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Evidence-Based Surgery

Extent of Resection in Parasagittal Meningioma

December, 2011

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Case: VB

• 52 year old lady

• Foot drop since April 2010

• Craniotomy and excision of tumour (08/11)

• Histology: Atypical meningioma with bone involvement

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Clinical Questions:

• In patients with meningioma involving the SSS, does a greater extent of resection (opening the sinus or resecting & bypassing the sinus) result in lower recurrence rates?

 

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Search strategy

• P = Patients with parasagittal meningioma

• I = Total resection

• C = sinus sparing surgery / subtotal resection

• O = recurrence rate

• Search terms (exp MESH and keywords): “meningioma” “superior sagittal sinus” “resection” “surgery” “recurrence”

Results of search: • 3 articles

Results of search: 1 further article

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MENINGIOMAS INVADING THE SUPERIOR SAGITTALSINUS: SURGICAL EXPERIENCE IN 108 CASESFrancisco Di Meco et al , Department of Neurosurgery,Istituto Nazionale Neurologico, Milan, Italy, Neurosurgey (55) 1263-1271,December 2004

Objective

• to provide definitive guidelines for the surgical treatment of parasagittal meningiomas invading the SSS

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Methods

• Retrospective review of data

• 1986 – 2001

• 108 patients

• tumor invasion of the SSS

• Preoperative CT,MRI,MRV

• Categorical variables were compared with the x 2 test.

• Recurrence-free rates - Kaplan-Meier method.• Univariate and multivariate analyses - Cox

proportional hazards regression model

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Surgical Methods

1. In sinus patency - marginal resection of the

tumor along the sinus + suturing/patching ( cadaveric graft)

2. In complete SSS obliteration – en bloc removal & reconstruct

with dural patch graft

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Results

• Mean follow up 74 months ( 0 -223)

Histology• Grade l – 79.6%• Grade ll – 14.8%• Grade lll – 3.7%

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Extent of Removal

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Mortality & Morbidity

• Mortality – 1.85% (2 pts) : 1 post op haematoma, 1 PE

• Brain Swelling – 8.3% (9 pts)

6 middle third

2 posterior third

1 anterior third

3 complete resection of SSS all recovered

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Recurrence

• 13.9%• Median time to recurrence : 156 months

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• Related to :

1) Extent of resection

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2) histology

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3) Tumour size

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Discussion

• Recurrence : failure to achieve radical resection

• Complete sinus occlusion by the tumor mass allows the sinus to be sacrificed – no bypass

• When there is sinus patency – just repair the lateral wall

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Results of attempted radical tumour removal and venous repair in 100 consequtive meningiomas involving the major dural sinuses Sindou MP et al , Université Claude-Bernard de Lyon, France; and Department of Neurosurgery, Tulane University, New Orleans, LouisianaNeurosurgery 105:514-525 ,2006

Objective:

1) Effects of complete lesion removal including the invaded portion of the sinus, in terms of recurrence,morbidity and mortality

2) Consequences of restoring or not restoring the venous sinuses

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Methods :

• Retrospective

• 100 consecutive patients

• 1980 to 2001

• 92 – SSS ( 28 in anterior third, 48 in the middle third and 16 in posterior third

• 5- transverse sinus

• 3 – confluence

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• Mean follow up 8 yrs

• All patients underwent CT,MR and angiography

• Total removal was defined as a resection equivalent to Simpson Grade I or II

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Classification of Sinus Involvement

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Surgical Strategy

1. Simple resection of the outer dural layer and coagulation of the inner layer

2. Resection of the invaded sinus wall(s) and repair by:

a) suturing the recess edges

b) autologous patch,

c) bypass with either an autologous vein

or a Gore-Tex tube graft

3. Resection of sinus with no reconstruction

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• All patients -semisitting position/sitting position

• Heparin therapy - morning after surgery and for 3 weeks

• Warfarin – 3 months

• CTB – within 48 hrs, 3 months, 3 years, symptomatic

• Angio - 2 weeks post op

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Statistical Analysis

• Biosta TGV software

• Student t –test : pre/post op KPS score

• Mean values at 95% CI

• Fischer’s exact test & chi-square test : recurrence rate & mortality

• - p< 0.05

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ResultsType of surgery

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Post op complications

• Air embolism 1%• Subdural / extradural haematoma 3%• Neurological deficit 8% 5 no venous repair, 3 venous repair

• Mortality 3% - brain swelling Type Vl ,complete resection without venous reconstruction

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Recurrence

4 pts recurrence:

1- treated with patch, ( anaplastic)

1- resuturing

1- bypass graft (atypical)

1- not known

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Angiographic patency

• Simple suturing : 100%• Patch : 87%• Autologous vein bypass : 72.7%• Gertex graft : 0%

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KPS scores

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Discussion

• Low recurrence of 4% with radical resection• Preserve the bridging veins

• Safety of resecting a totally occluded sinus remains disputable

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Hoeslly et al (1955 )

• 196 pts , parasagittal meningioma

• No venous reconstruction

• 10% mortality

Bonnai et al (1978)

• 21 pts

• 4.8 %mortality – no venous reconstruction

In this study

3% mortality – no venous reconstruction

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• 86.6% sinus repair – angiographically patent• 72.2% of bypasses were patent• Temporary occlusion of lumen with surgicel• Aneurysm clips/clamps too aggressive for

sinus walls

• Bypass in total resection has been debatable• Intrasinusal pressure• In this study all mortality involved totally

occluded sinus that was not reconstructed

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Conclusion

• Radical resection – low recurrence• Mandatory to reconstruct in incomplete

occlussion• Useful in complete occlussion – compromised

collaterals• Bypass with only autologous graft

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Perioperative and Longterm Outcomes From the Management of Parasagital MeningiomasShaan M. Raza et al / Neurosurgery, Oct 2010, Vol 67(4)

Objective

To retrospectively review the morbidity/mortality and long-term outcomes parasagittal meningiomas invading the superior sagittal sinus

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Methods

• Retrospective• 110 patients• 1992-2004• John Hopkins Medical Institutions• Minimum follow up was 24 months• 61 patients met criteria• All had MRI & DSA

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• Type ll – sinus not entered, remaining irradiated

• Type lll & lV – sinus entered & reconstructed

• Type V & Vl – ligated & resected

(no patency)

• Type V – tumour within sinus left & observed

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• MRI at 3 months for residual tumour

• SRS for progression

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Results

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• 11% recurrence • Mean follow up 41 months

• In recurrence, no statsitically significant difference in:

Histology Extent of sinus involvement Extent of resection

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Discussion

• recurrence rate of 11%.

• cerebral venous thrombosis/infarction in 3.6%

• bridging vein injury promote venous sinus thrombosis

• Lesions that partially obstruct the sinus without collateral pathways - risk for complications.

• Increasing amounts of evidence support the use of radiation therapy/radiosurgery in treating residual disease after initial surgical debulking

-Kondziolka et al

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Conclusion

• lesions partially invading the sinus should be resected to the greatest extent possible

• residual/recurrent disease is subsequently observed and treated with radiosurgery

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Results with Judicious Modern Neurosurgical Management of Parasagital and Falcine meningioma - Michael E. Sughrue et al ,University of California / Journal of Neurosurgery March 2011, Vol 114 (3)

Objective

to provide data regarding large tumors and

the surgical and clinicalsignificance of invasion of the SSS

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Methods

• 135 pts , retrospective study• Median follow up was 7.6 yrs• 61 pts had SSS invasion• Completely occluded SSS was resected• Small invasion was removed, haemostasis

with surgicel,fibrin glue• No patch or graft

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Results

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• Kaplan – Meier analysis analysis to compare GTR and STR

• No difference in tumour recurrence

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Complications

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Discussion

• Data suggest trend towards less aggressive surgery for patent sinus

• STR - Follow up with imaging

SRS for• STR + EGFR negative/ > 10% MIB1• STR + Recurrence

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Discussion

• Data suggest trend towards less aggressive surgery for patent sinus

• STR - Follow up with imaging

SRS for• STR + EGFR negative/ > 10% MIB1• STR + Recurrence

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Thank You