Combined Extradural and Intradural Pterional Transzygomatic Approach to Large Sphenoid Wing Meningiomas. Operative Technique and Surgical Results

Abstract

Objectives Describe a unique and safe surgical procedure for the microsurgical management of large sphenoid wing meningiomas (SWMs) aimed to a radical resection of these tumors.

Design A prospective series of 26 cases with SWMs larger than 3 cm in one of its main diameter is presented. All patients were studied following the same clinical and imaging procedures. The surgical approach was through a pterional transzygomatic craniotomy. The surgical procedure has the following steps: 1. Extradural tumor devascularization and resection of the hyperostotic and/or infiltrated bone and then intradurally; 2. Intradural tumor debunking; 3. Microdissection of vascular branches and perforators from the capsule; 4. Identification of the optic and oculomotor nerves and internal carotid artery; 5. Tumor capsule dissection and resection; 6. Dural resection or cauterization; 7. Dural and bone reconstruction and closing.

Results All lesions were completely removed. Most complications were transient. The most relevant complication was a large middle cerebral artery infarct with permanent hemiplegia despite a decompressive craniotomy.

Conclusion Large SWMs can be considered as a single pathology regarding the surgical approach and intraoperative microsurgical procedure strategies. The pterional transzygomatic approach allows an extradural devascularization of the tumor and an extensive bone resection that facilitates the intradural stage of tumor resection. The proposed approach allows a wide and radical resection of the duramater and bone that increases the Simpson grade. However, surgery does not control other biological or molecular prognostic factors involved in tumor recurrence.

Keywords

sphenoid wing meningioma - pterional craniotomy - transzygomatic craniotomy - meningioma recurrence

• References

• 1 Simpson D. The recurrence of intracranial meningiomas after surgical treatment. J Neurol Neurosurg Psychiatry 1957; 20 (01) 22-39
• 2 Louis DN, Perry A, Reifenberger G. , et al. The 2016 World Health Organization Classification of Tumors of the Central Nervous System: a summary. Acta Neuropathol 2016; 131 (06) 803-820
• 3 González-Darder JM, Quilis-Quesada V, Botella-Maciá L. [Transzygomatic pterional approach. Part 2: Surgical experience in the management of skull base pathology]. Neurocirugia (Astur) 2012; 23 (03) 96-103
• 4 Quilis-Quesada V, Botella-Maciá L, González-Darder JM. [Transzygomatic pterional approach. Part 1: anatomical study]. Neurocirugia (Astur) 2012; 23 (02) 47-53
• 5 Cushing H, Eisenhardt L. Meningiomas: their classification, regional behaviour, life history, and surgical results. Springfield, Charles C Thomas; 1938
• 6 Sughrue ME, Kane AJ, Shangari G. , et al. The relevance of Simpson Grade I and II resection in modern neurosurgical treatment of World Health Organization Grade I meningiomas. J Neurosurg 2010; 113 (05) 1029-1035
• 7 Voß KM, Spille DC, Sauerland C. , et al. The Simpson grading in meningioma surgery: does the tumor location influence the prognostic value?. J Neurooncol 2017; 133 (03) 641-651
• 8 Barbera S, San Miguel T, Gil-Benso R. , et al. Genetic changes with prognostic value in histologically benign meningiomas. Clin Neuropathol 2013; 32 (04) 311-317
• 9 Ambekar S, Sharma M, Madhugiri VS, Nanda A. Trends in intracranial meningioma surgery and outcome: a Nationwide Inpatient Sample database analysis from 2001 to 2010. J Neurooncol 2013; 114 (03) 299-307
• 10 Langevin CJ, Hanasono MM, Riina HA, Stieg PE, Spinelli HM. Lateral transzygomatic approach to sphenoid wing meningiomas. Neurosurgery 2010; 67 (2, Suppl Operative): 377-384
• 11 Sughrue ME, Rutkowski MJ, Chen CJ. , et al. Modern surgical outcomes following surgery for sphenoid wing meningiomas. J Neurosurg 2013; 119 (01) 86-93
• 12 Echlin F. Cranial osteomas and hyperostoses produced by meningeal fibroblastomas: a clinical pathologic study. Arch Surg 1934; 28 (02) 357-405
• 13 Goyal N, Kakkar A, Sarkar C, Agrawal D. Does bony hyperostosis in intracranial meningioma signify tumor invasion? A radio-pathologic study. Neurol India 2012; 60 (01) 50-54
• 14 Morcos JJ. Sphenoid wing meningiomas. J Neurosurg 2013; 119 (01) 82-84
• 15 Dubel GJ, Ahn SH, Soares GM. Contemporary endovascular embolotherapy for meningioma. Semin Intervent Radiol 2013; 30 (03) 263-277
• 16 Hishikawa T, Sugiu K, Hiramatsu M. , et al. Nationwide survey of the nature and risk factors of complications in embolization of meningiomas and other intracranial tumors: Japanese Registry of NeuroEndovascular Therapy 2 (JR-NET2). Neuroradiology 2014; 56 (02) 139-144
• 17 Raper DM, Starke RM, Henderson Jr F. , et al. Preoperative embolization of intracranial meningiomas: efficacy, technical considerations, and complications. AJNR Am J Neuroradiol 2014; 35 (09) 1798-1804
• 18 McCracken DJ, Higginbotham RA, Boulter JH. , et al. Degree of vascular encasement in sphenoid wing meningiomas predicts postoperative ischemic complications. Neurosurgery 2017; 80 (06) 957-966
• 19 AlMefty O. Meningiomas. New York: Raven Press, Ldt; 1991
• 20 Borovich B, Doron Y. Recurrence of intracranial meningiomas: the role played by regional multicentricity. J Neurosurg 1986; 64 (01) 58-63