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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
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