Lateral sphenoid wing meningiomas

Introduction

A common location (∼20%) for meningiomas to occur is along the sphenoid wing. ^, The sphenoid wing extends from the anterior clinoid process medially to the pterional laterally, and can be divided into thirds in which meningiomas involving the medial third are referred to as clinoidal meningiomas, the middle third are referred to as middle sphenoid wing meningiomas, and the lateral third are referred to as lateral sphenoid wing meningiomas. The distinction is important because even though these lesions all involve the sphenoid wing, they involve different neurovascular structures, and therefore have different potential morbidities. Regardless, complication rates range from 20% to 40% for lesions with sphenoid wing involvement. In this chapter, we present a case of a dominant hemisphere lateral sphenoid wing meningioma.

Example case

Chief complaint: headaches

History of present illness

A 51-year-old, right-handed man with a history of hypertension, asthma, and diabetes presented with progressive headaches. For the past 3 to 4 months, he developed increasing frequency and severity of headaches that became unresponsive to pain medications. He denied any speaking problems, weakness, or visual difficulties. His primary care physician ordered a brain magnetic resonance imaging (MRI) scan ( Fig. 49.1 ).

Medications : Metoprolol, metformin, valsartan, budesonide.
Allergies : No known drug allergies.
Past medical and surgical history : Hypertension, asthma, and diabetes; femur and hand fracture.
Family history : No history of intracranial malignancies.
Social history : Insurance agent, no smoking, occasional alcohol.
Physical examination : Awake, alert, oriented to person, place, and time; Cranial nerves II to XII intact; No drift, moves all extremities with full strength.

	Peter Nakaji, MD, Barrow Neurological Institute, Phoenix, AZ, United States	Kenji Ohata, MD, PhD, Osaka City University, Osaka, Japan	Daniel M. Prevedello, MD, Ohio State University, Columbus, OH, United States	Tony Van Havenbergh, MD, PhD, GasthuisZusters Antwerpen, Antwerpen, Belgium
Preoperative
Additional tests requested	Medicine evaluation	CT, CTA, CTB Angiogram	CTA Neuropsychological assessment Ophthalmology evaluation	Neuropsychological assessment
Surgical approach selected	Left mini-pterional craniotomy	Left frontotemporal craniotomy	Left frontotemporal craniotomy	Left frontotemporal craniotomy
Anatomic corridor	Left frontotemporal	Trans-Sylvian	Left frontotemporal	Left frontotemporal
Goal of surgery	Simpson grade I	Simpson grade I	Simpson grade I	Simpson grade I
Perioperative
Positioning	Left supine with 45-degree right rotation	Left supine with 15-degree right rotation	Left supine with right head rotation	Left supine with 30-degree right rotation
Surgical equipment	Surgical navigation Surgical microscope Endoscope	Surgical navigation Surgical microscope Ultrasonic aspirator	Surgical navigation IOM (SSEP) Surgical microscope Ultrasonic aspirator	Surgical navigation IOM (EEG) Ultrasonic aspirator
Medications	Steroids	Antiepileptics	Steroids Antiepileptics Mannitol	Steroids Antiepileptics
Anatomic considerations	MCA, temporal and frontal cortex, Sylvian veins	MCA, Sylvian veins, superior orbital fissure	Orbit, MCA and branches, ICA, optic nerves, Broca area	Insular arteries, temporal cortex
Complications feared with approach chosen	MCA injury, damage to frontotemporal cortex, injury to Sylvian veins	Stroke, venous congestion	Language dysfunction, recurrence	Vascular injury, temporal cortex
Intraoperative
Anesthesia	General	General	General	General
Skin incision	Pterional	Pterional	Pterional	Pterional
Bone opening	Left frontotemporal	Left frontotemporal	Left frontotemporal	Left frontotemporal
Brain exposure	Left frontotemporal	Left frontotemporal	Left frontotemporal	Left frontotemporal
Method of resection	Incision centered over sphenoid wing with navigation, preserve STA and facial nerve branches, elevate galea, incise fascia, separate fascia from underlying muscle, split temporalis muscle along its fibers preserving innervation and blood supply, small craniotomy, drill sphenoid wing and frontotemporal bone flat past base of tumor, coagulate MMA and dura under tumor, open dura, internally debulk, microdissect tumor at all of its edges with frequent bed manipulation to allow surgeon visualization, endoscope visualization and resection for any difficult areas, resect involved dura, dural repair with dural substitute	Interfascial temporalis dissection, temporalis fascia pericranial vascularized flap, temporalis muscle turned posteroinferiorly, frontotemporal craniotomy, drill out sphenoid ridge to superior orbital fissure, coagulate MMA at foramen spinosum, dura peeled from SOF, U-shaped dural opening with incision in dura parallel to Sylvian fissure, removal of tumor around sphenoid ridge and caudal portion first, after debulking then dissect from brain surface, dissect tumor from MCA, remove dura from middle fossa as much as possible, reconstruct with pericranium	Left pterional incision, skin flap rotated anteriorly without muscle incision, subfascial incision and flap rotated anteriorly protecting frontal branch of facial nerve, left temporalis detached and rotated inferiorly, craniotomy based on navigation and exposing entire tumor base, MMA coagulated, dura is opened in the center of the tumor and tumor debulked, dura is opened around the lesion, Sylvian fissure is opened and ICA and MCA and branches are identified and protected under microscopic visualization, complete resection achieved, dura closed with allograft, insertion of subgaleal drain	Left frontotemporal craniotomy up to temporal base, dural incision around insertion zone of the tumor, dissection of arachnoidal plane at the surface of the tumor and cortex, internal debulking of tumor, dissect around tumor capsule, dural replacement with dural synthetic, drill out areas of hyperostosis if present
Complication avoidance	Bony opening past base of tumor, coagulate MMA and dural blood supply early, rolling/tilting patient to optimize visualization, endoscope to facilitate resection	Large bone opening, remove tumor from sphenoid ridge to allow tumor mobilization, dissect from MCA	Internal debulking of tumor early, Sylvian fissure opening to protect ICA and MCA	Dural incision around tumor edge, internal debulking, remove areas of bony involvement
Postoperative
Admission	ICU	ICU	ICU	ICU
Postoperative complications feared	Speech dysfunction, motor deficit	Seizures, venous congestion, stroke	Pseudomeningocele, CSF leak, seizures, aphasia	Vascular injury, seizures, cerebral edema
Follow-up testing	MRI within 48 hours after surgery	CT immediately after surgery MRI 1 week after surgery	CT immediately after surgery MRI with DWI within 24 hours after surgery	MRI within 24 hours and 2 months after the surgery
Follow-up visits	10–14 days after surgery	3–6 months after surgery	14 days after surgery for staples 6 weeks after surgery for pathology
Adjuvant therapies recommended for WHO grade	Grade I–observation Grade II–possible radiation Grade III–radiation	Grade I–observation Grade II–radiation Grade III–radiation	Grade I–observation Grade II–radiation if residual Grade III–radiation	Grade I–observation Grade II–radiation Grade III–radiation