Category Archives: Neurooncology

Mannitol for intraoperative brain relaxation

The risk of brain edema after dural opening is high in patients with midline shift undergoing supratentorial tumor surgery. Brain swelling may result in intracranial hypertension, impeded tumor exposure, and adverse outcomes. Mannitol is recommended as a first-line dehydration treatment to reduce brain edema and enable brain relaxation during neurosurgery. Research has indicated that mannitol enhanced brain relaxation in patients undergoing supratentorial tumor surgery; however, these results need further confirmation, and the optimal mannitol dose has not yet been established 1).

Some clinicians 2) 3) advocate high doses (>1.0 g/kg) of mannitol to effectively reduce intracranial pressure, while others recommend lower doses (<1.0 g/kg) 4) 5).

Treatment guidelines for using mannitol in patients with traumatic brain injury and stroke have been published and provide recommendations regarding the dose and timing of mannitol. However, there is still controversy concerning dehydration treatment with mannitol in patients with preoperatively increased intracranial pressure during brain tumor surgery.


Seo et al. sought to determine the dose of mannitol that provides adequate brain relaxation with the fewest adverse effects.

A total of 124 patients were randomized to receive mannitol at 0.25 g/kg (Group A), 0.5 g/kg (Group B), 1.0 g/kg (Group C), and 1.5 g/kg (Group D). The degree of brain relaxation was classified according to a 4-point scale (1, bulging; 2, firm; 3, adequate; and 4, perfectly relaxed) by neurosurgeons; Classes 3 and 4 were considered to indicate satisfactory brain relaxation. The osmolality gap (OG) and serum electrolytes were measured before and after mannitol administration.

The brain relaxation score showed an increasing trend in patients receiving higher doses of mannitol (p = 0.005). The incidence of satisfactory brain relaxation was higher in Groups C and D than in Group A (67.7% and 64.5% vs 32.2%, p = 0.011 and 0.022, respectively). The incidence of OG greater than 10 mOsm/kg was also higher in Groups C and D than in Group A (100.0% in both groups vs 77.4%, p = 0.011 for both). The incidence of moderate hyponatremia (125 mmol/L ≤ Na+ < 130 mmol/L) was significantly higher in Group D than in other groups (38.7% vs 0.0%, 9.7%, and 12.9% in Groups A, B, and C; p < 0.001, p = 0.008, and p = 0.020, respectively). Hyperkalemia (K+ > 5.0 mmol/L) was observed in 12.9% of patients in Group D only.

The higher doses of mannitol provided better brain relaxation but were associated with more adverse effects. Considering the balance between the benefits and risks of mannitol, the authors suggest the use of 1.0 g/kg of intraoperative mannitol for satisfactory brain relaxation with the fewest adverse effects. Clinical trial registration no.: NCT02168075 ( clinicaltrials.gov ) 6).

1)

Peng Y, Liu X, Wang A, Han R. The effect of mannitol on intraoperative brain relaxation in patients undergoing supratentorial tumor surgery: study protocol for a randomized controlled trial. Trials. 2014 May 10;15:165. doi: 10.1186/1745-6215-15-165. PubMed PMID: 24884731; PubMed Central PMCID: PMC4018619.
2)

Wise BL. High-dose mannitol. J Neurosurg. 2004;101:566–567.
3)

Cruz J, Minoja G, Okuchi K, Facco E. Successful use of the new high-dose mannitol treatment in patients with Glasgow Coma Scale scores of 3 and bilateral abnormal pupillary widening: a randomized trial. J Neurosurg. 2004 Mar;100(3):376-83. PubMed PMID: 15035271.
4)

Myburgh JA, Lewis SB. Mannitol for resuscitation in acute head injury: effects on cerebral perfusion and osmolality. Crit Care Resusc. 2000;2:14–18
5)

Sorani MD, Morabito D, Rosenthal G, Giacomini KM, Manley GT. Characterizing the dose–response relationship between mannitol and intracranial pressure in traumatic brain injury patients using a high-frequency physiological data collection system. J Neurotrauma. 2008;25:291–298. doi: 10.1089/neu.2007.0411.
6)

Seo H, Kim E, Jung H, Lim YJ, Kim JW, Park CK, Se YB, Jeon YT, Hwang JW, Park HP. A prospective randomized trial of the optimal dose of mannitol for intraoperative brain relaxation in patients undergoing craniotomy for supratentorial brain tumor resection. J Neurosurg. 2017 Jun;126(6):1839-1846. doi: 10.3171/2016.6.JNS16537. Epub 2016 Aug 19. PubMed PMID: 27540904.

Cystic glioblastoma

Cystic glioblastoma is a descriptive term to one form of glioblastoma that contains large cystic component, rather than being a pathological subtype.

Epidemiology

It is a rare disease whose exact prevalence is unknown. Glioblastoma is usually seen as a unilateral solid tumor more commonly in the supratentorial compartment. The presence of cyst in the GBM is rare. Bilateral large cystic GBM is still rarer 1).

Tumor cysts may be a nutrient reservoir for brain tumors, securing tumor energy metabolism and synthesis of cell constituents. Serum is one likely source of cyst fluid nutrients. Nutrient levels in tumor cyst fluid are highly variable, which could differentially stimulate tumor growth. Cyst fluid glutamate, lactate, and phosphate may act as tumor growth factors; these compounds have previously been shown to stimulate tumor growth at concentrations found in tumor cyst fluid.


GBM cysts contained glucose at 2.2 mmol/L (median value; range <0.8-3.5) and glutamine at 1.04 mmol/L (0.17-4.2). Lactate was 7.1 mmol/L (2.4-12.5) and correlated inversely with glucose level (r = -0.77; P < .001). Amino acids, including glutamate, varied greatly, but median values were similar to previously published serum values. Ammonia was 75 μmol/L (11-241). B vitamins were present at previously published serum values, and riboflavin, nicotinamide, pyridoxal 5΄-phosphate, and cobalamin were higher in cyst fluid than in cerebrospinal fluid. Inorganic phosphate was 1.25 mmol/L (0.34-3.44), which was >3 times higher than in ventricular cerebrospinal fluid: 0.35 mmol/L (0.22-0.66; P < .001). Tricarboxylic acid cycle intermediates were in the low micromolar range, except for citrate, which was 240 μmol/L (140-590). In cystic metastatic malignant melanomas and lung tumors values were similar to those in GBMs. 2).


Cystic GBM may be confused rarely on radiology with tuberculoma as both may show a mass lesion with hypodense centre surrounded by a ring of enhancement. Peroperative cytological examination of smears prepared from fluid aspirated from cysts by rapid Diff-Quik method may prove beneficial for immediate diagnosis in suspicious cases and appropriate patient management may be carried out 3).

Outcome

The presence of cystic features in glioblastoma (GBM) has been described as a favorable prognostic factor, possibly because cystic GBMs showed comparatively little infiltration of the peritumoral brain parenchyma 4).

Case series

 2011

A retrospective review of 354 consecutive patients treated with resection of primary GBM was performed using medical records and imaging information obtained at the University of California, San Francisco from 2005 to 2009. Within this cohort, 37 patients with large cysts (≥ 50% of tumor) were identified. Clinical presentations and surgical outcomes were statistically compared between the cystic and noncystic patients.

There were no statistically significant differences in clinical presentation between groups, including differences in age, sex, presenting symptoms, tumor location, or preoperative functional status, with the exception of tumor size, which was marginally larger in the cystic group. Surgical outcomes, including extent of resection and postoperative functional status, were equivalent. The median actuarial survival for the patients with cystic GBM was 17.0 months (95% CI 12.6-21.3 months), and the median survival for patients with noncystic GBM was 15.9 months (95% CI 14.6-17.2 months). There was no significant between-groups difference in survival (p = 0.99, log-rank test). A Cox multivariate regression model was constructed, which identified only age and extent of resection as independent predictors of survival. The presence of a cyst was not a statistically significant prognostic factor.

This study, comprising the largest series of cases of primary cystic GBM reported in the literature to date, demonstrates that the presence of a large cyst in patients with GBM does not significantly affect overall survival as compared with survival in patients without a cyst. Preoperative discussions with patients with GBM should focus on validated prognostic factors. The presence of cystic features does not confer a survival advantage 5).

2004

A retrospective analysis was conducted in 22 patients by using imaging information and chart reviews of operative reports of GBMs with large cysts (> or = 50% of tumor volume) at The University of Texas M. D. Anderson Cancer Center between 1993 and 2002. Clinical and neurosurgical outcomes and recurrence rates were studied. A statistical comparison was made with a matching cohort of 22 patients with noncystic GBMs. No significant differences in clinical variables were found between the cohort with cystic GBMs and the matched cohort with noncystic GBMs. To avoid bias in preoperative assessment of tumor volume, the tumor burden was compared in patients whose tumors had cysts (excluding the cystic mass) and in patients whose tumors did not contain cysts. There was no statistically significant difference between the two groups (p = 0.8). In patients with cystic GBMs the median survival time after surgery was 18.2 months (95% confidence interval [CI] 11.9-24.5 months) and at 2 years 43% of the patients were still alive. In comparison, in patients with noncystic GBMs, the median survival time was 14.3 months (95% CI 12.1-16.4 months) and only 16% of patients were alive at 2 years. The median time to tumor recurrence was 7.6 months (95% CI 0.01-18 months) in patients harboring cystic GBMs and 4.2 months (95% CI 1.8-6.6 months) in the matched cohort (log-rank test, p = 0.04). In the cystic GBM group, no recurrence was observed in 53% of patients at 6 months, 45% at 1 year, and 38% at 2 years after surgery, whereas the corresponding numbers for the noncystic group were 36, 14, and 9%, respectively.

The results indicate that patients harboring a GBM that contains a large cyst survive longer and have a longer time to recurrence than those who lack such a cyst. This is the first such observation in the literature 6).

1)

Kumar S, Handa A, Sinha R, Tiwari R. Bilateral cystic glioblastoma multiforme. J Neurosci Rural Pract. 2013 Oct;4(4):476-7. doi: 10.4103/0976-3147.120196. PubMed PMID: 24347967; PubMed Central PMCID: PMC3858779.
2)

Dahlberg D, Struys EA, Jansen EE, Mørkrid L, Midttun Ø, Hassel B. Cyst Fluid From Cystic, Malignant Brain Tumors: A Reservoir of Nutrients, Including Growth Factor-Like Nutrients, for Tumor Cells. Neurosurgery. 2017 Jun 1;80(6):917-924. doi: 10.1093/neuros/nyw101. PubMed PMID: 28327992.
3)

Hasan M, Siddiqui B, Qadri S, Faridi S. Cystic glioblastoma multiforme masquerading as a cerebral tuberculoma. BMJ Case Rep. 2014 Oct 17;2014. pii: bcr2014206832. doi: 10.1136/bcr-2014-206832. PubMed PMID: 25326570; PubMed Central PMCID: PMC4202055.
4)

Utsuki S, Oka H, Suzuki S, Shimizu S, Tanizaki Y, Kondo K, Tanaka S, Kawano N, Fujii K. Pathological and clinical features of cystic and noncystic glioblastomas. Brain Tumor Pathol. 2006 Apr;23(1):29-34. PubMed PMID: 18095116.
5)

Kaur G, Bloch O, Jian BJ, Kaur R, Sughrue ME, Aghi MK, McDermott MW, Berger MS, Chang SM, Parsa AT. A critical evaluation of cystic features in primary glioblastoma as a prognostic factor for survival. J Neurosurg. 2011 Oct;115(4):754-9. doi: 10.3171/2011.5.JNS11128. Epub 2011 Jul 15. PubMed PMID: 21761969.
6)

Maldaun MV, Suki D, Lang FF, Prabhu S, Shi W, Fuller GN, Wildrick DM, Sawaya R. Cystic glioblastoma multiforme: survival outcomes in 22 cases. J Neurosurg. 2004 Jan;100(1):61-7. PubMed PMID: 14743913.

Butterfly glioma

 

Butterfly glioma is a high grade astrocytoma, usually a glioblastoma (WHO grade IV), which crosses the midline via the corpus callosum. Other white matter commissures are also occasionally involved. The term butterfly refers to the symmetric wing like extensions across the midline.

Epidemiology

Most frequently butterfly gliomas occur in the frontal lobes, crossing via the genu of the corpus callosum, however posterior butterflies are also encountered.

Differential diagnosis

Primary central nervous system lymphoma: especially in AIDS patients

cerebral toxoplasmosis: especially in AIDS patients

tumefactive demyelination

cerebral metastases (rare)

occasionally a leptomeningeal process which fills the quadrigeminal and ambient cisterns can cause confusion.

A meningioma can mimic butterfly glioma when it arises from the falx cerebri and crosses the midline. Presence of a cerebrospinal fluid intensity cleft between the tumour and adjacent brain cortex is a useful sign to identify the extra-axial location of these lesions and differentiate them from butterfly gliomas 1).

Treatment

Gliomas invading the anterior corpus callosum are commonly deemed unresectable due to an unacceptable risk/benefit ratio, including the risk of abulia.

Burks et al. in a study presents evidence that anterior butterfly gliomas can be safely removed using a novel, attention-task based, awake brain surgery technique that focuses on preserving the anatomical connectivity of the cingulum and relevant aspects of the cingulate gyrus 2).

Current management options include biopsy only, followed by radiation and chemotherapy; surgical decompression followed by radiation and chemotherapy; or biopsy followed by palliative measures (comfort care). Management decisions are subjective, based upon physician experience and/or patient/family preferences in light of the prognosis of this disease.

Outcome

The prognosis of glioblastoma multiforme (GBM) is poor even with aggressive first-line therapy, which includes surgery, radiation therapy, and adjuvant chemotherapy. Although the ideal course of treatment for elderly patients with newly diagnosed GBM is still undecided and requires further studies, the new chemotherapeutic agents administered with or without concomitant radiation therapy have shown promising results. However, in our setting, where resources are limited and newer treatment options are expensive, it is often difficult to deliver the best care to the patient 3).

Case series

2017

Burks et al. reviewed clinical data on all patients undergoing glioma surgery performed by the senior author during a 4-year period at the University of Oklahoma Health Sciences Center. Forty patients were identified who underwent surgery for butterfly gliomas. Each patient was designated as having undergone surgery either with or without the use of awake subcortical mapping and preservation of the cingulum. Data recorded on these patients included the incidence of abulia/akinetic mutism. In the context of the study findings, the authors conducted a detailed anatomical study of the cingulum and its role within the DMN using postmortem fiber tract dissections of 10 cerebral hemispheres and in vivo diffusion tractography of 10 healthy subjects.

Forty patients with butterfly gliomas were treated, 25 (62%) with standard surgical methods and 15 (38%) with awake subcortical mapping and preservation of the cingulum. One patient (1/15, 7%) experienced postoperative abulia following surgery with the cingulum-sparing technique. Greater than 90% resection was achieved in 13/15 (87%) of these patients.

This study presents evidence that anterior butterfly gliomas can be safely removed using a novel, attention-task based, awake brain surgery technique that focuses on preserving the anatomical connectivity of the cingulum and relevant aspects of the cingulate gyrus 4).

2014

Of 336 patients with newly diagnosed GBM who were operated on, 48 (14 %) presented with bGBM, where 29 (60 %) and 19 (40 %) underwent surgical resection and biopsy, respectively. In multivariate analysis, a bGBM was independently associated with poorer survival [HR (95 % CI) 1.848 (1.250-2.685), p < 0.003]. In matched-pair analysis, patients who underwent surgical resection had improved median survival than biopsy patients (7.0 vs. 3.5 months, p = 0.03). In multivariate analysis, increasing percent resection [HR (95 % CI) 0.987 (0.977-0.997), p = 0.01], radiation [HR (95 % CI) 0.431 (0.225-0.812), p = 0.009], and temozolomide [HR (95 % CI) 0.413 (0.212-0. 784), p = 0.007] were each independently associated with prolonged survival among patients with bGBM. This present study shows that while patients with bGBM have poorer prognoses compared to non-bGBM, these patients can also benefit from aggressive treatments including debulking surgery, maximal safe surgical resection, temozolomide chemotherapy, and radiation therapy 5).

2011

Median age was 59 years; 52 % were female; median preoperative Karnofsky performance score (KPS) was 80. Twelve patients underwent biopsy and eleven underwent surgical decompression. The median tumor volume for the biopsy group was 60.6 cm(3) and for the surgically decompressed group 40.5 cm(3). In the biopsy group, five patients received adjuvant therapy but one died prior to its completion; two died prior to the initiation of adjuvant therapy and five were lost to follow up. In the surgical decompression group, seven patients received adjuvant therapy, one died prior to the initiation of adjuvant therapy, two were treated with palliative measures only, and one was lost to follow up. Kaplan-Meier estimates of overall median post surgical-survival of the whole group was 180 days, the biopsy group 48 days, and the surgically decompressed group 265 days (p = 0.14). Our results show that there was a higher median survival in the surgically decompressed group; but a direct correlation could not be established, and that the median KPS did not improve in either group after treatment. A larger multicenter review is required to quantitatively assess the factors, including tumor biomarkers that are associated with patient outcome 6).

Case reports

A 54-year-old man presented with change in behaviour, nocturnal enuresis, abnormal limb movement and headache of one week’s duration. The diagnosis of butterfly glioma (glioblastoma multiforme) was made based on imaging characteristics and was further confirmed by biopsy findings. As the corpus callosum is usually resistant to infiltration by tumours, a mass that involves and crosses the corpus callosum is suggestive of an aggressive neoplasm 7).

1)

Watts J, Box G, Galvin A, et al. Magnetic resonance imaging of meningiomas: a pictorial review. Insights Imaging. 2014;5:113–22.
2) , 4)

Burks JD, Bonney PA, Conner AK, Glenn CA, Briggs RG, Battiste JD, McCoy T, O’Donoghue DL, Wu DH, Sughrue ME. A method for safelyresecting anterior butterfly gliomas: the surgical anatomy of the default mode network and the relevance of its preservation. J Neurosurg. 2017 Jun;126(6):1795-1811. doi: 10.3171/2016.5.JNS153006. Epub 2016 Sep 16. PubMed PMID: 27636183.
3)

Agrawal A. Butterfly glioma of the corpus callosum. J Cancer Res Ther. 2009 Jan-Mar;5(1):43-5. PubMed PMID: 19293489.
5)

Chaichana KL, Jusue-Torres I, Lemos AM, Gokaslan A, Cabrera-Aldana EE, Ashary A, Olivi A, Quinones-Hinojosa A. The butterfly effect on glioblastoma: is volumetric extent of resection more effective than biopsy for these tumors? J Neurooncol. 2014 Dec;120(3):625-34. doi: 10.1007/s11060-014-1597-9. Epub 2014 Sep 6. PubMed PMID: 25193022; PubMed Central PMCID: PMC4313925.
6)

Dziurzynski K, Blas-Boria D, Suki D, Cahill DP, Prabhu SS, Puduvalli V, Levine N. Butterfly glioblastomas: a retrospective review and qualitative assessment of outcomes. J Neurooncol. 2012 Sep;109(3):555-63. doi: 10.1007/s11060-012-0926-0. Epub 2012 Jul 18. PubMed PMID: 22806339; PubMed Central PMCID: PMC3992290.
7)

Krishnan V, Lim TC, Ho FC, Peh WC. Clinics in diagnostic imaging (175). Corpus callosum glioblastoma multiforme (GBM): butterfly glioma. Singapore Med J. 2017 Mar;58(3):121-125. doi: 10.11622/smedj.2017017. PubMed PMID: 28361164; PubMed Central PMCID: PMC5360865.

Sphenoid wing meningioma

It is a type of anterior skull base meningioma.

These intracranial meningiomas may be associated with hyperostosis of the sphenoid ridge and may be very invasive, spreading to the dura of the frontal, temporal, orbital, and sphenoidal regions. Medially, this tumor may expand into the wall of the cavernous sinus, anteriorly into the orbit, and laterally into the temporal bone.

Epidemiology

The relative incidence of meningiomas of the sphenoid ridge is 17%. This tumor usually arises from the lesser wing of the sphenoid bone. Sphenoid wing meningiomas, or ridge meningiomas, are the most common of the basal meningiomas.

Types

Tumors found in the external third of the sphenoid are of two types: en-plaque and globoid meningiomas.

En plaque meningiomas characteristically lead to slowly increasing proptosis with the eye angled downward. Much of this is due to reactive orbital hyperostosis. With invasion of the tumor into the orbit, diplopia is common.

Patients with globoid meningiomas often present only with signs of increased intracranial pressure. This leads to various other symptoms including headache and a swollen optic disc.

see Medial sphenoid wing meningioma or clinoidal meningioma.

see Meningioma en plaque of the sphenoid ridge.

see Sphenoorbital meningioma

Clinical Features

Tumors growing in the inner wing (clinoidal) most often cause direct damage to the optic nerve leading especially to a decrease in visual acuity, progressive loss of color vision, defects in the field of vision (especially cecocentral), and an afferent pupillary defect.

If the tumor continues to grow and push on the optic nerve, all vision will be lost in that eye as the nerve atrophies.

Proptosis, or anterior displacement of the eye, and palpebral swelling may also occur when the tumor impinges on the cavernous sinus by blocking venous return and leading to congestion. Damage to cranial nerves in the cavernous sinus leads to diplopia.

The Ophthalmic nerve (is often the first affected, leading to diplopia with lateral gaze. The patient will have pain and altered sensation over the front and top of the head.

Horner syndrome may occur if nearby sympathetic fibers are involved.

Endocrine testing is important because pituitary insufficiency has been reported to occur in 22% of patients with anterior skull base meningiomas, including thyroid stimulating hormone (TSH), follicle stimulating hormone (FSH), and luteinizing hormone (LH).

Diagnosis

Following the physical exam, the diagnosis is confirmed with neuro-imaging. Either a head CT or MRI with contrast such as gadolinium is useful, as meningiomas often show homogenous enhancement. Angiography looking for signs like stretched arteries may be used to supplement evaluation of vascular involvement and to determine whether embolization would be helpful if surgery is being considered.

On MRI imaging, T1- and T2-weighted sequences have variable signal intensity, but they enhance intensely and homogeneously after injection of gadolinium. They also tend to exhibit hyperostosis and calcifications which can be seen on either CT or MRI imaging. Additionally, the presence of a dural extension (also known as a dural tail) is helpful in distinguishing a meningioma from fibrous dysplasia.

Differential diagnosis

The differential diagnosis for sphenoid wing meningioma includes other types of tumors such as optic nerve sheath meningioma, cranial osteosarcoma, metastases, and also sarcoidosis.

Treatment

Microsurgery may be the most effective method for the large and giant medial sphenoid wing meningiomas 1).

With the improved requirement of postoperative quality of life in patients, intentional incomplete resection should be considered as an acceptable treatment option. Multivariate analysis confirmed that incomplete resection, poor blood supply, lack of adhesion or encasement of adjacent structure were independent predictive factors for favorable postoperative quality of life. An individual treatment strategy could help improved quality of life 2).

Outcome

Large and giant medial sphenoid wing meningiomas that are located deeply in the skull base where they are closely bounded by cavernous sinus, optic nerve, and internal carotid artery make the gross resection hard to achieve. Also, this kind of meningiomas is often accompanied by a series of severe complications.

For medial sphenoid wing meningiomas, visual loss and abnormalities of cranial nerves III, IV, VI, V1, and V2 may occur because the meningioma may have some degree of encasement of these structures as they ride through the cavernous sinus.

Seizures, paresis, and sensory loss may result depending on potential damage to adjacent brain parenchyma for patients with lateral sphenoid wing meningiomas.

Sphenoid wing meningiomas (SWMs) can encase arteries of the circle of Willis, increasing their susceptibility to intraoperative vascular injury and severe ischemic complications.

Case series

2017

A retrospective review of 75 patients surgically treated for SWM from 2009 to 2015 was undertaken to determine the degree of circumferential vascular encasement (0°-360°) as assessed by preoperative magnetic resonance imaging (MRI). A novel grading system describing “maximum” and “total” arterial encasement scores was created. Postoperative MRIs were reviewed for total ischemia volume measured on sequential diffusion-weighted images.

Of the 75 patients, 89.3% had some degree of vascular involvement with a median maximum encasement score of 3.0 (2.0-3.0) in the internal carotid artery (ICA), M1, M2, and A1 segments; 76% of patients had some degree of ischemia with median infarct volume of 3.75 cm 3 (0.81-9.3 cm 3 ). Univariate analysis determined risk factors associated with larger infarction volume, which were encasement of the supraclinoid ICA ( P < .001), M1 segment ( P < .001), A1 segment ( P = .015), and diabetes ( P = .019). As the maximum encasement score increased from 1 to 5 in each of the significant arterial segments, so did mean and median infarction volume ( P < .001). Risk for devastating ischemic injury >62 cm 3 was found when the ICA, M1, and A1 vessels all had ≥360° involvement ( P = .001). Residual tumor was associated with smaller infarct volumes ( P = .022). As infarction volume increased, so did modified Rankin Score at discharge ( P = .025).

Subtotal resection should be considered in SWM with significant vascular encasement of proximal arteries to limit postoperative ischemic complications 3).

2015

The clinical materials of 53 patients with sphenoid wing meningiomas treated microsurgically between January 2008 and January 2012 were analyzed retrospectively. Follow-up period ranged from 6 to 62 months (median, 34 months). Clinical outcomes including postoperative quality of life and recurrence rate were evaluated. Univariate and multivariate statistical analysis were performed among factors that might influence postoperative quality of life.

The mean age of patients was 49 years. Mean tumor size was 3.9cm. Total tumor resection was achieved in 38 cases (71.7%), subtotal in 10 cases (18.9%) and partial resection in 5 cases (9.4%). Within the follow-up period, ten patients (18.9%) had recurrence and three patients (5.7%) died. In univariate analysis, we found the postoperative Karnofshky Performance Score (KPS) improvement was determined by various factors, including extent of tumor resection, peritumoral edema, tumor blood supply, size, adhesion, encasement and preoperative KPS. However, multivariate analysis showed that complete resection, rich blood supply, adhesion to adjacent structure, encasement of neurovascular were independent predictive factors for worse postoperative KPS.

With the improved requirement of postoperative quality of life in patients, intentional incomplete resection should be considered as an acceptable treatment option. Multivariate analysis confirmed that incomplete resection, poor blood supply, lack of adhesion or encasement of adjacent structure were independent predictive factors for favorable postoperative quality of life. An individual treatment strategy could help improved quality of life 4).

Case reports

2014

Endo et al. report the utility of a pulsed water jet device in meningioma surgery. The presented case is that of a 61-year-old woman with left visual disturbance. MRI demonstrated heterogeneously enhanced mass with intratumoral hemorrhage, indicating sphenoid ridge meningioma on her left side. The tumor invaded the cavernous sinus and left optic canal, engulfing the internal carotid artery in the carotid cistern and encased middle cerebral arteries. During the operation, the pulsed water jet device was useful for dissecting the tumor away from the arteries since it was safe in light of preserving parent arteries. The jet did not cause any vascular injury and did not induce vasospasm as shown by postoperative symptomatology and MRIs. With the aid of pulsed water jet, we could achieve total resection of the tumor except for the piece within the cavernous sinus. The patient had no new neurological deficits after the operation 5).

1)

Yang J, Ma SC, Liu YH, Wei L, Zhang CY, Qi JF, Yu CJ. Large and giant medial sphenoid wing meningiomas involving vascular structures: clinical features and management experience in 53 patients. Chin Med J (Engl). 2013 Dec;126(23):4470-6. PubMed PMID: 24286409.
2) , 4)

Ouyang T, Zhang N, Wang L, Li Z, Chen J. Sphenoid wing meningiomas: Surgical strategies and evaluation of prognostic factors influencing clinical outcomes. Clin Neurol Neurosurg. 2015 May 4;134:85-90. doi: 10.1016/j.clineuro.2015.04.016. [Epub ahead of print] PubMed PMID: 25974397.
3)

McCracken DJ, Higginbotham RA, Boulter JH, Liu Y, Wells JA, Halani SH, Saindane AM, Oyesiku NM, Barrow DL, Olson JJ. Degree of Vascular Encasement in Sphenoid Wing Meningiomas Predicts Postoperative Ischemic Complications. Neurosurgery. 2017 Jun 1;80(6):957-966. doi: 10.1093/neuros/nyw134. PubMed PMID: 28327941.
5)

Endo T, Nakagawa A, Fujimura M, Sonoda Y, Shimizu H, Tominaga T. [Usefulness of pulsed water jet in dissecting sphenoid ridge meningioma while preserving arteries]. No Shinkei Geka. 2014 Nov;42(11):1019-25. doi: 10.11477/mf.1436200025. Japanese. PubMed PMID: 25351797.