neurosurgical management of giant meningiomas. arturo ayala arcipreste md faans

Surgical management of giantmeningiomas in supratentorialcompartment. Experience of 58 cases.

Arturo Ayala-Arcipreste. MD , FAANS

Neurosurgery Department

Hospital Juárez de México

México City.

Collaborators

Dr. Rafael Mendizabal-Guerra. Chairmann of Neurosurgery Department.

Dr. Jose Luis Hernández-Moreno. Neurosonology unit.

Dra. Durdica López-Vujnovic. Neurosonology Unit.

Dr. Moises Jimenez-Jimenez. Neurosurgery Department.

Dr. Ruben Acosta-Garces. Neurosurgery Department.

Dr. Gustavo Melo-Guzmán. Endovascular Neurosurgery.

Dra. Teresa Cuesta. Neuropathology Department.

Disclosure

The authors report no conflict of interest concerning the material or methods used in this study or the findings specified in this presentation.

Background.

The Challenge in giant meningiomas is the total resection of thetumor with the least possible mortality and morbidity. Thedevelopment and improved operative techniques have shown a considerable progress, providing a wide exposure with minimalbrain retraction.

Giant meningiomas are described like tumors bigger than 4.5 centimeters in the major diameter, and are considered a complex lesion due to the effects on the brain, intracranialpressure, including neural and hemodynamics changes.

Background

SINAIS (National Stadistic Health System. México) 2004-2010 report 9901 cases of meningeal tumors.

Neurosurgery Department of Hospital Juárez de México attending 19 to 31 cases per year (2004-2012)

n: 233

Giant Meningiomas (>4.5cm) n:58

Objectives.

To demostrate the surgical experience of our departmentwith high complexity meningiomas with basic technology.

Describe the use of the transoperative Doppler

flowmetry in the meningioma surgery.

Material and Methods

A retrospective analysis was performed in 58 patients withgiant meningiomas (diameter > 4.5cm) which were treated surgically in our department, between June 2004 to January 2013.

The location of the tumor was divided in: supratentorial, and supra-infratentorial compartments.

All the patients were studied with CT Scan and MRI, only 10 patients were embolized.

The surgical approach was chosen depending on the location of the tumor, extension and vascular or neural structures involved. The Simpson scale was used to describe the grade of tumor resection.

Gender & Age

Location.

Supratentorialgroup n:48

Supra-infratentorialn:10

Signs and Symptoms

Progressive headache, Pyramidal tractsinvolve, seizures, mental and visual disturbances.

Frontal syndrome.

Progressiveheadache, cranialnerve paresis, dysmetria, ataxia, seizures.

Intracranial effects of the High Volume Meningiomas

ICP

Compressive effect on venous structures…edema

Compressive effect on arteries….ischemic phenomena.

Hydrodinamics effects on CSF drainage.

Electrophysiological effects……Seizures

Monro-Kellie Doctrine.

Mean maximal tumor diameter- Location

Supratentorial

(n: 48 )

Supra-infratentorial(n:10)

Gender F:31 M:17 F: 8 M:2

Age (13 to 81 ) m: 48.9 (28-57) m:44.2

Embolization 7 cases 3 cases

Maximus tumor´s diameter

(5cm – 18cm)

m:7.82 cm

(6cm-13cm)

m: 8.21cm.

Considerations

Angiography ?

Relationship with vessels

Feeders vessels.

Embolization ?

Intraoperative monitoring

Surgical technnique to plan.

Peritumoral Edema

Location…

Venous Circulation.

Pial blood supply…

Tumoral size?

Tumor Biology…

Biochemical factors…

SURGICAL APPROACHES

Sphenoidal wing meningiomas n:10 Parasagital meningiomas n: 8

Surgical approaches

Anterior Floor Meningiomas(8) Convexity meningiomas (14)

Surgical approaches

Hemispherics n:3 Ventricular n:3

Surgical Approaches.

Supra-infratentorial meningiomas (n: 10)

Falco-tentorial meningiomas (2)

Transoperative Doppler Flowmetry (16 Mhz transductor)

Five sphenoid ridge, 3 anterior floor , 2 parasagital and 1 supra-infratentorial were monitorized with transoperative Doppler flowmetry to localize the main arterial trunks avoiding damage in arterial wall, and measure the velocity of local blood flow.

ICA: 40-43 cm/seg

MCA: 75-80 cm/seg

ACA:60-64 cm/seg

In one case found a severe arterial vasospam in anterior circulation (> 220 cm/s) for two days after surgery, without neurological deficit.

Simpson Index resection.

Surgical complicationsSupratentorial group

Supra-infratentorial group

CSF Fistula 0 2Meningitis 1 2Malignant edema and infarct

1 0

Transient nerve palsy

2 3

Subdural hematoma

1 0

Transient hemiparesis

6 2

Wound necrosis 1 2

Hystopathologic results.

Supratentorialgroup n:48

Supra-infratentorialn:10

Hystopathology Meningothelial (15)

Psammomatous (9)

Fibrous (8)

Transitional(6)

Angiomatous (2)

Hemangyopericitic(2)

Papillary (2)

Atypical (4)

Meningothelial(4)

Atypical (1)

Fibrous (2)

Psammomatous(3)

Benign: 49 (84.48%)

Malignant: 9 (15.5%)

Follow-up

Follow-up ( 2 months - 8 years)

All 9 malignant cases received radiotherapy.

Malignat cases: 3 die due tumor progression.

1 die for pneumonia.

1 die for gastric bleeding.

3 patients with tumor recurrence.

Bening cases:

Simpson I-II: withoutrecurrences

Grades IV: with residual tumor in the surgical bedand no changes in tumor volume.

Discussion.

In this serie of 58 cases of giantmeningiomas, in which thesupratentorial location waspredominant, we used a varietyof mixed wide craniotomy witha linear incition (bicoronal) and Craneo-Orbito-Zigomaticapproach like one of the mostflexible and extensive providinga wide window and resect thetumor without brain retraction.

In supra-infratentorial group itwas used a skull base approachmixed with extensivesupratentorial craniotomy dueto the structures involved.

The critical areas are the clivusand cavernous sinus wheremany cases of these serie are involved. The most of series about meningiomas infiltredthis area shows a poor surgicalresection.

Discussion.

We found that complications of our serie is similar to the worldseries of meningiomas thatinvolve skull base.

Simpson Index of tumor resection is better onsupratentorial cases , howeveron cases with a massivemeningioma, many vascular structures are infiltrated and the resection is difficult.

The behavioral of the tumor were atypical in 9 cases and themanagement includeradiotherapy several weeksafter the surgery.

Our serie has a large number of giant meningiomas with resultssimilar to other series of meningiomas in the world.

Conclusion.

Giant meningiomas are one of themost difficult challenge in neurosurgery. Multiple factors mustbe considered to study and plannigthe best approach including thepostoperative care.

The skull base and neurovascularknowledge is fundamental for theneurosurgeon who takes care of these cases.

The use of the Doppler monitoringgive information not only about thevessels topography, also measurethe flow velocity to study thevasoreactivity in the surgey process.

“Giant meningioma” describes a very high complex tumor due tomany vascular elements, neural and skull base spaces that are involved, what makes thesefeatures difficult to obtain a good index of resection. There isalso high risk of morbidity and poor outcome, predominantly onskull base tumors.

F 40. External third sphenoidal wing

Question mark incision and fronto temporal craniotomy

A-V shunt

Total Resection (Simpson 1)

Postsurgical MRI

Frontal convexity tumor F 26

Postsurgical CT

Left parasagital meningioma with bone vault invasion.

Bicoronal incision and bifrontal osteotomy

Dural reconstruction with periostium.

Postsurgical MRI

Right sphenoidal wing

meningioma

1.-Question mark incision.

2.-Fronto-temporal craniotomy.

3.-High speed drill of lesser sphenoidal wing and orbital lateral wall.

4.- Simpson 1.

Post surgical CT

Hemispheric parasagital meningioma.F 81

Bicoronal incision and bifrontal osteotomy

Total resection with CUSA and transoperativeDoppler flowmetry

Postsurgical CT with contrast

Massive frontal meningioma.

M 45.

M

Massivefrontal

meningioma.M 45.

Simpson IV.

Residual tumor

in midline.

Olfactory groove-tuber sella-sphenoidal wing meningioma

Postoperative CT (Simpson 4)

Olfactory groove meningioma

Postoperative MRI

Occipito-parietal convexity meningioma.

Simpson I. (embolized)

Temporo-parietal convexity meningioma

Right Sphenoidal wing meningioma

Embolization

Left sphenoidal wing meningioma

COZ approach.

Male 28, hemispheric ventricular meningioma

First Surgery, transulcal approach

Very solid and calcified mass: parcial

resection.

2nd surgery: Subtotal tumorectomy

3rd surgery, hydrocephalus….ventriculo-

peritoneal shunt

5 months follow-up

Left Hemiparesys 4-/5

Ventricular meningioma

MRI post

Listen to me.

Point 23:

Above all else, the patient’s

well-being is your duty.

It requires your full

commitment without

distraction.

Dr. Ossama Al-Mefty