Egyptian Journal of Neurosurgery Volume 29 / No. 3 / July - September 2014 17-24 Original Article Surgical Management of Sphenoid Wing Meningiomas Mohamed Emara, Alaa Farag*, Walid Badawy, Hosam Maaty, Fathy Elnos Department of Neurosurgery, Banha University ARTICLE INFO ABSTRACT Background: Sphenoidal meningiomas constitute 18% of intracranial masses. Sphenoid wing meningiomas still present a difficult surgical challenge especially when they are Received: large in size and involve neurovascular structures. Objective: The aim of the study is to 5 November 2014 shed light on the management of sphenoid wing meningioma, study the outcome of microsurgical resection and factors affecting its resectability. Patients and Methods: In Accepted: 20 December 2014 this prospective study, thirty cases were included thirteen outer and / or middle sphenoid wing, thirteen clinoidal and four meningiomas en plaque. In each case diagnosis was made clinically and confirmed radiologically and histo-pathologically. Results: Key words: Between March 2011 and June 2014, thirty patients with meningiomas primarily Meningioma, originating from sphenoid ridge were operated, 22 (73.3%) patients were females and Sphenoid wing, 8(26.7%) were males. In seventeen cases total resection was achieved, and subtotal Surgical treatment resection in thirteen cases. In this study mortality was recorded in two case and morbidity in nine cases. Eight cases has excellent outcome fourteen were good and six were fair and two died. Conclusion: The surgical treatment of sphenoid wing meningiomas still represents a challenge for neurosurgeons. Surgery for sphenoid wing meningiomas poses a variety of problems reflecting the complex anatomy of the sphenoid region. © 2014 Egyptian Journal of Neurosurgery. Published by MEDC. All rights reserved INTRODUCTION encase the internal carotid artery (ICA) and middle 1,2,14 cerebral artery (MCA) as well as cranial nerves . Meningiomas are among the most common primary The clinical presentation of sphenoid wing intracranial tumors. They are slow growing tumors meningiomas is manifestation of increased intracranial originating from the arachnoidal cap cells and may tension. Clinical features unique to this group of occur anywhere that arachnoid cells are found8. meningiomas include: exophtalmous, transient diplopia Meningioma account for 14.3-19% of primary due to occlumotor nerve dysfunction, periorbital pain or intracranial neoplasms with a reported incidence 4.4 per numbness in the territory of the V1 branch, progressive 6,13 100000 person-year. Female: male ratio is 2:1. The true visual loss, and seizures . prevelance is likely even greater, as incidental Contrasted-enhansed cranial CT and MR imaging meningiomas have been reported in 2.3% of autopsy are the predominant imaging techniques used in the examinations. Most commonly diagnosed in middle- diagnosis and management of meningiomas; however, aged and eldery patients. Cranial meningiomas are in selected cases, MR spectroscopy, MR angiography 7 roughly 10 fold more common than spinal and Positron emission tomography may be useful . meningiomas9 The most appropriate surgical treatment of lateral Deletion of the neurofibro-matosis type 2(NF2) and middle sphenoid wing meningioma is total removal. gene, ionizing radiation and head truma are associ-ated Complete removal implies total removal of the tumor, with an increase risk, while the role of sex hormones in including the dural attachment and bone that is involved 9 meningioma development is still uncertain8 with the tumor Sphenoid wing meningioma account for about Clinoidal meningiomas consid-ered a major 11.9% of intracranial meningiomas, they are classified neurosurgical challenge due to involvement of into lateral sphenoid wing (or pterional) which are important neuron-vascular structures, cranial base usually similar to convexity meningioma, middle (or techniques can be used for surgical removal of these 10 alar) and medial (or clinoidal). The medial type tends to tumors with good results . Sterotactic radiosurgery can be used as an *Corresponding Author: alternative treatment to surgery. For incomplety Alaa A Farag resected or recurrent tumors conventional radio-therapy Department of Neurosurgery Banha University, Egypt Email: [email protected], Tel.: +2/01287518299 is beneficial. When the lesion is considered unresectable Egyptian Journal of Neurosurgery 17 Emara et al / Sphenoid Wing Meningiomas, Volume 29 / No. 3 / July - September 2014 17-24 or all other treatments have failed; hormonal therapy or Removal of the tumor was started with internal chemotherapy should be considered15. decompression depending on understanding of the bony Future therapies will include combination of and neurovascular anatomy of the middle cranial fossa, targeted molecular agents, and this will most likely be sellar and parasellar region. accomplished through continued progress in the Parts of the tumor adherent to middle cerebral understanding of the genetics and biological changes artery or internal carotid artery or infilterating the associated with meningioma.15 cavernous sinus (CS) were not removed. Infilterated The aim of the study is to shed light on the dura and bone was removed. Hemostasis was done with management of sphenoid wing meningioma, study the the aid of surgicell. Watertight dural closure was done outcome of microsurgical resection and factors affecting using pericranial flap or fascia lata graft. The wound its resectability. was closed in anatomical layers The grading for meningioma resection is PATIENTS AND METHODS conventional Simpson grading. In the resection of sphenoidal meningiomas, sometimes it is difficult for Between March 2011 and June 2014, a prospective the surgeon to ascertain that the entire area of dural study including 30 patients with meningiomas primarily involvement or attachment has been exposed, resected, originating from sphenoid ridge was done. The or coagulated. Therefore, we choose to define "Gross meningioma extended along the anterior and middle total resection" in this series as Simpson grade I and II cranial fossae. All patients were admitted to the and "subtotal" for other grades. Neurosurgery department in Banha University Hospital Cases with histological evidence of malignancy or and Nasser Institute hospital. with residual lesions were sent for conventional In this study, the patients were subjected to radiotherapy or gamma knife. thorough neurological examination. Computerized Follow up of cases was conducted in the tomography as well as Magnetic resonance imaging, Neurosurgical outpatient clinic. Evaluation was done with and without contrast enhancement, were done for both clinically and radiologically by the help of CT and all cases preoperatively. MRA or CT angiographies MRI with contrast, to detect any residual of the excised were also done when the relation of tumor to vessels tumor. need to be delinned. All these patients were submitted to In this study, the outcome was considered to be: surgery. Postoperative CT and MRI were done as a Excellent: Total tumor removal with improvement routine. of clinical condition with no deficit. Tumors were classified according to size into small Good: Total tumor removal without improvement (less than 3cm in maximum dimention), large (more than of clinical condition or with development of new 3 and less than 5cm in maximum dimention) and giant treatable deficit or In complete tumor removal done (more than 5cm in maximum dimention). with improvement of the clinical condition. Operative Management: Fair: Incomplete tumor removal without clinical Surgery was performed with general anaesthesia, improvement or Total removal with development of with the aid of an operating microscope and micro- new untreatable deficit or deterioration of previous surgical instrumentation in all cases. deficit. The choice of surgical approach for these Poor: Incomplete tumor removal with development meningiomas depended on the location of the tumor and of a new untreatable deficit extent of its dural attachment. The aim of surgery was either total or subtotal excision depending on the RESULTS preoperative imaging study. Pterional and fronto–orbito - zygomatic approaches were used. Thirty patients with meningiomas primarily Intra-operatively, the aim was complete originating from sphenoid ridge were operated. Twenty microsurgical removal of the tumor aiming to cure the two (73.3%) patients were females and eight (26.7%) patients unless the tumor was encasing vessels or were males. The mean age was (49.1+10.1) year. The nervous tissue. The plan of tumor removal included patients were divided into three groups according to the infilterated dura and bone. origin of tumor into A, B and, C: A carefully planned craniotomy was done exposing Group A: 13 patients har-boring inner sphenoidal the tumor and also any part of the dura invaded by the (clinoidal) meningioma meningioma. The dura was coagulated, to provide early Group B: 13 patient harboring outer and/or middle control of the tumor blood supply. The dura was incised sphenoidal meningiomas. in circumferential manner. Group C: 4 cases of meningioma en plaque. 18 Egyptian Journal of Neurosurgery Emara et al / Sphenoid Wing Meningiomas, Volume 29 / No. 3 / July - September 2014 17-24 Headache was the most common presenting symptom (63.3%). The above mentioned symptoms symptoms among the studied cases (83.3%), followed were the most common among each individual group by symptoms of increased intracranial tension (76.6%).