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Papers of the Week

2020 May 13

World Neurosurg

Resection of Invasive Sphenoorbital and Cavernous Sinus Meningioma via Frontotemporal Craniotomy.


Cohen MA, Cannon RB, Couldwell WT
World Neurosurg. 2020 May 13.
PMID: 32416238.


Spheno-orbital meningiomas require extensive bone removal around the superior and lateral orbital walls, superior orbital fissure, and anterior middle fossa floor. Incomplete resection can lead to recurrence or growth into the cavernous sinus (CS). This case involved a 46-year-old woman with history of childhood leukemia treated with chemotherapy and whole-body radiation. After presenting to an outside institution in 2004 with headache and vision changes, she underwent subtotal resection for a right spheno-orbital meningioma. As residual tumor growth caused progressive optic neuropathy, she underwent multiple orbital decompressions and fractionated radiation for the tumor. In 2017, she underwent another craniotomy for re-resection. Additional tumor growth causing neuropathic facial pain syndrome and progressive ophthalmoplegia was treated with orbital enucleation. Upon referral to our institution, MRI demonstrated right spheno-orbital and CS meningioma extending into the sella and nearly to the medial border of the contralateral CS. Given her complete ophthalmoplegia and recent orbital enucleation, the patient underwent a revision right frontotemporal craniotomy for radical resection of invasive meningioma including right internal carotid artery occlusion and CS resection. The skull-base defect was repaired with autologous fascia and free muscle flap. Postoperative transient aphasia and left hemiparesis resolved over several days. At 1-month follow-up, she was neurologically intact and had moderate improvement in her facial pain syndrome (preoperative pain score 9/10, postoperative pain score 6/10). MRI demonstrated gross-total resection. Pathological tissue analysis was consistent with a grade 1 meningioma with increased MIB-1 proliferative index, although clinically this tumor behaved more malignantly. The patient provided consent.