Evidence-Based SurgeryExtent of Resection in Parasagittal Meningioma               December, 2011                         ...
Case: VB• 52 year old lady• Foot drop since April  2010• Craniotomy and  excision of tumour  (08/11)• Histology: Atypical ...
Clinical Questions:• In patients with meningioma involving the SSS, does  a greater extent of resection (opening the sinus...
Search strategy•   P = Patients with parasagittal meningioma•   I = Total resection•   C = sinus sparing surgery / subtota...
Results ofsearch:• 3 articles
Results of search: 1 further article
MENINGIOMAS INVADING THE SUPERIOR SAGITTALSINUS: SURGICAL EXPERIENCE IN 108 CASESFrancisco Di Meco et al , Department of N...
Methods•   Retrospective review of data•   1986 – 2001•   108 patients•   tumor invasion of the SSS•   Preoperative CT,MRI...
Surgical Methods1. In sinus patency - marginal resection of the    tumor along the sinus + suturing/patching ( cadaveric g...
Results• Mean follow up 74 months ( 0 -223)Histology• Grade l – 79.6%• Grade ll – 14.8%• Grade lll – 3.7%                 ...
Extent of Removal                    11
Mortality & Morbidity• Mortality – 1.85% (2 pts) : 1 post op haematoma, 1  PE• Brain Swelling – 8.3% (9 pts)              ...
Recurrence• 13.9%• Median time to recurrence : 156 months                                           13
• Related to :1) Extent of resection                         14
2) histology               15
3) Tumour size                 16
Discussion•   Recurrence : failure to achieve radical resection•    Complete sinus occlusion by the tumor mass allows    t...
Results of attempted radical tumour removal and venous repair in 100consequtive meningiomas involving the major dural sinu...
Methods :• Retrospective• 100 consecutive patients• 1980 to 2001• 92 – SSS ( 28 in anterior third, 48 in the middle third ...
• Mean follow up 8 yrs• All patients underwent CT,MR and  angiography• Total removal was defined as a resection  equivalen...
Classification of Sinus Involvement                                      21
Surgical Strategy1. Simple resection of the outer dural layer and   coagulation of the inner layer2. Resection of the inva...
• All patients -semisitting position/sitting position• Heparin therapy - morning after surgery and for 3  weeks• Warfarin ...
Statistical Analysis• Biosta TGV software• Student t –test : pre/post op KPS score• Mean values at 95% CI• Fischer’s exact...
ResultsType of surgery                  25
Post op complications• Air embolism 1%• Subdural / extradural haematoma 3%• Neurological deficit 8% 5 no venous repair, 3...
Recurrence4 pts recurrence:1- treated with patch, ( anaplastic)1- resuturing1- bypass graft (atypical)1- not known        ...
Angiographic patency•   Simple suturing : 100%•   Patch : 87%•   Autologous vein bypass : 72.7%•   Gertex graft : 0%      ...
KPS scores             29
Discussion• Low recurrence of 4% with radical resection• Preserve the bridging veins• Safety of resecting a totally occlud...
 Hoeslly et al (1955 )• 196 pts , parasagittal meningioma• No venous reconstruction• 10% mortality Bonnai et al (1978)• ...
•   86.6% sinus repair – angiographically patent•   72.2% of bypasses were patent•   Temporary occlusion of lumen with sur...
Conclusion• Radical resection – low recurrence• Mandatory to reconstruct in incomplete  occlussion• Useful in complete occ...
Perioperative and Longterm Outcomes From the Managementof Parasagital MeningiomasShaan M. Raza et al / Neurosurgery, Oct 2...
Methods•   Retrospective•   110 patients•   1992-2004•   John Hopkins Medical Institutions•   Minimum follow up was 24 mon...
• Type ll – sinus not entered, remaining  irradiated• Type lll & lV – sinus entered & reconstructed• Type V & Vl – ligated...
• MRI at 3 months for residual tumour• SRS for progression                                        37
Results          38
39
• 11% recurrence• Mean follow up 41 months• In recurrence, no statsitically significant  difference in: Histology Extent...
Discussion•   recurrence rate of 11%.•   cerebral venous thrombosis/infarction in 3.6%•   bridging vein injury promote ven...
Conclusion• lesions partially invading the sinus should be  resected to the greatest extent possible• residual/recurrent d...
Results with Judicious Modern NeurosurgicalManagement of Parasagital and Falcine meningioma - Michael E. Sughrue et al ,Un...
Methods• 135 pts , retrospective study• Median follow up was 7.6 yrs• 61 pts had SSS invasion• Completely occluded SSS was...
Results          45
• Kaplan – Meier  analysis analysis to  compare GTR and  STR• No difference in  tumour recurrence                         46
Complications                47
Discussion• Data suggest trend towards less aggressive  surgery for patent sinus• STR - Follow up with imagingSRS for• STR...
Discussion• Data suggest trend towards less aggressive  surgery for patent sinus• STR - Follow up with imagingSRS for• STR...
Thank You            50
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Ebs meningioma 2011

  1. 1. Evidence-Based SurgeryExtent of Resection in Parasagittal Meningioma December, 2011 1
  2. 2. Case: VB• 52 year old lady• Foot drop since April 2010• Craniotomy and excision of tumour (08/11)• Histology: Atypical meningioma with bone involvement 2
  3. 3. 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? 3
  4. 4. 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” 4
  5. 5. Results ofsearch:• 3 articles
  6. 6. Results of search: 1 further article
  7. 7. MENINGIOMAS INVADING THE SUPERIOR SAGITTALSINUS: SURGICAL EXPERIENCE IN 108 CASESFrancisco Di Meco et al , Department of Neurosurgery,Istituto NazionaleNeurologico, Milan, Italy, Neurosurgey (55) 1263-1271,December 2004Objective• to provide definitive guidelines for the surgical treatment of parasagittal meningiomas invading the SSS 7
  8. 8. 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 8
  9. 9. Surgical Methods1. 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 9
  10. 10. Results• Mean follow up 74 months ( 0 -223)Histology• Grade l – 79.6%• Grade ll – 14.8%• Grade lll – 3.7% 10
  11. 11. Extent of Removal 11
  12. 12. 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 12
  13. 13. Recurrence• 13.9%• Median time to recurrence : 156 months 13
  14. 14. • Related to :1) Extent of resection 14
  15. 15. 2) histology 15
  16. 16. 3) Tumour size 16
  17. 17. 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 17
  18. 18. Results of attempted radical tumour removal and venous repair in 100consequtive meningiomas involving the major dural sinuses Sindou MP et al , Université Claude-Bernard de Lyon, France; and Department ofNeurosurgery, 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 18
  19. 19. 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 19
  20. 20. • 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 20
  21. 21. Classification of Sinus Involvement 21
  22. 22. Surgical Strategy1. Simple resection of the outer dural layer and coagulation of the inner layer2. 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 graft3. Resection of sinus with no reconstruction 22
  23. 23. • 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 23
  24. 24. 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 24
  25. 25. ResultsType of surgery 25
  26. 26. 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 26
  27. 27. Recurrence4 pts recurrence:1- treated with patch, ( anaplastic)1- resuturing1- bypass graft (atypical)1- not known 27
  28. 28. Angiographic patency• Simple suturing : 100%• Patch : 87%• Autologous vein bypass : 72.7%• Gertex graft : 0% 28
  29. 29. KPS scores 29
  30. 30. Discussion• Low recurrence of 4% with radical resection• Preserve the bridging veins• Safety of resecting a totally occluded sinus remains disputable 30
  31. 31.  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 31
  32. 32. • 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 32
  33. 33. Conclusion• Radical resection – low recurrence• Mandatory to reconstruct in incomplete occlussion• Useful in complete occlussion – compromised collaterals• Bypass with only autologous graft 33
  34. 34. Perioperative and Longterm Outcomes From the Managementof Parasagital MeningiomasShaan M. Raza et al / Neurosurgery, Oct 2010, Vol 67(4)ObjectiveTo retrospectively review the morbidity/mortality and long-term outcomes parasagittal meningiomas invading the superior sagittal sinus 34
  35. 35. Methods• Retrospective• 110 patients• 1992-2004• John Hopkins Medical Institutions• Minimum follow up was 24 months• 61 patients met criteria• All had MRI & DSA 35
  36. 36. • 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 36
  37. 37. • MRI at 3 months for residual tumour• SRS for progression 37
  38. 38. Results 38
  39. 39. 39
  40. 40. • 11% recurrence• Mean follow up 41 months• In recurrence, no statsitically significant difference in: Histology Extent of sinus involvement Extent of resection 40
  41. 41. 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 41
  42. 42. Conclusion• lesions partially invading the sinus should be resected to the greatest extent possible• residual/recurrent disease is subsequently observed and treated with radiosurgery 42
  43. 43. Results with Judicious Modern NeurosurgicalManagement of Parasagital and Falcine meningioma - Michael E. Sughrue et al ,University of California / Journal of NeurosurgeryMarch 2011, Vol 114 (3)Objectiveto provide data regarding large tumors andthe surgical and clinicalsignificance of invasion of the SSS 43
  44. 44. 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 44
  45. 45. Results 45
  46. 46. • Kaplan – Meier analysis analysis to compare GTR and STR• No difference in tumour recurrence 46
  47. 47. Complications 47
  48. 48. Discussion• Data suggest trend towards less aggressive surgery for patent sinus• STR - Follow up with imagingSRS for• STR + EGFR negative/ > 10% MIB1• STR + Recurrence 48
  49. 49. Discussion• Data suggest trend towards less aggressive surgery for patent sinus• STR - Follow up with imagingSRS for• STR + EGFR negative/ > 10% MIB1• STR + Recurrence 49
  50. 50. Thank You 50

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