brain sciences Article Surgical Strategies and Clinical Outcome of Large to Giant Sphenoid Wing Meningiomas: A Case Series Study Adrian Balasa 1,2, Corina Hurghis 1,2, Flaviu Tamas 1,2 and Rares Chinezu 1,2,* 1 Department of Neurosurgery, George Emil Palade University of Medicine, Pharmacy, Science and Technology, 540142 Tîrgu Mures, , Romania; [email protected] (A.B.); [email protected] (C.H.); fl[email protected] (F.T.) 2 Department of Neurosurgery, Tîrgu Mures, Emergency Clinical County Hospital, 540136 Tîrgu Mures, , Romania * Correspondence: [email protected] Received: 23 November 2020; Accepted: 8 December 2020; Published: 9 December 2020 Abstract: Large to giant sphenoid wing meningiomas (SWMs) remain surgically challenging due to frequent vascular encasement and a tendency for tumoral invasion of the cavernous sinus and optic canal. We aimed to study the quality of resection, postoperative clinical evolution, and recurrence rate of large SWMs. This retrospective study enrolled 21 patients who underwent surgery between January 2014 and December 2019 for SWMs > 5 cm in diameter (average 6.3 cm). Tumor association with cerebral edema, extension into the cavernous sinus or optic canal, degree of encasement of the major intracranial arteries, and tumor resection grade were recorded. Cognitive decline was the most common symptom (65% of patients), followed by visual decline (52%). Infiltration of the cavernous sinus and optical canal were identified in five and six patients, respectively. Varying degrees of arterial encasement were seen. Gross total resection was achieved in 67% of patients. Long-term follow-up revealed improvement in 17 patients (81%), deterioration in two patients (9.5%), and one death (4.7%) directly related to the surgical procedure. Seven patients displayed postoperative tumor progression and two required reintervention 3 years post initial surgery. Tumor size, vascular encasement, and skull base invasion mean that, despite technological advancements, surgical results are dependent on surgical strategy and skill. Appropriate microsurgical techniques can adequately solve arterial encasement but tumor progression remains an issue. Keywords: sphenoid wing meningiomas; cavernous sinus; optic canal; vascular encasement; gross total resection; skull base invasion 1. Introduction Meningiomas are the most common benign intracranial tumor, representing up to 18% of all intracranial tumor pathologies. Among the supratentorial locations, sphenoid wing meningiomas (SWMs) account for up to one-quarter [1–8]. Typically, meningiomas are slow growing and over 90% are benign lesions (World Health Organization grade 1) that do not infiltrate surrounding structures. As such, symptomatology onset is insidious and, consequently, the clinical presentation, surgical risk, and prognosis can vary from case to case [1,3,9–13]. Meningiomas originating along the sphenoidal ridge were first classified by Cushing and Eisenhardt as medial, middle, and lateral SWMs (Figure1)[14]. Brain Sci. 2020, 10, 957; doi:10.3390/brainsci10120957 www.mdpi.com/journal/brainsci Brain Sci. 2020, 10, 957 2 of 13 Brain Sci. 2020, 10, x FOR PEER REVIEW 2 of 13 Figure 1. Meningiomas: localization along the sphenoid ridge. Figure 1. Meningiomas: localization along the sphenoid ridge. Large to giant SWMs represent a surgical challenge not only because they come into contact Large to giant SWMs represent a surgical challenge not only because they come into contact with with important anatomical structures such as the large intracerebral anterior circulation arteries, important anatomical structures such as the large intracerebral anterior circulation arteries, cavernous sinus, optic chiasm, and optic nerves, but also because they show a high recurrence rate, cavernous sinus, optic chiasm, and optic nerves, but also because they show a high recurrence rate, often infiltrating the bony structures [15–21]. often infiltrating the bony structures [15–21]. Due to the rarity of this subcategory of SWMs, there are few studies addressing surgical results. Due to the rarity of this subcategory of SWMs, there are few studies addressing surgical results. There is no consensus in recent studies in regarding the optimal surgical solution, alternating from There is no consensus in recent studies in regarding the optimal surgical solution, alternating from aggressive to conservative surgical attitudes, especially when dealing with significant skull base and aggressive to conservative surgical attitudes, especially when dealing with significant skull base and vascular involvement [4,22–30]. vascular involvement [4,22–30]. The aim of our study was to evaluate the surgical results of large to giant SWMs, especially how The aim of our study was to evaluate the surgical results of large to giant SWMs, especially how the arterial encasement and cavernous sinus infiltration influences the postoperative clinical outcome, the arterial encasement and cavernous sinus infiltration influences the postoperative clinical tumor recurrence rate, and its origin. outcome, tumor recurrence rate, and its origin. 2. Materials and Methods 2. Materials and Methods This is a retrospective case series study involving 21 consecutive patients with large to giant SWMs This is a retrospective case series study involving 21 consecutive patients with large to giant who underwent surgery in the Department of Neurosurgery, Tîrgu Mures, Clinical Emergency Hospital, SWMsRomania, who betweenunderwent January surgery 2014 in andthe Department December 2019. of Neurosurgery, All cases were Tîrgu histopathologically Mureș Clinical Emergency confirmed. Hospital,All subjectsRomania, gave between their Januar informedy 2014 consent and December for inclusion 2019. before All cases they were participated histopathologically in the study. confirmed.The study was conducted in accordance with the Declaration of Helsinki, and the protocol was approvedAll subjects by the gave Ethics their Committee informed of consent our University. for inclusion before they participated in the study. The study was conducted in accordance with the Declaration of Helsinki, and the protocol was approved by2.1. the Inclusion Ethics Committee and Exclusion of our Criteria University. We defined large to giant SWMs as tumors measuring greater than 5 cm in diameter in at least 2.1. Inclusion and Exclusion Criteria one direction. All patients operated on for the first time for large to giants SWMs were included in thisWe study. defined large to giant SWMs as tumors measuring greater than 5 cm in diameter in at least one direction.We considered All patients en plaqueoperated meningiomas, on for the first cavernous time for large sinus to giants meningiomas, SWMs were anterior included clinoid in thismeningiomas, study. and extensions of petroclival meningiomas to represent different pathologies, and as such,We patients considered with theseen plaque categories meningiomas, of tumor were cave excluded.rnous sinus meningiomas, anterior clinoid meningiomas, and extensions of petroclival meningiomas to represent different pathologies, and as such,2.2. Clinicalpatients and with Radiological these categories Evaluation of tumor were excluded. Each patient was clinically evaluated at multiple timepoints: prior to surgical intervention, 24 h 2.2.postoperatively, Clinical and Radiological upon discharge, Evaluation 3 months postoperatively, and annually thereafter. Clinical data wereEach recorded patient inwas individual clinically evaluated evaluation at sheetsmultiple that timepoints: accompanied prior to the surgical patients intervention, throughout 24 theh postoperatively,monitoring period. upon discharge, 3 months postoperatively, and annually thereafter. Clinical data were Cognitiverecorded in function individual was evaluation evaluated sheets using that the accompanied Montreal Cognitive the patients Assessment throughout Test the [31 ], monitoringvisual function period. was evaluated using visual acuity and visual field tests, motor function was evaluated usingCognitive the Medical function Research was Councilevaluated scale using [32 ],the and Montreal aphasia wasCognitive assessed Assessment using the KaplanTest [31], score visual [33 ]. functionPreoperative was evaluated radiological using visual evaluation acuity was and performed visual field using tests, a motor 1.5 Tesla function magnetic was resonance evaluated imaging using the(MRI) Medical machine Research (T1- andCouncil T2-weighted scale [32], sequences), and aphasia with was a focusassessed on identifyingusing the Kaplan tumor score association [33]. with cerebralPreoperative edema, tumor radiological extension eval intouation the cavernous was performed sinus or using optic canal,a 1.5 andTesla the magnetic degree of encasementresonance imagingof the major(MRI) intracranial machine (T1- arteries. and T2-weighted Arterial encasement sequences), was with established a focus as on either identifying total or tumor partial. association with cerebral edema, tumor extension into the cavernous sinus or optic canal, and the Brain Sci. 2020, 10, x FOR PEER REVIEW 3 of 13 BrainBrain Sci.Sci. 20202020,, 1010,, 957x FOR PEER REVIEW 33 of of 13 13 degree of encasement of the major intracranial arteries. Arterial encasement was established as either Wetotal defined or partial. total We encasement defined total as occurring encasement when as at occu leastrring one when of the at major least intracranial one of the major arteries intracranial was totally engulfedarteries was