Sphenoid wing meningioma: Microsurgery and clinical outcomes in Vietduc Hospital

Journal of military pharmaco-medicine no3-2018

SPHENOID WING MENINGIOMA: MICROSURGERY AND
CLINICAL OUTCOMES IN VIETDUC HOSPITAL
Do Van Dung*; Dong Van He**; Vu Van Hoe***
SUMMARY
Objectives: Sphenoid wing meningiomas (SWMs) are skull base tumors that are associated
with significant morbidity and mortality, especially in medial sphenoid wing meningiomas
(MSWMs) as their anatomic proximity to many critical neurological and vascular structures. This
study aimed to evaluate the clinical outcome and SWM surgical resection. Subjects and
methods: A descriptive and interventional study was conducted on 60 SWMs which were
operated from 2013 to 2015 at Vietduc Hospital. Result and conclusion: According to Simpson’s
classification, tumor resection grade I and II accounted for 60%, good outcome (KPS 80-100)
achieved in 65% of the patients, average outcome: 35%, mortality 5%. Visual improved in 23.81%.
Cranial nervous outcome: III 65.39%, V: 29.2%, IV: 57.14%, VI: 53.85%. Recurrence 15.4%,
follow-up period 14.5 months.
* Keywords: Sphenoid wing meningiomas; Microsurgery; Clinical outcome.

INTRODUCTION
Sphenoid wing meningiomas (SWMs)
are in the skull base tumors, accounting
for approximately 15 - 20% of intracranial
meningiomas. It was divided into three
groups on the basis of preoperative
radiology findings: lateral, middle, medial.
Among them, there are some parts
related to the medial, such as internal
carotid, cavernous sinus and cranial
nervous II, III, IV, V, VI. As a result, how
to resect the whole tumor but still preserve
the relevant components to improve the

cranial nervous outcome and the quality
of life after operation is an emerging issue
that neurosurgeons are faced with.
However, the results vary from center to
center due to many factors. Some recent
reports also inform that the rate of total
tumors resection ranges from 59 to 86.7%,

mortality remains as high as 14.5%, cranial
neuro increases from 4 to 29%.
SUBJECTS AND METHODS
1. Subjects.
60 patients were diagnosed with
sphenoid
wing
meningiomas
and
operated in Vietduc Hospital from March
2013 to September 2015 with adequate
profiles and hermatology of menigioma.
Patients were assigned to 3 groups
depending on the sites of the tumor.
Group 1: outer part of the sphenoid ridge
(lateral); group 2: middle part of the
sphenoid ridge (intermediate); group 3:
inner part of the sphenoid ridge (medial).
This database included 24 tumors of the
medial sphenoid ridge and 08 tumors of
lateral sphenoid ridge and 28 tumors
of middle.

* 198 Hospital
** Vietduc Hospital
*** 103 Military Hospital
Corresponding author: Do Van Dung ()
Date received: 08/11/2017
Date accepted: 28/02/2018

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Journal of military pharmaco-medicine n03-2018
Cushing and Eisenhardt (1938) [6] were
the first to describe the sphenoid wing by
dividing it into thirds, with changes in the
orientation of the wing roughly demarcating
the boundaries of these segments; firstly,
a medial third, which represents the
medial posterior-to-anterior segment, the
most adjacent to the anterior clinoid
process; a middle third, which runs medial
to lateral and lastly, a lateral third, which
runs anterior to posterior.
2. Method.
This is a descriptive and interventional
study with follow-up. The Chi-square test
was used for statistical analysis and
comparisons between different groups.
Probability values of less than 0.05
indicated significant diferences.

* Perioperative management: Preoperative
evaluation of all patients included
T1-and/orT2-weighted MRI studies obtained
with or without contrast. Use of contrast
allows visualization of the extent of tumor
while T2 images may display the arachnoid
layer around the tumor and also adjacent
brain edema, the latter giving some

indication of adhesion to the surrounding
parenchyma [1, 3, 9].
- Surgical techniques: All patients were
positioned supine with the head elevated
slightly above the heart to promote
venous drainage. The head was rotated
30 degrees opposite the side of the
tumor, bringing the sphenoid ridge into a
vertical orientation. A fronto-temporal
(pterional) craniotomy was performed.
Using a high-speed pneumatic drill and
remaining extradural, drilling of the lesser
wing reach anterior clinoid and clinoidectomy
in medial meningioma resections. After
the tumor was exposed, tumor debulking
was managed in piecemeal removal, base
of tumor could be determined and major
feeding artery was bloked. If the tumor
invased into cavernous sinus, the
extracavernous portion of tumor was
removed while preserving neurovascular

structures of cavernous sinus [4, 8, 9, 10].
- Assessment of tumor resection based
on Simpson grade (Simpson D, 1957) [11]:

Table 1:
Grades

Description

Grade I

Total tumors resection include the invation dura and skull

Grade II

Total tumors resection include the root tumor and burn the dura where the tumor stick

Grade III

Total tumor resection but leave the root and do not burn it

Grade IV

The large tumor resection

Grade V

Only decompression and bioxy

* Surgical results: Evaluate the outcome of treatment, patients were assigned to a

03-category scoring system based on the Karnofsky performance score (KPS) [4]:
Worse outcome with deterioration of symptoms or death: KPS 0 - 40; average with
unchanged symptoms: KPS 50 - 70; good outcome KPS 80 - 100 with complete
regression of preoperative tumor-related symptoms.
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Journal of military pharmaco-medicine no3-2018
* Follow-up examinations: After surgical treatment, patients were followed clinical
and radiological examinations. The first follow-up was checked up MRI during 3 or
6 months after surgery. In cases with regrowth, patients were re-investigated at least
after 1 year [2, 8].
RESULTS
Table 2: The result of tumor resection (by area).
Tumor resection
(Simpson grade)

Tumor positions
Total
Lateral

Middle

Medial

I

7 (87.5%)

9 (32.1%)

1 (4.2%)

17

II

1 (12.5%)

14 (50%)

4 (16.7%)

19

IV

0

5 (17.9%)

19 (79.1%)

24

8

28

24

60

Total

p

0.000

The difference between these three positions is statistically significant (p < 0.05).
Total tumor resection at the position of 1/3 inside is lower than the other positions.
Table 3: Karnofsky performance score (KPS) result before and after surgery.
KPS before surgery

KPS after surgery

Result

p
n

%

n

%

Good (KPS: 80 - 100)

23

38.3%

39

65%

Average (KPS: 50 - 70)

33

55%

18

30%

Worse (KPS: 0 - 40)

4

6.7%

3

5%

Total

60

100

60

100

0.012

Patients have better KPS after the surgery, statistically significant (p < 0.05).
Mortality 5%.
Table 4: Rehabilitation of neurological deficits before and after surgery (n = 52).
Cranial nervous

Before surgery

Imprvove

Unimprove

II

21

5 (23.81%)

16 (76.19%)

III

26

17 (65.39%%)

9 (34.61%)

IV

7

4 (57.14%)

3 (42.86%)

V

24

7 (29.2%)

17 (70.8%)

VI

13

7 (53.85%)

6 (46.15%)

Vision improvement after surgery is still limited, in which the cranial nerve number III
improves the best after surgery.
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Table 5: Residual and recurrence.
MRI

n

%

Total resection

31

59.7

Subtotal resection

21

40.3

Recurrence

8

15.4

DISCUSSION
1. Evaluate the degree of tumor
resection.
How to get rid of tumor is still controversial.
In our report as well as other authors’, we
use the chart for the degree of tumor
resection (Simpson D, 1957) [11]: all
tumor resection (grade I, II) achieved
60%, left subtotal resection accounted for
40%. In some recent reports, Attia M
(2012) [2] have the capture result after
surgery with 07 cases (31.8%) of thorough
removal, 68.2% residual. Scheitzach J.D
and his partner (2014) [10] conducted a
research on 227 patients, of which
67 patients with SWMs found 34.5% of
tumor residual. 2.7% of them suffered
from grade IV resection. Result of all
tumor resection at medial sphenoid wing
is still limited but it proves that the tumor
location is very important to tumor
removal, the position 1/3 inside just take
up 5/24 cases (20.8%), this difference is
statistically significant. We also realized
that the position of the tumor is of great
significance in tumor resection (p < 0.05).
Complete removal is more difficult
when the site of origin is more medial and
the extension of the tumor is greater. In

meningiomas located at the outer part of
the ridge, complete resection is possible
in almost every case, except for those
with vascular encircling. In a considerable

amount of sphenoid wing meningiomas of
the middle or inner region, total resection
is unrecognizable without an unacceptable
risk of additional morbidity including its
cranial nerves and adjacent arteries,
posteriorly. Therefore, some authors proposed
to reconceive the original Simpson’s
classification due to a close relationship to
neurovascular structures, where radical
dural resection is more hazardous
compared to supratentorial convexity
meningiomas [2, 8].
2. The result of surgery.
Patients’ post-operation outcome (KPS
80 - 100 points): good outcome accounted
for 65%, average 30%, worse 5%. Compared
with the KPS before surgery, we realized
that the patients in average group reduced,
so this difference was statisticaly significant
(p < 0.05). Abdel Aziz (2004) [1] also
recorded the results after surgery following
the KPS: good outcome in the first 3 months
achieved 74%, bad 26%, no normal result.
This rate in the study by Honig S (2010)
[7] in the first 3 months after surgery was

77.8% good, 11.1% normal (5 cases), 8.9%
bad (4 cases). Stephen M.R (2008) [11] also
confirmed good result in 32.4%, bad: 11. 8%.
Hence, in this study, the average
outcome was to be expected for group of
medial sphenoid wing meningiomas due
to less surgical accessibility, more frequent
vascular and nerve involvement and a higher
incidence of preoperative neurological deficit.
3. Mortality.
Three patients died after surgery, two
of whom had giant tumors at medial
sphenoid wing due to intra-operative
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Journal of military pharmaco-medicine no3-2018
bleeding and massive cerebral edema
after surgery and a patient died during
follow-up period of heart disease.
Mortallity rate in our study was 5%. We
realized that when the tumor adhered to
the ICA or cavernous sinus, anterior
clinoid process and large vascular
feeding, we should be cautious otherwise
there will be injury of neurovascular
structures and vasopasm during operation
and complication may occur after surgery
such as hematoma, ischemia, edema,
infarction. Some recent reports also

revealed a high mortallity like the study by
Honig S (2010) [7] (4.7%); Verma S.K
(2016) (2.6%)...
4. Cranial nervous outcome.
Our result shows that the vision recovery
after surgery is limited, especially the
patients whose vision are still counting
fingers and blind. Improvement of cranial
nerver number II: 23.81%, visual disturbance
symptoms concentrated at the medial
sphenoid wing meningiomas, optic canal
invasion and carvenous sinus involvement
are frequent features of these tumors.
Most of all researches announced
about the limitation in vision recovery after
tumor resection. Like those authors,
however, we realized that the result
depended on the tumor expense with the
other parts like the visual tract, into the
visual hole and the degree of adhesion to
the visual cords and the subtotal tumor
resection.
Nakamura and his partner (2006) [9]
also discussed the cranial nerve deficit
from 4 - 29% and realized that in some
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reports about medial sphenoid wing
meningiomas involved with cavernous
sinus, there will be poor recovery. In his

study, Verma S.K (2016) reported 11/58
(18.9%) cases suffered from cranial nerve
paralysis III, IV, VI before surgery and
didn’t improve after surgery because tumor
expended cavernous sinus, 6 cases were
affected by cranial nerve V. Scheizach J
(2014) [10] didn’t find the colleration
between the tumor resection and tumor
deficit recovery. Our result showed that
this improvement wasn’t associated with
tumor resection.
5. Evaluate the tumor residual and
reccurence after surgery.
Most meningiomas are benign, the
reccurence time is usually slow after
surgery in both total and subtotal
resection, therefore, we as well as the
other authors indicated that after
12 months’ surgery the view of
meningiomas at the surgery position is
still residual tumor. Nakamura (2006) [9]
reported that average reccurence time
was 32 months. In our research,
reccurence rate was 15.4%, our mean
time was 14.5 months, which is shorter
than that in the other studies, so the
reccurence has low confident value. We
all agree that tumor reccurence depends
on many factors, mainly tumor resection
and histopathology. Hence, the aim of the

surgery was to resect all the tumors which
the tough part sticks to, the effected bone
will limit the reccurence time. But it seems
to be a great challenge to remove all the
tumor at the position of 1/3 inside .


Journal of military pharmaco-medicine n03-2018
CONCLUSION
After studying 60 patients who were
diagnosed with sphenoid wing meningiomas
and treated at Vietduc Hospital from April
2013 to September 2015, we drew out
some conclusions:
- Surgical management of meningiomas
involving the sphenoid ridge does not
contribute to increased procedure-related
morbidity compared to other intracranial
meningiomas. However, meningiomas
involving vascular structures of ICA
(internal carotid atery) and MCA (middle
cerebral atery) still has high mortality.
Complete resection is feasible in nearly all
cases with lateral located sphenoid wing
meningioma. In cases of meningiomas of
the middle or medial, total removal should
not be attempted at the expense of new
cranial nerve deficits or visual deterioration.
With a view to improving the quality of life
after operation, incomplete resection

should be considered as an acceptable
treatment option. The outcome is worse in
medial meningiomas due to less surgical
accessibility, greater vascular and nerve
involvement and a higher incidence of
preoperative neurological deficits. All patients
should be followed closely with clinical,
ophthalmological and radiological investigations
to identify timely tumor regrowth.
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