Management of Meningiomas Invading the Major Dural Venous Sinuses: Operative Technique, Results, and Potential Benefit for Higher Grade Tumors

Management of Meningiomas Invading the Major Dural Venous Sinuses: Operative Technique, Results, and Potential Benefit for Higher Grade Tumors

Peer-Review Reports 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 ...

4MB Sizes 0 Downloads 12 Views

Peer-Review Reports

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58

Management of Meningiomas Invading the Major Dural Venous Sinuses: Operative Technique, Results, and Potential Benefit for Higher Grade Tumors Q6

Alessandra Mantovani1, Salvatore Di Maio2, Manuel J. Ferreira1, Laligam N. Sekhar1

- OBJECTIVE:

The optimal surgical management of meningiomas involving the major venous sinuses represents a therapeutic dilemma. The decision is whether to leave a fragment of the lesion and have a higher recurrence rate, especially for World Health Organization classification II/III tumors, or to attempt total removal and potentially increase risk to the venous circulation. We present the surgical strategies we follow in managing meningiomas involving the major venous sinuses and the potential benefit of these techniques for higher grade tumors.

Key words Dural sinus - Meningioma - Parasagittal meningioma - Sinus thrombosis - Torcular Herophili - Venous reconstruction - Venous sinus occlusion - WHO grade II meningiomas -

Abbreviations and Acronyms CT: Computed tomography CTV: Computed tomography venogram MRI: Magnetic resonance imaging MRV: Magnetic resonance venography SSS: Superior sagittal sinus WHO: World Health Organization classification From the 1Department of Neurological Surgery, University of Washington, Harborview Medical Center, Seattle, Washington, USA; and 2Division of Neurosurgery, McGill University, Jewish General Hospital, Montreal, Quebec, Canada To whom correspondence should be addressed: Q1 Salvatore Di Maio, M.D.C.M. [E-mail: [email protected]] Citation: World Neurosurg. (2013). http://dx.doi.org/10.1016/j.wneu.2013.06.024 Supplementary digital content available online. Journal homepage: www.WORLDNEUROSURGERY.org Available online: www.sciencedirect.com 1878-8750/$ - see front matter ª 2013 Elsevier Inc. All rights reserved.

INTRODUCTION The optimal surgical management of meningiomas involving the major dural venous sinuses remains controversial (3, 5-7, 10, 11, 14, 17, 20, 21, 24, 33, 35, 41, 44, 47). Decision making revolves around 1) whether to pursue complete surgical resection including the portion invading the sinus, versus leaving remnants within the sinus and prescribing adjuvant radiation therapy or observation as needed; and 2) when and how to reconstruct the dural venous circulation after the meningioma has been removed. Especially in case of higher grade meningiomas (World Health Organization classification [WHO] grade II and III), the risks of an aggressive strategy must be

- METHODS:

Between 2005 and 2013, 38 patients underwent operations. Preoperative and postoperative data were retrospectively analyzed. The surgical strategies based on sinus invasion are discussed.

- RESULTS:

Meningiomas involved the superior sagittal sinus (26 patients), Torcular Herophili (5), transverse (5), or sigmoid sinus (2 patients). In 13 patients, the sinus was totally occluded, in 9 subtotally (50%e95%), and in 14 patients partially (<50%), whereas two tumors involved the outer layer of the sinus wall. Twenty-seven patients had World Health Organization classification grade I meningiomas and 11 grade II. A gross total resection was achieved in 86.9% of patients, and sinus reconstruction followed in 21 cases: 13 by direct suture and 8 using a patch. Postoperatively, the sinus was patent (52.4%), or narrow but patent (33.3%) in 85.7% of these patients. No deaths and one major postoperative complication occurred, and the mean postoperative KPS score was 88.9  15.3. Two recurrences (5.3%) occurred during a mean follow-up of 26.05 months.

- CONCLUSIONS:

The surgical strategies presented, achieving minimal morbidity, support the practice of aggressive removal of tumors invading the sinus, particularly in the case of higher grade meningiomas.

weighed against a demonstrated higher recurrence rate, as well as increased risk of tumor-related mortality (2, 36). Furthermore, the optimal strategies of preoperative evaluations, technical aspects of sinus reconstruction, and perioperative management remain to be determined. The purpose of this article is to analyze results from our consecutive surgical series of meningiomas involving the major venous sinuses, with emphasis on intraoperative decision making, on reviewing in detail the various technical options for sinus reconstruction, and on preoperative and perioperative patient management. Furthermore, we discuss the potential benefit of these techniques for higher grade tumors.

WORLD NEUROSURGERY - [-]: ---, MONTH 2013

METHODS Study Design This study was a retrospective review of all consecutive meningiomas invading the dural venous sinuses that were operated on at Haborview Medical Center in Seattle, Washington, by Laligam N. Sekhar and Manuel J. Ferreira, between September 2005 and January 2013. Concurrently, a total of 304 meningiomas were resected during the same period, including skull base, parasagittal, convexity, intraventricular, and moramen magnum meningiomas. Inclusion criteria were a histologically proven meningioma with WHO grading and involvement of a major dural venous sinus that had been diagnosed on preoperative

www.WORLDNEUROSURGERY.org

REV 5.2.0 DTD  WNEU1964_proof  30 September 2013  9:38 am  ce

1

59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102 103 104 105 106 107 108 109 110 111 112 113 114 115 116

PEER-REVIEW REPORTS ALESSANDRA MANTOVANI ET AL.

117 118 119 120 121 122 123 124 125 126 127 128 129 130 131 132 133 134 135 136 137 138 139 140 141 142 143 144 145 146 147 148 149 150 151 152 153 154 155 156 157 158 159 160 161 162 163 164 165 166 167 168 169 170 171 172 173 174

imaging and was subsequently confirmed at surgery. Patient data were obtained through chart review, including imaging and surgical dictations. Institutional review board approval was obtained for this study. Outcomes of interest included the extent of resection, postoperative sinus patency, surgical and follow-up scores. All patients underwent a preoperative magnetic resonance imaging (MRI) to determine the extent of the tumor and the degree of brain and venous sinus invasion. Patients also underwent preoperative vascular imaging in the form of digital subtraction angiography, magnetic resonance venography (MRV), or computed tomography venogram (CTV). Total removal was defined as a resection equivalent to Simpson grade I or II. Treatment Principles Our primary goals for treatment were 1) complete tumor resection and 2) avoidance of severe venous infarction or brain swelling. Preoperative evaluation is important to assess 1) the degree of occlusion of the sinus in question, 2) anatomy of sinus and associated large cortical draining veins, and 3) development of venous collaterals. Clinical findings, such as papilledema, also give an indication of the extent of venous collateralization. Patients who have a partially (<50%) occluded sinus, or minimal sinus invasion (edges only) are especially at risk for complications because the collateralization may not have had time to develop (27, 39). The best preoperative evaluation is by intraarterial digital subtraction angiography, using bilateral injections and multiple oblique views. In some patients, ipsilateral internal carotid artery injection may be supplemented with simultaneous contralateral common carotid artery compression to delineate flow through the superior sagittal sinus (SSS). Anatomic variations, such as a paired SSS or septations within the SSS, may exist and can confound interpretation of angiography. Also, flow can sometimes be found at surgery even if the sinus was angiographically occluded. For these reasons, the final decision whether to proceed is taken only after the intraoperative observation. Other factors influencing the decision to pursue tumor resection within the sinus include the patient’s age, informed consent,

2

www.SCIENCEDIRECT.com

MENINGIOMA INVADING VENOUS SINUSES

and the known or anticipated WHO meningioma grade. In general, more than age of 65 years and the patient’s life expectancy (other physiologic factors should also be considered) may not justify aggressive resection, particularly for WHO grade I tumors (1, 30). In patients with WHO grade II meningiomas, complete tumor resection is extremely important (2, 9, 12, 17, 36), and should influence the decision to perform sinus tumor removal. Our recent practice has been to offer radiotherapy to patients with WHO grade II meningiomas, even after complete tumor removal; however, the value of this practice remains controversial (2, 9, 12, 13, 15-17, 32, 36). Patients with known higher grade meningiomas may also require a radiologic staging of the neuraxis to exclude the presence of other lesions. In patients with meningiomatosis or other conditions characterized by multiple meningiomas, an aggressive strategy has no theoretical benefit. Last, all options available for tumor treatment, including radiosurgery, partial resection with observation or radiotherapy, and complete tumor removal should be discussed with the patient and family along with attendant risks and expected recurrence rates. Surgical Technique The general surgical technique involves, first, removal of all of the tumor outside of the sinus area, obtaining frozen section pathology, and then re-evaluating the surgical plan based on imaging, surgical findings, and information on histology. Once the decision to proceed is made, removal of the fragment in the sinus is performed, followed by rapid reconstruction with (usually) autologous material. Great attention is paid to preservation of the uninvolved walls of the sinus. When sinus repair is planned, the patient is started on aspirin preoperatively, and, when available, a test of antiplatelet efficacy, such as Verify Now (Accumetrics, San Diego, California, USA) is performed, and medication dose adjusted accordingly (clopidrogel may be substituted for aspirin-resistant patients). The patient is placed under balanced general anesthesia, allowing for monitoring of motor evoked potentials (when the patient has had multiple seizures preoperatively, this is not used), and somatosensory evoked responses. In selected cases, motor mapping and cranial nerve monitoring is

performed. Both a precordial Doppler probe and a central venous right atrial catheter are placed to detect and treat possible air embolisms. The patient is positioned for surgery in the supine, prone, or lateral position, depending on the location of the lesion. For lesions near the torcula or a dominant transverse sinus, a right-sided frontal ventriculostomy may be placed for intracranial pressure monitoring. Computerized neuronavigation may be used to plan the incision and craniotomy. The craniotomy encompasses the extent of the tumor and will occasionally have to be extended, based on intraoperative inspection. The craniotomy is first made on the side of the larger tumor, and then with a tangential view extended across the sinus, after separating the sinus from the inner table of the skull. The dura mater is opened away from the sinus, and flapped toward it, with careful attention to cortical veins. These drain medially into the sinus, and sometimes into a dural venous sinus before draining into the main venous sinus. The tumor is debulked on both sides of the sinus, and gradually dissected and removed from the brain. In case of the SSS, the tumor is removed from the falx cerebri (which is also resected if attached to the tumor) or, in the case of the transverse sinuses, the tentorium. Early during tumor removal a frozen section is obtained to confirm the diagnosis and provide information about the histologic grade. Once a decision is made to remove the tumor from the sinus, both large temporary clips and a balloon shunt (Pruitt Inahara Balloon Carotid Shunt, Horizon Medical, Santa Ana, California, USA) should be available on the operating scrub table, and the anesthesiologist alerted. The remainder of the surgery depends on whether the sinus is occluded or open by preoperative angiography. Occluded sinus. A short segmental occlusion (2 cm) may lend itself to removal and restitution of flow. It is very important to preserve the orifices and drainage of major draining veins. The sinus is opened through the most abnormal wall, and the tumor is progressively removed with an ultrasonic aspirator or microinstruments from the central area of obstruction toward each normal side. When venous bleeding is encountered from the normal sinus, the remaining tumor is removed from that area, and the bleeding controlled with two

WORLD NEUROSURGERY, http://dx.doi.org/10.1016/j.wneu.2013.06.024

REV 5.2.0 DTD  WNEU1964_proof  30 September 2013  9:38 am  ce

175 176 177 178 179 180 181 182 183 184 185 186 187 188 189 190 191 192 193 194 195 196 197 198 199 200 201 202 203 204 205 206 207 208 209 210 211 212 213 214 215 216 217 218 219 220 221 222 223 224 225 226 227 228 229 230 231 232

PEER-REVIEW REPORTS

Figure 1. Sinus invasion by location.

to three pieces of Surgicel (Johnson & Johnson, New Brunswick, New Jersey, USA), 2  4 cm in dimension, which have been precut and kept ready. A similar process is carried out at the other healthy end of the sinus. If the decision is made to try and reopen the occluded sinus, the most abnormal walls are excised, and reconstruction is done with a dural flap, or a free dural patch. The sutures near the terminal ends are left loose, and tied after the Surgicel pieces occluding the sinus are removed, and brisk retrograde venous bleeding should be demonstrated. After completion of suturing, patency can be checked immediately by a Doppler probe or an indocyanine green fluorescence angiography, and postoperatively by CTV. When a longer segment of the sinus is occluded, the decision is to ligate the sinus. Then it should be sutured shut, after removing the pieces of tumor near the entry sites of cortical veins, to keep them flowing. Partially Occluded Sinus. In these patients, the objective is to preserve the patent portion of the sinus and sinus walls, and repair the rest by using autologous materials. The surgeon can use preoperative measurement of sinus pressure (a 20-G needle inserted into the sinus and connected to an arterial pressure monitoring line) and check it again after temporary occlusion of the sinus for 1 minute. The opening of the sinus is done by following the path of the tumor, which allows the

MENINGIOMA INVADING VENOUS SINUSES

healthy area to be preserved. Although the distal portion (downstream from the obstruction) is occluded with Surgicel, the proximal portion of the sinus may be allowed to bleed at least partially during tumor removal and repair take place. Repair is done by using a dural patch (free patch, hinged vascularized patch, or vascularized sliding patch), pericranial patch, or, rarely, a synthetic graft material (Dacron). In case of obstruction of the torcula or the dominant venous sinus, an intraluminal shunt should be strongly considered (see illustrative case 4). Intravenous heparin (5000 units) is administered during the sinus repair. Any patient who had a sinus reconstruction with some concern about blood flow may be considered for short-term (5e7 days) heparinization, in addition to perioperative aspirin. In such patients, heparin is started during the sinus repair and continued as a drip postoperatively to maintain partial thromboplastin time at 40 to 60 seconds. Postoperative Management Antiplatelet therapy was usually continued for 3 months after surgery. Both a postoperative computed tomography (CT) scan and an MRI with and without gadolinium were obtained within 24 hours after surgery to look for a tumor remnant. A venous flow study (CTV or MRV) is also performed postoperatively to evaluate the patency of the venous system. All tumors underwent final histopathologic diagnosis and were graded according to WHO, and histopathologic subtypes of

Total Sinus occlusion (13)

WORLD NEUROSURGERY - [-]: ---, MONTH 2013

Histology

27

WHO Grade II

11

Atypical meningioma

10

Chordoid meningioma

1

WHO, World Health Organization.

meningiomas were defined for WHO grade II. A control MRI study with contrast was performed at the first outpatient visit after 6 weeks and, for the follow-up, at 3 and 12 months after surgery to look for recurrence.

RESULTS Patient Population and Tumor Characteristics From September 2005 to January 2013, 38 patients with meningiomas involving the major dural sinuses underwent surgical resection. Thirteen patients were men and 25 were women, with ages ranging from 19 to 78 years (mean [ standard deviation], 51.58  15.56 years). Thirty-four of 38 patients (89.5%) underwent preoperative cerebral angiography with bilateral internal carotid artery injection by the transfemoral arterial route, and 17 tumors were embolized; the remaining four patients underwent MRV and/or CTV.

Occluded (8)

6 Patent (2)

1 Total tumor resection (10)

Number

WHO Grade I

Sinus ligation, Global resection without any reconstruction (8)

2

Subtotal tumor resection (3)

Table 1. Tumor Histology

2

Resection of tumor + resuture (3) Narrowed (1) print & web 4C=FPO

233 234 235 236 237 238 239 240 241 242 243 244 245 246 247 248 249 250 251 252 253 254 255 256 257 258 259 260 261 262 263 264 265 266 267 268 269 270 271 272 273 274 275 276 277 278 279 280 281 282 283 284 285 286 287 288 289 290

print & web 4C=FPO

ALESSANDRA MANTOVANI ET AL.

2 Resection of tumor + patch (2)

Narrowed (2)

Figure 2. Scheme of the surgical technique adopted and results for group I.

www.WORLDNEUROSURGERY.org

REV 5.2.0 DTD  WNEU1964_proof  30 September 2013  9:38 am  ce

3

291 292 293 294 295 296 297 298 299 300 301 302 303 304 305 306 307 308 309 310 311 312 313 314 315 316 317 318 319 320 321 322 323 324 325 326 327 328 329 330 331 332 333 334 335 336 337 338 339 340 341 342 343 344 345 346 347 348

PEER-REVIEW REPORTS ALESSANDRA MANTOVANI ET AL.

Tumor Resection and Type of Sinus Reconstruction Patients were divided into four groups based on the type of sinus involvement: group I, total sinus occlusion (13 patients); group II, subtotal sinus occlusion (9 patients; subtotal occlusion was defined as invasion of 50%e 95% of the sinus lumen, with evidence of sinus patency preoperatively); group III, partial sinus occlusion (14 patients; partial invasion was defined as less than 50% occlusion of the lumen); group IV, lesion attached only to the outer layer of the sinus wall (2 patients). Results for group I (total sinus occlusion) are shown in Figure 2. In five patients the sinus was reopened and reconstructed, three by direct suture and two using a patch, with 100% of postoperative sinus patency (the sinus was completely patent in two patients, and patent with some narrowing in the remaining three patients).

4

www.SCIENCEDIRECT.com

Sinus ligation, global resection without any reconstruction (1)

1

Subtotal Sinus Occlusion (9)

Total tumor Resection (8)

Occluded (1)

Occluded (1) 5

Resection of tumor +patch (5)

2

Narrowed (1) Patent (3)

Subtotal resection (1)

Resection of the tumor + Resuture (3)

Occluded (1) (total resection)

Narrowed (2) (1 total, 1 subtotal resection)

print & web 4C=FPO

Meningiomas included in the study were those involving the SSS, the transverse sinuses, the Torcular Herophili, or the sigmoid sinuses. Six (15.8%) of the tumors involved the anterior third of the SSS, 14 (36.9%), the middle third, two (5.3%) were large tumors involving both the anterior and middle part of the SSS, and four (10.5%), the posterior third. Five lesions (13.1%) involved the transverse sinuses: two on the left, three on the right. Five tumors (13.1%) arose from the Torcular Herophili, two of them invading the posterior part of the SSS, two invading the right transverse sinus. Two tumors (5.3%) involved the right sigmoid sinus (Figure 1). Thirty-three patients (86.9%) had a total (Simpson grade I or II) resection of the tumor, whereas five patients (13.1%) had a subtotal resection (Simpson grade III or greater). Of these five subtotal resections, three patients were more than 60 years-old and had a lesion involving the middle or posterior part of the SSS, therefore a fragment was left to avoid major complications. The remaining two patients presented meningiomatosis cerebri and multiple diffuse meningiomas, therefore there was no theoretical benefit to total removal of the tumor. As indicated in Table 1, 27 of 38 patients (71%) had WHO grade I meningiomas, whereas 11 patients (29%) had a WHO grade II meningioma.

Figure 3. Scheme of the surgical technique adopted and results for group II.

In eight of nine patients with subtotal sinus occlusion (group II; Figure 3), the invaded sinus was resected and then reconstructed with either primary resuturing (n ¼ 3) or using a patch (five patients: three using dura mater, one with galea, and one with a Gore-Tex patch [DuPont, Wilmington, Delaware, USA]). In six of eight patients (75%) the sinus was postoperatively patent (completely patent in three patients, narrowed in the other three). In the remaining patient, the sinus was occluded without venous reconstruction, given the lack of any brain swelling or hemorrhage after 30 minutes of temporary occlusion. Figure 4 shows results for group III (sinus invasion <50%). A gross total removal of

1

Partial Occlusion (14)

Gross Total resection (13)

Partial resection (1)

the tumor was achieved in 13 of 14 patients, and the sinus was opened and reconstructed in 11 patients. Postoperatively, 10 of 11 patients (91%) had sinus patency and only 1 patient had a sinus occlusion. The remaining two patients with involvement of only the outer layer of the sinus (group IV) were treated with sharp dissection of the outer sinus wall to healthy tissue layers, without obvious entry or involvement of the sinus lumen, and coagulation of the remaining sinus wall (Figure 5). Postoperative results about sinus patency are shown in Table 2. Twenty-one patients underwent total tumor resection and venous sinus reconstruction, 13 by direct suture and 8 using a patch. Of these patients, the sinus was patent (52.4%), or

Resection of tumor + patch (1)

Narrowed(1)

Peeling of the outside layer (3)

Patent (3)

Q2

3

Patent (7) 9

Resection of the tumor + Resuture (10)

1

(6 total, 1 partial resection)

Narrower (2) (2 total resection)

Occluded(1) (total resection)

Figure 4. Scheme of the surgical technique adopted and results for group III.

WORLD NEUROSURGERY, http://dx.doi.org/10.1016/j.wneu.2013.06.024

REV 5.2.0 DTD  WNEU1964_proof  30 September 2013  9:38 am  ce

print & web 4C=FPO

349 350 351 352 353 354 355 356 357 358 359 360 361 362 363 364 365 366 367 368 369 370 371 372 373 374 375 376 377 378 379 380 381 382 383 384 385 386 387 388 389 390 391 392 393 394 395 396 397 398 399 400 401 402 403 404 405 406

MENINGIOMA INVADING VENOUS SINUSES

407 408 409 410 411 412 413 414 415 416 417 418 419 420 421 422 423 424 425 426 427 428 429 430 431 432 433 434 435 436 437 438 439 440 441 442 443 444 445 446 447 448 449 450 451 452 453 454 455 456 457 458 459 460 461 462 463 464

PEER-REVIEW REPORTS

465 466 467 468 469 470 471 472 473 474 475 476 477 478 479 480 481 482 483 484 485 486 487 488 489 490 491 492 493 494 495 496 497 498 499 500 501 502 503 504 505 506 507 508 509 510 511 512 513 514 515 516 517 518 519 520 521 522

print & web 4C=FPO

ALESSANDRA MANTOVANI ET AL.

Only outer layer of the sinus wall involved (2)

MENINGIOMA INVADING VENOUS SINUSES

Peeling of the outside layer (2)

Narrowed, as preoperatively (2)

Figure 5. Scheme of the surgical technique adopted and results for group IV.

narrowed but patent (33.3%) in a total of 85.7% of cases. Two of three patients with postoperative sinus occlusion had no related complication, due to the presence of collateral venous pathways. The remaining patient developed focal right hand seizures in the postoperative period, which responded to antiepileptics. No significant difference in postoperative sinus patency was found between WHO grade I and II meningiomas. Intraoperative and Postoperative Complications Intraoperative and postoperative complications are shown in Table 3. There were no deaths, and one patient had complications, such as brain swelling and intraventricular hemorrhage, related to the sinus reconstruction. This 46-year-old woman had a torcular and left occipital-tentorial meningioma, subtotally occluding the nondominant left transverse and straight sinuses. She underwent a bilateral occipital and suboccipital craniotomy and craniectomy and total removal of the meningioma, including the part of tumor inside the sinuses. The left

Table 2. Postoperative Patency of Sinus Repair Procedure Complete tumor resection and sinus reconstruction Patch (dura, galea, Gore-Tex) Direct suture Postoperative sinus patency (MRV, CTV, angiogram) Sinus patent Sinus narrowed Sinus occluded

transverse and straight sinuses were reconstructed by using a dural flap, as well as a free dural graft, and patency was checked intraoperatively by Doppler. Despite that she had brain swelling, as well as an intraventicular hemorrhage and hydrocephalus, therefore a larger occipital craniotomy and suboccipital decompressive craniectomy were performed and a right frontal ventriculostomy was placed. She made a complete recovery. A postoperative angiography showed patency of both the left transverse and the straight sinuses, previously occluded (see illustrative case 3). Three patients developed postoperative seizures, which were controlled by medical therapy. Two of these had patency of the sinus on postoperative imaging, whereas the second patient had complete patency of the middle segment of the SSS, which was invaded by the tumor and repaired. However, the segment of sinus immediately anterior showed evidence of thrombus formation, without other clinical or radiologic sequelae. One patient with a frontoparietal meningioma invading the midportion of the SSS developed a left hemiparesis postoperatively. He had a history of childhood radiation, meningiomatosis, and multiple intracranial aneurysms. He also had right hemispheric ischemia from

Number of Patients 21

Table 3. Intraoperative and Postoperative Complications

8 13 Number (%) 11/21 (52.4) 7/21 (33.3) 3/21 (14.3)

MRV, magnetic resonance venography; CTV, computed tomography venogram.

Type of Complication None

Number (%) 23 (60.5)

Brain swelling, venous infarction

1 (2.6)

Neurological (deficits, seizures)

5 (13.1)

Systemic

1 (2.6)

CSF or wound related

9 (23.7)

Death

0 (0)

CSF, cerebrospinal fluid.

WORLD NEUROSURGERY - [-]: ---, MONTH 2013

chronic middle cerebral artery occlusion with prior infarction. It was evident on preoperative imaging that some of the blood supply to the left-sided parasagittal meningioma was going across to feed the right hemisphere, and it was believed that the postoperative worsening of his left hemiparesis was secondary to interruption of this right hemispheric supply. He ultimately underwent an external carotid artery-to-middle cerebral artery bypass using a radial artery graft. His clinical condition improved subsequently. Outcomes and Recurrence Rate Six weeks after surgery, the imaging confirmed the presence of a residual in patients with subtotal resection (n ¼ 5). No residuals were noted in patients with total resection. There was no significant difference between the mean preoperative KPS score (86.1  12.9) and the postoperative score (88.9  15.3; P ¼ 0.257). A postoperative KPS >70 was achieved in 35 of 38 patients (92.1%). The mean follow-up for the entire cohort was 26.05 months. During this period, there were two recurrences: one in a patient at 3 months, the other one at 6 years after surgery. The first recurrence was in a 72-year-old woman with a recurrent large frontoparietal parasagittal meningioma, WHO grade II (atypical histology), occluding the anterior and middle thirds of the SSS. She had previously been operated on at another institution for a large parasagittal meningioma, with considerable deterioration of her neurological condition after that surgery. When she presented at our institution with an extensive tumor regrowth and further clinical deterioration, surgery and radiotherapy were discussed, and the patient decided to undergo surgical resection of the tumor. A complete tumor resection was achieved, but despite this she developed frank recurrent disease at 3 months, for which she underwent palliative whole brain radiation therapy, and died at 1 year postoperatively from progressive neurological decline. The second recurrence was in a 31-yearold man with a history of a giant left parietal meningioma, WHO grade I, involving the middle part of the SSS. He presented with several episodes of numbness and seizures and underwent a total resection of the tumor and a sinus repair

www.WORLDNEUROSURGERY.org

REV 5.2.0 DTD  WNEU1964_proof  30 September 2013  9:38 am  ce

5

Q3

523 524 525 526 527 528 529 530 531 532 533 534 535 536 537 538 539 540 541 542 543 544 545 546 547 548 549 550 551 552 553 554 555 556 557 558 559 560 561 562 563 564 565 566 567 568 569 570 571 572 573 574 575 576 577 578 579 580

PEER-REVIEW REPORTS ALESSANDRA MANTOVANI ET AL.

581 582 583 584 585 586 587 588 589 590 591 592 593 594 595 596 597 598 599 600 601 602 603 604 605 606 607 608 609 610 611 612 613 614 615 616 617 618 619 620 621 622 623 624 625 626 627 628 629 630 631 632 633 634 635 636 637 638

MENINGIOMA INVADING VENOUS SINUSES

cerebellum was draining into the left transverse sinus. After discussing the options, the patient decided on a surgical resection. She underwent a bilateral occipital and suboccipital craniotomy and craniectomy and Illustrative Case 2 total removal of the meningioma, including This 55-year-old woman presented with the part of tumor inside the sinuses a generalized seizure. Her MRI disclosed (Video 1). We found the tumor arose inside a large right parieto-occipital meningioma the Torcular Herophili, and extended invading the brain and partially occluding through the dura toward the left occipital the posterior part of the SSS, as further lobe, invading it. This extrasinus tumor was demonstrated by the preoperative angioIllustrative Case 1 removed, and followed into the sinus. The gram (Figure 9). She underwent a right This 47-year-old woman presented with hole in the dura was repaired with a dural parieto-occipital stereotactic craniotomy persistent occipital headaches after flap from the left occipital dura. There was and total microsurgical resection of the a minor automobile accident. A torcular more tumor inside the torcular, invading the tumor. The SSS was opened and reconmeningioma was found with partial posterior dural wall, which was excised. The structed by using a direct suture. The postobstruction of the left transverse sinus part of the tumor obstructing operative imaging showed no (Figure 6). Observation, surgical resection, the left transverse and the tumor residual and a patent and radiotherapy were discussed with the straight sinuses was completely SSS. The patient recovered well patient and she decided on a complete removed. There was a septum and was discharged home surgical resection. The tumor was totally between the two transverse without any complication or removed, including the portion within the Video available at sinuses, and no connection WORLDNEUROSURGERY.org neurological deficit. At the torcular, by a bioccipital and suboccipital with the uninvolved right follow-up visit, 6 weeks after craniotomy. The left transverse sinus transverse sinus. This portion of the sinus surgery, the MRI and MRV showed no tumor adjacent to the torcular was opened and was repaired with a free dural patch from the residual and a complete patency of the a temporary occlusion was done with suboccipital area (Figure 13). The patency of sinuses (Figure 10). Surgicel (Johnson & Johnson). The sinus the sinuses was checked intraoperatively by was reconstructed with a patch of galea Doppler. After the posterior fossa dural Illustrative Case 3 (Figure 7). Postoperative imaging showed defect was repaired, the left occipital lobe This 46-year-old woman presented with complete removal of the tumor and and cerebellum suddenly developed severe frontal headaches and was incidentally a patent sinus. During recovery she had swelling, necessitating a larger occipital discovered to have a torcular and left occipno neurological deficits. A pseudomecraniotomy and suboccipital decompressive ital-tentorial WHO grade I meningioma ningocele was resolved with a lumbar craniectomy. The patient was on aspirin and (Figure 11). The preoperative angiogram drainage and the patient, doing well, was her platelet count was low, therefore she had showed a subtotal occlusion of the discharged home. At the follow-up visit 1 a platelet transfusion. A further Doppler nondominant left transverse sinus and an year after surgery the patient was normal control checked the patency of all the veins occlusion of the straight sinus, with retro(KPS 100), her MRI demonstrated no and sinuses involved, and this was grade flow (Figure 12). However, the residual enhancement, and the MRV confirmed by an intraoperative CT scan and CTV. However, an emergent right frontal ventriculostomy was placed because the CT scan also showed an intraventicular hemorrhage and hydrocephalus, and the bone flap was left out (Figure 14). After the surgery, the patient recovered and, after 1 week, underwent an autologous cranioplasty and a right frontal VP shunt. The postoperative angiogram showed narrowed, but patent left transverse and straight sinuses (Figure 15). She was discharged home after a short stay in inpatient rehabilitation. At the follow-up visit 6 weeks after surgery the patient did well and her MRI showed no tumor residual (Figure 16). This case illustrates the worse complication in our series. It is believed that Figure 6. Preoperative images for illustrative case 1. (A) Coronal T1-weighted magnetic resonance during closure there was a transient image with gadolinium showing the torcular meningioma. (B) Venous phase angiogram showing obstruction of the left transverse sinus. a partial invasion of the left transverse sinus. This finding, combined with a low platelet by direct suture. Postoperatively, the MRV showed a narrowed, but patent sinus in the region of the tumor resection. He had no complications or complaints during the following years and the follow-up MRI presented no clear signs of recurrence. Six years after surgery, the patient presented with seizures and his MRI showed a tumor regrowth.

6

www.SCIENCEDIRECT.com

showed a complete patency of the torcular region, and the left transverse sinus (Figure 8).

WORLD NEUROSURGERY, http://dx.doi.org/10.1016/j.wneu.2013.06.024

REV 5.2.0 DTD  WNEU1964_proof  30 September 2013  9:38 am  ce

Q4

639 640 641 642 643 644 645 646 647 648 649 650 651 652 653 654 655 656 657 658 659 660 661 662 663 664 665 666 667 668 669 670 671 672 673 674 675 676 677 678 679 680 681 682 683 684 685 686 687 688 689 690 691 692 693 694 695 696

PEER-REVIEW REPORTS

697 698 699 700 701 702 703 704 705 706 707 708 709 710 711 712 713 714 715 716 717 718 719 720 721 722 723 724 725 726 727 728 729 730 731 732 733 734 735 736 737 738 739 740 741 742 743 744 745 746 747 748 749 750 751 752 753 754

MENINGIOMA INVADING VENOUS SINUSES

print & web 4C=FPO

ALESSANDRA MANTOVANI ET AL.

Figure 7. Description of the surgical procedure for case 1. (A) The large posterior fossa meningioma partially invading the left transverse sinus and the torcula; the dura mater was opened in an L-shaped fashion on the left side in the occipital area to allow a more superior view of the sinus should this become necessary. (B) The sinus was opened for the total tumor

count and the aspirin, may have caused the intraventricular hemorrhage. Illustrative Case 4 This 65-year-old woman started to hear a pulsatile tinnitus in the right ear and this led to the discovery of a WHO grade I right occipital meningioma, subtotally occluding the dominant right transverse sinus at the sigmoid sinus junction (Figure 17). Because of the subtotal occlusion of a dominant

excision (arrows), and a temporary occlusion done with Surgicel. (C) A piece of pericranium is taken for the sinus reconstruction. This was sutured circumferentially to the defect and the Surgicel rolls were removed so as to allow flow into the area that was previously obstructed.

sinus, she underwent a right occipital and suboccipital craniotomy and craniectomy with partial mastoidectomy. Intraoperatively, it was apparent that the tumor was growing into the transverse sinus, therefore a balloon shunt (Pruitt Inahara Balloon Carotid Shunt, Horizon Medical, Santa Ana, California, USA) was inserted on either side and inflated. The patient was given 2500 units of heparin and she was on aspirin preoperatively. The tumor was completely

removed and the transverse sinus reconstructed using a dural patch. A microDoppler probe was used to verify the flow through the sinuses (Video 2). The patient recovered well and the postoperative images (MRI and angiogram) showed no residual tumor, as well as patency of the sinuses (Figure 18). Despite placement of the balloon shunt, there was a considerable leakage of blood around the shunt tube, requiring Surgicel (Johnson & Johnson) packing and blood transfusion. A better shunt needs to be designed for sinus repairs. DISCUSSION

Figure 8. At 1-year follow-up for case 1. (A) Axial T1-weighted magnetic resonance image with gadolinium showing no residual. (B) Axial magnetic resonance venography showing patent venous sinuses.

WORLD NEUROSURGERY - [-]: ---, MONTH 2013

The optimal management of meningiomas involving the major venous sinuses represents a therapeutic dilemma. The primary issue is whether to leave residual tumor within the involved sinus at the possible expense of a higher rate of recurrence (28, 34, 41, 46) or attempt total tumor removal, and potentially risk venous infarction, and even death. Opponents of aggressive resection cite a more severe complication profile, including intracranial hypertension, cerebral edema, and venous infarction, leading to neurological dysfunction, seizures, and possibly death. Therefore, the rate of iatrogenic venous thrombosis from aggressive resection and failure to adequately

www.WORLDNEUROSURGERY.org

REV 5.2.0 DTD  WNEU1964_proof  30 September 2013  9:38 am  ce

7

755 756 757 758 759 760 761 762 763 764 765 766 767 768 769 770 771 772 773 774 775 776 777 778 779 780 781 782 783 784 785 786 787 788 789 790 791 792 793 794 795 796 797 798 799 800 801 802 803 804 805 806 807 808 809 810 811 812

PEER-REVIEW REPORTS ALESSANDRA MANTOVANI ET AL.

813 814 815 816 817 818 819 820 821 822 823 824 825 826 827 828 829 830 831 832 833 834 835 836 837 838 839 840 841 842 843 844 845 846 847 848 849 850 851 852 853 854 855 856 857 858 859 860 861 862 863 864 865 866 867 868 869 870

MENINGIOMA INVADING VENOUS SINUSES

Figure 9. Preoperative images for illustrative case 2. (A) Sagittal T1-weighted magnetic resonance image with gadolinium showing the parieto-occipital meningioma invading the posterior part of the superior sagittal sinus (SSS). (B) Sagittal venous phase angiogram showing a partial invasion of the posterior SSS.

reconstruct the sinus needs to be compared with a potential rate of spontaneous sinus occlusion related to tumor residual. Particularly for WHO grade II or III meningiomas, complete surgical resection leads to a lower recurrence rate compared with subtotal resection with or without the addition of radiation therapy (2, 36). When preoperative imaging suggests a higher grade tumor that is then confirmed by intraoperative frozen sectioning, an aggressive removal may need to be performed. This applies to a substantial proportion of these tumors, especially those in younger patients. Various treatment paradigms have been proposed by different investigators, based

primarily on the location and extent of sinus involvement (3, 5-7, 10, 11, 14, 17, 20, 21, 24, 27, 33, 35, 39, 41, 44, 47). In the case of total sinus occlusion, particularly if collateral venous channels have developed, many surgeons agree that complete removal of the tumor, including the segment of the invaded sinus, can be performed safely. Typically, this does not require venous flow restoration (10, 29, 33). Nevertheless, relevant delayed complications can occur (27, 43, 44), including brain swelling or venous infarction. A more controversial issue is what to do in the setting of partial invasion of the sinus. Several investigators consider sinus patency to be a contraindication to

Figure 10. At 6-week follow-up for case 2. (A) Sagittal T1-weighted magnetic resonance image with gadolinium showing no residual. (B) Sagittal magnetic resonance venography showing patent venous sinuses.

8

www.SCIENCEDIRECT.com

aggressive resection (6, 35). After a conservative approach, the residual tumor may thus be observed, or stereotactically irradiated either initially or at the time of recurrence (4, 8, 18, 19, 23, 37, 45). In recent literature, Caroli et al. (6) presented a large series of meningiomas involving the SSS, in which they support en bloc resection only when the sinus is completely occluded, and partial resection followed by an eventual reintervention in patients with meningioma with partial SSS infiltration. Mean time to recurrence was 5.4 years after Simpson grade I removal, and 4.7 years after grade II or III removal. No operative mortality is described in this series, but data regarding postoperative complications are limited. Conversely, more aggressive strategies are presented in different articles. Sindou and Alvernia (44) presented a series of 100 consecutive cases of meningiomas involving the major dural sinuses. They argue that venous sinus reconstruction after radical tumor removal is mandatory when the sinus is partially invaded, and potentially useful even in cases of complete occlusion to restore flow that may be compromised by underdeveloped compensatory collateral channels. A mortality rate of 3% and venous-related morbidity of 8% was observed in this series. In a mean follow-up period of 8 years, four patients developed recurrence, two of whom had WHO grade II meningiomas. DiMeco et al. (10) published their results in 108 patients with meningiomas invading the SSS. They advocate radical resection and sinus entry with primary suture repair in the setting of partial sinus invasion, while the sinus can be taken entirely in case of complete occlusion. They reported severe brain swelling in 9 of 108 patients (8.3%) and postoperative hematoma in 2 (1.85%). Although 5-year recurrence-free survival was similar across Simpson grade I-IV resections, 10-year recurrence-free survival was 86.5% in patients with Simpson grade I removal, compared with 76% and 51% for Simpson grade II and IV resections, respectively (P ¼ 0.03). The surgical strategy adopted is not so clear in the study by Raza et al. (35). They presented a series of 61 parasagittal meningiomas involving the SSS. They follow a policy of total tumor removal when feasible. In more difficult cases, they advocate a partial resection and treatment of the residual tumor with radiosurgery.

WORLD NEUROSURGERY, http://dx.doi.org/10.1016/j.wneu.2013.06.024

REV 5.2.0 DTD  WNEU1964_proof  30 September 2013  9:38 am  ce

871 872 873 874 875 876 877 878 879 880 881 882 883 884 885 886 887 888 889 890 891 892 893 894 895 896 897 898 899 900 901 902 903 904 905 906 907 908 909 910 911 912 913 914 915 916 917 918 919 920 921 922 923 924 925 926 927 928

PEER-REVIEW REPORTS ALESSANDRA MANTOVANI ET AL.

929 930 931 932 933 934 935 936 937 938 939 940 941 942 943 944 945 946 947 948 949 950 951 952 953 954 955 956 957 958 959 960 961 962 963 964 965 966 967 968 969 970 971 972 973 974 975 976 977 978 979 980 981 982 983 984 985 986

MENINGIOMA INVADING VENOUS SINUSES

Figure 11. Preoperative magnetic resonance image for case 3. Sagittal (A) and axial (B) T1-weighted magnetic resonance images with gadolinium and

The overall mortality rate was 1.5% and the rate of postoperative cerebral venous thrombosis and/or infarction was 7%. Recurrences occurred in 11% of patients after a mean follow-up period of 45 months. No delayed complications from radiosurgery of residual tumor were observed. However, the inhomogeneous nature of the series due to the involvement of multiple surgeons makes it difficult to identify a common treatment paradigm. A few studies specifically address radiation therapy outcomes for meningiomas involving the dural venous sinuses in selected cases (18, 19, 31). The results of these series suggest that patients with

coronal T2-weighted image (C) showing the torcular and left occipital-tentorial meningioma arising from the confluence of sinuses.

smaller tumors may benefit from radiosurgery. However, there are limited data regarding long-term recurrence and the incidence of delayed sinus stenosis or occlusion and associated neurological complications. The philosophy followed in our series was to attempt a total tumor removal whenever possible, with careful preservation of the venous circulation and restoration of venous flow either with primary suture or patching. Important features of this series are use of a dural or pericranial patches for the repair, preservation of at least one-third of the dural wall of the sinus, and sinus occlusion with oxidized

Figure 12. Preoperative venous phase angiogram for case 3, showing a subtotal occlusion of the nondominant left transverse sinus and an occlusion of the straight sinus, with retrograde flow. (A) Left vertebral

WORLD NEUROSURGERY - [-]: ---, MONTH 2013

cellulose, which allows for some leakage of blood in most cases. Although not used extensively, intrasinus pressure monitoring, close observation of the brain for swelling (this often occurs after a delay and, thus, should not be relied upon as the only sign), and the use of an intraluminal shunt can make the operations safer. Most patients with subtotal or total sinus occlusion by tumor have developed some venous collaterals, thus allowing a temporary occlusion. The high rate of postoperative sinus patency confirms that our approach, using antiplatelet therapy and autologous materials for repair is a good one.

injection, coronal view. (B) Left internal cerebral artery injection, sagittal view. (C) Right internal cerebral artery injection, coronal view.

www.WORLDNEUROSURGERY.org

REV 5.2.0 DTD  WNEU1964_proof  30 September 2013  9:38 am  ce

9

987 988 989 990 991 992 993 994 995 996 997 998 999 1000 1001 1002 1003 1004 1005 1006 1007 1008 1009 1010 1011 1012 1013 1014 1015 1016 1017 1018 1019 1020 1021 1022 1023 1024 1025 1026 1027 1028 1029 1030 1031 1032 1033 1034 1035 1036 1037 1038 1039 1040 1041 1042 1043 1044

PEER-REVIEW REPORTS ALESSANDRA MANTOVANI ET AL.

Figure 13. Description of the surgical procedure for case 3. (A) The tumor arose inside the Torcular Herophili, and extended through the dura toward the left occipital lobe, invading it. (B) The extrasinus part of the tumor was removed first, and then the tumor was followed into the sinus and the torcular region. (C) The dural hole was repaired using a free dural patch. (D) The part of the meningioma obstructing the left transverse and the straight sinuses was completely removed, as well as the posterior dural wall, invaded by the tumor. (E) The meningioma was completely removed and the sinus wall repaired using a dural flap.

print & web 4C/FPO

1045 1046 1047 1048 1049 1050 1051 1052 1053 1054 1055 1056 1057 1058 1059 1060 1061 1062 1063 1064 1065 1066 1067 1068 1069 1070 1071 1072 1073 1074 1075 1076 1077 1078 1079 1080 1081 1082 1083 1084 1085 1086 1087 1088 1089 1090 1091 1092 1093 1094 1095 1096 1097 1098 1099 1100 1101 1102

MENINGIOMA INVADING VENOUS SINUSES

In our series, 29% of meningiomas were WHO grade II, for which a total removal is extremely important for a longterm tumor control. Furthermore, our results demonstrate that, in case of a partial sinus invasion, preserving the unaffected sinus walls with reconstruction using a small

Figure 14. Intraoperative computed tomography (CT) scan for case 3. Axial CT image showing intraventricular hemorrhage and some brain swelling. The bone flap was left out.

10

www.SCIENCEDIRECT.com

autologous patch leads to favorable results in terms of postoperative sinus patency and a low rate of associated complications. In these circumstances, patients are carefully followed for a longer time to assess a permanent sinus patency. Although delayed complications related to sinus

reconstruction would not be expected, a longer follow-up is nevertheless required to confirm a permanent sinus patency. Our series, as presented, is considerably smaller than some others in the literature, but some of the technical nuances we introduce have allowed us to obtain

Figure 15. Postoperative venous phase angiogram images for case 3, showing narrowed, but patent left transverse and straight sinuses. (A) Right internal cerebral artery injection, sagittal view. (B) Left vertebral artery, coronal view.

WORLD NEUROSURGERY, http://dx.doi.org/10.1016/j.wneu.2013.06.024

REV 5.2.0 DTD  WNEU1964_proof  30 September 2013  9:38 am  ce

1103 1104 1105 1106 1107 1108 1109 1110 1111 1112 1113 1114 1115 1116 1117 1118 1119 1120 1121 1122 1123 1124 1125 1126 1127 1128 1129 1130 1131 1132 1133 1134 1135 1136 1137 1138 1139 1140 1141 1142 1143 1144 1145 1146 1147 1148 1149 1150 1151 1152 1153 1154 1155 1156 1157 1158 1159 1160

PEER-REVIEW REPORTS ALESSANDRA MANTOVANI ET AL.

1161 1162 1163 1164 1165 1166 1167 1168 1169 1170 1171 1172 1173 1174 1175 1176 1177 1178 1179 1180 1181 1182 1183 1184 1185 1186 1187 1188 1189 1190 1191 1192 1193 1194 1195 1196 1197 1198 1199 1200 1201 1202 1203 1204 1205 1206 1207 1208 1209 1210 1211 1212 1213 1214 1215 1216 1217 1218

Figure 16. Postoperative sagittal T1-weighted magnetic resonance image with gadolinium at 6 weeks after surgery, showing no tumor residual.

satisfactory results in terms of clinical and functional outcome (35/38 patients had a postoperative KPS>70) and a remarkable low postoperative complication profile. In fact, the strategy we adopted did not increase the mortality and morbidity rate. In our series there are no deaths, and only one patient (2.6%) had a major complication, related to sinus reconstruction and venous damage. Several factors may have contributed to a lower complication rate: 1) the preoperative management strategy, based on the described factors, emphasizing the importance of accurate angiographic evaluations; 2) technical aspects, such as allowing the sinus to back-bleed partially from the proximal end during a rapid reconstruction, to prevent sinus or vein thrombosis; 3)

MENINGIOMA INVADING VENOUS SINUSES

attempted sinus reconstruction in nearly all patients, including certain cases with complete segmental sinus occlusion, and venous pressure; 4) the adoption of an antiplatelet therapy protocol and, when needed, postoperative anticoagulation; 5) neurophysiologic and venous pressure monitoring in selected patients during temporary sinus occlusion; and 6) the implementation of a new meningioma classification system based on the degree of venous sinus invasion. In fact, although didactic classification schemes based on the extent of sinus wall(s) involvement have been proposed (5, 22, 42, 43), we consider the degree of lumen invasion (total, subtotal when 50%e95%, partial if <50%) to be a more practical and clinically relevant factor influencing the decision making about the venous reconstruction. The various techniques for reconstruction implemented in our series are described in detail, and the results showed by postoperative vascular studies are satisfactory. The sinus was patent (52.4%), or narrow but patent (33.3%) in a total of 85.7% of the patients. In three patients (one with patch and two with direct suture) the sinus was occluded but without postoperative sequelae, such as brain swelling or venous infarction or hematoma, because of the presence of a compensatory collateral venous circulation. This was well known before the sinus reconstruction was attempted. The presence of a collateral venous pathway, as well as the sinus anatomy and dominance, assessed on

Figure 17. Preoperative images for case 4. (A) Sagittal T1-weighted magnetic resonance image with gadolinium showing the meningioma invading the right transverse sinus, at the sigmoid sinus junction. (B)

WORLD NEUROSURGERY - [-]: ---, MONTH 2013

preoperative angiography and confirmed with the intraoperative observation, must be carefully considered for deciding whether to attempt a sinus reconstruction in certain patients. Several techniques for sinus reconstruction have been described in detail in previous reports (5, 21, 25-27, 38-40), including the utilization of venous grafts or Gore-Tex tubes (27, 39, 42, 44), which have been associated with early thrombosis (15, 42). Similarly, angiographic results of autologous venous grafting show an appreciable risk of thrombosis (42, 44). Results in our series are partially attributable to the absence of venous grafting and the use of autologous materials for patching the sinus, starting from the preserved uninvolved sinus wall. The surgical technique presented has allowed us to obtain a complete resection of tumors with minimal morbidity. This is extremely important for more aggressive meningiomas that carry a consistent high recurrence rate and an increased tumorrelated mortality (2). Also, radiation therapy, radiosurgery, and other adjuvant therapies are less effective in reducing recurrence in higher grade meningiomas that are not completely removed (36). The natural history of these tumors when weighed against the risks associated with attempted complete removal appears to favor a more aggressive surgical strategy, especially for younger patients. In terms of recurrence rate, in the series presented here a complete surgical resection was accomplished in 33 of 38 patients

Coronal magnetic resonance venography image. (C) Venous phase angiogram, showing subtotal occlusion of the dominant right transverse sinus (arrow).

www.WORLDNEUROSURGERY.org

REV 5.2.0 DTD  WNEU1964_proof  30 September 2013  9:38 am  ce

11

1219 1220 1221 1222 1223 1224 1225 1226 1227 1228 1229 1230 1231 1232 1233 1234 1235 1236 1237 1238 1239 1240 1241 1242 1243 1244 1245 1246 1247 1248 1249 1250 1251 1252 1253 1254 1255 1256 1257 1258 1259 1260 1261 1262 1263 1264 1265 1266 1267 1268 1269 1270 1271 1272 1273 1274 1275 1276

PEER-REVIEW REPORTS ALESSANDRA MANTOVANI ET AL.

1277 1278 1279 1280 1281 1282 1283 1284 1285 1286 1287 1288 1289 1290 1291 1292 1293 1294 1295 1296 1297 1298 1299 1300 1301 1302 1303 1304 1305 1306 1307 1308 1309 1310 1311 1312 1313 1314 1315 1316 1317 1318 1319 1320 1321 1322 1323 1324 1325 1326 1327 1328 1329 1330 1331 1332 1333 1334

MENINGIOMA INVADING VENOUS SINUSES

sinus: surgical considerations of 328 cases. Neurosurg Rev 29:236-241, 2006. 7. Chan RC, Thompson GB: Morbidity, mortality, and quality of life following surgery for intracranial meningiomas. A retrospective study in 257 cases. J Neurosurg 60:52-60, 1984. 8. Chin LS, Szerlip NJ, Regine WF: Stereotactic radiosurgery for meningiomas. Neurosurg Focus 14:e6, 2003. 9. Condra KS, Buatti JM, Mendenhall WM, Friedman WA, Marcus RB Jr, Rhoton AL: Benign meningiomas: primary treatment selection affects survival. Int J Radiat Oncol Biol Phys 39:427-436, 1997.

Figure 18. Postoperative images for case 4. (A) Axial T1-weighted magnetic resonance image with gadolinium showing no residual. (B) Coronal venous phase angiogram, showing a patent right transverse sinus.

(86.9%) and there were only two recurrences (5.3%) after a mean follow-up of 26.05 months. Although the study is limited by a relatively short follow-up period, due to the recent interval of treatment (2005e2013), and cannot be compared with the long-term recurrence rates presented in the literature. There are reasons to expect a long-term freedom from tumor recurrence. These include the high rate of complete tumor resection and routine use of adjuvant radiation therapy in histologically more aggressive meningiomas, even after complete tumor removal.

The surgical strategies we follow in managing meningiomas involving the major venous sinuses are presented. Our low complication profile supports a practice of aggressive removal of tumor invading the sinus, with the goal of preventing long-term recurrence, particularly in the case of histologically aggressive meningiomas. Specific technical nuances have contributed to satisfactory results, such as leading the sinus to backbleed during a rapid repair, preservation of the uninvolved walls, sinus reconstruction with autologous materials, and a classification scheme based on the degree of sinus lumen invasion, which is relevant in our decision making about surgical strategy. In the setting of subtotal or partial sinus occlusion preoperatively, we recommend tumor clearance and repair by suture or a small patch. Total sinus invasion can be managed

www.SCIENCEDIRECT.com

11. Giombini S, Solero CL, Lasio G, Morello G: Immediate and late outcome of operations for Parasagittal and falx meningiomas. Report of 342 cases. Surg Neurol 21:427-435, 1984. 12. Goyal LK, Suh JH, Mohan DS, Prayson RA, Lee J, Barnett GH: Local control and overall survival in atypical meningioma: a retrospective study. Int J Radiat Oncol Biol Phys 46:57-61, 2000.

ACKNOWLEDGMENTS

13. Harris AE, Lee JY, Omalu B, Flickinger JC, Kondziolka D, Lunsford LD: The effect of radiosurgery during management of aggressive meningiomas. Surg Neurol 60:298-305 [discussion 305], 2003.

James Pridgeon, M.H.A., edited the manuscript. The illustrations were prepared by Jennifer Pryll, medical illustrator.

14. Hoessly GF, Olivecrona H: Report on 280 cases of verified parasagittal meningioma. J Neurosurg 12: 614-626, 1955.

REFERENCES 1. Aghi M, Barker FG 2nd: Benign adult brain tumors: an evidence-based medicine review. Prog Neurol Surg 19:80-96, 2006.

CONCLUSION

12

with segmental resection. Alternatively, especially in cases of short segment occlusion, the sinus may be reconstructed to reestablish flow. A perioperative antiplatelet therapy protocol and/or anticoagulation are almost always implemented when a venous sinus repair is performed.

10. DiMeco F, Li KW, Casali C, Ciceri E, Giombini S, Filippini G, Broggi G, Solero CL: Meningiomas invading the superior sagittal sinus: surgical experience in 108 cases. Neurosurgery 55: 1263-1272 [discussion 1272-1274], 2004.

2. Aghi MK, Carter BS, Cosgrove GR, Ojemann RG, Amin-Hanjani S, Martuza RL, Curry WT Jr, Barker FG 2nd: Long-term recurrence rates of atypical meningiomas after gross total resection with or without postoperative adjuvant radiation. Neurosurgery 64:56-60 [discussion 60], 2009. 3. Baird M, Gallagher PJ: Recurrent intracranial and spinal meningiomas: clinical and histological features. Clin Neuropathol 8:41-44, 1989. 4. Bauman GS, Wong E: Re: new radiotherapy technologies for meningiomas: 3D conformal radiotherapy? Radiosurgery? Sterotactic radiotherapy? Intensity modulated radiotherapy? Proton beam radiotherapy? Spot scanning proton radiation therapy? Or nothing at all? [Radiother Oncol 2004; 71(3):247-249]. Radiother Oncol 73:251-252, 2004.

15. Huffmann BC, Reinacher PC, Gilsbach JM: Gamma knife surgery for atypical meningiomas. J Neurosurg 102 (Suppl):283-286, 2005. 16. Hug EB, Devries A, Thornton AF, Munzenride JE, Pardo FS, Hedley-Whyte ET, Bussiere MR, Ojemann R: Management of atypical and malignant meningiomas: role of high-dose, 3D-conformal radiation therapy. J Neurooncol 48:151-160, 2000. 17. Jaaskelainen J: Seemingly complete removal of histologically benign intracranial meningioma: late recurrence rate and factors predicting recurrence in 657 patients. A multivariate analysis. Surg Neurol 26:461-469, 1986. 18. Kondziolka D, Flickinger JC, Perez B: Judicious resection and/or radiosurgery for parasagittal meningiomas: outcomes from a multicenter review. Gamma Knife Meningioma Study Group. Neurosurgery 43:405-413 [discussion 413-414], 1998.

5. Bonnal J, Brotchi J: Surgery of the superior sagittal sinus in parasagittal meningiomas. J Neurosurg 48:935-945, 1978.

19. Kondziolka D, Nathoo N, Flickinger JC, Niranjan A, Maitz AH, Lunsford LD: Long-term results after radiosurgery for benign intracranial tumors. Neurosurgery 53:815-821 [discussion 821822], 2003.

6. Caroli E, Orlando ER, Mastronardi L, Ferrante L: Meningiomas infiltrating the superior sagittal

20. Kropp F, La Motta A, Landucci C, Sagratella S, Scarano P: Recurrence of parasagittal

WORLD NEUROSURGERY, http://dx.doi.org/10.1016/j.wneu.2013.06.024

REV 5.2.0 DTD  WNEU1964_proof  30 September 2013  9:38 am  ce

1335 1336 1337 1338 1339 1340 1341 1342 1343 1344 1345 1346 1347 1348 1349 1350 1351 1352 1353 1354 1355 1356 1357 1358 1359 1360 1361 1362 1363 1364 1365 1366 1367 1368 1369 1370 1371 1372 1373 1374 1375 1376 1377 1378 1379 1380 1381 1382 1383 1384 1385 1386 1387 1388 1389 1390 1391 1392

PEER-REVIEW REPORTS ALESSANDRA MANTOVANI ET AL.

1393 1394 1395 1396 1397 1398 1399 1400 1401 1402 1403 1404 1405 1406 1407 1408 1409 1410 1411 1412 1413 1414 1415 1416 1417 1418 1419 1420 1421 1422 1423 1424 1425 1426 1427 1428 1429 1430 1431 1432 1433 1434 1435 1436 1437 1438 1439 1440 1441

meningioma after surgical treatment. Riv Neurobiol 24:236-242, 1978. Q5

MENINGIOMA INVADING VENOUS SINUSES

21. Logue: Parasagittal meningiomas. Adv Techn Stand Neurosurg 2:171-198, 1975.

32. Pearson BE, Markert JM, Fisher WS, Guthrie BL, Fiveash JB, Palmer CA, Riley K: Hitting a moving target: evolution of a treatment paradigm for atypical meningiomas amid changing diagnostic criteria. Neurosurg Focus 24:E3, 2008.

22. Merrem G: Parasaggital meningiomas. Fedor Krause memorial lecture. Acta Neurochir (Wien) 23:203-216, 1970.

33. Philippon J, Bataini JP, Cornu P, Grob R, Kujas M, Poisson M, Rivierez M: Recurrent meningioma. Neurochirurgie 32 (Suppl 1):1-84, 1986.

23. Mirimanoff RO: New radiotherapy technologies for meningiomas: 3D conformal radiotherapy? Radiosurgery? Stereotactic radiotherapy? Intensity-modulated radiotherapy? Proton beam radiotherapy? Spot scanning proton radiation therapy. or nothing at all? Radiother Oncol 71: 247-249, 2004.

34. Pollock BE, Stafford SL, Utter A, Giannini C, Schreiner SA: Stereotactic radiosurgery provides equivalent tumor control to Simpson Grade 1 resection for patients with small- to medium-size meningiomas. Int J Radiat Oncol Biol Phys 55: 1000-1005, 2003.

24. Mirimanoff RO, Dosoretz DE, Linggood RM, Ojemann RG, Martuza RL: Meningioma: analysis of recurrence and progression following neurosurgical resection. J Neurosurg 62:18-24, 1985.

35. Raza SM, Gallia GL, Brem H, Weingart JD, Long DM, Olivi A: Perioperative and long-term outcomes from the management of parasagittal meningiomas invading the superior sagittal sinus. Neurosurgery 67:885-893 [discussion 893], 2010.

25. Morita A, Sekhar LN: Reconstruction of the vein of Labbe by using a short saphenous vein bypass graft. Technical note. J Neurosurg 89:671-675, 1998.

36. Rogers L, Gilbert M, Vogelbaum MA: Intracranial meningiomas of atypical (WHO grade II) histology. J Neurooncol 99:393-405, 2010.

26. Murata J, Sawamura Y, Saito H, Abe H: Resection of a recurrent parasagittal meningioma with cortical vein anastomosis: technical note. Surg Neurol 48:592-595 [discussion 595-597], 1997. 27. Natarajan SK, Sekhar LN: Venous reconstruction in the management of intracranial meningiomas. In: Lee JH, ed. Meningiomas. London: SpringerVerlag; 2008:603-618. 28. Obeid F, Al-Mefty O: Recurrence of olfactory groove meningiomas. Neurosurgery 53:534-542 [discussion 542-543], 2003. 29. Oka K, Go Y, Kimura H, Tomonaga M: Obstruction of the superior sagittal sinus caused by parasagittal meningiomas: the role of collateral venous pathways. J Neurosurg 81:520-524, 1994. 30. Oya S, Kim SH, Sade B, Lee JH: The natural history of intracranial meningiomas. J Neurosurg 114:1250-1256, 2011. 31. Pamir MN, Peker S, Kilic T, Sengoz M: Efficacy of gamma-knife surgery for treating meningiomas that involve the superior sagittal sinus. Zentralbl Neurochir 68:73-78, 2007.

37. Rogers L, Jensen R, Perry A: Chasing your dural tail: Factors predicting local tumor control after gamma knife stereotactic radiosurgery for benign intracranial meningiomas: In regard to DiBiase et al. (Int J Radiat Oncol Biol Phys 2004;60:15151519). Int J Radiat Oncol Biol Phys 62:616-618 [author reply 618-619], 2005. 38. Schmid-Elsaesser R, Steiger HJ, Yousry T, Seelos KC, Reulen HJ: Radical resection of meningiomas and arteriovenous fistulas involving critical dural sinus segments: experience with intraoperative sinus pressure monitoring and elective sinus reconstruction in 10 patients. Neurosurgery 41:1005-1016 [discussion 1016-1018], 1997. 39. Sekhar LN, Chanda A, Morita A: The preservation and reconstruction of cerebral veins and sinuses. J Clin Neurosci 9:391-399, 2002. 40. Sekhar LN, Duff JM, Kalavakonda C, Olding M: Cerebral revascularization using radial artery grafts for the treatment of complex intracranial aneurysms: techniques and outcomes for 17 patients. Neurosurgery 49:646-658 [discussion 658-659], 2001.

WORLD NEUROSURGERY - [-]: ---, MONTH 2013

41. Simpson D: The recurrence of intracranial meningiomas after surgical treatment. J Neurol Neurosurg Psychiatry 20:22-39, 1957. 42. Sindou M: Meningiomas invading the sagittal or transverse sinuses, resection with venous reconstruction. J Clin Neurosci 8 (Suppl 1):8-11, 2001. 43. Sindou M, Auque J: The intracranial venous system as a neurosurgeon’s perspective. Adv Tech Stand Neurosurg 26:131-216, 2000. 44. Sindou MP, Alvernia JE: Results of attempted radical tumor removal and venous repair in 100 consecutive meningiomas involving the major dural sinuses. J Neurosurg 105:514-525, 2006. 45. Stafford SL, Pollock BE, Foote RL, Link MJ, Gorman DA, Schomberg PJ, Leavitt JA: Meningioma radiosurgery: tumor control, outcomes, and complications among 190 consecutive patients. Neurosurgery 49:1029-1037 [discussion 1037-1038], 2001. 46. Strassner C, Buhl R, Mehdorn HM: Recurrence of intracranial meningiomas: did better methods of diagnosis and surgical treatment change the outcome in the last 30 years? Neurol Res 31: 478-482, 2009. 47. Yamashita J, Handa H, Iwaki K, Abe M: Recurrence of intracranial meningiomas, with special reference to radiotherapy. Surg Neurol 14:33-40, 1980.

Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. Received 14 March 2013; accepted 29 June 2013 Citation: World Neurosurg. (2013). http://dx.doi.org/10.1016/j.wneu.2013.06.024 Journal homepage: www.WORLDNEUROSURGERY.org Available online: www.sciencedirect.com 1878-8750/$ - see front matter ª 2013 Elsevier Inc. All rights reserved.

www.WORLDNEUROSURGERY.org

REV 5.2.0 DTD  WNEU1964_proof  30 September 2013  9:38 am  ce

13

1442 1443 1444 1445 1446 1447 1448 1449 1450 1451 1452 1453 1454 1455 1456 1457 1458 1459 1460 1461 1462 1463 1464 1465 1466 1467 1468 1469 1470 1471 1472 1473 1474 1475 1476 1477 1478 1479 1480 1481 1482 1483 1484 1485 1486 1487 1488 1489 1490