Stratification of predictive factors to assess resectability and surgical outcome in clinoidal meningioma

https://doi.org/10.1016/j.clineuro.2016.01.005Get rights and content

Highlights

  • Meningiomas of the clinoidal region pose significant surgical challenges.

  • The grading system was developed to assess the resectability and long-term outcomes of clinoidal meningioma.

  • Group 1 patients had higher gross total resection rate than group 2 (p = 0.009).

  • Radical resection can be planned in groups 1 patients and safe surgery followed by radio surgery may be better for group 2 patients.

Abstract

Objective

Meningiomas of the clinoidal region pose significant surgical challenges due to their close proximity and intimate relation with surrounding critical neurovascular structures. Our aim was to describe our institution’s experience with the management of clinoidal meningiomas, identify predictive factors and develop a comprehensive grading system to assess the extent of resection.

Methods

The medical records of 36 consecutive patients underwent surgery from 1995 to 2015 with clinoidal meningiomas were retrospectively reviewed. Using selected clinical features and tumor characteristics, a grading scale was devised and utilized to assess a degree of tumor resectability. The factors included: preoperative visual status(no visual loss = 0, visual loss = 1), tumor volume: small (<13.5 cm3 = 1), moderate (13.5–30 cm3 = 2), and large (>30 cm3 = 3),relationship with the internal carotid artery (no displacement = 0, displacement = 1, encasement = 2, stenosis = 3 and bilateral involvement = 4) tumor extension into the cavernous sinus (yes = 1, no = 0) and invasion into the optic canal (yes = 1, no = 0), (defined as tumor beyond the falciform ligament). A grading system was designed using the total scores (10) in this classification and separating patients into two groups: group 1 with scores of 5 or less, group 2 with scores more than 5.

Results

The patients mean age at the time of intervention was 61 years. The tumor involved the cavernous sinus in 38.9% of patients and invaded the optic canal in 36% of cases. The patient presented with visual impairment in 89% of cases. Vision improved in 28% and remained stable in 63% of cases. The mean volume of a tumor was 16.99 cm3. The most common approach involved pterional with or without anterior clinoidectomy. After stratification, group 1 consisting of 22 patients and in group 2, 14 patients. Gross total resection (Simpson Grade I or II) was achieved in 75% of surgeries and subtotal and partial resections were achieved in 25% of cases. Group 1 patients had higher gross total resection rate than group 2 (p = 0.009). Only optic canal involvement was significantly associated with the extent of resectabilty in a univariate analysis (p = 0.03). Four patients developed tumor recurrence with median recurrence duration of 89 months (53–204 months). Three patients underwent GKRS and one patient underwent repeat surgery at the time of recurrence.

Conclusions

A grading system can be employed in patients who present with clinoidal meningiomas and serve as an aid in planning an appropriate treatment strategy and establishing the prognosis. Radical resection can be planned in patients with favorable tumor criteria (groups 1) while a less aggressive surgical approach followed by stereotactic radiosurgery may be better suited for patients with less favorable tumor characteristics (group 2).

Introduction

Meningiomas arising from the anterior cranial fossa floor constitute about 40% of all intracranial meningiomas [10]. Such tumors may involve and extend along the dura of the olfactory groove, planum sphenoidale, anterior clinoid process, diaphragma sellae, orbital roof and tuberculum sellae. In reported series of sphenoidal meningiomas, the incidence of clinoidal meningiomas constitutes 34–43.9% [3], [24] of cases. Surgical resection of clinoidal meningiomas is challenging due to the close association of the tumor with critical neurovascular structures such as the internal carotid artery, the anterior cerebral artery, the anterior communicating artery complex and associated perforators, the optic apparatus and the pituitary gland and infundibulum. The objective of this study was to critically analyze our series of 36 surgically treated clinoidal meningiomas and assess the predictive factors individually as well as collectively for extent of resection.

Section snippets

Materials and methods

After obtaining local institutional review board approval, and in compliance with Health Insurance Portability and Accountability Act (HIPAA) regulations, we retrospectively reviewed the medical records, neuroimaging studies, and pathology reports of all patients who underwent resection of clinoidal meningiomas from 1995 to 2015 in our institute. There were 36 patients identified with clinoidal meningiomas. All patients were evaluated with gadolinium-enhanced MRI of the brain prior to surgery.

Results

A total of 36 consecutive patients of clinoidal meningioma were recruited for outcome analysis. The mean age at surgery was 61 years (range 33–82 years). Twenty-six patients were female and 10 patients were male. Twenty-one meningiomas were located on the left and 15 were on the right. Presenting symptoms included visual impairment (89%), headache (72%), memory deficits (<1%) and seizures (<1%) (Table 2). The mean volume of a tumor was 16.99 cm3. The most commonly utilized surgical approaches

General

Clinoidal meningiomas by definition are ambiguous, and its management protocol for large lesions is also still debatable. In 1938, Cushing and Eisenhardt broadly classified this group as “deep inner or clinoidal third sphenoid ridge meningiomas” and this marked the first use of “clinoidal” to distinguish these tumors [7]. Al-Mefty’s more detailed system [2], introduced in 1990, classified clinoidal meningiomas into three separate groups depend on interfacing arachnoid membranes between the

Conclusions

Clinoidal meningiomas are the unique subset of tumors due to its close proximity to neurovascular structures and extension into the cavernous sinus and optic canal. They can be safely excised with minimal morbidity and mortality using microsurgical techniques. We recommend considering all possible clinical, radiological and intraoperative findings to predict the extent of resection for clinoidal meningiomas. This grading system will help to tailor the management plan and prognosticate in an

Conflicts of interest

None.

Approval from Institutional review board (IRB: H13-019) was obtained prior to this study.

Disclosure

A portion of this manuscript was presented during the scientific session at the annual meeting of the Congress of Neurological Surgeons held in October, 2015 at New Orleans, Louisiana.

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