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Microsurgical management of suprasellar and intraventricular meningiomas P. Conforti. A. Moraci, V. Albanese. M. Rotonde. C. Pariato Instituteor Neurosurgery, t" Faculty of Medicine. Unlversity of'Naples . Italy

Introduction

Aseries of 78 intracranial meningio mas (68 suprasellar, 10 intraventricular) wer e operated on in our Institute afte r the advent of the ope rating microsco pe. In Dur review , we discuss the microsurgical technical prob lems related to the preservation of vascular and brain structures in the rem oval of intravent ricular and parasellar meningiomas. Basicdiagnostic criteria to plan correctly th e su rgical a pproac h will be emphasized .

Mortality and morbidity in paraseHar meningiomas is, in Dur opinion . related to the ex perience of th e surgeo n in using the operating microscope rath er then in using the la ser a nd CUSA. We will a lso discuss th e utility of preoperative em bolization of the les ion as we Ilas the ind ica tions for intra oper a tive EC/ IC bypass. Fina lly, morb idity and mortality related to ditTeren t ap proach es for intraventricular meningiom as will be discuss ed. Mikr och iru rgische T he rapi e s up rasellä rer un d int ra ventrikulärer Meningiom e In unser er Klinik wurden 78 int rak ranielle Meningiome (68 sup raselläre, 10 intraventrikulä rel mikroch iru rgisch operiert. In dieser Arbeit werd en die technischen m ikrochirurgischen Problem e bes prochen in bezug auf die Schonung der vaskulären und de r Hirnst ru kture n bei der En tfernung de r intraventrikulären und suprasellä ren Men ingiome. Es ist unumgänglich , daß gru ndlegende diagnostische Unters uch unge n für die korrekt e Oper ati on spla nu ng durch geführt we rde n. Mort alität und Morbidität be i pa rasellären Meningiomen sind na ch unserer Meinung abhän gig von der Erfah rung des Chirurgen sowohl im Umgang mit dem Operationsmikros kop als auch in der Benutzung von Las er und CUSA. Es wird ebe nso die Nützlichkeit pr ä operativer Embolisation wi e auch die Indikation für intrao pe ra tiven EClIC-bypass diskutier t. Schließlich we rden Morbidi tät und Mortalität der intraventriku lären Men ingi om e in Abhängigkeit von den ver schi ed enen operativen Zugängen besprochen . Key-Word s Micr osur gery - Meningioma, parasellar Meningiom a, intravent ricular - Mortality

Neurochirurgia 34 (199 1) 85-89 © Georg ThiemeVerlagStuttgart . New York

This pap er describes 68 suprasellar rnenin giomas an d 10 meningiomas of the lateral ve ntrieles . Suprase llar meningiomas accou nt for approximately 4 to 10 % of all int racranial men ingiomas. They often involve the anterio r visual pathways and are cornmon ly the ca use of vision failure . The locati on of these men ingiomas is proximal to the opti c apparatus an d to the major vessels, an d the ir hard consistency has made them a conside rable challenge for the neu rosu rgeo n. Men ingiomas of the lateral vent rieles a re unco mmo n tumors . They represe nt about 2 %of all intracranial meningiomas. We have evaluated our own resea rch w ith these suprasellar and intraventricular lesion s to ass es s wha t effect, if any , tumo r size, duration of symptoms, use of rnicr osurgery, la ser and CUSA have on su rgical resu lts , emphasizing a t a ll tim es the imp ortance of early dia gnosis to tr eatment. Our se ries reports minimal opera tive rnortalit y an d mo rbidity. We attribute th is principa lly to the use ofthe ope ra ting microseope. whic h greatly facilita tes surgical techniques.

Case m aterial 78 patients with intracranial meningiomas have been evaluated in this study. They represent 24 %orthe total of 320 cases. ofwh ich 68 were suprasellar tumors, 10 were Intraventricular meningiornas. All patien ts un derw en t s urgical treat ment. Of't he 78 patients. 67.3 %were fernale. The youngest patlent was a 30year old woman whlle the oldest was a 74-year-old wom an . Most patients wcre between 40 and 60 years of age .

Suprasella r men lngtoma s C/inicalfe at ures

In th e series of 68 sup rasella r meni ngiomas, tumors a rising from the tub er culum se llae. jugum, diaphragma se llae , medi al plan um sphenoid, and cave rnous sin us wer e exami ne d (Ta ble 1). Clinical sym ptoms a re descri bed in Ta ble 2 a nd a re divided int o ophthalmo logical a nd ne urologica l symptoms with visual loss in 95 % and changes in visua l fields in 56 %. Amo ng neu rologieal features headache was noted in 59 % of ca ses , mental deterioration in 13 %. and motor deficiencies in 10 %. The mo st cornmon complaint on admission was that of visual loss a nd changes in visu al fields in one or both eyes . Visu al 1055 was insidious at the onset and steadily progressive.

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Summa ry

P. Conf orti. A. Mora ci. V. Albanese. At. Rotondo. C. Parlato

Neuro chlrurqiu 34 (199 1) Tab. I

Suprasellar Meningiomas

tumor IDeation

cases I total I partial I morremoval removal tahty

tuberculum Sellae jugum diaphragma sellae sphenoid ridge (medial) cavemous Sinus

22 14 3 24 5 68

total cases

I 22

14 3 16 55 (80%)

i

I

8 5 13 (19%)

3 1 1 4 2

I morI re bidity covery I

I

2 1

17 12 2 16 1

4 2 11 9 48 (16%) (13%) (70%)

Tab.2 Symptoms recorded on admtssion on 68 patients with Suprasel1ar Meningiomas

ophtalmological symptoms

N.

neurological

N.

%

This technique is followed at the same intervention or three or four days later.

No substantial difTerence was noted in ernbolized cases, but conclusi ons cannot be drawn as the number of cases is too few [th ree ca ses),

symptoms

65 8 3 fundi alteration 38 visual fields changes 25 Foster-Kennedy Syndrome 4

visualloss oculomotor palsy exophthalmos

%

lar structures, particularly in meningiomas arising from the inner th ird and med ial sphe noid rid ge and th e cave rnous sinus . Seleclive angiography is also requ ired for embolizing the branches of the external carotid . even in the same radiological exa rnination: occlusion of the superficial tempor al a rtery, which could potent ially be us ed for a bypass, shou ld be avo ide d if Ihe surgical closure of th e int ernal ca ro tid a nd the middle cerebra l artery is for eseen .

95 12 4 56 37 6

headache 40 mental detenoration 9 motor deficits 7 sensorydeficits 2 tngeminal pain 6 sceech difficulty 2 endocrine dysfunction 2

incontinence cizziness

2 6

59 13 10 3 9 3 3 3 9

whereas in a few cases, vision deteriorated more acutely. Headache wa s the next most commo n symptome. Other sym pto ms were far less common: The y inclu ded menlal changes in 9 cases: oculomotor palsy in eight; dizziness in six : trigeminal pain in slx: Foster-Kennedy syndrome in four . Endoc rine dysfu nclion was recorded in only two pati ents : in one decreased libido a nd lack of ene rgy we re noted one year a fter th e onset of visu al complai nts , whil e in Ihe othe r a me no rrhea/ga lactorrhea developed 15 months aft er th e onset of visua l symptom s.

Diagnosti c invest igations Diagnosis was performed with CT-Scan, angiog ra phy, a nd recently with MRI. In some cases the internat carotid is occluded by the tu mor . Skull roentgen ogr ams were eva luated in all 68 cases of suprasellar meningiomas and ab no rm alities were dis cove red in 46 cases (67 %). Hyperost otic changes were noted in 28 cases, erosion of the dorsum sellae in 11, erosion of the sphe noid al plan um in three, sup ra se lla r calcilica lion in live a nd enla rge ment ofthe se lla turci ca in two. CT-Scan - both with a nd without centrast wa s ca r rie d out in 49 cases (72 %). In all cases a n isodense or slightly hyperden se mass was visua lized in the suprasella r area which strongly enhance d on administration of contrast medium. Hydrocephalu s was present in two cases. Angiogr aphy was perform ed in 60 cases a nd abnormalities we re noted in 96% ofthem . The most common linding was va scula r dis plac ement. A tumor biush was pres ent in 18 ca ses . Seieclive angiography is ind isp ensable for an evaluation of the relation between tumors and vascu-

It seems more important to use the bypass tec hn ique whe n there is th e possibility of the med ia l andJor internat arterial closure. In patients who hav e undergone the bypass and the closure oft he internal carotid (4 cases oftumors of one third int erna l sphe noid rid ge), the re wer e no neu rologtcal deficits, excep t in one case were there was a transitory loss .

Surgical procedur e The pterional a pproa ch is pr eferabie eve n if th e tum or is extended cont ra laterally. Usually the syivia n cistern is opened to obtain an undamaged displacement of the frontal lobe. Particular care and attention is given to the temporal veins so as not to create vascular alterations. This is very important in preventing post-operative edema and strake. Microcoagulation is currently used in preference to the laser, es pecia lly in crucial stages of the intervention (surgical isolation of the internal carotid and of its bra nches and dissection of the optic nerv e). Wit h the a id of the operative microsco pe and microcoagulation , vascular and nervous st ruclures can be protecled (ph oto I A-B).

CUSA (ultrasonic aspiration) is also useful (but not ind ispe nsable), especially in soft meningiomas in the most delicate stages or when th ere are sm all fragments attached to the vessels , to the thi rd cranial nerv e, or to th e diencephalon. Meningiomas of the cavernous sinus were nev er tota lly removed , and Ihere was a high mortality rate (2 of 5 cases) as weIl as one recovery without neurological delicit (l of 5 cases). In on e case of alm ost total rem ova l, surviving without deficit, a pseudoaneurysm of the intracavernous siphon was located in a man of 67 yea rs old : he is doing weil afte r 18 months. In 24 patients with meningiomas ofthe medial sphenoi d rid ge, a total rem oval was perfor med in 16 ca ses and partial removal in 8 cases , with mortality in 4 cases. 4 cases underwent a bypass with good results, after closure ofthe internal carotid. It is useful to mention these cases but it is not possible to draw conclusions from them . We would like to emphasized the pa rticu larly rare meningiomas arising from the se lla r diaphragma, because they must be removed with specia l care and atten-

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86

Microsurgical management 01 suprasellar and intraventricular meningiomas

Neurochirurgia 34 (1991)

87

Abb.lb Abb.la

Abb.2a

tion to prevent damage to the optic nerves and their vascularisation and to avoid the destruction of the pituitary stalk. There do not seem to be controversial problems in meningiomas of th e jugum, which can be removed totally with a complete recovery in the majority of cases . Major attention and more accurate diss eetion must be appIied to meningiomas of the tuberculum because of their more posterior Iocation and because of their closer relationsh ip to the anterior communicating and the anterior cerebral arteries . ln one case there was a small laceration of the A, segment ofthe left anterior cerebral artery whi ch was repaired with suspension ofl ocal circulation for 12 minutes and suture (3 nylon 11-0), with ren ewal of circulation and without cere bral damage and with barbiturate prot ection . These meningiomas are difficult to remove, especially when th ey ar e voluminous. Modern methods of early diagnosis can help in the surgery of small tumors.

Results (Table 1) Among 68 cases of suprasellar men inglomas, total removal was achieved in 55 cases (80 %). In 13 (19 %) cases optic nerve involvement andlo r severe vascular involvement predude tota l excision for fear of dam aging these important structures : cavernous sinus (5 casesl, medial sph enoid ridge (8 cases) . There were eleven deaths during the first postoperative da ys giving a 16 % mortality rate. Morbidity following surg ery occurred in 9 cases (13 %). Anosmia was present in one case, confusiona l state in 3 cases . Diabetes insipidus was seen in 2 cases , transient 3 rd nerve palsy in 3 cases. Visual function was improved in 40 cases (59 %), unchanged in 16 cases (23 %), wors ened in 9 cas es (13%). Of57 cases surviving of the operation nine were lost to the follow-up review. The remaining were followed in the clinic for an averag e of 6.5 years (ran ge 6 months to 13

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Abb.2b

P. Confo rti. A. Moraci. V. Alba nese. M. Rotondo. C. Parlat o

Neurochirurgia 34 (1991)

yea rs). Reeurrenee was noted in four of the 13 eases with partial reseeti on.

Tab.3 Intraventricular Meningiomas

------ -=-- --I mortality --------tumor I cases- I-total I partial Imorbidity recovery removal removal

location

Intraventricular meningiomas Clinicalfeatures This series consists of 10 cases of total removal of intrav entricula r meningiomas (Tahl e 3). The CTSca n has been a grea t help to neurosurgery. giving greater information to the neurosurgeon. Often pati ent s with few c1inical fea tures have large intraventrieular meningiomas. The elinieal features of these patients are shown in Table 4..

The most common mode of presentation in this se ries includ ed symptoms relat ed to intracranial hyper tension. All patients eomplained of progressive or inte rmit tent headach es . Six patients presented mental deterioration including aggressive behaviour, eonfabulation, and memory disturbances. These mental disturbanees were quantifia ble by the use ofpsychometric testing. We a re in agree me nt with othe r autho rs as to th e non specificity of c1inical signs and symptoms ofth ese tumors. Diaqnostic investigations

CT-Sca n pictures a re often meanin gful for the diagn osis ofloca tion a nd type. particularly ifthe cho roida l peduncle displ aced from the mass can be seen .

In our series skull roentgenograms showed no abnormalities in 6 cases , but sellar changes consistent with increased intraeranial pressure were discovered in 4 ca ses . Com puted tomogra phy was perform ed in 8 of our cases a nd the site of th e tum or wa s ea sily detected in all of them . Angiograp hy rem ains indisp ensa ble for the visua lisation of the tum or vascularizati on . of the choro idal peduncle, a nd of the vesse ls attached to the menin giomas. It was performed in 9 eases . 6 patients underwent a four vessels study. The rationale for this derives from the fact that most tumors obtain their vaseular sup ply from bot h a nterior and posterior choro ida l circula tion. Surqical pro cedure

Various faetors eondition the results of the re moval of these me ningiomas. The least damaging approaches are: the posterior pa rietal occipita! - the posteri or middle temp oral gyros - an d the posterior middle frontal gyrus, in relat ion to the locati on a nd the greatest developm ent of the mass. The posterior pa rietal occipita l a pproac h renders the leas t neurological losses a nd a greater possihility to encompass th e mass and th e vascular ped uncl e.

Microsurgery and bipolar microeoagulation have redueed the mo rtality rate even if the operative tim e is longer . The use of ultrasoni c as pirato r (CUSA) rather th a n th e laser , is

frontal homs I bodies trigone temporal homs ocoprtet horns total cases

1 3

I

1

5 1 10

I

I

I

I

1

3

1

2

5 1

2

3

3 (30%)

6 (60%)

10 (100%)

1 (10%)

Tab.4 Symptoms recorded onadmission on10Intraventricular Meningiomas Symptoms N. ot cases headache

corticospinal disturbances homonymous hemianopsia papilJ oedema gart disturbances speech difficutty

parietalseeta t disturbances parietalsensory disturbances diuiness

10

7 6 5 4 3

I I 3

very useful in this type of surgery. Intraventricular tumors even if very voluminous are not usually vaseularized. Their rem oval must be executed in fragment s (piece by piece) so as to localize the vascular peduncle. Large tumors ean be removed in the same way. Particular attention in this type of tumor must be given to the control of intraoperative edema and arterial pressure. Resulls

These ten cases are aUofthe lateral ventricles: all un derwent tota l removal with recovery in 6 cases, with neurologicallosses of slight degree in 3 cases a nd with only one mort ality (Tahle 3). One very significant cas e is report ed with CT-Sca n follow up afte r 1 yea r (Photo 2 A-B). Concl usions We should Iike to conclude by sta ting th at the surgery of suprasellar and intraventri cular meningiomas is actually easier today. We must adrnit , however, tha ti t remains a type ofs urgery ofgreat com plexity and with many difflcult techn ica! pr oblem s to resolve, particularly when the mass involves arte ries, nerves, and structures.

Microsurgery and microcoagulation have rende red thi s type of surgery more accessible, an d some adva nta ges can be gained from use of CUSA a nd the laser. Th e results, however, still depend on the following principles: ea rly and particulari zed diagnosis surgical st ra tegy and correct a pproac h microneurosurgical experience anesthes ia. and post-operative intensive care

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Microsurgica/ management 0/ suprase //ar and intruoentricuiar meningiomas

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Prof P. Conforti Institute of Neurosurge ry ,