was used to quantify working volume and exposed area for each approach. Mixed linear models with random intercepts were used for statistical analyses. RESULTS Anterolateral MTAs offer a direct route to the greater wings (GWs) and lesser wings (LWs); only they guarantee exposure of the anterior clinoid. Lateral MTAs provide access to a large area corresponding to the GW, up to the superior orbital fissure (SOF) anteriorly and the foramen rotundum medially. ETOAs also access the GW, close to the lateral portion of SOF, but with a different angle of view as compared to lateral MTAs. Access to deep and medial structures, such as the lamina papyracea and the medial SOF, is offered only by EEA, which exposes the LW and GW only to a limited extent. CONCLUSION This is the first study that offers a quantitative comparison of the most used approaches to SOR. A detailed knowledge of their advantages and limitations is paramount to choose the ideal one, or their combination, in the clinical setting.
... 5 Shapey dkk melaporkan sebanyak 38,5% pasien yang dioperasi mengalami perbaikan proptosis. 10 Young dkk melaporkan sebanyak 24% pasien dengan proptosisnya hilang dan 53% pasien mengalami perbaikan proptosis. 11 Di lain pihak, Pace dkk mengatakan 85% pasien mengalami perbaikan secara kosmetik. ...
... Tidak ada perbedaan yang bermakna antara visus pascaoperasi pertama dengan reoperasi. 10 Kompresi saraf optikus yang terjadi dalam jangka waktu yang lama mungkin juga menjadi penyebab rendahnya jumlah subjek dengan peningkatan visus. Lamanya gejala praoperasi mempunyai korelasi negatif dengan visus praoperasi dan semakin rendah perbaikan visus pada pasien dengan gejala lebih dari 6 bulan. ...
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Pendahuluan: Meningioma sphenoorbita (MSO) adalah massa tumor eksofitik yang menginfiltrasi tulang pada sphenoid ridge, dinding lateral orbita, atap orbita, dan meluas ke fisura orbita superior. Trias klasik dari klinis pasien adalah penonjolan bola mata (proptosis), penurunan ketajaman penglihatan (visus) dan oftalmoplegia. Hasil dari operasi pasien MSO belum pernah dievaluasi sebelumnya, terutama terhadap visus dan proptosis. Tujuan: Mengevaluasi karakteristik klinis pasien meningioma sphenoorbita sebelum dan sesudah operasi. Metode: Penelitian deskriptif dengan desain potong lintang. Subjek adalah pasien MSO yang datang ke Unit Rawat Jalan Bedah Saraf RSUPN Dr. Cipto Mangunkusumo (RSCM) dari Januari 2014 hingga Desember 2015. Semua pasien menjalani operasi kraniektomi, orbitotomi lateral dan reseksi tumor. Ketajaman visus dievaluasi dengan Snell chart dan indeks proptosis pasien dievaluasi sebelum dan sesudah operasi dengan mengukur mata yang proptosis pada CT scan aksial. Hasil: Terdapat 66 pasien yang dievaluasi dalam penelitian ini dan 65 pasien adalah perempuan. Rentang usia 31-64 tahun. Indeks proptosis rata-rata preoperasi adalah 18,27 dan pascaoperasi adalah 16,43. Pengurangan indeks proptosis rata-rata adalah 1,84. Visus pasien pascaoperasi mengalami perbaikan hanya pada 9,7% pasien. Diskusi: Pasien MSO yang dioperasi terdapat pengurangan indeks proptosis tetapi hanya sedikit perbaikan visus. Kata kunci: Indeks proptosis, meningioma sphenoorbita, visus
... 5 Shapey dkk melaporkan sebanyak 38,5% pasien yang dioperasi mengalami perbaikan proptosis. 10 Young dkk melaporkan sebanyak 24% pasien dengan proptosisnya hilang dan 53% pasien mengalami perbaikan proptosis. 11 Di lain pihak, Pace dkk mengatakan 85% pasien mengalami perbaikan secara kosmetik. ...
... Tidak ada perbedaan yang bermakna antara visus pascaoperasi pertama dengan reoperasi. 10 Kompresi saraf optikus yang terjadi dalam jangka waktu yang lama mungkin juga menjadi penyebab rendahnya jumlah subjek dengan peningkatan visus. Lamanya gejala praoperasi mempunyai korelasi negatif dengan visus praoperasi dan semakin rendah perbaikan visus pada pasien dengan gejala lebih dari 6 bulan. ...
... In the review of 23 studies of the literature that reports the median follow-up ( Table 7), we have chosen a cutoff of 60 months, a reliable period for evaluating recurrence. The median recurrence rate of 10 studies, including ours, with a median follow-up >60 months (29.25%) 6,13,14,19,23,24,27,28,33,40 was not significantly different from that of the other 14 studies with median followup 60 months (15.4%) 5,[15][16][17][18][20][21][22]25,26,[29][30][31][32] (P ¼ 0.4) (Figure 2). In the same review, we have studied the correlation of recurrence rate with both median follow-up and rate of patients with complete resection !70% (19 studies) ( Table 8). ...
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Full-text available
Background The extent of resection constitutes one of the most important predictive risk factors of recurrence for spheno-orbital meningiomas, with gross total resection representing the gold standard, nevertheless it is not always achievable, with consequent high recurrence rate. The purpose of management of these tumors is a surgical challenge and is represented by maximal safe resection with preservation of function.The aim of the present study is to discuss the risk factors for recurrence and the best management of the recurrent tumors. Methods Eighty patients operated on for spheno-orbital meningiomas were retrospectively reviewed. Two groups were identified: group 1, 30 patients (37.5%) who experienced recurrence and group 2, 50 patients with no recurrence from 5 to 28 years after the initial surgery. The analyzed factors in both groups include the involvement of the skull base structures, the extent of resection and WHO grade. In the recurrence group, the pattern of tumor regrowth, the entity of resection and the management were also analyzed. Results The invasion of the whole orbit, the involvement of orbital apex, superior orbital fissure, infratemporal fossa and sphenoidal-ethmoidal sinuses, and the WHO grade II are risk factors of recurrence. All 30 patients with recurrence underwent reoperation, nine of them had two or three reoperations. Overall, 70 among the 80 patients (88%) had tumor control and no progression after one or more reoperations. Conclusion We suggest the re-surgery for spheno-orbital meningioma recurrences to prevent a worsening of the visual function and the proptosis. Because of their slow natural course, even multiple reoperations may be performed, resulting in a long overall survivals with stable symptoms and good quality of life.
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Background Highly performed nowadays, the pterional craniotomy (PC) has several widespread variants. However, these procedures are associated with complications such as temporalis muscle atrophy, facial nerve frontal branch damage, and masticatory difficulties. The postoperative cranial aesthetic is, nonetheless, the main setback according to patients. This review aims to map different pterional approaches focusing on final aesthetics. Methods This review follows the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Studies were classified through the Oxford method. We searched PubMed/MEDLINE, EMBASE, and Cochrane Library from January 1969 to February 2021 for cohorts and randomized clinical trials that met our inclusion criteria. Results 1484 articles were initially retrieved from the databases. 1328 articles did not fit the inclusion criteria. 118 duplicates were found. 38 studies were found eligible for the established criteria. 27 (71.05%) were retrospective cohorts, with low evidence level. Only 5 (13.15%) clinical trials were found eligible to the criteria. The majority of the studies (36/38) had the 2B OXFORD evidence level. A limited number of studies addressed cosmetic outcomes and patient satisfaction. The temporal muscle atrophy or temporal hollowing seems to be the patient’s main complaint. Only 17 (44.73%) studies addressed patient satisfaction regarding the aesthetics, and only 10 (26.31%) of the studies reported the cosmetic outcome as a primary outcome. Nevertheless, minimally invasive approaches appear to overcome most cosmetic complaints and should be performed whenever possible. Conclusion There are several variants of the classic PC. The esthetic outcomes are poorly evaluated. The majority of the studies were low evidence articles.
... However, few reports investigated the efficacy of postoperative radiotherapy for SOMs. Most of the studies reported on small patient cohorts with SOM and postoperative radiotherapy without providing clear conclusions on the role of postoperative radiotherapy (4,17,19,20). Others recommended postoperative radiotherapy in the case of atypical/rapidly progressive tumors (12,13,16,21). ...
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Objective Spheno-orbital meningiomas (SOM) are rare intracranial tumors that arise at the sphenoid wing. These tumors can invade important neurovascular structures making radical resection difficult, while residual tumors often lead to recurrence. The purpose of this study was to evaluate prognostic factors influencing the recurrence and progression-free survival (PFS) rates of spheno-orbital meningiomas, with a particular focus on the role of surgery and postoperative radiotherapy. Methods Between 2000 and March 2020, 65 cases of spheno-orbital meningioma were included, of which 50 cases underwent surgical treatment alone, and 15 cases underwent resection and radiotherapy. A Kaplan-Meier analysis was performed to provide median point estimates and PFS rates; further, Cox regression analysis was used to identify significant factors associated with treatment. Results Gross total resection significantly reduced the risk of recurrence (p-value = 0.0062). There was no significant benefit for progression-free survival after postoperative radiotherapy (p-value = 0.42). Additionally, spheno-orbital meningiomas with an invasion of the cavernous sinus and intraconal invasion showed significantly worse PFS compared to other locations (p-value = 0.017). Conclusion The maximal safe resection remains the most important prognostic factor associated with lower recurrence rates and longer PFS in patients with spheno-orbital meningioma. The invasion of the cavernous sinus and intraconal invasion was an independent factor associated with worse PFS. Patients with postoperative high-precision radiotherapy did not show significantly better PFS due to the small number of patients.
... However, in the two patients with newly developed visual deficits due to postoperative tumor growth, reoperation was chosen in an attempt to decompress the optic system to improve the visual function of the patient. These percentages and treatment strategies for recurrent disease are in line with other case series [2,6,28,33]. Although our case series did not include any patients with a WHO grade II tumor, other authors advise upfront radiotherapy for these patients [6,29]. ...
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Abtract: BACKGROUND: Most spheno-orbital meningioma series span multiple decades, and predictors of visual outcomes have not yet been systemically assessed. We describe visual outcomes in a recent cohort and assess predictors of postoperative visual outcomes. Methods: Consecutive case series operated by a team of a neurosurgeon and orbital surgeon between May 2015 and January 2019. Best corrected visual acuity (BCVA), visual fields (static perimetry), and relative proptosis were measured preoperatively and postoperatively at 3/6/12 months after which it was assessed yearly. Predictors were assessed with linear regression analysis. Results: Nineteen patients (all WHO grade I) were operated by the pterional approach (median follow-up 2.4 years). Preoperative visual acuity deficits (n = 10) normalized in 70% and improved in 10% (median preoperative: 0.8, postoperative: 1.2, p = 0.021). Preoperative visual field deficits (n = 8) normalized in all patients (preoperative: - 6.5 dB, postoperative: - 1.5 dB, p = 0.008). Preoperative proptosis (n = 16) normalized in 44% and improved in 56% (preoperative: 5 mm, postoperative: 2 mm, p < 0.001). BCVA and visual fields remained stable at longer follow-up in 95% of patients, while 21% showed progression of proptosis. Predictors for worse longer-term (> 12 months) BCVA were worse preoperative BCVA (p = 0.002) and diagnosis of multiple meningioma (p = 0.021). Predictors for worse longer-term visual fields were higher diameter of hyperostosis (p = 0.009) and higher Simpson grade (p = 0.032). Predictor for short-term (3 months) proptosis was preoperative proptosis (p = 0.006). Conclusion: We recommend surgery, even of patients with minimal visual impairment or hyperostosis, as patients who present with deteriorated visual function or extensive hyperostosis are less likely to have postoperative visual outcomes restored to normal.
... In the literature review, we found 83 publications between 2010 and 2019, among which 24 series of spheno-orbital meningiomas, and we excluded 7 series because they lacked some relevant data [10][11][12][13][14][15][16]. Two teams published their series twice in this period [6,[17][18][19] and we excluded the smaller one in each case. ...
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Objective The great heterogeneity of meningiomas is challenging and we need to distinguish relevant subgroups. Spheno-orbital osteomeningiomas (SOOM) constitute a clinically specific entity, with slow-growing benign osteo-meningiomatous tumors, which recur after surgery in one fourth of cases. Neurosurgical daily practice, supported by the literature, shows that the vast majority of patients with SOOM are women, and we explored whether their epidemiological and hormonal profiles suggest a progesterone influence.Methods We retrospectively documented all radiologically and histologically confirmed cases of SOOM operated in 2005–2019 in our institution. We completed the clinical and hormone history by systematic telephone interviews.ResultsIn the literature, SOOM occur significantly more often in women than other meningiomas (749/847, 86.4% versus 73.8%, p = 0.002). Among 175 cases, we included 124 patients, 93.5% were women, younger than men (51 ± 5 versus 63 ± 8, p = 0.02). Women’ meningiomas showed more progesterone receptors (96.4% versus 50%, p < 0.001). Exogenous hormonal intake, reliable in 82 cases, concerned 83.3% (64/78) of women, with frequent progesterone intake: 13 oestroprogestogenic treatment only, with old-generation progesterone analogs, 41 progesterone analogs (cyproterone acetate, nomegestrol acetate, chlormadinone, promegestone, etonogestrel, levonogestrel), 7 substitutive hormonal therapy for menopause, 3 others. Duration of treatment was 2–40 years, median 10 years.ConclusionsSOOM develop preferentially in women in their fifties, who often received progesterone analogs, and show progesterone receptors. Progesterone analogs are incriminated in skull base meningiomas, and this is the first report on the prevalence of exogenous hormone therapy specifically in SOOM. Whether SOOM reduce after treatment discontinuation, in particular the osteoma part, needs to be explored. Anti-progesterone treatments may represent an avenue for future research in soom.
Article
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.
Article
Purpose Surgical resection is the mainstay of treatment for spheno-orbital meningiomas. The Sonopet® is an ultrasonic aspirator device that provides several advantages over the traditional standard suction techniques and bone drill, including decreased collateral soft tissue damage, more precise bone removal and a clearer operative field. The purpose of the study was to examine the treatment outcomes of Sonopet®-assisted resection of spheno-orbital meningiomas. Methods A retrospective chart review was conducted in seven patients with spheno-orbital meningioma in a single institution who underwent surgical resection with the Sonopet®. Pre-operative and post-operative data included the assessment of visual acuity, relative afferent pupillary defect (RAPD), Ishihara score, proptosis, fundus examination, computerised visual fields and the presence or absence of diplopia, headache, and other neuro-ophthalmic complications. Results Nine Sonopet®-assisted procedures were performed on seven patients. Post-operatively, 89% of cases had stabilization or improvement of visual acuity and colour vision, whilst 29% had improved visual fields with the remainder being stable. Proptosis improved in all patients. Five of nine cases (44%) had new post-operative cranial nerve palsies, of which 75% were transient. One patient had tumour recurrence after 14 months, requiring further tumour resection and radiotherapy. Conclusion Sonopet®-assisted resection of spheno-orbital meningiomas has comparable outcomes of visual improvement and complication rates to traditional resection techniques. Longer periods of post-operative observation and follow-up are recommended to observe long-term benefits.
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Cranioplasty remains a difficult procedure for all craniofacial surgeons, particularly when concerning the reconstruction of large lacunae in the skull. Considering the significant clinical and economic impact of the procedure, the search for materials and strategies to provide more comfortable and reliable surgical procedures is one of the most important challenges faced by modern craniofacial medicine.The purpose of this study was to compare the available data regarding the safety and clinical efficacy of materials and techniques currently used for the reconstruction of the skull. Accordingly, the scientific databases were searched for the following keywords autologous bone, biomaterials, cranial reconstruction, cranioplasty, hydroxyapatite, polyetheretherketone, polymethylmethacrylate, and titanium. This literature review emphasizes the benefits and weaknesses of each considered material commonly used for cranioplasty, especially in terms of infectious complications, fractures, and morphological outcomes.As regards the latter, this appears to be very similar among the different materials when custom three-dimensional modeling is used for implant development, suggesting that this criterion is strongly influenced by implant design. However, the overall infection rate can vary from 0% to 30%, apparently dependent on the type of material used, likely in virtue of the wide variation in their chemico-physical composition. Among the different materials used for cranioplasty implants, synthetics such as polyetheretherketone, polymethylmethacrylate, and titanium show a higher primary tear resistance, whereas hydroxyapatite and autologous bone display good biomimetic properties, although the latter has been ascribed a variable reabsorption rate of between 3% and 50%.In short, all cranioplasty procedures and materials have their advantages and disadvantages, and none of the currently available materials meet the criteria required for an ideal implant. Hence, the choice of cranioplasty materials is still essentially reliant on the surgeon's preference.
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Background Internal variation among spheno-orbital meningiomas (SOM) is surgically challenging. Optic canal invasion management is discussed. Method This retrospective study includes 70 patients with SOM who underwent surgery between 1995 and 2012. Preoperative ophthalmological, neurological and aesthetic clinical signs were collected. All patients benefitted from repeated tomography and magnetic resonance imaging (MRI). The surgical team consisted of a neurosurgeon and a plastic surgeon. In the majority of cases, resection was followed by bone reconstruction using an autologous iliac crest graft. The extent of resection was evaluated on the dural and osseous sides. Early clinical outcomes, long-term follow-up, recurrence and adjuvant therapies were reported. Results The mean age was 52 years old, and 91 % of the patients were women. Initial symptoms primarily included proptosis (65 %), decreased visual acuity (39 %) and soft tissue tumefaction (16 %). We classified 40 cases as the internal variety when considering the inner third of the greater wing of the sphenoid, optic canal, anterior clinoid process or cavernous sinus. The remaining cases were described as the external variety. The complete resection rates for the internal and external varieties were 12 % and 61 %, respectively (P < 0.001). In total, 90 % of cases were grade I meningiomas. For grade I, we reported 30 % recurrence, and 50 % of these cases recurred in the first 2 years. Grade II cases without early adjuvant radiotherapy increased at 2 years. We did not observe any difference in recurrence rate among grade I tumours with or without tumour remnants. At the end of follow-up, visual acuity was stabilised or increased in 88 % of patients. In addition, 14 % of patients experienced persistent pain at the location of the iliac harvesting site. Conclusions The internal SOM variety exhibited a reduced total resection rate and a shorter progression-free survival (PFS). Unroofing of the optic canal extended PFS. Among grade I cases, the persistence of a negligible tumour remnant did not alter the probability of recurrence. For superior grades, radiotherapy must be administered in addition to surgery as soon as possible. SOMs require prolonged follow-up. Autologous iliac reconstruction is related to substantial morbidity and could be replaced by prosthetic bone three-dimensional reconstruction.
Article
Advances in anesthetic and surgical techniques as well as the precision of modern imaging techniques have allowed the surgical treatment of tumors of the cranial base previously considered inoperable. The ensuing defects pose a challenge to the reconstructive surgeon. This article presents an overview of cranial base surgery including a review of the pathologic entities encountered, but with particular reference to current reconstructive techniques in this area.
Article
Objective: Cranioplasty (CP) can be either embedded or covered, according to the implants used. However, determining which one is better in treating cranial defects is difficult. This study aimed to compare the clinical outcomes and complications of embedded CP and covered CP. Methods: A multicenter retrospective study was carried out with patients who underwent CP with polyetheretherketone (PEEK) implants and titanium implants between January 2014 and March 2017. The medical records of these patients were reviewed retrospectively and statistically analyzed. Results: There were 185 patients, including 75 patients(40.5%)who underwent embedded CP with PEEK implants (PEEK group) and 110 patients (59.5%) who underwent covered CP using titanium mesh (titanium group), in this study. Compared to titanium group, the incidence of overall complications (P=0.03), postoperative new seizures (P=0.01), postoperative implant exposure (P=0.03) and reoperation (P=0.01) was significantly lower in PEEK group. The rate of brain function improvement (P=0.01) after CP and satisfaction with CP (P=0.01) in patients in PEEK group were higher than that in titanium group. Conclusions: Our results showed that embedded CP with PEEK had a distinct advantage in brain function improvement and fewer postoperative complications compared with covered CP with titanium mesh. However, the high cost of PEEK is an obvious drawback. This study may help both neurosurgeons and patients in choosing a better therapeutic method to achieve the most satisfactory outcome in treating cranial defects.
Article
Background: Spheno-orbital meningiomas (SOMs) are complex tumors involving the sphenoid wing, the orbit, and sometimes the cavernous sinus with bone hyperostosis and sheet-like dural involvement. Optimal removal, proptosis cure and visual preservation remain a challenge. Objective: To study the management of surgically treated SOMs METHODS: The clinical records of 130 consecutive patients undergoing surgery for SOMs were retrospectively collected in a database during a 20-year period to analyze symptoms, surgical technique, clinical outcome, and follow-up. Results: Among the 130 patients (mean age 51.2+/-9.5 years), 91.5% were females. The most typical symptoms recorded were proptosis in 94.6%, visual impairment in 37.7%, and oculomotor paresis in 10.0%. Simpson I-II removal was achieved in 97 patients (74.6%). After 1-year, proptosis was improved in 60% of cases. 44.9% of the patients with preoperative visual acuity impairment were improved. Periorbital excision was statistically linked to proptosis decreasing (p=0.0001) and optic canal decompression was linked to visual stabilization (p=0.03). Bone reconstruction prevented temporal muscle atrophy (p=0.01) and unaesthetic results (p=0.0001). Mean follow-up was 76.5 months (range 3-288 months) and the mean time for recurrence was 54.2 months. Conclusions: A single-stage optimal surgery with bone reconstruction appears to be the best first-line treatment, on a case-by-case analysis. Optic canal decompression and periorbital excision have to be performed in case of visual disturbance and proptosis. SOMs require a long-term follow-up because of a delayed high rate of recurrence.
Article
Introduction: Dr. Collin S. MacCarty (1915-2003) invented the MacCarty keyhole, which is now widely used as the starting burr hole for orbitozygomatic craniotomy. We present a historical vignette on MacCarty's life and chronicle his contributions to neurosurgery. Methods: A detailed search for articles relating to the biography and professional career of Dr. MacCarty was conducted on PubMed and Google Scholar using the keywords "Collin MacCarty" and "MacCarty keyhole". References found in those article were also reviewed. Results: On September 20, 1915, Collin MacCarty was born in Rochester, Minnesota. MacCarty was exposed to the medical field at an early age. He witnessed legendary surgeons like Alfred Adson perform brain and spine operations. Expectedly, MacCarty pursued a career in neurosurgery. He was influenced by Walter Dandy as a house office at Johns Hopkins and completed his neurosurgical training at the Mayo Clinic under Adson. In a distinguished career in neurosurgery at the Mayo Clinic, MacCarty served many important roles, including Chairman of the Department of Neurosurgery from 1963-1975, and president of the AANS. He was world-renowned for his vast experience with meningiomas. In 1961, MacCarty described a burr hole to expose the periorbita and frontal dura while approaching intraorbital meningiomas. This burr hole became immortalized as the "MacCarty keyhole" and is used widely today in frontotemporal orbitozygomatic approaches. Conclusion: Collin S. MacCarty was an influential neurosurgeon who invented the "MacCarty keyhole." In a distinguished career in neurosurgery, he served as AANS President and Chairman of Department of Neurosurgery at the Mayo Clinic.
Article
Objective: The aim of this study was to describe the surgical technique utilized for removal of spheno-orbital meningiomas (SOMs) in our practice and to review the operative outcome. Methods: Review of the senior author's (JHL) practice between 1994 and 2009 revealed 39 patients (mean age 48 years) eligible for this study. Clinical presentation, surgical technique, postoperative outcome, and follow-up data are presented. Surgical technique was detailed with an emphasis on aggressive removal consisting of drilling of the hypertrophied sphenoid bone, orbital wall, and anterior clinoid process, followed by tumor removal and a wide resection of the involved dura. A simple dural closure without reconstruction of the orbital roof or the lateral wall of the orbit was also described. Results: Gross total resection was achieved in 15 (38.4%) patients, 20 (51.2%) had near total resection with small residual in the cavernous sinus or periorbita, and 4 (10.2%) had subtotal resection. Postoperative complications included trigeminal hypesthesia in 10, oculomotor palsy in 2, and seizure in 2. Seven patients had recurrence within the mean follow-up period of 40.6 months. Preoperative visual deficits were present in 21 patients (53.8%). Of these, 14 (66.6%) experienced visual recovery to normal levels postoperatively. Statistical analyses revealed preoperative severe visual deficit and sphenoid bone hypertrophy as an independent risk factor and an independent favorable factor, respectively, for a favorable visual outcome. Proptosis was resolved (≤2 mm) in 76.4% of our patients. No patient had postoperative enophthalmos. Conclusions: In our practice, surgery for SOMs consists of resection of the orbital/sphenoid intraosseous, intraorbital, and intradural tumor components. We believe that aggressive removal of the orbital/sphenoid intraosseous tumor is critical for a favorable visual outcome and tumor control. Furthermore, satisfactory cosmetic results can be achieved with simple reconstruction techniques as described.
Article
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 by the senior author (KOL) between 2000 and 2016 was performed. Demographics, operative details, post-operative outcomes, recurrence rates and radiation treatment plans were analyzed. Statistical analysis was performed to assess for factors affecting recurrence (Fisher's exact and student's t-test), changes in exophthalmos index (student's t-test) and progression free survival (Kaplan-Meier and log rank). Results: Twenty-five patients were included. 92% were female. Mean age was 51 years. WHO grade was I (n = 21) and II (n=4). Simpson grade was: I (n = 14), II (n = 3), IV (n = 8). Mean follow-up time was 44.8 months. Proptosis was significantly improved at the 3-6 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 18/19 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. Conclusion: 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 sub-totally resected skull base meningiomas.
Article
Aim: To present a review of the contemporary surgical management of skull base tumors. Background: Over the last two decades, the treatment of skull base tumors has evolved from observation, to partial resection combined with other therapy modalities, to gross total resection and no adjuvant treatment with good surgical results and excellent clinical outcomes. Materials and methods: The literature review of current surgical strategies and management of skull base tumors was performed and complemented with the experience of Barrow Neurological Institute. Results: Skull base tumors include meningiomas, pituitary tumors, sellar/parasellar tumors, vestibular and trigeminal schwannomas, esthesioneuroblastomas, chordomas, chondrosarcomas, and metastases. Surgical approaches include the modified orbitozygomatic, pterional, middle fossa, retrosigmoid, far lateral craniotomy, midline suboccipital craniotomy, and a combination of these approaches. The selection of an appropriate surgical approach depends on the characteristics of the patient and the tumor, as well as the experience of the neurosurgeon. Conclusion: Modern microsurgical techniques, diagnostic imaging, intraoperative neuronavigation, and endoscopic technology have remarkably changed the concept of skull base surgery. These refinements have extended the boundaries of tumor resection with minimal morbidity.
Article
Cranioplasty, one of the oldest surgical procedures used to repair cranial defects, has undergone many revolutions over time to find the ideal material to improve patient prognosis. Cranioplasty offers cosmetic and protective benefits for patients with cranial defects. The first primitive cranioplasty procedures date back to 7000 bc and used metal and gourds to repair cranial defects. Cranioplasty was first documented by Fallopius who described repair using gold plates; the first bone graft was documented by van Meekeren. The first significant improvement for this procedure began with experimentation involving bone grafts in the late 19th century as a more natural approach for repairing cranial defects. The next impetus for advancement came because of wartime injuries incurred during World Wars I and II and involved experimentation with synthetic materials to counter the common complications associated with bone grafts. Methyl methacrylate, hydroxyapatite, ceramics, and polyetheretherketone implants among other materials have since been researched and used. Research now has shifted toward molecular biology to improve the ability of the patient to regenerate bone using bone growth factors. This paper reviews the evolution of materials used over time in addition to the various advantages and pitfalls associated with each change. It is important for neurosurgeons to be mindful of how these techniques have evolved in order to gain a better understanding of this procedure and how it has been adapted.