SURGICAL EXPERIENCE IN THE MANAGEMENT OF GIANTS MENINGIOMAS, CASES AND OUTCOMESIN HOSPITAL JUAREZ OF MEXICO IN MEXICO CITY.2012.

1. Surgical management of giant
meningiomas in supratentorial
compartment. Experience of 58 cases.
Arturo Ayala-Arcipreste. MD , FAANS
Neurosurgery Department
Hospital Juárez de México
México City.

2. Collaborators
Dr. Rafael Mendizabal-Guerra. Chairmann of
Neurosurgery Department.
Dr. Jose Luis Hernández-Moreno. Neurosonology unit.
Dra. Durdica López-Vujnovic. Neurosonology Unit.
Dr. Moises Jimenez-Jimenez. Neurosurgery Department.
Dr. Ruben Acosta-Garces. Neurosurgery Department.
Dr. Gustavo Melo-Guzmán. Endovascular Neurosurgery.
Dra. Teresa Cuesta. Neuropathology Department.

3. Disclosure
The authors report no conflict of interest
concerning the material or methods used in
this study or the findings specified in this
presentation.

4. Background.
The Challenge in giant meningiomas is the total resection of the
tumor with the least possible mortality and morbidity. The
development and improved operative techniques have shown a
considerable progress, providing a wide exposure with minimal
brain retraction.
Giant meningiomas are described like tumors bigger than 4.5
centimeters in the major diameter, and are considered a
complex lesion due to the effects on the brain, intracranial
pressure, including neural and hemodynamics changes.

5. Background
SINAIS (National Stadistic Health System. México)
2004-2010 report 9901 cases of meningeal tumors.
Neurosurgery Department of Hospital Juárez de
México attending 19 to 31 cases per year (2004-2012)
n: 233
Giant Meningiomas (>4.5cm) n:58

6. Objectives.
To demostrate the surgical experience of our department
with high complexity meningiomas with basic technology.
Describe the use of the transoperative Doppler
flowmetry in the meningioma surgery.

7. Material and Methods
A retrospective analysis was performed in 58 patients with
giant meningiomas (diameter > 4.5cm) which were treated
surgically in our department, between June 2004 to January
2013.
The location of the tumor was divided in: supratentorial, and
supra-infratentorial compartments.
All the patients were studied with CT Scan and MRI, only 10
patients were embolized.
The surgical approach was chosen depending on the location of
the tumor, extension and vascular or neural structures
involved. The Simpson scale was used to describe the grade of
tumor resection.

8. Gender & Age

9. Location.

10. Supratentorial
group n:48
Supra-
infratentorial
n:10
Signs and
Symptoms
Progressive headache,
Pyramidal tracts
involve, seizures,
mental and visual
disturbances.
Frontal syndrome.
Progressive
headache, cranial
nerve paresis,
dysmetria, ataxia,
seizures.

11. Intracranial effects of the High
Volume Meningiomas
ICP
Compressive effect on
venous structures…edema
Compressive effect on
arteries….ischemic
phenomena.
Hydrodinamics effects on
CSF drainage.
Electrophysiological
effects……Seizures
Monro-Kellie Doctrine.

12. Mean maximal tumor diameter- Location

13. Supratentorial
(n: 48 )
Supra-infratentorial
(n:10)
Gender F:31 M:17 F: 8 M:2
Age (13 to 81 ) m: 48.9 (28-57) m:44.2
Embolization 7 cases 3 cases
Maximus tumor´s
diameter
(5cm – 18cm)
m:7.82 cm
(6cm-13cm)
m: 8.21cm.

14. Considerations
Angiography ?
Relationship with vessels
Feeders vessels.
Embolization ?
Intraoperative monitoring
Surgical technnique to plan.

15. Peritumoral Edema
Location…
Venous Circulation.
Pial blood supply…
Tumoral size?
Tumor Biology…
Biochemical factors…

16. SURGICAL APPROACHES
Sphenoidal wing
meningiomas n:10 Parasagital meningiomas n: 8

17. Surgical approaches
Anterior Floor Meningiomas(8) Convexity meningiomas (14)

18. Surgical approaches
Hemispherics n:3 Ventricular n:3

19. Surgical Approaches.
Supra-infratentorial
meningiomas (n: 10)
Falco-tentorial meningiomas (2)

20. Transoperative Doppler
Flowmetry (16 Mhz transductor)
Five sphenoid ridge, 3 anterior floor , 2 parasagital and 1 supra-
infratentorial were monitorized with transoperative Doppler
flowmetry to localize the main arterial trunks avoiding damage in
arterial wall, and measure the velocity of local blood flow.
ICA: 40-43 cm/seg
MCA: 75-80 cm/seg
ACA:60-64 cm/seg
In one case found a severe arterial vasospam in anterior
circulation (> 220 cm/s) for two days after surgery, without
neurological deficit.

21. Simpson Index resection.

22. Surgical complications
Supratentorial
group
Supra-
infratentorial
group
CSF Fistula 0 2
Meningitis 1 2
Malignant
edema and
infarct
1 0
Transient nerve
palsy
2 3
Subdural
hematoma
1 0
Transient
hemiparesis
6 2
Wound necrosis 1 2

23. Hystopathologic results.
Supratentorial
group n:48
Supra-
infratentorial
n:10
Hystopathology Meningothelial (15)
Psammomatous (9)
Fibrous (8)
Transitional(6)
Angiomatous (2)
Hemangyopericitic
(2)
Papillary (2)
Atypical (4)
Meningothelial
(4)
Atypical (1)
Fibrous (2)
Psammomatous
(3)
Benign: 49
(84.48%)
Malignant: 9
(15.5%)

24. Follow-up
Follow-up ( 2 months - 8
years)
All 9 malignant cases
received radiotherapy.
Malignat cases: 3 die due
tumor progression.
1 die for pneumonia.
1 die for gastric bleeding.
3 patients with tumor
recurrence.
Bening cases:
Simpson I-II: without
recurrences
Grades IV: with residual
tumor in the surgical bed
and no changes in tumor
volume.

25. Discussion.
In this serie of 58 cases of giant
meningiomas, in which the
supratentorial location was
predominant, we used a variety
of mixed wide craniotomy with
a linear incition (bicoronal) and
Craneo-Orbito-Zigomatic
approach like one of the most
flexible and extensive providing
a wide window and resect the
tumor without brain retraction
.
In supra-infratentorial group it
was used a skull base approach
mixed with extensive
supratentorial craniotomy due
to the structures involved.
The critical areas are the clivus
and cavernous sinus where
many cases of these serie are
involved. The most of series
about meningiomas infiltred
this area shows a poor surgical
resection.

26. Discussion.
We found that complications of
our serie is similar to the world
series of meningiomas that
involve skull base.
Simpson Index of tumor
resection is better on
supratentorial cases , however
on cases with a massive
meningioma, many vascular
structures are infiltrated and
the resection is difficult.
The behavioral of the tumor
were atypical in 9 cases and the
management include
radiotherapy several weeks
after the surgery.
Our serie has a large number of
giant meningiomas with results
similar to other series of
meningiomas in the world.

27. Conclusion.
Giant meningiomas are one of the
most difficult challenge in
neurosurgery. Multiple factors must
be considered to study and plannig
the best approach including the
postoperative care.
The skull base and neurovascular
knowledge is fundamental for the
neurosurgeon who takes care of
these cases.
The use of the Doppler monitoring
give information not only about the
vessels topography, also measure
the flow velocity to study the
vasoreactivity in the surgey process.
“Giant meningioma” describes a
very high complex tumor due to
many vascular elements, neural
and skull base spaces that are
involved, what makes these
features difficult to obtain a
good index of resection. There is
also high risk of morbidity and
poor outcome, predominantly on
skull base tumors.

28. F 40. External third sphenoidal
wing

29. Question mark incision and
fronto temporal craniotomy

30. A-V shunt

31. Total Resection (Simpson 1)

32. Postsurgical MRI

33. Frontal convexity tumor F 26

34. Postsurgical CT

35. Left parasagital meningioma with bone vault
invasion.

36. Bicoronal incision and bifrontal
osteotomy

38. Dural reconstruction with periostium.

39. Postsurgical MRI

40. Right sphenoidal
wing
meningioma

41. 1.-Question mark incision.
2.-Fronto-temporal
craniotomy.
3.-High speed drill of lesser
sphenoidal wing and orbital
lateral wall.
4.- Simpson 1.

43. Post surgical CT

44. Hemispheric parasagital meningioma.F 81

46. Bicoronal incision and bifrontal
osteotomy

47. Total resection with CUSA
and transoperative
Doppler flowmetry

48. Postsurgical CT with contrast

49. Massive
frontal
meningioma.
M 45.
M

50. Massive
frontal
meningioma
M 45.

51. Simpson IV.
Residual tumor
in midline.

52. Olfactory groove-tuber sella-
sphenoidal wing meningioma

55. Postoperative CT (Simpson 4)

56. Olfactory groove meningioma

57. Postoperative MRI

58. Occipito-parietal
convexity meningioma.
Simpson I. (embolized)

59. Temporo-parietal convexity meningioma

61. Right Sphenoidal wing meningioma

63. Embolization

64. Left sphenoidal wing meningioma
COZ approach.

66. Male 28, hemispheric ventricular
meningioma

68. First Surgery, transulcal approach

69. Very solid and calcified mass: parcial
resection.

70. 2nd surgery: Subtotal tumorectomy

71. 3rd surgery,
hydrocephalus….ventriculo-
peritoneal shunt

72. 5 months follow-up
Left Hemiparesys 4-/5

73. Ventricular meningioma

74. MRI post

75. Listen to me.
Point 23:
Above all else, the patient’s
well-being is your duty.
It requires your full
commitment without
distraction.
Dr. Ossama Al-Mefty