Results with judicious modern neurosurgical management of parasagittal and falcine meningiomas

Sughrue, Michael E.; Rutkowski, Martin J.; Shangari, Gopal; Parsa, Andrew T.; Berger, Mitchel S.; McDermott, Michael W.

doi:10.3171/2010.9.jns10646

Cited by 54 publications

(77 citation statements)

References 19 publications

(31 reference statements)

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“…Vein sacrifice can therefore be safely performed only by combining temporary clipping and function monitoring. 3 With regard to the outcome data for our strategy, larger series have reported a radical resection rate of 81%-93%, 4,14,19,22 quite similar to the one presented in our study (86%). Our data are similar to those published in the literature also when focusing on the pattern of SSS invasion: resection rates of meningiomas invading or not invading the SSS have been reported in 62% and 96% of cases, respectively, in the literature, 22 and in 71% and 100%, respectively, in our experience.…”

Section: Comparison Of Our Data With Relevant Literaturesupporting

confidence: 78%

“…22,23 A recent MEDLINE review of the literature on parasagittal meningiomas published over the last 60 years reported no evidence that aggressive management presents an advantage in terms of recurrence rate. …”

mentioning

confidence: 99%

“…21 With regard to the specific topic of superior sagittal sinus (SSS) invasion, it has been reported that a small coagulated intrasinusal remnant (Simpson Grade III resection) tends to remain stable over time, 22,23 thus making acceptable the cost of leaving a small remnant within a partially occluded sinus for a safer venous outflow.…”

mentioning

confidence: 99%

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Application of indocyanine green video angiography in parasagittal meningioma surgery

Puppa

Rustemi

Gioffrè

et al. 2014

FOC

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Object There are no doubts about the role that indocyanine green video angiography (ICGVA) can play in current vascular neurosurgery. Conversely, in brain tumor surgery, and particularly in meningioma surgery, this role is still unclear. Vein management is pivotal for approaching parasagittal meningiomas, because venous preservation is strictly connected to both extent of resection and clinical outcome. The authors present the technical traits and the postoperative outcome of the application of ICGVA in patients undergoing parasagittal meningioma surgery. Methods The authors retrospectively collected demographic, radiological, intraoperative, and follow-up data in 43 patients with parasagittal meningiomas who underwent surgery with the assistance of ICGVA at Padua Neurosurgical Department between October 2010 and July 2013. Intraoperative ICGVA findings at different stages (before dural opening, after dural opening, during resection, after resection) were reviewed. Additional data on functional monitoring, temporary venous clipping, and flow measurements were also recorded. The overall postoperative outcome was evaluated by assessing both the extent of resection and the clinical outcome data. Results The ICGVA studies were performed 125 times in 43 patients, providing helpful data for vein management and tumor resection in all stages of surgery. In 16% of meningiomas completely occluding the superior sagittal sinus, the ICGVA data differed from radiological findings and changed the surgical approach. In 20% of cases the intraoperative ICGVA findings directly guided the surgical strategy: venous sacrifice was necessary in 7 cases, without postoperative consequences; temporary clipping with neurophysiological monitoring proved to be predictive of safe venous sacrifice. In 7% of cases the ICGVA data needed to be supplemented with flow measurements. Simpson Grade I–II and Grade III resections were achieved in 86% and 14% of cases, respectively, with a 4.6% rate of overall morbidity. Conclusions This study shows that ICGVA can assist the different stages of parasagittal meningiomas surgery, guiding the vein management and tumor resection strategies with a favorable final clinical outcome. However, in the authors' experience the use of other complementary tools was mandatory in selected cases to preserve functional areas. Further studies are needed to confirm that the application of ICGVA in parasagittal meningioma surgery may improve the morbidity rate, as reported in this study.

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Section: Comparison Of Our Data With Relevant Literaturesupporting

confidence: 78%

mentioning

confidence: 99%

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Application of indocyanine green video angiography in parasagittal meningioma surgery

Puppa

Rustemi

Gioffrè

et al. 2014

FOC

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“…The recurrence rate was 8.6% after a mean follow-up of 5.9 years. In a study of 55 patients with parasagittal or falcine meningiomas and partial occlusion of the superior sagittal sinus who were not good candidates for radiosurgery, Sughrue et al 47 reported subtotal resection for 22 cases in which sinus involvement was extensive. Among these cases were 8 patients who underwent radiosurgery for residual disease.…”

Section: Conservative Managementmentioning

confidence: 99%

Management of meningiomas involving the transverse or sigmoid sinus

Mazur¹,

Cutler²,

Couldwell³

et al. 2013

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Meningiomas that invade the transverse or sigmoid sinuses are uncommon tumors that are challenging to treat surgically. Although the risk of recurrence is associated with the extent of resection, complete removal of meningiomas in these locations must be balanced with avoidance of venous outflow obstruction, which could cause venous infarction and significant neurological consequences. When a meningioma occludes a venous sinus completely, gross-total resection of the intravascular portion is commonly performed. When the tumor invades but does not completely obliterate a major venous sinus, however, opinions differ on whether to accept a subtotal resection or to open the sinus, perform a complete resection, and reconstruct the venous outflow tract. In this paper, the authors review the different strategies used to treat these lesions and provide illustrative case examples.

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“…A staged approach (resection followed by radiosurgery to treat the residual meningioma) as described by Dr. Kondziolka and others seems reasonable for those patients with larger PSPF meningiomas next to a patent sinus or large draining vein; it is clear that the goal in contemporary management of disease in such patients need not be a Simpson Grade I resection. 4 Resection of tumor invading the superior sagittal sinus and reconstruction of the sinus seem less necessary given the efficacy of radiosurgery.…”

Section: Department Of Neurological Surgery University Of Virginia mentioning

confidence: 99%

Editorial: Radiosurgery for parasagittal and parafalcine meningiomas

Kondziolka¹

2013

JNS

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Ding and colleagues at the University of Virginia review their results after Gamma Knife surgery for parasagittal and parafalcine (PSPF) meningiomas.1 This analysis details outcomes in 65 patients with 90 WHO Grade I tumors with an average imaging follow-up of almost 5 years. The tumor control rate was 85% at 3 years and 70% at 5 years, which is somewhat less than other long-term radiosurgery reports in patients with Grade I meningiomas. This may reflect the fact that cranial base tumors were not included, and indeed may have a more benign course and outcome after radiosurgery. The authors note that the supratentorial tumors may be associated with higher recurrence rates due to more extensive dural tails. However, this remains unproven. The procedure was well tolerated and postradiosurgery edema was noted in only 4 patients, 3 of these sustaining only temporary symptoms. Because management for such patients is so individualized, there is not ever likely to be a randomized trial comparing meningioma resection to radiosurgery.Although the report is about both parasagittal and falcine meningiomas, the two tumor types pose somewhat different clinical challenges. In their discussion the authors link the two together. Of course, the regional venous anatomy is important for both locations. However, falcine tumors are more amenable to complete resection and less likely to have residual tumor after resection. The authors found that parasagittal tumors had a higher control rate (p = 0.031) and discuss that this may be true due to more superficial draining veins. However, it is not clear to me why this would be true, and it is not my own experience.This study and others raise the question of how initially to manage meningiomas in this location. Although some still advocate sagittal sinus resections and repair when the sinus is not completely occluded, this practice has largely been eliminated. Certainly a larger tumor with mass effect should be resected. If residual tumor remains, I favor planned radiosurgery within a few months. At the other end of the clinical spectrum is the younger patient with an incidentally identified and smaller tumor. Should this patient have radiosurgery early while the superior sagittal sinus is open, brain edema has not yet occurred, and regional veins are less compromised? Given the problems that can be caused by such tumors, and a somewhat variable natural history, close observation is certainly warranted and early radiosurgery is reasonable depending on patient goals. For tumors between 2 and 4 cm in maximum diameter, the indications for resection compared to radiosurgery can be debated. Certainly if the goal is to improve symptoms from mass effect more rapidly, then resection is optimal. The conclusion of this report-"Radiosurgery can be used as initial and adjunct therapy for PSPF meningiomas with significant sinus invasion, meningiomas that cannot be completely resected, and patients with minimal to no symptoms"-is an appropriate one. As for all complex meningiomas, the options provided t...

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Results with judicious modern neurosurgical management of parasagittal and falcine meningiomas

Abstract: Importantly, these data provide a more modern estimate of the expected outcomes that can be obtained with treatment of these tumors, in which a combination of image guidance, advanced microsurgical tools, and conformal radiation treatments is used.

Cited by 54 publications

References 19 publications

Application of indocyanine green video angiography in parasagittal meningioma surgery

Application of indocyanine green video angiography in parasagittal meningioma surgery

Management of meningiomas involving the transverse or sigmoid sinus

Editorial: Radiosurgery for parasagittal and parafalcine meningiomas

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