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Year : 2020  |  Volume : 4  |  Issue : 2  |  Page : 166-173

Management of parasagittal meningiomas invading superior sagittal sinus

1 Department of Neurosurgery, Faculty of Medicine for Girls, Al-Azhar University, Cairo, Egypt
2 Department of Neurosurgery, Alzahraa University Hospital, Cairo, Egypt

Date of Submission03-Feb-2020
Date of Decision09-Feb-2020
Date of Acceptance19-Feb-2020
Date of Web Publication29-Jun-2020

Correspondence Address:
MD Mohammad F Eissa
Assistant Prof. of Neurosurgery, Al-Azhar University, 11573, Nasr City, Cairo
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/sjamf.sjamf_18_20

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Introduction Meningioma in parasagittal location represents between 20 and 30% of meningioma cases in the cranial cavity. The close relation of it with superior sagittal sinus makes its surgical resection a great challenge to the surgeon to get a good result.
Aim A retrospective and prospective study of management of 15 cases of parasagittal meningiomas invading superior sagittal sinus was conducted, including clinical assessment, diagnosis, and surgical management done in Al Azhar University Hospitals.
Patients and methods The authors recruited 15 patients with parasagittal meningioma who were admitted to the Neurosurgery Department, Al Azhar University Hospitals. These cases had been assessed according to clinical picture, radiological evaluation, operative details, and postoperative complications. Surgical resection was achieved for these cases in the period between October 2015 and February 2019.
Results The patients’ age varied between 20 and 60 years. Patients comprised eight males and seven females. The presenting symptoms were headache (15 patients), seizures (10 patients), motor weakness (12 cases), papilledema (four patients), and frontal manifestation (four cases). A total of 11 cases had gross total tumor excision, whereas four cases showed partial tumor removal. Moreover, there were two mortality cases.
Conclusion Several factors contribute to the success of parasagittal meningioma surgery. The authors consider the preservation of the cortical veins to be important, and when possible should be done. The experience has led to believe that until now, surgery is a winning choice if practiced by expert hands.

Keywords: meningioma, parasagittal meningioma, superior sagittal sinus

How to cite this article:
Eissa MF, El Hamed Zaki RA, El Noty NZ. Management of parasagittal meningiomas invading superior sagittal sinus. Sci J Al-Azhar Med Fac Girls 2020;4:166-73

How to cite this URL:
Eissa MF, El Hamed Zaki RA, El Noty NZ. Management of parasagittal meningiomas invading superior sagittal sinus. Sci J Al-Azhar Med Fac Girls [serial online] 2020 [cited 2020 Oct 26];4:166-73. Available from: http://www.sjamf.eg.net/text.asp?2020/4/2/166/288266

  Introduction Top

The sagittal sinus has a triangular shape in the coronal section, and its size gradually increases as it extends posterior [1]. The superior sagittal sinus (SSS) communicates with irregular venous cavities called lateral venous lacunae, which lie in the dura mater. In certain areas, the arachnoid projects into the venous sinuses to form the arachnoid villi. These are mushroom-shaped outpouchings of the subarachnoid space that invaginate into them allowing cerebrospinal fluid (CSF) to flow inside the sinuses. When they are very large, the villi can be perceived with naked eye and are called Pacchionian granulations. Sometimes these granulations may be seen on magnetic resonance imaging as a filling defect or a mass within a large dural sinus [2].

Parasagittal meningiomas have the dural attachment on the external layer of the SSS and invade the parasagittal angle displacing brain away from its normal position. Cushing and Eisenhardt, in their series of 295 meningiomas, found that the parasagittal location is the most common, 22% [3]. The frequency of parasagittal meningiomas among all meningiomas ranges in the literature between 16.8 and 25.6% [4]. Olivecrona classified parasagittal meningiomas taking into account their anatomic insertion along SSS. He divided the SSS into anterior, middle, and posterior third, keeping in mind the different consequences of sinus occlusion in each area [5]. Along the first third of the SSS (from crista galli to the coronal suture) are located 15–42% of parasagittal meningiomas, and only 9–16% of parasagittal tumors are located along the posterior third of the SSS (between the bregma and torcula) [6].

Signs and symptoms

The clinical picture of parasagittal meningiomas depends on the tumor location along the SSS. Thus, all tumors can produce headache, but meningiomas of the anterior third of the SSS often cause personality changes, tumors of the middle third of the SSS are often associated with Jacksonian seizures and progressive hemiparesis, and those of the posterior third can cause hemianopsia [3],[4],[5].

Even in extensive resections with sinus reconstruction or bypass, which has increased perioperative morbidity and mortality, local recurrence still remains a major problem [1],[7],[8]. Therefore, because of the potential morbidity of such cases and the efficacy of adjuvant radiosurgery for the management of residual tumors and recurrent meningiomas, surgeons have adopted lately a more conservative approach in the management of sinus invasion [9].

Surgical management

We used anatomical landmarks to estimate the position of SSS in planning the skin incision and operative flap to minimize SSS injury. We used mainly two options in reconstruction of the dura layer defect after meningioma removal: galea capitis if the defect is small and fascia lata graft in large dural layer defect, and in a few cases, we used artificial dura mater [6],[10].

Under general anesthesia, endotracheal intubation was done. The position of the patient on operative table was planned according to the meningioma location: if the tumor is in the anterior half of the sinus, the patients are placed in a supine position, whereas the patient was placed in the lateral position if the meningioma was present in the posterior half of the SSS. The patients were held in a position by three-point fixation Mayfield [1],[4].

We used saline solution for injection subdermis and subperiosteum as the first step in galea flap preparation. The craniotomy flap was made according to matching the anatomical landmarks in the images and the patient. The craniotomy flap was centered in SSS with rectangular flap with burr holes on SSS both sides. Care must be taken in separation of the dura from the bone flap to avoid SSS injury. We applied microscope in all cases [6],[10],[11].

The dura was opened carefully in the lateral dural flap edge from posterior forward then open it from lateral to medial, making the dural flap base attachment to the SSS. We began by coagulation of the tumor feeders and venus drainage with preservation of collateral veins (that appeared under the microscope hypertrophied, wide caliber attached to SSS and run parallel to it) as much as possible by early identification under the microscope. Care was taken to avoid aggressive brain retraction by working inside the meningioma by piecemeal tumor excision (internal tumor debulking), then freeing of the capsule from the brain tissue was done by identifying the tumor brain interface that represents the arachnoid plane to reduce pial and brain vessel injury. We applied wet cotton strips in this plane continuously till complete tumor removal. Finally, we removed the meningioma part that invaded the SSS if possible. We controlled the tumor bed blood oozing by hemostatic materials after blood pressure normalization for at least 10 min. At the end of the procedure, we reconstructed the dural defect by galea capitis flap if it was small and fascia lata graft if it was large in most cases, but few were reconstructed by artificial dura mater. If we removed the bone that invaded by the tumor, we used titanium mesh and mini-screws to cover the bone defect [7],[11].

We used dexamethasone intraoperatively and for 1 week postoperatively. Beside antibiotic, mannitol, loop diuretic, and phenytoin were routinely administrated to these patients. We recommend antiplatelet therapy after hospital discharge.

In normal course of the cases, we requested MRI brain before and after contrast plus Venus MRA after 6 months (unless complication occurred we requested it earlier), and then every 1-year interval.

  Aim Top

A retrospective and prospective study of management of 15 cases of parasagittal meningiomas invading SSS, including clinical assessment, diagnosis, surgical management, was done in Al Azhar University Hospitals.

  Patients and methods Top

This study was performed at the Department of Neurosurgery in Al Azhar University Hospitals on 15 patients who were admitted to our department either from out-patient clinic or from emergency unit from October 2015 to February 2019.

After admission, every patient was examined clinically regarding conscious level and neurological deficits, such as weakness and sensory affection, mainly in middle third tumors, frontal lobe manifestations in anterior third tumors, and visual affection in posterior third tumors.

Moreover, proper history was taken from the patient or his/her relatives if the patient is unconscious regarding fits, course of the disease, and any associated morbidities like hypertension, diabetes mellitus, liver or renal affection, pulmonary or cardiac condition, or any drugs taken by the patient like aspirin or marevan, which may affect the timing of surgery.

Regarding the preoperative preparation it included laboratory and radiological investigations, complete blood count, bleeding profile, liver and kidney functions, electrolytes, bleeding time, and clotting time for patients on aspirin.

Radiological investigations included computed tomography (CT) brain without and with contrast and MRI brain with contrast and magnetic resonance venography (MRV) for exact localization of the tumor site, size, relation to sinus, and whether the sinus is patent or not.

Preoperatively the patients are examined by the anesthesiologist to assess surgical fitness, and also preoperative blood is prepared, and the patients are loaded by phenytoin, dexamethasone intravenously, and preoperative antibiotic coverage. After approval by Local Ethical Committee of Al-Azhar University, a written, informed consent was taken from the all patients after information by presenting symptoms and expected complications.

The patient is operated upon with a bone flap crossing the sinus to be exposed, and dura is cauterized to devascularize the tumor. The dura is opened in a U-shaped manner based on the sinus, and tumor is excised by dissection it from the sinus. Preservation of bridging veins is maintained, and duroplasty was done, if the dura is invaded, and cranioplasty, if the bone flap is invaded.

Intraoperatively, the patient received medications in the form of antibiotics before skin incision, phenytoin, dexamethasone, primprane, and zantac. Postoperatively, the patient is examined for conscious level and neurological deficits such as weakness or visual affection. Postoperative laboratory examinations are ordered like complete blood count to assess the need for postoperative blood. Postoperative images are done in the form of CT brain without and with contrast to assess the extent of tumor removal, any residual tumor, and postoperative hematoma in tumor bed. Those patients are followed up by serial CTs over a period of 1 year by regular visits to our outpatient clinics.

Inclusion criteria

The following were the inclusion criteria:
  1. Meningioma invading SSS at any grade.
  2. Meningioma greater than 3 cm.
  3. All patients fit for surgery.

Exclusion criteria

Exclusion criteria included the following:
  1. Unfit patients.
  2. Small size less than 3 cm.

Illustrative cases

Case 1

A 30-year-old female patient presented with headache, focal fits, and left foot drop. MRI showed RT middle third parasagittal meningioma. Gross total tumor resection was achieved. Postoperative headache improved and fits were controlled, and she regained her full power.

Sections showed cellular whorls of meningothelial and spindle cells with eosinophilic cytoplasm, no mitosis, or atypia (meningothelial).

Case 2

A 56-year-old male presented with headache, dysphasia, and seizures. MRI brain with contrast revealed left anterior parasagittal meningioma. Simpson grade 2 was achieved. Postoperative dysphasia improved gradually 2 months later and seizures were controlled.

The section showed multiple syncytial cell with round to oval nuclei impeded in eosinophilic cytoplasm alternating with spindle shaped cells and elongated nuclei separated by fibrous septa (mixed). There was no evidence of mitosis or atypia.

  Results Top

[Table 1] shows the distribution of sex in the studied group. There were seven (46.67%) female and eight (53.33%) male patients.
Table 1 Sex distribution among 15 cases of parasagittal meningioma

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[Table 2] shows the distribution of parasagittal meningioma along SSS in 15 cases, where eight (53.33%) cases were in the middle third, four (26.67%) cases in anterior third, and three (20%) cases in the posterior third ([Table 3],[Table 4],[Table 5]).
Table 2 Distribution of meningioma along superior sagittal sinus

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Table 3 Presenting symptoms of cases parasagittal meningioma.

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Table 4 Follow-up symptoms after surgical excision of 15 cases parasagittal meningioma

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Table 5 Extent of resection data among in this study

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Postoperative complications

Postoperatively, we had three cases with increased motor weakness. Those patients were maintained on neurotonics, vitamin B complex, and regular physiotherapy, and they followed up in regular visits, where one case improved within 1 year.

Two patients had infection postoperatively. We maintained them on course of injectable broad-spectrum antibiotics with regular dressing and topical antibiotic spray till recovery within two weeks.

Two cases had postoperative CSF leakage, which were managed by tight bandage course of injectable broad-spectrum antibiotics till spontaneous stoppage after 2 weeks.

We had two cases with postoperative hemorrhage, which were not sizable enough for evacuation. We just followed them up by serial CT brain, which show no increase in size and spontaneously resolved ([Figure 1],[Figure 2],[Figure 3],[Figure 4],[Figure 5],[Figure 6],[Figure 7],[Figure 8],[Figure 9],[Figure 10]).
Figure 1 Preoperative MRI brain with contrast T1W1 axial, sagittal, and T2 coronal showing RT middle third parasagittal meningioma.

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Figure 2 Postoperative MRI brain T1W1 with contrast axial, sagittal, and coronal views showing total tumor excision.

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Figure 3 Postoperative computed tomography brain showing total tumor excision, mild brain edema, and pneumocephaly (without dott).

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Figure 4 MRV.

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Figure 5 Histopathology.

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Figure 6 Preoperative MRI brain T1W1 with contrast axial, sagittal, and coronal views showing LT anterior third parasagittal meningioma.

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Figure 7 Postoperative MRI brain with contrast T1W1 axial, sagittal, and coronal views showing total excision of the tumor.

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Figure 8 Postoperative computed tomography brain showing total tumor excision and area of pneumocephaly with mild brain edema.

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Figure 9 MRV.

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Figure 10 Histopathology

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Regarding mortality, two patients died within one week after surgery; one of them had venous infarction, and other case had deep venous thrombosis (DVT) and pulmonary embolism (PE) ([Table 6]).
Table 6 Postoperative complications data among this study

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Finally, in our study on 15 cases of parasagittal meningiomas, we had nine cases with postoperative improvement of preoperative symptoms (motor weakness, fits, papilledema, and dysarthria), three cases had postoperative deterioration of preoperative patient complain, and three cases had no significant changes, neither improvement nor deterioration ([Table 7]).
Table 7 The follow-up outcome after surgical excision of 15 cases of parasagittal meningioma

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  Discussion Top

In our study, we operated on 15 patients. Headache was the chief complaint in 15 patients. Motor weakness was the main presentation in 12 patients, and fits were the presenting symptoms in 10 patients. Visual affection in the form of papilledema was seen in four patients. However, Lynch et al. [12] reported in 58 patients, headache was the chief complaint in 39 patients, fits in 21 patients, motor deficits in 17 patients, and visual affection in 12 patients, whereas D’Avella et al. [13] operated upon 15 patients, and nine of them had headache as the main complaint, fits were the presenting symptom in seven patients, and weakness was seen in four patients. In the study by Deibert and Kondziolka [14] which was done on 26 operated patients, all reported various degrees of dizziness and headache: 10 presented with epilepsy, 15 with lateral limb numbness, 16 with hemiparesis, and two with coma.

In our study, we operated upon 15 patients, comprising five patients with tumor at the anterior third of SSS, eight patients with tumor at the middle third of the sinus, and two patients with tumor at the posterior third of the SSS. However, Bonnal and Brotchi [15] operated upon 21 parasagittal meningiomas: three were located in the anterior third of the sinus, 14 in the middle third, and four in the posterior third. Moreover, DiMeco et al. [16] operated upon 92 patients with 28 at anterior third, 48 at middle third, and 16 at posterior third.

In our study, we operated upon 15 patients, and the sinus was invaded in 10 patients and was patent in five patients. However, DiMeco et al. [16] operated upon 92 patients and reported that the sinus was invaded in 63 patients and was patent in 29 patients. Levoshko et al. [17] operated upon 106 patients, and the sinus was invaded in 50 patients and patent in 56 patients. Ni Ming-shan et al. [18] operated upon 35 patients, where the sinus was invaded in 20 patients and patent in 15 patients.

In our study we operated upon 15 patients with total removal in 11 patients of which sinus was invaded in six patients with, subtotal resection in four patients all of which sinus was invaded. While Han Wen-tao et al. [19] operated upon 36 patients 29 of which were totally removed, and seven cases were sub-totally removed. While operated upon 35 patients with 28 cases totally removed and seven cases were subtotally removed. While operated upon 30 patients 23 of them undergone total resection and seven cases were sub-totally removed.

DiMeco et al. [16] operated upon 108 patients with total removal in 100 patients of which the sinus was occluded in 30 patients, with only eight patients with subtotal removal. Sindou and Alvernia [20] operated upon 92 patients with total removal in 85 patients with sinus invasion in 69 cases, whereas subtotal removal in seven cases. Nowak and Marchel [21] operated upon 50 patients, and sinus was invaded in 21 patients and patent in 29 patients; among the 21 cases, total resection was in nine cases.

In our series, we operated upon 15 patients from which motor weakness occurred in three cases, CSF leak in two cases, postoperative hemorrhage in two cases, venous infarction in one case, which died, and two cases of infection. However, DiMeco et al. [16] operated upon 92 patients, where air embolism occurred in a single patient, extradural and/or subdural hematoma in three patients, neurological deficit in eight patients, and venous infarction in three patients, who died. On the contrary, Girvigian et al. [22] operated upon 30 patients, and seven of these patients developed post-treatment symptomatic peritumoral edema. .In our series, we operated upon 15 patients: nine patients improved, three patients remained the same, and three patients deteriorated. However, DiMeco et al. [16] operated upon 92 patients, where 70 patients improved, six patients remained the same, and 16 patients deteriorated. On the contrary, Girvigian et al. [22] operated upon 30 patients, where 23 patients improved and seven deteriorated. Levoshko et al. [17] operated upon 106 patients, where six patients deteriorated, five patients remained the same, and 95 patients improved.

  Conclusion and recommendation Top

Parasagittal meningioma is a tumor that occupies the angle between the dura and the sinus, usually benign tumor but may be malignant. Through our series, we could detect cardinal factors in prognosis of these cases, which included tumor size, histology, preoperative identification of the venous collaterals, and preservation of it in the surgical maneuver.

It has to be totally removed for complete cure, but complete resection is sometimes difficult because of sinus invasion.

Attempts for total removal in sinus invasion may lead to postoperative complications. The most common is venous infarction, which may be fatal. Gamma knife radiosurgery is now the best option to handle a tumor residual within the sinus.

The possibility of total removal is best with the anterior third tumors and least with posterior third ones. Better results are obtained in tumors just attached to the wall of the sinus and decreases with sinus invasion.

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Conflicts of interest

There are no conflicts of interest.

  References Top

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  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10]

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]


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