Surgical Management of
Meningioma en Plaque of the
Sphenoid Ridge
Orlando De Jesús, M.D., F.A.C.S., and Marı́a M. Toledo, M.D.
Section of Neurosurgery, University of Puerto Rico, San Juan, Puerto Rico
De Jesús O, Toledo MM. Surgical management of meningioma en
plaque of the sphenoid ridge. Surg Neurol 2001;55:265–9.
BACKGROUND
Meningioma en plaque represents a morphological sub-
group within the meningiomas defined by a carpet or
sheet-like lesion that infiltrates the dura and sometimes
invades the bone. Differential diagnosis includes fibrous
dysplasia, osteoma, and osteoblastic metastasis. This
study was conducted to obtain pathological information
on patients with meningioma en plaque and to correlate
with the surgical management.
METHODS
A retrospective review of all the adult operative cases at
the University Hospital in a seven and a half-year period
from July 1, 1990 to December 31, 1997 identified 150
patients who were operated on for intracranial meningi-
omas. The medical records were reviewed to identify
cases of meningioma en plaque. Forty-seven patients had
involvement of the sphenoid ridge and 6 of them fulfill the
criteria for meningioma en plaque.
RESULTS
All 6 patients with meningiomas en plaque were female
and had hyperostosis of the sphenoid bone. In 5 of them,
the bone was sent for histopathological examination.
Four of those had infiltration of the bone by meningioma
cells. Proptosis was the most common presentation. Half
of the patients presented with visual disturbances that
improved after surgery. All patients were operated using
a fronto-temporal approach with orbital decompression.
CONCLUSION
All the involved bone should be removed to prevent
recurrence. In those cases with involvement of the cav-
ernous sinus and/or the orbital apex, a subtotal but ex-
tensive removal combined with bony decompression of
the cranial nerves at the superior orbital fissure and optic
canal frequently produces good functional and cosmetic
results. © 2001 by Elsevier Science Inc.
KEY WORDS
En plaque, meningioma, hyperostosis, sphenoid ridge, skull
base surgery.
Address reprint requests to: Orlando De Jesús, M.D., UPR Medical
Sciences Campus Section of Neurosurgery, GPO Box 5067, San Juan, PR
00936.
Received August 18, 2000; accepted February 27, 2001.
© 2001 by Elsevier Science Inc.
655 Avenue of the Americas, New York, NY 10010
eningiomas are extra-axial, slow-growing,
M usually benign tumors that arise from the
arachnoid cap cells. They are the most common
nonglial intracranial primary tumors [1]. Meningi-
oma en plaque represents a morphological sub-
group defined by a carpet or sheet-like lesion that
infiltrates the dura and sometimes invades the
bone. The term was given by Cushing and Eisen-
hardt [6] to differentiate them from the most com-
mon form called meningioma en masse.
Patients and Methods
A retrospective review of all the adult operative
cases at the University Hospital in a seven and a
half-year period from July 1, 1990 to December 31,
1997 showed that 150 patients were operated on for
intracranial meningiomas. Of these, 47 were located
adjacent to the sphenoid ridge. Six were considered
to fulfill the criteria for meningioma en plaque (Ta-
ble 1). The female-to-male ratio for patients with
intracranial meningiomas was 3:1, and for those
patients with involvement of the sphenoid bone
was 4:1. All 6 patients with meningiomas en plaque
were female. The bone was sent for histopatholog-
ical examination in 5 cases.
Case Illustration
PATIENT #3
A 52-year-old woman complained of left eye prop-
tosis and headache for several years. On examina-
tion, there was a noticeable elevation of the ante-
rior temporal area. Visual acuity and extraocular
eye movements were normal. Magnetic resonance
imaging (MRI) with gadolinium showed enhance-
ment of the dura in the left anterior temporal area
but no enhancement of the hyperostotic bone (Fig-
ure 1). There was significant hyperostosis of the
0090-3019/01/$–see front matter
PII S0090-3019(01)00440-2
266 Surg Neurol De Jesús and Toledo
2001;55:265–9

1 Summary of Patients with Meningioma En Plaque

VISUAL INFILTRATED ADJUVANT
# AGE SYMPTOMS ACUITY BONE RECURRENCE REOPERATION THERAPY
1 43 Proptosis 20/20 Yes Yes (residual) Yes (1) 5400 rads
2 39 Proptosis, visual loss 20/50 Right Not examined Yes Yes (3) No
3 52 Proptosis, headache 20/20 Yes No No No
4 54 Seizure 20/25 Yes No No No
5 52 Proptosis, visual loss 20/200 Left No No No No
6 64 Proptosis 20/20 Yes No No No

sphenoid bone including the lateral orbital wall.
The hyperostosis at the lesser wing of the sphenoid
bone was removed by using a high-speed drill. The
lateral wall of the orbit was removed and the supe-
rior orbital fissure decompressed. The basal tem-
poral dura was opened and all the involved por-
tions were removed. Areas of the periorbita
involved by the tumor were also removed. A peri-
craneum dural graft was used to close the dura. A
methyl methacrylate cranioplasty was used to
cover the temporal bone defect. Histopathological
examination of the hyperostotic bone showed nests
of meningeal cells between the bony trabeculae
(Figure 2). Postoperative study 96 months after the
surgery did not show evidence of recurrence.
discussion
An average of 20 patients were operated for intra-
cranial meningioma each year at our Institution.
Our series showed that 4% of these cases were
meningioma en plaque. All patients were female.
Average follow-up was 4 years (range: 3– 8 years).
Meningioma en plaque is almost exclusively found
in females [24], although some male cases have
been reported [3,4,17,26]. Toledo et al [26] re-
ported that meningioma en plaque represents
about 2% of operated meningiomas. Pompili et al
[24] reported that hyperostosing meningiomas of
the sphenoid ridge represent 9% of all the cases of
intracranial meningiomas treated surgically.
For reasons that are unclear, meningiomas en
plaque are more likely to provoke adjacent bony
hyperostosis than the larger globular tumors [1,7,
12,17,18,24,25,27]. It is this bony hyperostosis that
frequently produces the clinical signs and symp-
toms by pressing against adjacent structures [4,7,
9]. The duration of symptoms is usually long be-
cause of the minimal discomfort produced [4,24].
Proptosis is the most common presentation in pa-
tients with meningioma en plaque [3,4,21,24]. It is
unilateral, non-pulsating, and irreducible; causing
forward displacement of the eyeball [4]. Other
symptoms and signs produced by this tumor in-
clude decreased visual acuity or blindness, head-

T1-weighted MRI scan with gadolinium in case #3

1 shows enhancement of the dura in the left anterior
temporal area. There is significant hyperostosis of the
sphenoid bone including the lateral orbital wall. The area
of hyperostosis is hypointense and did not change after
gadolinium injection.
Photomicrograph of the hyperostotic bone speci-
2 men from case #3 showing nests of meningeal cells
located between the bony trabeculae (hematoxylin and
eosin, ⫻100).
Meningioma en Plaque
ache, and extraocular movements disturbances
[1,3,4,8,19,24]. Found less frequently is swelling of
the temporal region, seizures, and facial pain [19,
24]. Computed tomography (CT) scan is excellent
for visualization of the hyperostosis [17,25]. MRI
shows the tumor and involved dura much better
than contrast CT scan. Postcontrast fat suppression
T1-weighted MRI is useful to evaluate the presence
and degree of meningeal enhancement especially in
those cases extending into the orbit [5]. The sphe-
noid ridge is the most common site for meningio-
mas en plaque, but other locations in the convexity
may be affected as well [7,17,18,20]. Differential di-
agnosis of this lesion includes fibrous dysplasia,
osteoma, and osteoblastic metastasis [1,5,17,27].
In 5 patients in our series, the bone was sent for
histopathological examination. Four of them had
infiltration of the bone by meningioma cells. Bonnal
et al [3] demonstrated invasion by meningioma
cells in most of the studied bone specimens. Most
authors agree with Cushing’s [7] conclusion that
the infiltration of the bone by meningioma cells
stimulates osteoblastic activity resulting in the hy-
perostosis [8,11,18,24,27]. Kim et al [17] postulated
that the new bone growth probably resulted from
periosteal stimulation by tumor invasion. Some au-
thors consider intraosseous meningioma, a tumor
in which the largest component is inside the bone
with minimal or no dural component, a separate
entity [1,2,27]. Thickening and enhancement of the
dura on CT scan and microscopic infiltration on
pathological examination were found in 43% to 50%
of the reported cases of intraosseous meningioma
[1,2,27]. We consider that all these cases should
have been reported as meningioma en plaque. Now-
adays MRI, with its better definition of the enhanc-
ing dura, has made the diagnosis of intraosseous
meningiomas rare.
In 1952, Castellano et al [4] concluded that pa-
tients with meningioma en plaque should not be
operated and surgical measures should be consid-
ered only as a last resort because of the high sur-
gical mortality rate. Nowadays, a fronto-temporal
approach with lateral cranial base resection is used
to remove these tumors [8 –10,14,15]. Removal of
the orbitozygomatic bone can be added to increase
exposure [13,14]. Our approach is a fronto-
temporal craniectomy with orbital decompression.
The hyperostotic temporal bone is removed with a
high-speed drill. The anterior clinoid process,
lesser sphenoid wing, and greater sphenoid wing
are removed extradurally. Removal of the lesser
sphenoid wing opens the optic canal and upper part
of the superior orbital fissure while removal of the
greater sphenoid wing opens the lateral and lower
Surg Neurol 267
2001;55:265–9
parts of the superior orbital fissure. Then the lateral
and superior walls of the orbit are removed until
the periorbita is completely exposed. The dura is
opened even if it looks normal and all portions
involved by the tumor are removed. The periorbita
is explored and if it has been invaded by the tumor,
it is also removed. A pericranium graft is used to
reconstruct the dura. A cranioplasty is performed
to cover the temporal bone defect. The superior
and lateral walls of the orbit are not reconstructed.
Meticulous aggressive surgery offers the best re-
sults in these rare tumors [9,19,21]. Early operation
allows a complete tumor resection before the tu-
mor extends to the cavernous sinus [14].
Nagale et al [23] showed that the dural tail adjacent
to meningiomas represents a hypervascular, non-
neoplastic dural reaction. They did not find neoplastic
tissue more than 2 mm away from the main tumor. In
our cases of meningioma en plaque, we found that the
hypervascular dura contained neoplastic cells more
than 10 mm away from the main tumor. We recom-
mend that an extensive amount of dura be removed
with the main tumor and the margins should be stud-
ied. In those patients with residual tumor, the intraor-
bital component has always regrown but the intracav-
ernous component has not [19]. Pompilli et al [24]
found that in 31% of the cases the periorbita was
invaded, in 12% the temporal muscle was invaded,
and in 93.8% the bone was infiltrated by meningioma
cells. Gaillard et al [13,14] found invasion of the tem-
poral muscle in 35% of his cases. To obtain the best
surgical result and avoid recurrences, all of the in-
volved bone should be removed [3,5,13]. Unfortu-
nately, the neuropathologist cannot determine during
the operative procedure if the bone is infiltrated by
tumor cells; therefore, aggressive removal of the hy-
perostotic bone is recommended. Tumor involve-
ment of the orbital rim has been reported in 55% of
cases [13]. The superior orbital rim has to be pre-
served or reconstructed for a good cosmetic result,
but the sphenoid ridge does not need reconstruction.
Complete removal of meningiomas en plaque is
often difficult because of their extensive involve-
ment of the sphenoid ridge and cavernous sinus.
The best results are obtained with tumors located
at the middle and external third of the sphenoid
ridge because they do not involve the cavernous
sinus or the periorbita. In fact, meningiomas of the
sphenoid ridge represent 25% of recurrent menin-
giomas [16,22]. Invasion of the cavernous sinus is
considered the main cause of recurrences [3]. In
cases with infiltration of the cavernous sinus and
Zinn’s fibrous ring at the orbital apex, a subtotal
resection was obtained [3,14,19,24]. A subtotal but
extensive removal combined with bony decompres-
268 Surg Neurol
2001;55:265–9
sion of the cranial nerves at the superior orbital
fissure and optic canal frequently provides good
functional and cosmetic results. Some authors have
recommended radiation therapy when the tumor
resection was incomplete or for high-grade menin-
giomas [5,14,21,24]. In the series by Maroon et al
[21], there was no progressive growth in 10 patients
who received radiation therapy with a follow-up
period ranging from 16 to 95 months. One patient in
our series received radiation therapy after subtotal
resection of all the involved bone and has been
tumor-free for a follow-up period of 5 years.
The best way to completely remove these tumors
is early diagnosis and treatment. If the lesion is
found in a young or middle-aged patient, surgery
should be conducted to prevent progressive
growth and deformity that may later result in an
incomplete resection. Reports of patients with non-
operated meningiomas en plaque are few [4,6]. Cas-
tellano et al [4] followed 9 patients for several
years; some remaining stable and others develop-
ing slight discomfort and increased exophthalmos.
Gaillard et al [13,14] noted mild residual enophthal-
mos or exophthalmos in 30% of the patients and
unchanged or improved visual impairment in 63%
of the patients. Pompili et al [24] noted that exoph-
thalmos regressed partially in 30% of the patients
and completely in 60%, while visual changes im-
proved in 48% of the patients and extraocular dis-
turbances improved or resolved in 50%. Exophthal-
mos regressed in all the patients in our series, and
the visual acuity and visual fields improved in the 3
patients who had deficits before surgery.
Complications may result mainly from injury to the
internal carotid artery and from cortical injury from
retraction during removal of the tumor. Injury to the
optic nerve can occur while opening the optic canal.
If a drill is used, continuous irrigation should be used
to prevent heat damage to the nerve. Transient deficit
in extraocular movements may occur from direct
trauma to the muscles. During aggressive removal of
the tumor at the orbital apex, a permanent deficit can
occur because of nerve injury.
Conclusions and
Recommendations
1. Hyperostosis is suggestive of meningioma en
plaque, particularly if it involves the sphenoid
ridge. It merits further diagnostic studies.
2. MRI is the best study to identify the meningioma
attached to the dura.
3. An extensive amount of dura should be removed
with the main tumor to prevent recurrence.
De Jesús and Toledo
4. By performing an extensive resection, good dis-
ease control with minimal morbidity and good
cosmetic and functional results can be achieved
in the majority of cases.
5. In patients less than 70 years old without medi-
cal complications, surgery should be done as
soon as the diagnosis is obtained to avoid pro-
gressive deformities and incomplete resection
that may lead to recurrences.
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commentary
De Jesús et al have presented a series of 6 cases of
meningioma en plaque involving the sphenoid wing
area. This is a well recognized lesion in neurosur-
gery; I call it the spheno-orbital meningioma. The
tumor typically involves the dura of the middle
fossa, the cavernous sinus (in more extensive cas-
es), the spheno-orbital bone, the periorbita, the
orbital muscles (including the orbital apex in some
patients), the temporalis muscle, and the muscles
of the pterygopalatine-infratemporal fossa (in more
advanced cases). The treatment consists of resec-
tion of all the involved areas, without producing any
cranial nerve deficits. Although the hyperostotic
bone is involved in the tumor in every case, it may
not be necessary to remove all the involved bone in
older patients, because such tumors are
slow-growing.
I prefer to reconstruct extensive areas of bone
removal with autologous split calvarial bone, tita-
nium mesh, and artificial bone cement or cadaveric
bone paste, rather than with methyl methacrylate,
because the former grafts become better integrated
with the body tissues.
Liligam N. Sekhar, M.D.
Neurosurgeon
Annandale, Virginia
—Gaelic proverb
—Chinese proverb