Surgical management of ocular symptoms in spheno-orbital meningiomas. Is orbital reconstruction really necessary?

Abstract

Spheno-orbital meningioma (SOM) is an intriguing tumor because of the many different factors that can influence clinical and oncological outcome after treatment. Reasoning that outcome indicator measurement is key to improving therapy, we retrospectively evaluated the management of proptosis and other ocular symptoms in 47 patients surgically treated for SOM at our department in the last 10 years. This patient series was characterized by a high rate of tumor infiltration of the extradural cranial base. Clinical outcome was assessed by comparing preoperative and postoperative ophthalmological and neurological signs. Acute postoperative complications were reported, and clinical and radiological outcome was assessed at 4-6 months, 12 months, and the last follow-up. Proptosis (measured by Hertel exophthalmometry), visual acuity, visual field defect (measured by Goldmann perimetry), diplopia (measured by the Hess-Lancaster test), and other disturbances were rated as normalized, improved, or unchanged/worsened. The most common presenting symptoms were proptosis (95.7%), visual impairment (51%), and cranial nerve deficit (38.2%). Surgery via the frontotemporal approach was performed in all 47 cases, with the primary aim to relieve symptoms/signs and maximize tumor resection. Bony orbital reconstruction was never performed. Complete resection was achieved in 51% of cases (Simpson grades I and II) with minimal morbidity. At a mean follow-up of 52 months (range, 12-112), proptosis normalized in 90.9% and improved in the remaining patients, visual acuity normalized in 20.8% and improved in 45.8% patients, cranial nerve deficit subsided in all but two cases. The recurrence rate was 29.7%. One of the gold standards of surgical treatment, normalization of proptosis, can be achieved by accurate resection of the superior and lateral orbital walls. In this setting, careful reconstruction of the frontobasal dura is far superior to bony reconstruction. Complete tumor resection should not be pursued at the expense of increased morbidity.

Internal and external spheno-orbital meningioma varieties: different outcomes and prognoses

“…The recurrence rate in our study was 29 %, consistent with previous series [13,19]. Among recurrent tumours, the majority were histological grade I.…”

“…In our series, proptosis was corrected in 86 % of patients. Other series reported similar results [12,13,17]. None of our patients required additional interventions to correct persistent proptosis.…”

“…Proptosis was the most frequent clinical finding, occurring in 80 % of patients as reported in other studies without differences between the external or internal varieties [11][12][13]. The main cause of proptosis was hyperostosis of orbital walls in the majority of cases and intraorbital meningioma invasion in a very few cases [13].…”

“…The main cause of proptosis was hyperostosis of orbital walls in the majority of cases and intraorbital meningioma invasion in a very few cases [13]. Decreased visual acuity at diagnosis was noted in 39 % of patients, as in other series [13,14].…”

Surgical management of skull base tumors

“…Based on location, sphenoid wing meningiomas can be subclassified in spheno-orbital (en plaque or hyperostotic) and globoid meningiomas. 15,16 Sphenoid wing meningiomas can be resected through a pterional or orbitozygomatic craniotomy. Lateral sphenoid wing meningiomas are frequently associated with hyperostosis.…”