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Abstract Background Medial sphenoid wing meningiomas are best treated through pterional craniotomy, as pterional craniotomy provides wide and multidirectional exposure of the anterior and middle cranial fossa. Anterior clinoidectomy can increase the exposure potential. To delineate the role of anterior clinoidectomy (AC) in the standard pterional craniotomy approach through the evaluation of operability score measures (manoeuvrability arc, depth of surgical field, and surgical angle of attack). All patients with inner sphenoidal wing meningioma who underwent microsurgical excision between February 2022 and October 2023 were enrolled in the study. Preoperative and postoperative imaging studies (MR contrast studies and 3D thin-slice CT scans of the brain) were performed to determine the tumour size, extent, and pattern of optic canal involvement by comparing pre- and postoperative operability score parameters. Results Twenty-five patients met our inclusion criteria: 2 males (8%) and 23 females (92%). The mean age (SD) was 49.08 ± 6.42 years, with an age range of 39–60 years. The preoperative visual manifestations were as follows: eight patients (32%) had mild visual impairment, five patients (20%) had moderate visual impairment, six patients (24%) had severe visual impairment, and five patients (20%) had blindness. There was a significant positive correlation between the operability score and extent of resection (gross total resection was correlated with a higher operability score) (r = 0.301, n = 25, p = 0.005). Conclusions A well-planned manoeuvrable arc allows neurosurgeons to perform surgery with precision, ultimately impacting surgical outcomes and the potential for complete tumour removal with minimal patient morbidity.

Background: Medial sphenoid wing meningiomas are best treated through pterional craniotomy, as pterional craniotomy provides wide and multidirectional exposure of the anterior and middle cranial fossa. Anterior clinoidectomy can increase the exposure potential. To delineate the role of anterior clinoidectomy (AC) in the standard pterional craniotomy approach through the evaluation of operability score measures (manoeuvrability arc, depth of surgical field, and surgical angle of attack). All patients with inner sphenoidal wing meningioma who underwent microsurgical excision between February 2022 and October 2023 were enrolled in the study. Preoperative and postoperative imaging studies (MR contrast studies and 3D thin-slice CT scans of the brain) were performed to determine the tumour size, extent, and pattern of optic canal involvement by comparing pre- and postoperative operability score parameters. Results: Twenty-five patients met our inclusion criteria: 2 males (8%) and 23 females (92%). The mean age (SD) was 49.08 ± 6.42 years, with an age range of 39–60 years. The preoperative visual manifestations were as follows: eight patients (32%) had mild visual impairment, five patients (20%) had moderate visual impairment, six patients (24%) had severe visual impairment, and five patients (20%) had blindness. There was a significant positive correlation between the operability score and extent of resection (gross total resection was correlated with a higher operability score) (r = 0.301, n = 25, p = 0.005). Conclusions: A well-planned manoeuvrable arc allows neurosurgeons to perform surgery with precision, ultimately impacting surgical outcomes and the potential for complete tumour removal with minimal patient morbidity. [ABSTRACT FROM AUTHOR]

To study the rare and unusual causes of monocular elevation deficit. Five patients presenting to us with diplopia and elevation deficit were thoroughly examined and were found to have monocular elevation deficit due to rare causes. All five were found to have different underlying etiologies – iatrogenic, sphenoid wing meningioma, cysticercosis, sarcoidosis and mid brain infarct, and were managed appropriately. Monocular Elevation Deficit can occur due to a variety of causes. Having a high index of suspicion for the more serious etiologies is of utmost importance. Thorough clinical examination and imaging help clinch the diagnosis. [ABSTRACT FROM AUTHOR]

A 78-year-old man presented with acute-onset left temporal pain, eyelid swelling, and double vision. Computed tomography (CT) demonstrated a left sphenoid wing mass with extra-osseous intra-orbital and intracranial extension, thought to be a typical sphenoid wing meningioma by the primary team. The patient was admitted for an urgent craniotomy, which was planned for the following day. However, upon consultation with ophthalmic plastic surgery, concern was raised for an alternative diagnosis given the atypical timeline, inflammatory changes, and uncharacteristic imaging findings of mixed lytic and sclerotic bony changes without hyperostosis on CT and extensive peri-lesional dural thickening and enhancement on magnetic resonance imaging. A serum prostate-specific antigen was elevated to 206 ng/mL. Subsequent positron emission tomography (PET)/CT using 18F-fluorodeoxyglucose radiotracer was negative for metastatic disease. A prostate-specific membrane antigen (PSMA) PET/CT was then obtained and demonstrated extensive metastases. An orbital biopsy revealed poorly differentiated prostatic adenocarcinoma. The significant incongruence between the standard PET/CT and PSMA PET/CT highlights the value of this novel advanced radiographic modality in narrowing the differential diagnosis and determining the extent of disease. Findings of widespread metastasis on the PSMA PET/CT ultimately helped to avoid a large, morbid neurosurgical intervention in this patient, allowing for a minimally invasive orbital biopsy to characterize the tumor for therapeutic targeting. [ABSTRACT FROM AUTHOR]

Background: Meningiomas are the most common primary central nervous system neoplasm in the United States. While the majority of meningiomas are benign, the World Health Organization (WHO) Grade I tumors, a not-insignificant proportion of tumors are in anatomically complex locations or demonstrate more aggressive phenotypes, presenting a challenge for local disease control with surgery and radiation. Laser interstitial thermal therapy (LITT) consists of stereotactic delivery of laser light for tumor ablation and is minimally invasive, requiring implantation of a laser fiber through a cranial burr hole. Herein, we demonstrate the first use of this technology in a progressive atypical sphenoid wing meningioma for a previously resected and irradiated tumor. Case Description: A 47-year-old female was diagnosed with a left-sided atypical meningioma, the WHO 2, of the sphenoid wing following acute worsening of bitemporal headache and dizziness. Given neurovascular involvement, a subtotal resection was performed, followed by stereotactic radiosurgery. Following progression 9 months from resection, the patient elected to proceed with LITT. The patient's postoperative course was uncomplicated and she remains progression free at 24 months following LITT. Conclusion: We present the first use of LITT for a sphenoid wing meningioma documented in the literature, which demonstrated enhanced disease control for a lesion that was refractory to both surgery and radiation. LITT could represent an additional option for local control of progressive meningiomas, even in locations that are challenging to access surgically. More evidence is needed regarding the technical nuances of LITT for lesions of the skull base. [ABSTRACT FROM AUTHOR]

Objective: Sphenoid wing meningiomas (SWMs) often cause occlusion or stenosis of the superficial middle cerebral vein (SMCV) by tumor compression. This study aimed to analyze the correlation between SMCV compression and peritumoral brain edema (PTBE) in SWM patients and to clarify the importance of surgical preservation of the SMCV in SWM surgery., Methods: This retrospective study included 31 patients who underwent surgery for SWM at our institution from April 2011 to March 2022. Patient demographics, tumor characteristics, PTBE size, and SMCV patency before and after surgery were evaluated using preoperative and postoperative MRI or digital subtraction angiography., Results: Of the 31 patients, 24 (77.4 %) exhibited PTBE, with varying degrees of severity: mild (32.3 %), moderate (25.8 %), and severe (41.9 %). Preoperative MRI showed SMCV patency in 14 patients (45.2 %) and SMCV compression in 17 patients (54.8 %). There was a significant association between PTBE severity and SMCV compression (p = 0.002). Postoperatively, SMCV recanalization was observed in 4 out of 16 patients (25.0 %) with preoperative SMCV compression. These patients had significantly smaller tumors (p = 0.013) and larger preoperative PTBE volumes (p = 0.042) compared to those without recanalization., Conclusions: Our study demonstrates a significant correlation between SMCV compression and severe PTBE in SWM patients. A subset of patients showed postoperative SMCV recanalization, particularly those with smaller tumors and more pronounced PTBE. These findings highlight the importance of SMCV preservation during SWM surgery to potentially improve postoperative outcomes., Competing Interests: Declaration of Competing Interest None of the authors has any conflict of interest to disclose., (Copyright © 2024 Elsevier B.V. All rights reserved.)

Sphenoidal meningiomas constitute 18% of intracranial masses, and still present a difficult surgical challenge. PTBE has been associated with several complications and future recurrence. This study aims to evaluate the outcome of the operatively treated sphenoid wing meningiomas in relation to PTBE as a prognostic factor in a series of 65 patients. The clinical materials of 65 patients with SWM treated microsurgically between 2007 and 2020 were analyzed retrospectively. Follow-up ranged from 6 to 156 months (median, 86). Clinical outcomes include postoperative major neurological deficit, quality of life using KPS, recurrence, and mortality rates. The mean age of patients was 53.9 years (range 20–74), males 24.6% and females75.4%. An edema index (EI) of 1 (40%) was considered as absent edema, and EI > 1 (60%) indicated present edema. Total resection (Simpson I–II) was achieved in 64.6% and subtotal (Simpson IV) in 13.8%. Postoperative complications included vision impairment in 3 patients, motor weakness 6, third nerve palsy 6, intraoperative bleeding and edema 5, and MCA infarct 2, recurrence in 17% and 7.7% died. In univariate analysis, we found that the PTBE is one of the serious risk factors in the immediate surgical outcomes and complication, though more data is needed to support this claim, while having a negative effect on postoperative KPS at short-term follow up (χ2 = 6.44, p = 0.011). PTBE was associated with decline in KPS and quality of life in the early postoperative period (three months) while showing no significant effect at long-term outcomes. [ABSTRACT FROM AUTHOR]

Simple Summary: Sphenoid wing meningiomas account for 11–20% of all intracranial meningiomas and have a higher recurrence rate than those at other sites. The molecular background of meningiomas has been clarified in recent years; therefore, in this study, we aimed to analyze factors associated with the recurrence of sphenoid wing meningiomas. We found that NF2 alteration/22q loss is associated with recurrence in WHO grade 1 sphenoid wing meningiomas, as well as some radiological findings. Together, our study suggests that genotyping meningiomas could help to inform treatment strategies and play an important role in precision medicine, while the preoperative prediction of genotype from radiological features could influence surgical strategies. Furthermore, appropriate follow-up planning could improve the appropriate distribution of medical resources and provide both medical and economic benefits. Sphenoid wing meningiomas account for 11–20% of all intracranial meningiomas and have a higher recurrence rate than those at other sites. Recent molecular biological analyses of meningiomas have proposed new subgroups; however, the correlation between genetic background and recurrence in sphenoid wing meningiomas has not yet been fully elucidated. In this study, we evaluated the clinical characteristics, pathological diagnosis, and molecular background of 47 patients with sphenoid wing meningiomas. Variants of NF2, AKT1, KLF4, SMO, POLR2A, PIK3CA, TRAF7, and TERT were determined using Sanger sequencing, and 22q loss was detected using multiplex ligation-dependent probe amplification. Alterations were localized at NF2 in 11 cases, had other genotypes in 17 cases, and were not detected in 12 cases. Interestingly, WHO grade 1 meningiomas with NF2 alteration/22q loss (p = 0.008) and a MIB-1 labeling index > 4 (p = 0.03) were associated with a significantly shorter recurrence-free survival, and multivariate analysis revealed that NF2 alteration/22q loss was associated with recurrence (hazard ratio, 13.1). The duration of recurrence was significantly shorter for meningiomas with NF2 alteration/22q loss (p = 0.0007) even if gross-total resection was achieved. Together, these findings suggest that NF2 alteration/22q loss is associated with recurrence in WHO grade 1 sphenoid wing meningiomas. [ABSTRACT FROM AUTHOR]

Meningiomas are one of the most common intracranial primary tumors. They are more common in women, their number increases with age. Sphenoid wing meningiomas make up 15–20 % of intracranial meningiomas. The aim of the study – to evaluate the relationship between preoperative peritumoral cerebral edema (PTCE) and tumor size, histological structure and location. Materials and Methods. Data from 67 patients with removed sphenoid wing meningioma in the period from January 2007 to January 2021 were retrospectively examined. One-factor and two-dimensional statistical analysis of factors that may affect PTCE was performed. Results. The average age of the patients examined was 47 years (ranging from 20 to 74), men – 16 (23.9 %), women – 51 (76.1 %). The mean tumor volume was 32.8 cm3, ranging from 4.2 cm3 to 143.7 cm3. The edema index (EI) is 1 in 27 (40.3 %) was absent, EI > 1 in 40 (59.7 %) was present. Small tumor volume was in 21 cases, PTCE – 57.2 %, medium – 32 cases, PTCE – 59.2 %, large tumor volume was in 9 cases, PTCE – 66.7 % and giant – in 5 cases, PTCE – 60.0 %. According to the WHO classification, there were 54 cases of central nervous system malignant tumors grade I (80.6 %), which were classified into endothelial type – 37 (68.5 %), fibrous – 7 (12.9 %), transient – 5 (9.2 %), angiomatous – 6 (11.1 %) ) and psammomatous type, which was found in one patient. Tumors grade II – atypical type, found in 11 cases (16.4 %), and III – anaplastic type, were in 2 cases (3.0 %). In a one-way analysis, we found a significant relationship between PTCE and the degree of malignancy (χ2 = 8.59, p = 0.0034), while no relationship was found between PTCE and tumor volume (W = 627, p = 0.27). PTCE was more pronounced in the lateral, middle and medial variants of location and less pronounced in the case of spheno-orbital location of the tumor (p = 0.10) and the overall edema index (χ2 = 4.48, p = 0.034). Conclusions. The relationship between PTCE and tumor volume is statistically insignificant. We found that high-grade (grade II and III) and low-grade subtypes (grade I, angiomatous type) are strongly associated with PTCE, although there is no relationship between the degree of malignancy and tumor location, χ2 = 0.37, p = 0.83. The results of a two-dimensional analysis of the simultaneous effect of tumor volume and PTCE on the pathological stage confirmed the higher risk of PTCE in tumors of grade II and III (p = 0.0027). There was also a small association between tumor volume and pathology (p = 0.74). A higher frequency of PTCE was found in the lateral variant in sphenoid wing meningioma, while a lower in spheno-orbital meningioma (p = 0.10), and a lower overall edema index (χ2 = 4.48, p = 0.034)

The frontotempotal-orbitozygomatic craniotomy (FTOZ) is a standard approach for large sphenoid wing meningiomas (SWMs). Nevertheless, resection of these tumors is not without ophthalmologic risks. This series presents two patients with acute postoperative restrictive strabismus following tumor resection and orbital wall reconstruction. Forced duction testing and postoperative imaging revealed impingement of the lateral rectus muscle caused by an alloplastic implant and/or residual bone, prompting immediate orbitotomy and restoration of normal extraocular muscle function. This report highlights the intricacies of orbital reconstruction, as well as the need for intraoperative forced duction testing.

Simple Summary: Medial sphenoid wing meningiomas are among the three most common intracranial meningiomas. They present a challenge to neurosurgeons, especially when they invade critical neurovascular structures and the cavernous sinus. This study was designed to evaluate prognostic features influencing recurrence and progression-free survival of medial sphenoid meningiomas invading the cavernous sinus, with a particular focus on the impact of surgery and postoperative radiotherapy. A retrospective analysis was conducted of the database of our institution. Included were 105 cases of medial sphenoid wing meningiomas with invasion of the cavernous sinus, of which 64 were treated by surgery alone and 41 were treated by surgery plus radiotherapy. Near-total resection did reduce the risk of tumor recurrence significantly compared to subtotal resection. Progression-free survival was also significantly prolonged after postoperative radiotherapy. In conclusion, we found that performing a maximal safe resection is the factor most strongly associated with a lower recurrence rate in patients with medial sphenoid meningioma infiltrating the cavernous sinus, and that postoperative stereotactic radiotherapy of the residual tumor also significantly prolongs PFS. Objective: Medial sphenoid wing meningiomas are among the three most common intracranial meningiomas. These tumors pose a challenge to neurosurgeons in terms of surgical treatment, as they may involve critical neurovascular structures and invade the cavernous sinus. In case of the latter, a complete resection may not be achievable. The purpose of this study was to investigate prognostic features affecting recurrence and progression-free survival (PFS) of medial sphenoid wing meningiomas involving the cavernous sinus, focusing on the contribution of surgery and postoperative radiotherapy. Methods: A retrospective analysis was conducted of the database of our institution, and 105 cases of medial sphenoid wing meningioma with invasion of the cavernous sinus, which were treated between 1998 and 2019, were included. Surgical treatment only was performed in 64 cases, and surgical treatment plus postoperative radiotherapy was performed in 41 cases. Kaplan–Meier analysis was conducted to estimate median survival and PFS rates, and Cox regression analysis was applied to determine significant factors that were associated with each therapeutic modality. Results: The risk of recurrence was significantly reduced after near-total resection (NTR) (p-value = 0.0011) compared to subtotal resection. Progression-free survival was also significantly prolonged after postoperative radiotherapy (p-value = 0.0002). Conclusions: Maximal safe resection and postoperative stereotactic radiotherapy significantly reduced the recurrence rate of medial sphenoid wing meningiomas with infiltration of the cavernous sinus. [ABSTRACT FROM AUTHOR]

ABSTRACT Objective: To describe our reconstruction of an orbital roof and lateral wall defect using a split- thickness calvarial bone graft with titanium mesh complex after resection of a meningioma of the left greater wing of the sphenoid with extension to the left frontotemporal bone and left orbital roof and lateral wall. Methods: Study Design: Surgical Innovation Setting: Tertiary Private University Hospital Patient: One Results: A 44-year-old woman with a left frontotemporal mass associated with left eye proptosis and epiphora underwent reconstruction of the left orbital roof and lateral wall defect using split-thickness calvarial bone graft with titanium mesh and screws after a left frontotemporal craniectomy, superior and lateral orbital wall resection of a mass of the sphenoid wing with orbital and frontotemporal extension. Final histopathology was consistent with meningioma. Surveillance of the mass and orbital reconstruction showed evidence of bone growth and osteointegration of the titanium mesh into the bone grafts. Conclusion: The initial good outcome of orbital roof and lateral wall reconstruction using split-thickness calvarial bone graft with titanium mesh is evidenced by osteointegration of the titanium mesh and revascularization leading to new bone growth. This autogenous-alloplastic complex may provide a more stable option for orbital reconstruction, but long term follow-up is needed for surveillance of recurrence and monitoring the status of orbital reconstruction.

Abstract Background Three-dimensional (3D) fusion imaging has been proved to be a promising neurosurgical tool for presurgical evaluation of tumor removal. We aim to develop a scoring system based on this new tool to predict the resection grade of medial sphenoid wing meningiomas (mSWM) intuitively. Methods We included 46 patients treated for mSWM from 2014 to 2019 to evaluate their tumors’ location, volume, cavernous sinus involvement, vascular encasement, and bone invasion by 3D multimodality fusion imaging. A scoring system based on the significant parameters detected by statistical analysis was created and evaluated. Results The tumor volumes ranged from 0.8 cm3 to 171.9 cm3. A total of 39 (84.8%) patients had arterial involvement. Cavernous sinus (CS) involvement was observed in 23 patients (50.0%) and bone invasion was noted in 10 patients (21.7%). Simpson I resection was achieved in 10 patients (21.7%) and Simpson II resection was achieved in 17 patients (37.0%). Fifteen patients (32.6%) underwent Simpson III resection and 4 patients (8.7%) underwent Simpson IV resections. A scoring system was created. The score ranged from 1 to 10 and the mean score of our patients was 5.3 ± 2.8. Strong positive monotonic correlation existed between the score and resection grade (R s = 0.772, P < 0.001). The scoring system had good predictive capacity with an accuracy of 69.60%. Conclusions We described a scoring system that enabled neurosurgeons to predict extent of resection and outcomes for mSWM preoperatively with 3D multimodality fusion imaging. Trial registration Retrospectively registered

Background and aim The aim of the study was to investigate the surgical techniques to remove meningioma en plaque and to compare our technique and results with other authors. Patients and methods This retrospective series case was done at our University Hospital. Eight patients were managed at Al-Zahraa University Hospital between March 2016 and March 2018. Preoperative and postoperative clinical and radiological assessments were done for each patient. Results There were eight patients in our study. All patients are women. The age range was from 34 to 60 years and the mean was 45.4 years. Proptosis was the main clinical manifestation and it was present in all eight patients. Three (37.5%) patients had visual impairment while two (25%) of them had headache and retro-orbital pain. We achieved total resection in six (75%) out of our eight patients. All tumors were WHO grade 1 meningiomas. Regarding surgical outcome, proptosis improved in six (75%) of the eight cases. Visual impairment improved in two (66.7%) cases out of three who had visual declination preoperatively. Conclusion Meningioma en plaque can be safely removed without any morbidity or mortality. Proptosis and hyperostosis in the sphenoid bone are highly suggestive and this requires more accurate radiological studies. MRI with contrast is essential for these cases. Extensive bony drilling is required for gross total resection. It also facilitates resection of the soft part of the tumor with its dura. Some cases may need orbital wall reconstruction. Proptosis mostly improves after surgery.

Purpose: Surgical resection is the mainstay of treatment for spheno-orbital meningiomas. The Sonopet® is an ultrasonic aspirator device that provides several advantages over the traditional standard suction techniques and bone drill, including decreased collateral soft tissue damage, more precise bone removal and a clearer operative field. The purpose of the study was to examine the treatment outcomes of Sonopet®-assisted resection of spheno-orbital meningiomas. Methods: A retrospective chart review was conducted in seven patients with spheno-orbital meningioma in a single institution who underwent surgical resection with the Sonopet®. Pre-operative and post-operative data included the assessment of visual acuity, relative afferent pupillary defect (RAPD), Ishihara score, proptosis, fundus examination, computerised visual fields and the presence or absence of diplopia, headache, and other neuro-ophthalmic complications. Results: Nine Sonopet®-assisted procedures were performed on seven patients. Post-operatively, 89% of cases had stabilization or improvement of visual acuity and colour vision, whilst 29% had improved visual fields with the remainder being stable. Proptosis improved in all patients. Five of nine cases (44%) had new post-operative cranial nerve palsies, of which 75% were transient. One patient had tumour recurrence after 14 months, requiring further tumour resection and radiotherapy. Conclusion: Sonopet®-assisted resection of spheno-orbital meningiomas has comparable outcomes of visual improvement and complication rates to traditional resection techniques. Longer periods of post-operative observation and follow-up are recommended to observe long-term benefits. [ABSTRACT FROM AUTHOR]

Surgical resection of spheno-orbital meningioma (SOM) is challenging, requiring a multidisciplinary surgical approach. We present our experience of the surgical management of patients with SOM. A retrospective analysis of patients with SOM who underwent joint neurosurgical and orbital surgical procedures between January 2000 and June 2017. Pre-operative clinical signs, indication for surgery, surgical complications and post-operative outcomes were recorded. Twenty-four operations were performed. Mean age was 49.5 years. Ninety-two percent of patients were female. Pre-operatively mean Snellen acuity vision was 6/12; 13 (54%) had an RAPD; 12 (50%) had reduced colour vision; 16 (67%) had a visual field defect. The majority (21 patients, 88%) had proptosis (average 4.5 mm ± 2.8 mm). The indication for surgery was evidence of visual dysfunction in 17 (71%), the remaining 7 (29%) had high risk of visual loss clinically or radiologically. Three-months post operatively, vision was stable in 13 (58%), improved in 6 (21%) and worse in 5 (17%). Average long-term follow-up was 82 months (1–220). Fourteen (58%) maintain improved or stable visual function. Four (17%) had reduced vision due to regrowth of the tumour at an average of 24 months. SOMs are very challenging to treat surgically. In this cohort the patients were predominantly young females with aggressive disease. Visual function was improved or stabilised in 79% of the patients. [ABSTRACT FROM AUTHOR]

Sphenoid wing meningiomas (SWMs) can be treated with complete surgical resection and the recently introduced endoscopic transorbital approach (ETOA) offers a minimally invasive alternative. In this study, the surgical outcome of ETOA and the extended mini-pterional approach (eMPTA) for SWMs with osseous involvement is compared. From October 2015 to May 2019, 24 patients underwent surgery for SWMs with osseous involvement. Among them, tumor resection was performed by ETOA for 11 patients (45.8%) and eMPTA for 13 patients (54.2%). The tumor characteristics, surgical outcome and morbidity, and approach-related aesthetic outcome were analyzed and compared retrospectively between ETOA and eMPTA based on SWM classification. The location of SWMs was mostly the middle sphenoid ridge (group III) (45.8%), followed by the greater sphenoid wing (group IV) (29.2%). Simpson resection grades I/II were achieved in 9 of 11 patients (81.8%) with ETOA and 11 of 13 patients (84.6%) with eMPTA. There were no differences in tumor characteristics between the 2 approaches. Surgery time, surgical bleeding, and hospital length of stay were significantly shorter with ETOA. Three patients had transient surgical morbidities such as diplopia (n = 1), ptosis (n = 1), and cerebrospinal fluid leak (n = 1) after ETOA. No differences could be seen in surgical morbidities between ETOA and eMPTA. ETOA can provide direct access to the sphenoid bone and resectability with a more rapid and minimally invasive exposure than does eMPTA. Maximal subtotal resection with extensive sphenoid bone decompression for tumors with cavernous sinus infiltration is the key to a good clinical outcome, regardless of the surgical approach. [ABSTRACT FROM AUTHOR]

A 78-year-old man presented with acute-onset left temporal pain, eyelid swelling, and double vision. Computed tomography (CT) demonstrated a left sphenoid wing mass with extra-osseous intra-orbital and intracranial extension, thought to be a typical sphenoid wing meningioma by the primary team. The patient was admitted for an urgent craniotomy, which was planned for the following day. However, upon consultation with ophthalmic plastic surgery, concern was raised for an alternative diagnosis given the atypical timeline, inflammatory changes, and uncharacteristic imaging findings of mixed lytic and sclerotic bony changes without hyperostosis on CT and extensive peri-lesional dural thickening and enhancement on magnetic resonance imaging. A serum prostate-specific antigen was elevated to 206 ng/mL. Subsequent positron emission tomography (PET)/CT using 18F-fluorodeoxyglucose radiotracer was negative for metastatic disease. A prostate-specific membrane antigen (PSMA) PET/CT was then obtained and demonstrated extensive metastases. An orbital biopsy revealed poorly differentiated prostatic adenocarcinoma. The significant incongruence between the standard PET/CT and PSMA PET/CT highlights the value of this novel advanced radiographic modality in narrowing the differential diagnosis and determining the extent of disease. Findings of widespread metastasis on the PSMA PET/CT ultimately helped to avoid a large, morbid neurosurgical intervention in this patient, allowing for a minimally invasive orbital biopsy to characterize the tumor for therapeutic targeting.

Introduction: Cortical blindness occurs with bilateral damage to the visual cortex. It can be caused by various reasons, including the posterior cerebral arteries stroke due to the tentorial herniation., Material and Methods: A case of a 40-year-old patient with a large right-sided sphenoidal meningioma. A systematic review on the problem of cortical blindness after tentorial herniation according to the PRISMA guideline., Results: Subtotal removal of dense meningioma. At night after the operation, there was an acute headache, then a coma. Immediately dehydration therapy, tracheal intubation, mechanical ventilation. CT scan showed a small hemorrhage in the tumor bed and subarachnoid space, brain edema and dislocation. After 53 minutes, ventricular drainage was installed, intracranial pressure was normal and ranged from 6 to 14 mmHg. After sedation withdrawal, cortical blindness was detected, which did not regress for 1.5 years. There are no other neurological symptoms, the patient walks, serves herself. Radiation therapy in a total of 54 Gy for the remainder of the grade 1 meningioma ensured tumor control., Discussion: The time window for restoration of the cerebral blood flow, according to the European Stroke Organization guidelines, is 4.5 hours. In this case, compression of the posterior cerebral arteries lasted less than 53 minutes, however, irreversible ischemia developed in their territory; the outcome on the modified Rankine scale was 4 points. Similar cases are not described in the literature., Conclusion: Patients should be warned about even the non-obvious risks of neurosurgical intervention, since even timely measures taken do not always avoid complications.

Objectives  Describe a unique and safe surgical procedure for the microsurgical management of large sphenoid wing meningiomas (SWMs) aimed to a radical resection of these tumors. Design  A prospective series of 26 cases with SWMs larger than 3 cm in one of its main diameter is presented. All patients were studied following the same clinical and imaging procedures. The surgical approach was through a pterional transzygomatic craniotomy. The surgical procedure has the following steps: 1. Extradural tumor devascularization and resection of the hyperostotic and/or infiltrated bone and then intradurally; 2. Intradural tumor debunking; 3. Microdissection of vascular branches and perforators from the capsule; 4. Identification of the optic and oculomotor nerves and internal carotid artery; 5. Tumor capsule dissection and resection; 6. Dural resection or cauterization; 7. Dural and bone reconstruction and closing. Results  All lesions were completely removed. Most complications were transient. The most relevant complication was a large middle cerebral artery infarct with permanent hemiplegia despite a decompressive craniotomy. Conclusion  Large SWMs can be considered as a single pathology regarding the surgical approach and intraoperative microsurgical procedure strategies. The pterional transzygomatic approach allows an extradural devascularization of the tumor and an extensive bone resection that facilitates the intradural stage of tumor resection. The proposed approach allows a wide and radical resection of the duramater and bone that increases the Simpson grade. However, surgery does not control other biological or molecular prognostic factors involved in tumor recurrence. [ABSTRACT FROM AUTHOR]

• There were a few cases of skull base tumors requiring vessel revascularization. This is the first clinical report on this issue in Vietnam. • Most of the vessel revascularization cases were meningiomas. • Saphenous vein graft (SVGs) was the most commonly reported graft, followed by radial artery graft (RAGs). • STA-MCA bypass was a safe and helpful choice, especially the collateral vessels were present and the need for blood flow augmentation was minimal. Sphenoid meningioma engulfed cerebral arteries has always been a challenge. To achieve a gross total resection, vessel sacrifice may be unavoidable. A 22-year-old man with a history of head trauma a week ago complained of a headache for one week. On examination, he was alert, denied paralysis and cranial nerves palsies. Preoperative MRI showed a hypervascular left sphenoid wing meningioma embedding left internal carotid artery and proximal segment of the middle cerebral artery. In operation, a branch of the MCA was divided when dissecting the tumor. The MCA was clipped but was still difficult to dissect vessel ends in the Sylvian fissure. We decided to extend craniotomy and did superficial temporal artery to M4 segment of MCA bypass. Then, the patient was resuscitated in surgical high dependency unit for 3 days. Surgical outcome in one year postoperative was good with KPS 90 out of 100 points and no neurological deficits. On postoperative MRA, STA-MCA bypass shown acceptable flow. There were a few cases of skull base tumors requiring vessel revascularization. Most of the revascularization cases were meningiomas. Saphenous vein graft (SVGs) was the most commonly reported graft, followed by radial artery graft (RAGs). In case of difficulty in dissecting the vessel ends due to the tumor infiltration, STA-MCA bypass was a safe and helpful choice, especially the collateral vessels were present and the need for blood flow augmentation was minimal. STA-MCA bypass was effective surgical management for MCA injury in sphenoid wing meningioma resection. [ABSTRACT FROM AUTHOR]

Background: Internal variation among spheno-orbital meningiomas (SOM) is surgically challenging. Optic canal invasion management is discussed. Method: This retrospective study includes 70 patients with SOM who underwent surgery between 1995 and 2012. Preoperative ophthalmological, neurological and aesthetic clinical signs were collected. All patients benefitted from repeated tomography and magnetic resonance imaging (MRI). The surgical team consisted of a neurosurgeon and a plastic surgeon. In the majority of cases, resection was followed by bone reconstruction using an autologous iliac crest graft. The extent of resection was evaluated on the dural and osseous sides. Early clinical outcomes, long-term follow-up, recurrence and adjuvant therapies were reported. Results: The mean age was 52 years old, and 91 % of the patients were women. Initial symptoms primarily included proptosis (65 %), decreased visual acuity (39 %) and soft tissue tumefaction (16 %). We classified 40 cases as the internal variety when considering the inner third of the greater wing of the sphenoid, optic canal, anterior clinoid process or cavernous sinus. The remaining cases were described as the external variety. The complete resection rates for the internal and external varieties were 12 % and 61 %, respectively ( P < 0.001). In total, 90 % of cases were grade I meningiomas. For grade I, we reported 30 % recurrence, and 50 % of these cases recurred in the first 2 years. Grade II cases without early adjuvant radiotherapy increased at 2 years. We did not observe any difference in recurrence rate among grade I tumours with or without tumour remnants. At the end of follow-up, visual acuity was stabilised or increased in 88 % of patients. In addition, 14 % of patients experienced persistent pain at the location of the iliac harvesting site. Conclusions: The internal SOM variety exhibited a reduced total resection rate and a shorter progression-free survival (PFS). Unroofing of the optic canal extended PFS. Among grade I cases, the persistence of a negligible tumour remnant did not alter the probability of recurrence. For superior grades, radiotherapy must be administered in addition to surgery as soon as possible. SOMs require prolonged follow-up. Autologous iliac reconstruction is related to substantial morbidity and could be replaced by prosthetic bone three-dimensional reconstruction. [ABSTRACT FROM AUTHOR]