Surgical approaches

1. Surgical management of
anterior skull base meningeoma
Presenter
Dr.Raj Kumar P
AIIMS , Rishikesh.
Moderator
Dr.Pranshu Bhargava

2. References
• Al – Mefty`s meningeomas – 2nd Edition.
• Schmidek & Sweet 6 Edition.
• Rhotons surgery of human cerebrum.
• Legacy of Harvey cushings book.
• Few original articles and case reports.
• Neurosurgical focus surgical videos.
• Neurosurgery tricks of trade by Remi

3. History
• These tumours are known to be the most frequent type of true
neoplasm. They are usually from the meninges , are encapsulated ,
loosely attached , affect nervous system by pressure rather than
infiltration.
• They are often accessible and easily shelled out.
• Offer most favourable type of tumour for operation.
-Legacy of Harvey cushing book.

4. • Meningeoma presses upon and excavates by pressure without
infiltrating the brain.
• Its removal is not as a rule one of greatest surgical difficulty.
• Yet there is a mortality of 46.6 % , which is very disappointing.
- H.H.Tooth , Describing victor horsley`s surgical
series, 1913.

5. History
• Sir William Macewen (1848-1924)
• Francesco Durante (1844-1934)
• Sir victor horsley (1857-1916)
• Harvey cushing (1869-1939)

6. Sir William Macewen
• Scottish surgeon , Glawgow.
• Considered one of the father of neurosurgery.
• Influenced by Joseph lister and carbolic acid.
• Pioneered in sterilization of surgical instruments and gowns.
• Brain abscess surgery
• Relationship between sinus infection and brain abscess.

7. First skull base meningioma surgery
• Operated in 1879.
• 14/F
• Swelling left orbit ,
ocasional frontal
headache
• left miotic pupil
• Right face and UL focal
seizures, later
generalized seizures
• Intra op findings:-
• Skull was thicker than
normal .
• Gummatous tumour
attached to bone and
dura.
• Spread towards the
base of frontal lobe.
Macewen W: Intra-cranial lesions: illustrating some points in connexion with the localization of cerebral
affections and the advantages of antiseptic trephining. Lancet 2:581–583, 1881

8. Francesco Durante
• Italian surgeon , Sicily.
• Case : Operated in 1884 , published 1887.
• 35/F
• Complaints : 1 year duration
• Anosmia
• Memory impairment , Names.
• Behavioural changes
Durante F: Contribution to endocranial surgery. Lancet 130: 654–655, 1887

9. • O/E
• Left eye low and drawn outwards
• Loss of smell.
• Surgical procedure:
• Skin : From inner aspect of left eye , upwards as far as temporal region,
• Left frontal craniotomy.
• Dura perforated by tumour.
• Tumour didn’t adhere beyond internal surface of dura.
Durante F: Contribution to endocranial surgery. Lancet 130: 654–655, 1887

10. • Enucleation was easy.
• Surrounding dura was also removed.
• Hemorrhage was slight and was easily controllable.
• Tumour was lobular.
• Size of an apple , 70 gm in weight.
• Suffered recurrence and succesful re do surgery in 1986.
• Last follow up 1905 , in good condition.
Durante F: Contribution to endocranial surgery. Lancet 130: 654–655, 1887

11. Harvey cushing (1869-1939)
• First case : 1922
• 62/F
• Complaints:
• Frontal headache: 2 y
• Impaired vision :1.5 y
• Loss of smell : 1.5 Y
• Altered behaviour : 1 month
• .
• O/E:
• Left exophthalmos.
• Left optic atrophy.
• Euphoric state.
1.Legacy of Harvey cushing , Profiles of patient care book.
2. Cushing H: Meningiomas, Their Classification, RegionalBehaviour, Life History and Surgical
End Results. Springfield,IL: Charles C Thomas, 1938

12. • Surgery 1: Jan 3 , 1922.
• Bone was vascular.
• Frontal lobe dura was tense with many protruding villi.
• Was not able to retract frontal lobe completely due to bleed and
tense brain.
• Needle ventriculostomy done to drain out CSF.
• Tumour was poked with needle , felt hard resistance .
• Bone flap kept back, skin closed.
1.Legacy of Harvey cushing , Profiles of patient care book.
2. Cushing H: Meningiomas, Their Classification, RegionalBehaviour, Life History and Surgical
End Results. Springfield,IL: Charles C Thomas, 1938

13. • Surgery 2 :-
• Jan 28, 1922.
• Large , nodular tumor underneath left
frontal lobe.
• Brain was easily separated from tumour.
• Highly vascular , patient became pulseless
twice during procedure.
• Revived with multiple blood transfusions.
• 72 gm tumour was removed , with larger
residual tumour in situ.

14. • Surgery 3 : Feb 6, 1922.
• Sutures were taken
from tumour bulk.
• Simultaneous traction
with sutures and
dissection from brain
surface done.
• Bone flap was not
replaced back.

15. • Follow up :
• Operated again for meningocele in Dec , 1922.
• Nodule of recurrent meningioma over skull in May 7 , 1927.
• Extended deep up till dura.
• Nodule biopsy – Meningeoma.
• Last follow up letter April , 1931.
1.Legacy of Harvey cushing , Profiles of patient care book.
2. Cushing H: Meningiomas, Their Classification, RegionalBehaviour, Life History and Surgical
End Results. Springfield,IL: Charles C Thomas, 1938

16. 1.Legacy of Harvey cushing , Profiles of patient care book.

17. Evolution of modern approaches
• Unilateral frontal craniotomy : Cushing.
• Bovie electrocautry : 1926.
• Bifrontal and transbasal approaches : Dandy.
• Operating microscope : 1970.
• Endoscope usage in neurosurgery.
1.Craniotomy for anterior cranial fossa meningiomas: historical overview , Valero et al., Neurosurg focus ,
36(4), E14, 2014.
2.Pia HW: The microscope in neurosurgery—technical improvements. Acta Neurochir (Wien) 26:251–255,
1972

20. Almefty 4D s of Meningeoma surgery
• D – De dress
• D –De vascularise
• D – Debulk
• D – Dissect
• Proper position
• Lumbar drain
• Manittol , Lasix

21. • Sub frontal approaches
• Pterional approaches and its variations
• Supra orbital approach
• Extender endonasal trans sphenoid approach
• Endoscopic approach
Craniotomy for anterior cranial fossa meningiomas: historical overview , Valero et al., Neurosurg focus ,
36(4), E14, 2014.

22. Sub frontal approach
Unilateral Bifrontal
Difficult while dealing large
tumours(superior portion)
Large tumours
Cranial base reconstruction
Spares SSS Ligation of SSS
Minimal edema Diffuse edema in both frontal lobes
Frontal sinus breach
Early visualisation.
Lateral view favors precise dissection.
Late visualisation of ICA , ACOM, ACA,
OPTIC APPARATUS
Nakamura M, Struck M, Roser F, Vorkapic P, Samii M: Olfactory groove meningiomas: clinical
outcome and recurrence rates after tumor removal through the frontolateral and bifrontal
approach. Neurosurgery 62 (6 Suppl 3):1224–1232, 2008

23. Types
• Olfactory groove meningioma
• Sphenoid wing meningeoma
• Tuberculum sellae
• Optic nerve meningeoma

24. Olfactory groove meningeoma
• 9 to 18 % of all
meningeomas.
• Frontosphenoid suture ,
crista galli to planum
sphenoidale.
• Large tumours may extend
back to pituitary fossa.

25. • Hyperostosis / erosion of anterior skull base.
• Ethmoid sinus involvement 15-20%.
• ACA pushed posteriosuperior and lateral.
• Orbitofrontal and frontopolar may incorporated in capsule.
• Blood supply:
• Ant and post ethmoidal arteries.
• Sphenoid branches of MMA.
• Pial branches of ACA and Acom in large tumours.

26. Clinical features
• Slow growing , insidious.
• Behavioural changes.
• Frontal headache.
• Anosmia.
• Visual disturbances.
• Foster kennedy syndrome rare in modern series.

29. Imaging features
• CT : hyperostosis and bony erosions.
• MRI : Modality of choice.
• Relation with optic apparatus , cerebral vessels , para nasal sinus
involvement.
• T2 , amount of edema correlates with pial blood supply.
• T2 also best for vessel correlation ( Flow voids).
• CTA , MRA for vascular relation.
• Cathetre angiography rarely required.

30. Management
• Incidentally found , <2.5 cm , conservative , serial image follow up.
•Approaches:
• Pterional
• Sub frontal
• Trans nasal endoscopic
• Lateral orbital
• Interhemispheric.

31. Key steps in resection
• Early interruption of blood supply.
• Identification of origin along the cranial base.
• Seperation from frontal lobes.
• Tumor debulking and devascularisation.
• Optic apparatus , Olfactory nerve , ACA preservation.
• Bone and dura resection.
• Skull base repair.

32. SUBFRONTAL
• Bicoronal skin incision.
• Pericranial graft.
• Subperiosteal dissection , supraorbital NV bundle preserved.
• Burr holes:
• B/l Key hole , one in midline over SSS or two lateral to SSS.
• Smaller craniotomy , more medial burr holes for smaller tumours.

33. • Frontal sinus mucosa excised , cranialised.
• Subperiorbital dissection within orbits and
anterior post ethmoid arteries coagulated.
• Dura opened over both frontal lobes .
• SSS sutured , ligated , divided along flax just
above crista galli.

34. • Small feeders from skull base coagulated .
• Brain retraction should be as much as possible.
• Internal tumour debulking first.
• Olfactory nerves , lateral to tumour . Preserve if possible.
• Inferior margin dissection , optic nerves and ACA preserved.

35. • Posterior margins , arachnoid intact in most cases.
• Optic nerves , pituitary stalk , blood vessels separated.
• All tumour extensions resected.
• Involved bone , dura excised.
• Skull base repair.
• Pericranial flap duroplasty.

36. Subfrontal approach
ADVANTAGES DISADVANTAGES
Wide frontal exposure and view Frontal sinus opened
Direct access to cranial base Superior saggital sinus divided
Early division of main blood supply ACA & Optic apparatus seen late
Easy cranial base repair
Shorter working distance to tumour
More working space

37. Pterional
• Lumbar drain preferred.
• Pericranial flap.
• Circumferential dura opening.
• Sylvian fissure dissection.
• Tumour located in frontal dura base.
• Open opticocarotid cistern.
• Dissect tumour from optic nerve and carotid artery.

38. • DE vascularise early from
base.
• DE bulk .
• Cautious with CUSA
around vessels and optic
nerve.

39. • Careful with frontal polar artery.
• Early identification of A1, Rcc A. of Heubner.

40. • Hemostasis.
• Drill the bone involved.
• Remove the involved dura.
• Skull base repair.
• Duroplasty.

41. ADVANTAGES DISADVANTAGES
Optic apparatus & ACA seen early Narrow working space
Early cistern opening Upper portion of tumour is hidden
Avoids frontal sinus entry-No CSF
fistula
Orbit roof height obscures base of
tumour
Shorter operative time
Shorter distance to ipsilateral part of
tumor
Greater distance to contralateral
part
No frontal lobe retraction
No SSS injury
Early proximal vascular control
Pterional craniotomy

42. Outcome of olfactory groove meningeoma
• Oncological : Despite large size , most cases complete resection.
• Cognitive : Improves in majority cases -> 50 to 90%.
• Visual : Improvement VA –> 26-83% , VF – >29 – 100%.
• Olfaction : Disappointing results , anatomical preservation is not
enough.
1.Zevgaridis D, Medele RJ, Müller A, Hischa AC, Steiger HJ. Meningiomas of the sellar region presenting with visual impairment: impact of various
prognostic factors on surgical outcome in 62 patients. Acta Neurochir (Wien) 2001;143(5):471–476.
2. Bassiouni H, Asgari S, Stolke D. Olfactory groove meningiomas: functional outcome in a series treated microsurgically. Acta Neurochir (Wien)
2007;149(2):109–121, discussion 121.
3. Gazzeri R, Galarza M, Gazzeri G. Giant olfactory groove meningioma ophthalmological and cognitive outcome after
bifrontal microsurgical approach. Acta Neurochir (Wien) 2008;150(11):1117–1125.
4. Welge-Luessen A, Temmel A, Quint C, Moll B, Wolf S, Hummel T. Olfactory function in patients with olfactory groove meningioma. J Neurol Neurosurg
Psychiatry.

43. Complications of O G M surgery
• CSF leak.
• Meningitis
• Hematoma.
• Visual worsening.
• Seizure.
Recurrence rates :
Failure to resect bone and dura.
Tumour in sinuses and orbital fossa.
• 30% at 5 years.
• 41% at 10 years.
Ojemann R, Martuza R. Surgical management of olfactory groove meningiomas. In: Schmidek H, Roberts D, eds. Operative Neurosurgical
Techniques. Vol 1. 5th ed. Philadelphia: Saunders Elsevier; 2006:207–214

44. Tuberculum sellae meningeoma
• At the region of chiasmatic sulcus and tuberculum.
• Junction of optic canal and lateral aspect of chismatic sulcus.
• 5-10% intracranial meningeomas.
• CLINICAL FEATURES:-
• Visual loss , depending on the site.
• U/L or Bitemporal field loss.
• ON displaced laterally and superiorly.
• Chiasma superiorly or posteriorly.
• Rarely frontal syndrome.

45. • Approach from worst vision
side.
• Decompression of optic canals.
• Displays optic nerve laterally ,
pituitary stalk posteriorly.
• Respects liliequist membrane.
• Post op visual deterioration
?????
• Ischemia.

46. Radiology
• Trajectory of growth
superior and posterior
towards optic
apparatus.
• Normal sella.

47. Management
• Approach
• Depends on 3 features.
• Optic canal involvement
• Chiasma relation.
• Vascular relation.

48. Optic canal
invasion
NO
Endonasal
Yes
unilateral Bilateral
Open
Pterional/Orbito
zygomatic
Bifrontal

49. Optic chiasma
location
Superiorly displaced,
prefixed
Tumour extension
above chiasma
Transphenoid Transcranial

50. Vascular
involvement
Open procedure

51. Meta analysis with 95% CI of Multiple comparison studies between
Transcranial and Transsphenoid approaches by Almefty et al.,
%GTR Vision
worsen
ed
Vision
same
Vision
improve
d
88-92 12-17 20-26 57-63
%GTR Vision
worsene
d
Vision
same
Vision
improve
d
55-78 0-9 91-100 54-86
Transcranial Transsphenoid

53. Endonasal endoscopic approach
• Early devascularisation.
• Simpson grade 1 resection.
• No brain retraction.

54. Steps
• Lumbar drain.
• Wide sphenoid post ethmoid
sinus exposure.
• Bony removal of Sellar floor ,
tuberculum sellae.

55. • Coagulation of dura and early devascularisation
• Dural opening.

56. • Open supra sellar dura in midline.
• Superior intercavernous sinus cauterised.

57. • Separate dura away from midline.
• Expose and DE vascularise the tumour.
• Debulk .

59. • Arachnoid separation.
• Tumour extraction.
• Don’t injure pituitary stalk.

60. Reconstruction

61. • Tumour debulking.
• Tumour dissection from optic apparatus, infundibulum , ICA and ACA.
• Reconstruction.

62. Trans cranial
• Frontobasal interhemispheric.
• Pterional
• Orbitozygomatic
• FTOZ

63. • Post op visual improvement is better in pterional and frontolateral
compared to Bifrontal.
• Early optic canal decompression  Improved vision.
• But risk of heat or physical trauma.
Nozaki K, Kikuta K, Takagi Y, Mineharu Y, Takahashi JA, Hashimoto N. Effect of early optic canal unroofing on the outcome of visual functions in surgery
for meningiomas of the tuberculum sellae and planum sphenoidale. Neurosurgery 2008;62(4):839– 844, discussion 844–846

64. Fronto temporal
• Easy elevation , with out significant retraction.
• Sphenoid wing should be drilled more aggressively : Better vision.
• Sylvian fissure to be opened.
• Elevate frontal lobe.
• Identify optic nerve and carotid artery early.
• De vascularise early.
• Debulk .

65. • Leave tumour part
adhered to carotid
artery.
• Careful with frontal
lobe retraction
prevents O N injury.
• .
Rt fronto temporal approach

66. • O N decompression with
rongeur , cut falciparum
ligament.
• Early decompression 
Less traction while
dissection

68. • Contralateral optic nerve.
• Use chiasm as landmark to
identify opposite O N ,

69. Complications
1.Visual loss :-
• Immediate : Direct trauma ,
• Delayed : hematoma , brain swelling or edema.
• How to avoid ??
• Early opening of optic canal.
• Preserve arachanoid layer over nerve.

70. • 2.CSF Leak:-
• Difficult to close area of tuberculum sellae from endonasal root.
• Absorbable plates and bone --> nerve compression.
• Fat pad + suture fixation = Reduces nerve compression.
• Pedicled nasoseptal flap.

71. Spheno orbital meningioma (8% ICM)
• Flat spreading with hyperostosis.
• Mostly low grade WHO I.(Meningothelial ).
• Bone HPE : Tumour invasion and meningothelial cells.
• May extend to cavernous sinus , orbital apex , superior orbital fissure.
• High risk of recurrence.
• Previously thought absolutely unresectable.

74. Clinical
• Non pulsating progressive proptosis.
• Decreased VA , field restriction.
• Diplopia , mainly due to extraocular muscle involvement.
• Cranial nerve III , IV , V, VI.

75. Radiology

77. Management
• Should be individualised
• Age , symptoms , size , comorbidities.
• Observation : with out optic neuropathy.
• Surgical resection :
• Tailored according to individual patient .
• Pterional
• FT
• FTO
• FTOZ

78. Orbitocranial zygomatic approaches

79. • Imp points to be noted :
• Large skin incision to preserve pericranium.
• If involved temporalis muscle excised.
• If infatemporal fossa exposure needed : Zygomatic osteotomy.
• Hyperostotoc bone , lesser wing , lateral wall , roof of orbit , until ant
clinoid process.
• Optic canal and upper part of SOF should be opened.

80. • Area of hyperostotic pterion is
drilled until soft bone
encountered.
• Involved dura identified.
• Ronguers used to remove
involved soft bony tumour part.
• Curette also used .

81. • Identify relative normal edges of
dura.
• Roof of orbit and
orbitozygomatic process were
cut.
• Modified FOZ craniotomy.

82. • Lesser sphenoid wing dissection.

83. • Greater wing and clinoid process
involved parts resected.
• Intra dural part of tumour.

84. • Middle meningeal artery feeding
the tumour.
• Tumour resected after
coagulating MMA.

85. • Dural edges coagulated.
• Pericranial duroplasty.

86. • Orbital rim : with implant.
• Calvarial defect : Titanium plate.
• Sub temporal defect will be
covered by muscle.

87. • Wide resection of dura.
• Early feeding vessel control.
• In large tumours , first debulk the avascular part.
• Don’t injure optic apparatus and vessels.
• Meticulous dissection from cerebral hemisphere.
• Dural repair.
• Orbital wall and cranial prosthesis replacement.

88. Reconstruction
• For cranioplasty : PMMA , bone cements other commercial
prosthesis.
• If periorbita is intact , no need to repair orbital wall and sphenoid
ridge.(1)
• If superior or lateral orbital rim is removed : Commercial prosthesis or
split calvarial grafts.
• Dead space can be filled with fat graft.
• Temporal fossa defects , cranioplasty can be done.
1.DeMonte F, Tabrizi P, Culpepper SA, Suki D, Soparkar CN, Patrinely JR. Ophthalmological outcome after orbital entry during anterior and anterolateral skull base surgery. J
Neurosurg 2002;97(4):851–856.

89. • Maroon et al, reasons for recurrence
1.Failure to diagnose early .
2. Involvement of cavernous sinus , orbital apex , superior orbital
fissure.
3.Failure to appreciate hyperostotic bone is neoplastic.
4.Tendency to insinuate into foramina , fissures , dura , skull base.
5.Apprehension of surgeons that radical resection produces morbidity
and mortality.
Maroon JC, Kennerdell JS, Vidovich DV, Abla A, Sternau L. Recurrent spheno-orbital meningioma. J Neurosurg 1994;80(2):202–208

90. Sphenoid wing meningeoma
• Visual symptoms
• Diplopia due to cavernous sinus and cranial nerve involvement.
• Intra orbital extension , restricted ocular movements.
• Seizures
• Exophthalmosis.

93. • Dura is stripped away from
orbital roof.
• Lateral sphenoid wing is
resected.
• Remove orbital roof to reach
pedicle / root of the tumour.
• Devascularise the tumour
extradurally.
• Dimond drill will coagulate bleed
from hyperostotic bone.

94. • Left pterional :
• Clinoid drilled .
• Large tumours finding clinoid is
difficult , can be resected after
tumour debulking.
• Circumferential dura opening.
• Sylvian fissure wide opening.
• Bridging vein coagulation.

95. • Devascularise along the
sphenoid wing.
• CUSA used.
• Further debulking.
• After decompression , MCA is
identified.
• Care not to injure MCA and
branches with CUSA.
• Subarachnoid dissection to
preserve vessels.

96. • Sharp dissection to preserve
vessels.
• Avoid CUSA and coagulation
near vessels.
• Cottonoids to preserve MCA
branches.
• Dissection is focused towards
anterior part.
• Occulomotor nerve is next to
Pcom.
• Respect arachnoid plane over 3rd
nerve.

97. • Posterior pole is mobilised.
• Pcom , Ant Ch A , ACA , MCA
preserved.
• If tumour encases optic nerve ICA ,
better to leave part of the tumour.
• Leave the perforators intact.
• If not great risk of basal ganglia
infract.
• Avoid using bipolar.

98. Thank you