Journal of Clinical Neuroscience (2005) 12(6), 664–668

0967-5868/$ - see front matter ª 2005 Published by Elsevier Ltd.

doi:10.1016/j.jocn.2005.05.002

Clinical study

Olfactory groove meningiomas

Hakan Tuna MD, Melih Bozkurt MD, Murat Ayten MD, Ahmet Erdogan MD, Haluk Deda MD
Department of Neurosurgery, Ankara University, School of Medicine, Ankara, Turkey

Summary Meningiomas originating from the olfactory groove account for approximately 10% of all intracranial meningiomas. They represent
only 2% of all intracranial tumors. We present the diagnostic, clinical and pathological features of olfactory groove meningiomas and describe
our surgical results and complications in a series of 25 patients. In 19 patients, surgery was via a bifrontal approach, and in the remaining six a
pterional approach was used.
ª 2005 Published by Elsevier Ltd.

Keywords: meningioma, olfactory groove, skull base, surgery

INTRODUCTION
Meningiomas are usually slow-growing, benign tumors, presumed
to develop from the arachnoidal cap cells. They account for
approximately 20% of all primary intracranial tumors.1–3 Of all
intracranial meningiomas, 10% arise from the olfactory groove.1–
3 Olfactory groove meningiomas develop at the dura of the
anterior cranial fossa over the cribriform plate and the planum
sphenoidale. These tumors usually receive their blood supply from
the anterior and posterior ethmoidal arteries.4
Olfactory groove meningiomas must be differentiated from other
anterior cranial fossa meningiomas, including those of the tubercu-
lum sella and clinoidal meningiomas, as there are significant differ-
ences in presenting symptoms, neurological findings, operative
approach, postoperative results, complications, and mortality rates.3
This retrospective study includes 25 patients with olfactory
groove meningioma who underwent surgery at Ankara University
between January 1995 and August 2003. There were 10 men and
15 women, with a mean age at diagnosis of 51 years.
PATIENTS AND METHODS
We reviewed 25 consecutive, surgically treated olfactory groove
meningiomas and report the clinical presentations, operative ap-
proaches, complications and results. Patients were treated during
an 8.5-year period, between January 1995 and July 2003, at the
Department of Neurosurgery, Ankara University. They represent
7% of 348 patients with intracranial meningiomas who were oper-
ated on during the same period. Data obtained from each patient’s
medical chart, follow-up examination, neuroradiological evalua-
tion, and histological analysis was reviewed.
The most common presenting sign was cognitive dysfunction
and the most common symptom was visual deterioration. At pre-
sentation, 13 of 25 patients had visual symptoms and 15 patients
had cognitive changes. Although not an actual complaint of most
patients, it was clear after examination that the olfactory nerve
was the most commonly affected cranial nerve, and 18 patients
had varying degrees of anosmia. Papilledema was present in 17
patients. The duration of symptoms prior to surgery was variable
Received 21 July 2004
Accepted 30 August 2004
Correspondence to: Hakan Tuna MD, 3624 Beckham Dr, Shreveport, LA,
71104, USA. Tel.: +1 318 6758229;
E-mail: ktuna@yahoo.com
and ranged from seven days to 25 months. The average preoper-
ative Karnofsky score was 90 € 10 (range 70–100).
Preoperatively, all patients underwent CT and/or MRI, includ-
ing axial, coronal, and sagittal T1-weighted images with and
without contrast enhancement and T2-weighted images. A bone-
window CT scan was obtained to evaluate the anterior skull base
and to show tumor calcification and local bone destruction. Accu-
rate preoperative diagnosis was possible due to characteristic
radiological features. Preoperatively, 14 patients had radiological
(CT or MRI) frontal lobe edema. Angiography was performed in
18 patients and preoperative embolization in six. Intraoperative
image-guided frameless stereotaxy was used in seven patients.
Based on the preoperative MRI scans, we divided the tumors
into ‘ midline” and ‘ off-midline” tumors (Fig. 1A, B). The tumor
lay on both sides of the falx equally in 19 patients and in the
remaining six the tumor extended laterally on only one side of
the falx. Three tumors invaded the anterior skull base and ex-
tended into the paranasal sinuses.
We used two major surgical approaches for tumor resection,
depending on tumor placement. The bifrontal approach was used
for ‘ midline” lesions. The pterional approach was used for ‘ off-
midline” tumors involving one side of the falx primarily.
Long-term follow-up was available for 20 (80%) patients, but
five were lost to follow-up. Average post-operative follow up
was 58.4 months (range 14–112).
RESULTS
Treatment was tailored to the findings of preoperative imaging, lo-
cal anatomy, and tumor characteristics and extensions in each pa-
tient. Microsurgical techniques and the ultrasonic aspirator were
used in all cases. Complete tumor removal was achieved for all
patients (Fig. 2).
There was no peri- or post-operative mortality. Seven of the 13
patients with visual loss due to optic chiasm or nerve compression
showed improvement in their visual acuity. Postoperative vision
was unchanged in five patients and worsened in one patient. In
the patients with normal preoperative visual acuity, none was im-
paired postoperatively. Cognitive dysfunction resolved within a
few weeks in all patients and all were normal at last follow-up.
Seven patients (28%) experienced 10 postoperative complica-
tions including: one exacerbated visual deficit, four postoperative
CSF leaks, one seizure, one significant psychotic episode and
three with worsened frontal lobe edema (which resolved).
One patient had worsening of her previously compromised vi-
sion. The patients with CSF rhinorrhea responded to lumbar

664
 Olfactory groove meningiomas 665

Fig. 1 A. Axial T1- weighted contrast enhanced MRI of a large ‘ midline” olfactory groove meningioma. B. Coronal T1-weighted contrast enhanced MRI of an
‘ off-midline” olfactory groove meningioma.

Fig. 2 A. Postoperative axial T1-weighted MRI of the patient in figure 1A. The tumor has been completely resected. B. Postoperative coronal T1-weighted
contrast enhanced MRI of the patient in the figure 1B. The tumor has been completely resected.

drain placement and prophylactic antibiotics; none developed
meningitis. One patient had seizures in the early postoperative
period that were controlled with anticonvulsants and another
patient had psychosis due to frontal lobe edema that required
drug therapy. No long-term functional decline occurred, with
the Karnofsky Performance Scale scores 80 to 100 for all pa-
tients at latest follow-up. The mean hospital stay was 13 days,
(range 9–27). The mean follow-up period in this series was
58.4 months (range 14–112). There were no tumor recurrences
during follow-up.
In 12 patients, pre-existing frontal lobe edema persisted postoper-
atively but was generally asymptomatic. Three patients with normal

ª 2005 Published by Elsevier Ltd. Journal of Clinical Neuroscience (2005) 12(6), 664–668
666 Tuna et al.
frontal lobes preoperatively developed postoperative frontal lobe
edema, which was mild in two patients and required no therapy.
In all patients who underwent bifrontal craniotomy, reconstruc-
tion of the anterior fossa was achieved with a pericranium flap
based anteriorly at the supraorbital vessels.
DISCUSSION
Olfactory groove meningiomas are a relatively uncommon type of
intracranial meningioma.1,5 Francis Durante, in 1895, first per-
formed successful resection of an olfactory groove meningioma. 3
These meningiomas can arise from the cribriform plate and front-
osphenoid suture.1,5 We report here the characteristics, treatment,
and complications of 25 patients with olfactory groove meningi-
oma who were treated at Ankara University during an 8.5-year
period. Gender distribution in our study (10 men, 15 women), with
a higher frequency of females, was similar to previous series of
cranial meningioma.6–8
Because of their slow growth, these tumors often are well toler-
ated by the patient for long periods before signs and symptoms of
raised intracranial pressure occur. The initial clinical symptoms are
usually related to the frontal lobe. Changes in cognitive function,
which are slow in onset, headache and visual disturbance are the
most common and principal symptoms of olfactory groove menin-
giomas.1,5–10 Patients rarely complain of loss of smell but, not
uncommonly, the neurological examination reveals impairment
of olfactory function due to tumor invasion into the anterior cra-
nial fossa.6,8–10 A small number of patients present with Foster-
Kennedy syndrome; unilateral optic atrophy and contralateral
papilledema. With the introduction of improved imaging tech-
niques, including CT and MRI, olfactory groove meningiomas
are diagnosed earlier and more accurately than in the pre-CT era,
when most meningiomas were detected by angiography. These tu-
mors, however, are still frequently large at presentation because
their relative rarity and slow growth leads to delayed diagnosis.6
In this series, patient presentation was characteristic for olfactory
groove meningiomas; the majority of patients presented with per-
sonality and cognitive changes and visual deterioration, and only a
minority presented with headache. The duration of the symptoms
varied between seven days and 25 months. Altered mental status
always resolved following removal of the tumor. In a retrospective
review of nine patients with meningioma, Chee et al concluded that
recovery from mental deterioration could be expected in most pa-
tients after removal of meningeal tumors.11 Loss of olfaction does
not usually recover. Resection of olfactory groove meningiomas
may improve visual impairment. Andrews and Wilson reported
that the duration of preoperative visual symptoms affected postop-
erative recovery.12 Rosenstein and Symon, and Zevgaridis et al re-
ported similar results.13,14 In this series, seven of the 13 patients
with visual loss showed improvement.
CT with and without contrast enhancement detects 95% and
85% of meningiomas, respectively.15 CT is also used to define lo-
cal bony anatomy of the anterior skull base and to determine tu-
mor involvement of bone (hyperostosis), calcification within the
tumor, tumor extensions and consistency and frontal lobe edema.
Accurate preoperative diagnosis is possible with MRI in all olfac-
tory groove meningiomas. MRI with gadolinium delineates regio-
nal neurovascular anatomy. The optic nerves and brain
parenchyma can be visualized relative to the meningioma, and
patent vessels demonstrate a flow void. Arterial encasement and
narrowing are evaluated by MRI and angiography. Disruption of
the blood-brain barrier and adherence of the tumor to brain tissue
is indicated by edema on T2-weighted MRI. Paranasal sinus inva-
sion was detected in three patients on preoperative radiological
studies. Preoperative angiography is important to establish the po-
Journal of Clinical Neuroscience (2005) 12(6), 664–668
sition and degree of displacement of the anterior cerebral arteries
(ACA), and to show meningeal branches of the carotid circulation
supplying the tumor and the vascular architecture of the tumor.
The second portion of the ACA is usually displaced posteriorly
and superiorly. The medial, orbito-frontal, and fronto-polar
branches of the ACA are usually lateral to the tumor. Angiography
was performed in 18 cases with preoperative embolization in
three. Intraoperative image-guided frameless stereotaxy was used
in seven patients.
Surgical treatment of olfactory groove meningiomas may be
difficult due to the intimate relationship with the ACA and optic
nerves and involvement of the ethmoid bone and anterior cranial
fossa. With the advent of microsurgical techniques, removal of
olfactory groove meningiomas has become increasingly safe.
Numerous surgeons have reported their experience with olfactory
groove meningiomas.5–10,12–14,16–19,21–24
The main considerations when choosing a surgical approach are
adequate visualization of the tumor, preservation of neural and
vascular structures, and prevention of complications. A number
of different approaches have been described. However, there is
no agreement concerning the best approach. The choice of surgi-
cal approach for olfactory groove meningiomas depends on tumor
size, origin, placement in the midline or para-midline and on the
major extensions, symmetrically or asymmetrically, to either side.
Controversies exist regarding which surgical approach to choose.
The most common surgical approaches used are the standard fron-
to-temporal and either unilateral or bilateral subfrontal ap-
proaches,4,6–8,16–18 depending on tumor location and the
relationship of the ACA and the optic nerves.
Different anatomic landmarks are encountered depending on the
surgical approach. Using an antero-lateral approach, one of the first
structures encountered is the optic nerve, with the ACA laying pos-
teromedially to the optic nerve and posterosuperiorly to the tumor.
Using a bifrontal approach, the tumor is the first structure encoun-
tered after division of the superior sagittal sinus with the falx and
retraction of the frontal lobes laterally. In ‘ midline” tumors, we
used a bifrontal approach. However, if the tumor was placed ‘ off-
midline”, it was removed via a frontotemporal approach. Tur- azzi
et al, Hassler et al, and Paterniti et al advocated a pterional
approach for all olfactory meningiomas, whereas Ojemann,
Symon, Babu et al, Hentschel and De Monte, Mayfrank et al and
El Gindi recommended either a unilateral or bilateral subfrontal
approach for all olfactory groove meningiomas.6–8,16–18,20,21 Al-
Mefty and Babu et al recommended a unilateral frontal craniot-
omy combined with an orbital osteotomy, Mayfrank et al reported
a unilateral frontal craniotomy to be superior to the frontal sinus
approach.8,16,22
Hentschel and De Monte classified meningiomas of the olfac-
tory groove into two major groups; midline and paramidline lo-
cated tumors.20 We also found this classification useful.
Accordingly, a bifrontal approach was used for lesions that were
located in the midline. The advantage of this approach is the direct
visualization and early interruption of the blood supply to the tu-
mor, ease of visualization and dissection of the tumor placed on
both sides of the falx and repair of dural defects. This approach
gives the surgeon access for inspection and drilling of the midline
of the anterior fossa and paranasal sinuses and minimizes brain
retraction. Compared with the antero-lateral route, the bifrontal
approach has the advantage of providing an excellent view for
the dissection of the ACA and the optic pathways, as well as
for resection of tumor invading the frontal cranial base. These tu-
mors usually displace the ACA postero-superiorly, rather than
encasing them. Therefore, preservation of the ACA during surgery
is generally always possible. This approach is particularly advan-
tageous for reconstruction of the anterior cranial fossa floor.
ª 2005 Published by Elsevier Ltd.

However, the disadvantage of this approach is retraction of both
frontal lobes with potential venous congestion. Removal of the
orbital bar and CSF drainage through a lumbar drain may mini-
mize frontal lobe retraction. We used an orbital osteotomy in three
patients whose tumors invaded the paranasal sinuses. With lumbar
spinal drainage for CSF removal, the brain is slack at retraction,
even in patients with prominent frontal lobe edema, reducing
the risk of unnecessary retraction. We routinely used lumbar
CSF drainage for tumor resection via a bifrontal approach. A wide
exposure facilitates easily identification of the tumor margin and
dissection from neural and vascular structures.
For ‘ off-midline” meningiomas, the tumor mass is mainly
localized at one side of the falx. Therefore, approach via the trans-
Sylvian route is, in our opinion, the best way to treat these tumors.
Dissection and wide splitting of the Sylvian fissure and drainage
of CSF allow a wide exposure of the tumor with minimal brain
retraction. Identification of the optic nerve and main arteries at the
beginning of surgery is crucial for their anatomic preserva- tion
during tumor removal. However, there are a number of disad-
vantages with this technique. Meningiomas extending toward the
contralateral frontal lobe are more difficult to manage.
A unilateral frontal craniotomy is one of the most often utilized
approaches for olfactory groove meningiomas. Proponents of this
approach, including Al-Mefty and Babu et al, emphasized that it
avoids bifrontal retraction and possible cognitive dysfunction. 16,22
Hassler and Zentner, in 1989, reported the first series of 11 pa-
tients with olfactory groove meningiomas surgically treated using
a unilateral pterional approach.18 Yasargil, Schaller et al and Tur-
azzi et al later reported the results of a larger series using the same
approach.6,23,24 Because of the limitations of the pterional ap-
proach, the bifrontal approach is the most widely used to remove
olfactory groove meningiomas.
We are in agreement with the above authors regarding ‘ off-
midline” tumors. In these cases, a pterional approach is sufficient
for surgical removal. However, for midline tumors, the bifrontal
approach provides direct access to the tumor with minimal, brain
retraction. Even Yasargil, pioneer of the pterional approach, rec-
ommended the bifrontal approach in selected cases.25
Skull base meningiomas often involve the underlying
bone.26,27 Pieper and Al-Mefty showed that hyperostosis associ-
ated with meningioma is the result of tumor invasion rather than
a reactive process.26 Occasionally, the tumor also invades the
paranasal sinuses and nasal cavity and this may be a limiting
factor in complete removal. Extension into the paranasal sinuses
has been reported in 15 to 46% of patients with olfactory groove
meningioma.20,27 Three patients (12%) in this series had tumor
in the paranasal sinuses. Extent of resection of meningioma is
associated with the recurrence rate. A subtotal resection may
be performed to preserve the integrity of the anterior fossa dura
to prevent a postoperative CSF leak19 but is associated with a
higher risk of recurrence. To achieve total tumor excision, re-
moval of the anterior cranial fossa dura is necessary. Watertight
dural closure after resection of the anterior cranial fossa dura and
drilling of hyperostotic bone may be difficult, however, meticu-
lous closure with fascial and fat autografts is necessary to
prevent potentially dangerous complications. We used a vascu-
larized pericranial flap in every case. Postoperative CSF leak
can generally be avoided with the combination of lumbar drain-
age and dural repair.
In this series, seven (28%) of 25 patients developed a total of
10 surgical complications (four CSF leaks, three patients with
frontal lobe edema, one with seizures, one with visual deteriora-
tion and one with a psychotic episode). Our results compare
favorably with contemporary series.6–9,12–14,16–18,20 Minimal
brain retraction, facilitated by orbital osteotomy in selected
ª 2005 Published by Elsevier Ltd.
Olfactory groove meningiomas 667
cases, CSF drainage, intratumoral debulking, cautious dissection
of the capsule for removal of all tumor, preservation of major
intracranial arteries and optic nerves, and meticulous repair of
basal dural defects are the vital operative steps for good surgical
results. Special care should taken to avoid postoperative CSF
leak, particularly when the tumor has invaded the anterior cranial
fossa dura and bone.
The mortality and extent of resection in the present series is
comparable to the 18 cases of olfactory groove meningiomas re-
ported by Mayfrank and Gilsbach, 20 by Paterniti et al, 37 by
Turazzi et al and 13 by Hentschel and DeMonte all of whom
achieved complete removal with no mortality.6–8,20 We recom-
mend that gross surgical resection or near total resection should
be the surgical goal. Recurrence is rare after complete excision,
however, the recurrence rate ranges from 5 to 41%, and long fol-
low-up is required.19,28
CONCLUSION
Olfactory groove meningiomas are benign tumors that can be
completely excised with current microsurgical techniques, with
minimal morbidity. Tailored approaches according to the tumor
location reduce the need for brain retraction and provide the nec-
essary exposure. Preoperative surgical planning with neuroradio-
logical studies and use of skull base approaches allows total
excision with preservation of neural and vascular structures. Re-
cent advances in repair of the anterior cranial fossa allow com-
plete excision with a better prognosis as complete removal is
associated with low recurrence. Our results suggest that complete
excision offers the best chance for a prolonged disease-free inter-
val in patients with olfactory groove meningioma.
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