Meningioma Last Updated: January 24, 2002 AUTHOR INFORMATION

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2#ic$ Find Author Information Introduction Clinical Differentials Worku !reatment "edication #ollo$%u "iscellaneous &ictures 'i(liogra hy Click for related images5

Author Information Introduction Clinical Differentials Worku !reatment "edication #ollo$%u "iscellaneous &ictures 'i(liogra hy Author) Georges Haddad, M , Clinical Assistant &rofessor, De artment of "edicine, Di*ision of +eurosurgery, American ,ni*ersity of 'eirut, -e(anon Coauthor.s/) !"imene Hato#m, M , 0taff &hysician, De artment of &athology, American ,ni*ersity of 'eirut, -e(anon 1eorges 2addad, "D, is a mem(er of the follo$ing medical societies) Royal College of &hysicians and 0urgeons of Canada Editor.s/) Frederic$ M %incent, Sr, M , &rofessor of Clinical "edicine, &sychiatry, and +eurology, De t of "edicine, De t of &sychiatry, De t of +eurology, "ichigan 0tate ,ni*ersity, College of 2uman "edicine,College of 3steo at4 Francisco Ta&a'era, ("arm , (" , 0enior &harmacy Editor, &harmacy, e"edicine4 )orge *atta", M , 2ead, &rogram Director, &rofessor, De artment of +eurology, ,ni*ersity of Illinois College of "edicine at &eoria4 Se&im R +en,adis, M , Director of Com rehensi*e E ile sy &rogram, Associate &rofessor, De artments of +eurology and +eurosurgery, ,ni*ersity of 0outh #lorida, !am a 1eneral 2os ital4 and Nic"o&as Loren-o, M , e"edicine Chief &u(lishing 3fficer, Chief Editor, e"edicine +eurology4 Consulting 0taff, +eurology 0 ecialists and Consultants INTRO U!TION Section . of 11

Re&ated Artic&es Aty ical #acial &ain 'rainstem 1liomas Ca*ernous 0inus 0yndromes Com le6 &artial 0ei=ures Cranio haryngioma #rontal -o(e 0yndromes

Author Information Introduction Clinical Differentials Worku !reatment "edication #ollo$%u "iscellaneous &ictures 'i(liogra hy

+ac$gro#nd: Coined (y 2ar*ey Cushing, the term meningioma refers to a set of tumors that arise contiguously to the meninges5 (at"op"/sio&og/: "eningiomas may occur intracranially or $ithin the s inal canal5 !hey are thought to arise from arachnoidal ca cells, $hich reside in the arachnoid layer co*ering the surface of the (rain5 "eningiomas commonly are found at the surface of the (rain, either o*er the con*e6ity or at the skull (ase5 Rarely, meningiomas occur in an intra*entricular or intraosseous location5 !he ro(lem of meningioma classification is that arachnoidal cells may e6 ress (oth mesenchymal and e ithelial characteristics5

1lio(lastoma "ultiforme -o$%1rade Astrocytoma +eurofi(romatosis, !y e 9 +eurofi(romatosis, !y e 2 3ligodendroglioma &ituitary !umors &rimary C+0 -ym homa

3ther mesodermal structures also may gi*e rise to similar tumors .eg, hemangio ericytomas or sarcomas/5 Classification of all of these tumors together is contro*ersial5 !he current trend is to se arate une7ui*ocal meningiomas from other less $ell%defined neo lasms5 ,ndou(tedly, ad*ances in molecular (iology $ill allo$ scientists to determine the e6act genomic a(erration res onsi(le for each s ecific neo lasm5

Fre0#enc/:

!ontin#ing 3d#cation ro6imately 20: of all rimary C"E a*aila(le for this to ic5 Click here to take this C"E5

In t"e US: !he incidence is 258 er 900,0005 "eningioma constitutes a intracranial neo lasms5

Internationa&&/: !he fre7uency of meningiomas in Africa is closer to ;0: of all rimary intracranial tumors5

(atient 3d#cation Click here for atient education5

Morta&it/1Mor,idit/:

!he mortality<mor(idity rates for meningiomas are difficult to assess accurately5 0ome meningiomas are disco*ered fortuitously $hen a C! scan or "RI is done for unrelated diseases or conditions5 !hus, some atients die $ith their meningioma and not secondary to it5 "eningiomas are usually slo$ly gro$ing and may roduce se*ere mor(idity (efore causing death5 #actors that may redict a higher osto erati*e mor(idity rate include atient%related factors .eg, ad*anced age, comor(id states such as dia(etes or coronary artery disease, reo erati*e neurological status/, tumor factors .eg, location, si=e, consistency, *ascularity, *ascular or neural in*ol*ement/, rior surgery, or rior radiothera y5

Race: "eningiomas are more re*alent in Africa than in +orth America or Euro e5 In -os Angeles county, meningioma is

re orted more commonly in African Americans5 Se4: "eningiomas afflict $omen more often than men4 male%to%female ratio ranges from 9)954 to 9)25>5 !he female re onderance may (e less ronounced in the (lack o ulation5 "eningiomas are distri(uted e7ually (et$een (oys and girls in childhood5 Age: !he incidence increases $ith age5

!LINI!AL

Section 5 of 11

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Histor/: "eningiomas roduce their sym toms (y se*eral mechanisms5 !hey may cause sym toms (y irritating the underlying corte6, com ressing the (rain or the cranial ner*es, roducing hy erostosis and<or in*ading the o*erlying soft tissues, or inducing *ascular in?uries to the (rain5 !he signs and sym toms secondary to meningiomas may a ear or (ecome e6acer(ated during regnancy (ut usually a(ate or im ro*e in the ost artum eriod5

Irritation) 'y irritating the underlying corte6, meningiomas can cause sei=ures5 +e$%onset sei=ures in adults ?ustify neuroimaging .eg, "RI/ to e6clude the ossi(ility of an intracranial neo lasm5 Com ression) -ocali=ed or nons ecific headaches are common5 Com ression of the underlying (rain can gi*e rise to focal or more generali=ed cere(ral dysfunction, as e*inced (y focal $eakness, dys hasia, a athy, and<or somnolence5 0tereoty ic sym toms) "eningiomas in s ecific locations may gi*e rise to the stereoty ed sym toms listed in the !a(le5 +ote that these stereoty ed sym toms are not athognomonic of meningiomas in these locations4 they may occur $ith other conditions or lesions5 Con*ersely, meningiomas in these locations may remain asym tomatic or roduce other unlisted sym toms5 !a(le5 0ym toms and 0igns Associated $ith "eningiomas in 0 ecific -ocations Location &arasagittal 0u(frontal 3lfactory groo*e Ca*ernous sinus 3cci ital lo(e Cere(ello ontine angle 0 inal cord 3 tic ner*e 0 henoid $ing !entorial #oramen magnum "ono aresis of the contralateral leg Change in mentation, a athy or disinhi(ited (eha*ior, urinary incontinence Anosmia $ith ossi(le i silateral o tic atro hy and contralateral a illedema .this triad termed @ennedy%#oster syndrome/ "ulti le cranial ner*e deficits .II, III, IA, A, AI/, leading to decreased *ision and di lo ia $ith associated facial num(ness Contralateral hemiano sia Decreased hearing $ith ossi(le facial $eakness and facial num(ness -ocali=ed s inal ain, 'ro$n%0e7uard .hemis inal cord/ syndrome E6o hthalmos, monocular loss of *ision or (lindness, i silateraldilated u il that does not react to direct light stimulation (ut might contract on consensual light stimulation4 often, monocular o tic ner*e s$elling $ith o tociliary shunt *essels 0ei=ures4 multi le cranial ner*e alsies if the su erior or(ital fissure in*ol*ed "ay rotrude $ithin su ratentorial and infratentorial com artments, roducing sym toms (y com ressing s ecific structures $ithin these 2 com artments &ara aresis, s hincteric trou(les, tongue atro hy associated $ith fasciculation S/mptoms

Aascular) !his resentation, although rare, should (e considered5 "eningiomas of the skull (ase may narro$ and e*en occlude im ortant cere(ral arteries, ossi(ly resenting either as transient ischemic attack .!IA/%like e isodes or as stroke5 "iscellaneous

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Intra*entricular meningiomas may resent $ith o(structi*e hydroce halus5 "eningiomas in the *icinity of the sella turcica may roduce anhy o ituitarism5

"eningiomas that com ress the *isual ath$ays roduce *arious *isual field defects, de ending on their location5

("/sica&: !he hysical findings mirror the aforementioned sym toms and include signs secondary to raised intracranial ressure, in*ol*ement of cranial ner*es, com ression of the underlying arenchyma, and in*ol*ement of (one and su(cutaneous tissues (y the meningioma5

Raised intracranial ressure leads to a illedema, decreased mentation and, ultimately, to (rain herniation5 In*ol*ement of the cranial ner*es may lead to anosmia, *isual field defects, o tic atro hy, di lo ia, decreased facial sensation, facial aresis, decreased hearing, de*iation of the u*ula, and hemiatro hy of the tongue5 Com ression of the underlying arenchyma may gi*e rise to yramidal signs that are e6em lified (y ronator drift, hy errefle6ia, ositi*e 2offman sign, and resence of the 'a(inski sign5 A arietal lo(e syndrome may occur if the arietal lo(es are com ressed5

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Com ression of the dominant .usually left/ arietal lo(e may gi*e rise to 1erstmann syndrome) agra hia, acalculia, right%left disorientation, and finger agnosia5 Com ression of the nondominant .usually right/ arietal lo(e leads to tactile and *isual e6tinction and neglect of the contralateral side5 Com ression of the occi ital lo(es leads to a congruent homonymous hemiano sia5

0 inal meningiomas may gi*e rise to a 'ro$n%0e7uard syndrome .ie, contralateral decreased ain sensation, i silateral $eakness, decrease in osition sense/, s hincteric $eakness and, ultimately, com lete 7uadri aresis or ara aresis5

!a#ses:

!rauma and *iruses ha*e (een in*estigated as ossi(le causati*e agents for de*elo ment of meningiomas5 2o$e*er, no definiti*e roof has yet (een found5 3n the other hand, the role of radiation in the genesis of meningiomas has (een sho$n5

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&atients su(?ected to lo$%dose irradiation for tinea ca itis may de*elo multi le meningiomas decades later in the field of irradiation5 2igh%dose cranial irradiation may induce meningiomas after a shorter latency eriod5

!he most consistent chromosomal a(normality isolated in meningiomas is on the long arm of chromosome 225

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-oss of a su

ressor gene in this region is theori=ed to lead to meningiomas5

Interestingly, the meningioma locus is close to, (ut ro(a(ly different from, the gene res onsi(le for neurofi(romatosis ty e 25

IFF3R3NTIALS

Section 6 of 11

Author Information Introduction Clinical Differentials Worku !reatment "edication #ollo$%u "iscellaneous &ictures 'i(liogra hy

Aty ical #acial &ain 'rainstem 1liomas Ca*ernous 0inus 0yndromes Com le6 &artial 0ei=ures Cranio haryngioma #rontal -o(e 0yndromes 1lio(lastoma "ultiforme -o$%1rade Astrocytoma +eurofi(romatosis, !y e 9 +eurofi(romatosis, !y e 2 3ligodendroglioma &ituitary !umors

&rimary C+0 -ym homa

Ot"er (ro,&ems to ,e !onsidered: 'ack ain 7OR*U( Section 8 of 11

Author Information Introduction Clinical Differentials Worku !reatment "edication #ollo$%u "iscellaneous &ictures 'i(liogra hy

La, St#dies:

+o s ecific la(oratory tests e6ist to screen for meningioma5

Imaging St#dies:

Imaging studies are the mainstay of diagnosis .see Images 9%B/5 &lain skull 6%ray may re*eal hy erostosis and increased *ascular markings of the skull as $ell as intracranial calcifications5 3n lain head C! scan, meningiomas are usually dural (ased, isodense to slightly hy erdense tumors5

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!hey enhance homogeneously and intensely after in?ection of iodinated contrast5 &erilesional edema may (e e6tensi*e5 2y erostosis and intratumoral calcifications may (e resent5 !he tumor com resses the (rain $ithout in*ading it5 "ulti le meningiomas may (e difficult to differentiate from metastasis5

3n "RI, the !9% and !2%$eighted signals are *aria(le5 If a meningioma is sus ected, o(taining an enhanced "RI is im erati*e5

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"eningiomas enhance intensely and homogeneously after in?ection of gadolinium gado entetate5 !he edema may (e more a arent on "RI than on C! scan5 arent on "RI5

An enhancing CtailD in*ol*ing the dura may (e a

Endo*ascular angiogra hy allo$s the surgeon to determine reo erati*ely the *asculari=ation of the tumor and its encroachment on *ital *ascular structures5

-ate *enous films are im ortant to determine the atency of the in*ol*ed dural sinuses5 Angiogra hic features of meningiomas include the follo$ing

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ly from the e6ternal circulation earance of the feeding arteries

"other%in%la$ (lush .$hich comes early and lea*es late/ 0un(urst or radial a

Although magnetic resonance arteriogra hy ."RA/ and magnetic resonance *enogra hy ."RA/ ha*e decreased the role of classical angiogra hy, the latter remains a o$erful tool to lan surgery5 Angiogra hy is still indis ensa(le if em(oli=ation of the tumor is deemed necessary5

+e$ research tools such as ositron emission tomogra hy .&E!/, including octreotide%&E!, or "R s ectrosco y ha*e (een used to characteri=e meningiomas in *i*o5

(roced#res:

&reo erati*e endo*ascular em(oli=ation of the *ascular feeders from the e6ternal circulation may (e (eneficial in e6tremely *ascular meningiomas5 If this is

the case, resection should (e erformed shortly after em(oli=ation to decrease the likelihood of tumor re*asculari=ation5

Histo&ogic Findings: "eningiomas are usually glo(ular, $ell%demarcated neo lasms5 !hey ha*e a $ide dural attachment and in*aginate into the underlying (rain $ithout in*ading it5 !heir cut surface is either translucent ale or homogeneously reddish (ro$n5 It may (e gritty on cutting5 0ome meningiomas occur as a sheet%like e6tension that co*ers the dura (ut does not in*aginate the arenchyma4 this *ariant is called meningioma en la7ue5 !he last mor hologic *ariant is the ca*ernous sinu meningioma that infiltrates the ca*ernous sinus and interdigitates $ith its contents5 !he ; most common histologic su(ty es of meningiomas are the meningothelial .syncytial/, transitional, and fi(ro(lastic meningiomas5 0ee Images >%E for re resentati*e athologic *ie$s of *arious su(ty es5

"eningothelial meningiomas re*eal densely acked cells that are arranged in sheets $ith no clearly discerni(le cyto lasmic (orders5 Although not rominent, $horls are resent .calcified $horls are termed sammoma (odies/5 +uclei sho$ intranuclear *acuoles5

#i(ro(lastic .fi(rous/ meningiomas re*eal sheets of interlacing s indle cells5 !he intercellular stroma is com osed of reticulin and collagen5 !he transitional *ariety re*eals features common to (oth the meningothelial and fi(ro(lastic *arieties4 others include angiomatous, microcystic, secretory, clear cell, choroid, lym ho lasmacyte rich, a illary, and meta lastic *ariants5 "eningiomas may (e associated $ith hy erostosis5 !he e6act nature of the cause of this hy erostosis is contro*ersial .ie, reacti*e *ersus tumoral infiltration/5 Imm#no"istoc"emistr/ Immunohistochemistry can hel diagnose meningiomas, $hich are ositi*e for e ithelial mem(rane antigen .E"A/ in >0: of cases5 !hey stain negati*e for anti%-eu B anti(odies . ositi*e in sch$annomas/ and for glial fi(rillary acidic rotein .1#A&/5 &rogesterone rece tors can (e demonstrated in the cytosol of meningiomas4 the resence of other se6 hormone rece tors is much less consistent5 0omatostatin rece tors also ha*e (een demonstrated consistently in meningiomas5 Ma&ignanc/

!he notion of malignancy in meningiomas is still *ague5 0ome histologic *ariants such as a illary meningioma undou(tedly carry a less fa*ora(le rognosis than other histologic ty es5 !$o features are considered clear signs of malignancy) cortical in*asion (y the tumor and distal metastasis5

0e*eral stains ha*e (een used to hel redict the (eha*ior of meningiomas5 !hese stains 7uantify the mitotic rate of these tumors5 'romodeo6yuridine .'udR/ la(eling re7uires an intra*enous .IA/ in?ection (efore tumor remo*al5 3n the other hand, immunohistologic staining for roliferating cell nuclear antigen .&C+A/ can (e erformed on fi6ed s ecimens5 0ome ha*e attem ted to correlate the athology and (eha*ior of meningiomas to the loss of s ecific genetic material5

TR3ATM3NT

Section 9 of 11

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Medica& !are:

"edical care for meningiomas has (een disa treatment ha*e failed5

ointing5 It is restricted either to erio erati*e drugs or to medications that are used after all other means of

!he use of corticosteroids reo erati*ely and osto erati*ely has significantly decreased the mortality and mor(idity rates associated $ith surgical resection5 Antie ile tic drugs should (e started reo erati*ely in su ratentorial surgery and continued osto erati*ely for a eriod of no less than ; months5 Drugs no$ undergoing trials include mife ristone and hydro6yurea5 "ife ristone is a synthetic anti rogestin, currently used as an a(ortifacient5 3ur e6 erience $ith this drug on 2 atients $as disa ointing5 Radiothera y is used in ino era(le cases or as ad?uncti*e thera y in recurrences or incom letely resected tumors5 Radiothera y also has (een used as rimary treatment for o tic ner*e meningiomas5 0tereotactic radiosurgery has (een ad*ocated as an effecti*e management strategy for small meningiomas and for meningiomas in*ol*ing the skull (ase or the ca*ernous sinus5 It is used rimarily to re*ent tumor rogression5

S#rgica& !are: !his section aims at ro*iding a frame$ork to the surgical a roach to meningiomas5 !he constant rinci les in meningioma resection are the follo$ing) If ossi(le, all in*ol*ed or hy erostotic (one should (e remo*ed5 !he dura in*ol*ed (y the tumor as $ell as a dural rim that is free from tumor should (e resected .dura lasty is erformed/5 Dural tails that are a arent on "RI are (est remo*ed, e*en though some may not (e in*ol*ed $ith the tumor5 "ake a ro*ision for har*esting a suita(le dural su(stitute . ericranium or fascia lata/5 !he surgeon also can use commercially a*aila(le dural su(stitutes5 If feasi(le, al$ays start (y coagulating the arterial feeders to the meningioma5 0urgical management strategies for meningiomas in s ecific locations include the follo$ing)

Con*e6ity meningioma o 3 ening the scal and skull may (e (loody (ecause of the hy ertro hy of (lood *essels originating from the e6ternal circulation5 o !he tumor may (reach the sanctity of the dura and the (one, thus a earing su(cutaneously5 o !he dural (lood *essels should (e coagulated (efore o ening the dura to decrease tumor *ascularity5

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,sually the tumor is se arated from underlying (rain arenchyma (y an arachnoid layer5 !his layer may not (e com lete at the de th of the tumor5 In this location, se arating the tumor from the (rain may (e difficult5 ,nless the tumor is small and can (e remo*ed in one iece, the (est strategy for e6cising con*e6ity meningiomas is to find the arachnoidal lane and dissect it gently5 &lacing atties circumferentially around the tumor $ill allo$ 7uick identification of this crucial lane at a later time5 Coagulate the surface of the tumor, then core it and in*aginate the outer layer to allo$ further circumferential dissection5 &erform dural grafting5

&arasagittal meningiomas

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!hese tumors may arise from the con*e6ity and in*ol*e the su erior sagittal sinus .000/ (y medial e6tension, or they may arise from the fal6 and in*ol*e the 000 (y u $ard e6tension5 !he former su(grou is easier to treat surgically (ecause of its su erficial location5 !he foremost consideration in surgically treating arasagittal meningiomas is to decide $hat to do $ith the 0005 "RA is not yet sensiti*e enough to confirm une7ui*ocally the com lete occlusion of the 0005 !he diagnostic test of choice is still an endo*ascular angiogram $ith late *enous films to look for a ossi(le delayed filling of the in*ol*ed ortion of the 0005 If the 000 is com letely o(literated (y tumor, it can (e ligated safely and e6cised5 !he surgeon should (e *ery careful not to in?ure the *eins that run anteriorly and osteriorly to the tumor5 !hese *eins may ro*ide crucial collateral circulation for the *enous drainage of the cere(rum and should (e reser*ed at all costs5 If the 000 is in*ol*ed only artially, the decision of $hether to sacrifice it de ends on the in*ol*ed segment5 !he anterior third of the 000 usually can (e sacrificed $ith im unity4 the middle third, sacrificed at times4 and the osterior third, ne*er ligated5 In this authorFs e6 erience, the 000 is ne*er sacrificed (eyond the anterior third5 0ome surgeons resect a artially in*ol*ed sinus and reconstruct it later .either $ith a *ein or rosthetic graft/5 !he authorFs o inion is that e6 laining to the atient that some tumor $as left (ehind that may need further resection at a later date is (etter than taking undue risk of neurological deficit (y o(literating more of the 000 5 If the sinus is occluded gradually (y the tumor, the *enous drainage $ill (e di*erted o*er time through arasagittal *eins5

3lfactory groo*e and tu(erculum sellae meningiomas o !o a*oid undue retraction of the frontal lo(es, these tumors are (est a roached through a lo$ craniotomy5 !his is achie*ed (y remo*ing the su raor(ital rim5 o A unilateral a roach is usually sufficient5 !he midline (urr hole should (e laced ?ust a(o*e the frontonasal suture5 'y entering the frontal sinus and remo*ing the or(ital rim, a *ery lo$ a roach is ro*ided5 o !o allo$ ade7uate *isuali=ation, the fal6 should (e sectioned after ligating the most anterior as ect of the 0005 E*ery attem t should (e made to reser*e at least one of the olfactory ner*es5 o !hese tumors recei*e their (lood su ly through *arious sources) the ethmoidal (ranches of the o hthalmic arteries, (ranches from the middle meningeal artery, and the carotid arteries5 o !hese tumors often in*ade the ethmoid sinuses and, at times, the s henoid sinus5 o Care should (e taken to identify and reser*e (oth o tic ner*es5 +ote that the usual relationshi (et$een the o tic ner*es and the carotid arteries might not hold true o$ing to dis lacement of these *ital structures (y tumor5 o !umor arterial su ly and erforator arteries to the hy othalamus need to (e differentiated, since (oth arise from the anterior circulation5 0 henoid $ing meningiomas o 0 henoid $ing meningiomas resent either as en la7ue meningiomas or as glo(ular masses5 o Remo*ing the =ygoma and the or(ital rim allo$s $ider e6 osure of the s henoid $ing, the middle cranial fossa, the anterior cranial fossa, and the anterior clinoid5 o "edial tumors may e6tend $ithin the ca*ernous sinus5 !entorial and torcular meningiomas

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!entorial meningiomas may (e su lied (y a multitude of *essels that arise from the tentorial leaf5 !hese should (e coagulated thoroughly rior to attem ting to remo*e the tumor5 A ma?or su ly may (e the 'ernasconi%Cassinari artery, $hich arises from the ca*ernous ortion of the carotid artery and runs osteriorly to su ly the tentorium5 !his artery usually is not a arent on normal angiograms (ut may (e cons icuous in angiograms of tentorial meningiomas5 A definite attem t should (e made at recogni=ing the 'ernasconi%Cassinari artery intrao erati*ely and coagulating it to decrease tumor *ascularity5 !entorial meningiomas often gro$ in (oth the infratentorial and su ratentorial com artments and should (e a roached accordingly5 0tudying the reo erati*e angiogram is im erati*e in cases of torcular meningiomas to delineate the atency of the different sinuses and the a*aila(le collateral circulation5 Remo*ing these tumors com letely often is im ossi(le (ecause of artial in*ol*ement of the *enous sinuses5

Cere(ello ontine angle meningiomas

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In acoustic neuromas, the facial ner*e usually lies anterosu eriorly to the tumor and is encountered late in surgery5 !his relationshi is lost in cere(ello ontine angle meningiomas, (ecause the facial ner*e may lie along the osterior tumor edge and can (e in?ured early in surgery .unless care is taken to identify it/5 'efore attem ting to remo*e the tumor, the surgeon should first diminish its (lood su ly (y coagulating its su lying arteries from the dura5 !o do so, the interface of the tumor and the etrous (one should (e follo$ed5 A artial cere(ellar resection may (e necessary to a*oid undue retraction of the (rain5

"eningiomas in*ol*ing the ca*ernous sinus

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!he issue of meningiomas in*ol*ing the ca*ernous sinus is currently an area of intense interest in neurosurgery5 +o one dou(ts that, in e6 erienced hands, such meningiomas can (e treated successfully5 !he de(ate centers on 2 oints) $hen to o erate and ho$ aggressi*e the resection should (e5 !he follo$ing o inion is a ersonal reflection on the matter, and di*erging *ie$s may (e found in the literature5 Asym tomatic ca*ernous sinus meningiomas should not (e o erated (ut should (e monitored carefully (y re eated hysical e6aminations and (y serial "RIs5 0ym tomatic meningiomas in other$ise healthy atients should (e resected (y neurosurgeons $ho are trained for such rocedures5 A*oid in?uring the cranial ner*es or the carotid artery5 !his author does not (elie*e in the (enefit of (y assing and resecting the ca*ernous carotid artery in these cases5 !he surgeon should remem(er that a multitude of rocesses may affect the ca*ernous sinus and mimic a meningioma, including sarcoidosis and infection<inflammation that lead to the !olosa%2unt syndrome5

Cli*al and etrocli*al meningiomas

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!hese tumors re resent some of the greatest challenges in neurosurgery4 although artial resection is relati*ely straightfor$ard, com lete resection remains a daunting task5 &artial resection usually does not translate into any (enefit for the atient and only renders further surgeries more difficult4 thus e*ery attem t shoul (e made to com lete the resection5 If surgery has to (e interru ted for logistical reasons, the second o eration should (e scheduled the earliest ossi(le o ortunity5 A multitude of a roaches has (een de*ised for these tumors5 !he traditional a roaches such as the su(occi ital or the su(tem oral are usually insufficient to allo$ com lete remo*al5 "ore e6tensi*e a roaches, such as the etrosal a roach, are needed5 !his a roach consists of com(ine su ratentorial and infratentorial craniotomies, associated $ith a sim le mastoidectomy do$n to the solid angle .ie, the (one encasing the inner ear/ After s litting the tentorium, the etrocli*al meningioma can (e *isuali=ed in its entirety5

!ons#&tations:

Consultation should (e sought in the follo$ing cases)

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If the atient suffers from neurofi(romatosis, the neurosurgeon may $ant to refer the atient for genetic counseling and for audiometric testing5 If the radiologic diagnosis is not clear%cut, a detailed discussion $ith the radiologist should attem t to rule out other athologic entities such as neurofi(romas or sarcomas5 In s ecific cases, consulting a radiation oncologist may (e a ro riate5 ro riate5

iet: +o dietary restrictions are necessary in atients $ith meningiomas5 If the atient is on erio erati*e steroids, a lo$%salt diet is a

Acti'it/: &atients $ith a meningioma $ho undergo surgery can resume their normal acti*ities after an ade7uate eriod of osto erati*e rest .9%; mo/5

M3 I!ATION

Section : of 11

Author Information Introduction Clinical Differentials Worku !reatment "edication #ollo$%u "iscellaneous &ictures 'i(liogra hy

!he goals of harmacothera y are to reduce mor(idity and re*ent com lications5 Drug Category) Corticosteroids %% !hese agents reduce edema around tumor, fre7uently leading to sym tomatic and o(?ecti*e im ro*ement in sym toms5 De6amethasone .Decadron, De6asone/ %% &ostulated mechanisms of action of corticosteroids in (rain tumors include reduction in *ascular ermea(ility, cytoto6ic effects on tumors, inhi(ition of tumor formation, and decreased C0# roduction5 98 mg<d &3<IA di*ided 78h in significant eritumoral edema4 continue until atient sho$s im ro*ement4 ta er to discontinue or to minimum effecti*e dose 059G mg<kg<d &3<IA di*ided 78h Documented hy ersensiti*ity4 acti*e (acterial or fungal infection4 e tic ulcer disease4 sychosis4 hy ertension 'ar(iturates, henytoin, and rifam in decrease effects4 decreases effects of salicylates and *accines used for immuni=ation C % 0afety for use during regnancy has not (een esta(lished5 In eritumoral edema, monitor atient carefully for ad*erse se7uelae

r#g Name Ad#&t ose (ediatric ose

!ontraindications Interactions (regnanc/ (reca#tions

Increases risk of multi le com lications, including se*ere infections4 monitor adrenal insufficiency $hen ta ering drug4 a(ru t discontinuation of glucocorticoids may cause adrenal crisis4 hy erglycemia, edema, osteonecrosis, Cushing syndrome, myo athy, e tic ulcer disease, hy okalemia, osteo orosis, eu horia, sychosis, myasthenia gra*is, gro$th su ression, and infections are ossi(le com lications FOLLO7;U( Section < of 11

Author Information Introduction Clinical Differentials Worku !reatment "edication #ollo$%u "iscellaneous &ictures 'i(liogra hy

F#rt"er Inpatient !are:

&atients $ith skull%(ase meningiomas may suffer from numerous disa(ilities either reo erati*ely or osto erati*ely) di lo ia, dys hasia, dys hagia, and motor $eakness5 !hese ro(lems should (e managed in con?unction $ith a multidisci linary a roach .eg, occu ational thera y, hysiothera y, s eech thera y/5

F#rt"er O#tpatient !are:

&atients $ho undergo o eration for meningiomas should ha*e regular follo$%u $ith enhanced "RI to check for ossi(le recurrences5 &atients $ho are discharged on antie ile tic agents should (e monitored (y a neurologist5

(rognosis:

&atients $hose meningiomas are com letely resected usually ha*e an e6cellent rognosis5 !he follo$ing ty es of meningiomas are most likely to recur) incom letely e6cised, malignant, or multi le tumors5

MIS!3LLAN3OUS

Section = of 11

Author Information Introduction Clinical Differentials Worku !reatment "edication #ollo$%u "iscellaneous &ictures 'i(liogra hy

Medica&1Lega& (itfa&&s:

0e*eral lesions may mimic meningiomas, including acoustic sch$annomas, metastases .single or multi le/, osteomas, chondrosarcomas, eosino hilic granulomas, and neurosarcoidosis5 +eurosarcoidosis is more re*alent among African Americans than among other races, and it is more common at the (ase of the skull5 If sarcoidosis is sus ected, order a chest 6%ray and a serum angiotensin%con*erting en=yme .ACE/ le*el5 +eurosarcoidosis may shrink im ressi*ely after a trial of corticosteroids5

!he hysician should kee in mind that $hat a ears on radiologic studies like a metastasis in a cancer atient may actually (e a meningioma5 An associatio of meningiomas and (reast carcinoma has (een re orted5

Specia& !oncerns:

Conclusions

!he study of meningiomas is ad*ancing ra idly in the fields of (asic science and surgical techni7ues5 !his cha ter reca itulates (riefly the resent (ody of kno$ledge .$ith a clinical em hasis/5 !he a ended reading list $ill allo$ interested readers to further their kno$ledge and to find se*eral $orks outlining the details of the resented surgical a roaches5

#or the neurosurgeon, meningiomas are still the ultimate (arometer of technical skills .from the small con*e6ity meningioma to the large etrocli*al meningioma/5 http://www.emedicine.com/NEURO/topic209.htm