Correspondence Giant Intraventricular Meningioma LETTER:
et al. (8) stated, it is a challenge to achieve total resection without any complication.
e read with great interest the article entitled “Surgical Management of Meningioma of the Trigone Area of the Lateral Ventricle” by Jun Ma et al. (8), They report their experience on a series of trigone intraventricular meningioma associated with a deeper and interesting analysis of the pertinent literature.
We recently operated on a patient with an unusually large right IM. A 46-year-old right-handed man presented to our department with a worsening trend characterized by headache, left lateral homonymous hemianopia, left central facial nerve paresis, and left hemiparesis.
We agree with Ma et al. (8) that the surgical experience with intraventricular meningiomas (IM) is rare in the literature and sparsely reported, and several surgical approaches exist.
CT scan and MRI showed a giant tumor localized in the right trigone with extension to the whole body of lateral ventricle and temporal and occipital horn (75 mm wide, 80 mm in length, 60 mm height) (Figure 1) The brain MRI revealed a large, isodense, intraventricular mass in the right lateral ventricle. On T1-weighted images the mass enhanced homogeneously with loculated enlargement of the temporal horn, suspect for an intraventricular meningioma.
W
Surgical approaches to the trigone of the lateral ventricle are challenging because of the eloquent nature of the surrounding anatomy (1, 2, 7, 9). The trigone of the lateral ventricle has an intimate relationship with the fibers of the internal capsule, the optic radiations, and the striate cortex (1, 2, 7-9, 11, 12). The surgical approach cannot be standardized because the specific location, size, and vascularization of these deep-seated tumors touch fundamental elements (1, 4, 6, 8, 9, 11, 12). The computerized tomography (CT) scan and the magnetic resonance imaging (MRI) features were similar to other meningiomas, except for the lack of dural attachment (2, 4). Furthermore, IMs pose a surgical challenge as they often remain asymptomatic until they become very large (1-6, 8), are in close proximity to vital and highly functional structures, and, during surgery, its devascularization is usually achieved only after significant tumor debulking (1, 3, 4, 6, 8-12). Their benign nature and large size makes them unsuitable for any treatment other than surgical excision. In addition, as Ma
This huge tumor was removed through a right transcorticaloccipito-parietal approach. Because of the high tumor vascularization, during the operation there was significant blood loss (1500 mL), which required blood transfusion. A ventricular drain was left in place and removed after 10 days. The histologic diagnosis confirmed a World Health Organization grade I meningothelial meningioma. The postoperative course was characterized by a deep hemorrhage in the surgical field that resolved without surgery, and transitory worsening of left motor hemiparesis associated with swallowing problems, which resolved after 30 days. The early postoperative CT scan showed total removal (Figure 1).
Marco Giulioni and Matteo Martinoni IRCCS Institute of Neurological Sciences, Section of Neurosurgery, Bellaria Hospital, Bologna, Italy To whom correspondence should be addressed: Marco Giulioni, M.D. [E-mail: [email protected]] Published online 19 August, 2014; http://dx.doi.org/10.1016/j.wneu.2014.08.039.
REFERENCES 1. Delfini R, Acqui M, Oppido PA, Capone R, Santoro A, Ferrante L: Tumors of the lateral ventricles. Neurosurg Rev 14:127-133, 1991. 2. Fornari M, Savoiardo M, Morello G, Solero CL: Meningiomas of the lateral ventricles. Neuroradiological and surgical considerations in 18 cases. J Neurosurg 54:64-74, 1981. 3. Kashiwazaki D, Takaiwa A, Nagai S, Akioka N, Kurosaki K, Noguchi K, Kuwayama N, Kuroda S: Reversal of cognitive dysfunction by total removal of a large lateral ventricle meningioma: a case report with neuropsychological assessments. Case Rep Neurol 6:44-49, 2014. 4. Kim EY, Kim ST, Kim HJ, Jeon P, Kim KH, Byun HS: Intraventricular meningiomas: radiological findings and clinical features in 12 patients. Clin Imaging 33:175-180, 2009. 5. Liu JK: Microsurgical resection of giant intraventricular meningioma. Neurosurg Focus 34(1 Suppl):Video 2, 2013. Figure 1. Axial (A), sagittal (B), and Coronal (C) T1- weighted magnetic resonance imaging after gadolinium contrast injection showing a right large intraventricular meningioma determining mass effect without perilesional edema. Postoperative computerized tomography scan (D) confirmed the total removal of the lesion and showed the temporary external ventricular derivation left during surgery.
WORLD NEUROSURGERY 82 [5]: e657ee669, NOVEMBER 2014
6. Lunardi P, Conti C, Corinaldesi R, Ghetti G: An unusual growth of an intraventricular meningioma: a case report. Neurol Sci 32:669-671, 2011. 7. Lyngdoh BT, Giri PJ, Behari S, Banerji D, Chhabra DK, Jain VK: Intraventricular meningiomas: a surgical challenge. J Clin Neurosci 14:442-448, 2007.
www.WORLDNEUROSURGERY.org
e657
CORRESPONDENCE
8. Ma J, Cheng L, Wang G, Lin S: Surgical management of meningioma of the trigone area of the lateral ventricle. World Neurosurg 82:757-769, 2014. 9. Nayar VV, DeMonte F, Yoshor D, Blacklock JB, Sawaya R: Surgical approaches to meningiomas of the lateral ventricles. Clin Neurol Neurosurg 112:400-405, 2010. 10. Okechi H, Albright AL: Intraventricular meningioma: case report and literature review. Pediatr Neurosurg 48:30-34, 2012. 11. Ødegaard KM, Helseth E, Meling TR: Intraventricular meningiomas: a consecutive series of 22 patients and literature review. Neurosurg Rev 36:57-64 [discussion 64], 2012. 12. Wang X, Cai BW, You C, He M: Microsurgical management of lateral ventricular meningiomas: a report of 51 cases. Minim Invasive Neurosurg 50: 346-349, 2007.
Postoperative Rhinorrhea without Intraoperative Cerebrospinal Fluid Leak After Endoscopic Transnasal Transphenoidal Surgery for Pituitary Macroadenomas LETTER: the pituitary literature, we find that cerebrospinal R eviewing fluid (CSF) leakage is a common and major complication of transphenoidal surgery. Rates of postoperative CSF rhinorrhea increase with surgery for macroadenomas, transphenoidal reoperation, and intraoperative leak (3, 5). Several techniques of sellar
floor reconstruction have been described for the reduction of rate of postoperative CSF rhinorrhea after the occurrence of an intraoperative leak (1, 4), whereas simple closure after transphenoidal surgery has been proposed in the absence of an intraoperative CSF leak. We present 3 patients from our early series subjected to endoscopic transnasal transphenoidal removal of pituitary macroadenomas. During surgery and after a thorough endoscopic visual inspection and induction of Valsalva maneuver, there was no evidence of CSF leak. After removal of the macroadenoma, a layer of SURGICEL (Ethicon, Bridgewater, New Jersey, USA) was left over the tumor bed for hemostasis. Postoperatively, CSF rhinorrhea was noticed, and all patients were successfully managed with the placement of CSF lumbar drainage. Couldwell et al. (2), in their technical note, report no incidence of postoperative CSF rhinorrhea if no intraoperative leak is encountered during transphenoidal surgery. Furthermore, all procedures were performed without reconstruction of the sellar floor, and no late CSF leak was observed. The results of the aforementioned study raised concerns about the possible causative factors that led to postoperative rhinorrhea in our 3 patients. Enlarged sella from a macroadenoma leads to expansion and possible incompetence of diaphragma sellae and exposed arachnoid membrane. With meticulous surgical technique, the integrity of arachnoid can be preserved and a Valsalva maneuver can elicit a subtle leak. However, either the constant force applied to the weakened diaphragma sellae from the continuous pulsatile flow of CSF or tearing of a herniated (Figure 1) diaphragma sellae through the sella opening from bony chips could explain postoperative CSF leak in this scenario. An autologus fat graft harvested from the lower abdomen or the lateral thigh can be inserted in the emptied sella after removal of a macroadenoma buttressed in place with multiple layers of surgicel or a fascia graft. With this technique the incompetent diaphragma sellae is reinforced and also prevented from herniation through the opened sellar floor. We now routinely use this technique in every case of macroadenoma surgery with occurrence of herniation of the diaphragma sellae through the opened sellar floor and negative inspection for intraoperative CSF leak after Valsalva maneuver, with excellent results in our late series.
Figure 1. Endoscopic image of herniation of the diaphragma sellae through the sellar floor opening that occurred after Valsalva maneuver during the final stages of a pituitary macroadenoma removal. This rare condition could potentially predispose to postoperative cerebrospinal fluid rhinorrhea, unless the diaphragma is buttressed back into place with the insertion in the emptied sella of autologus fat graft.
e658
www.SCIENCEDIRECT.com
Use of autologus fat or fascia graft is suggested for the sellar floor reconstruction in cases of intraoperative CSF leak during transphenoidal removal of pituitary macroadenomas. Furthermore, no reconstruction at all is proposed in cases where no intraoperative CSF leak is noted. Nevertheless, postoperative CSF rhinorrhea without intraoperative leakage, although rare, is not uncommon. Insertion of autologus fat graft in the sella turcica can be a feasible and effective surgical method for the prevention of postoperative CSF rhinorrhea in the setting of endoscopic transanal transphenoidal removal of pituitary macroadenomas without intraoperative leak, especially when herniation of the
82 [5]: e657ee669, NOVEMBER 2014 WORLD NEUROSURGERY
et al. (8) stated, it is a challenge to achieve total resection without any complication.
e read with great interest the article entitled “Surgical Management of Meningioma of the Trigone Area of the Lateral Ventricle” by Jun Ma et al. (8), They report their experience on a series of trigone intraventricular meningioma associated with a deeper and interesting analysis of the pertinent literature.
We recently operated on a patient with an unusually large right IM. A 46-year-old right-handed man presented to our department with a worsening trend characterized by headache, left lateral homonymous hemianopia, left central facial nerve paresis, and left hemiparesis.
We agree with Ma et al. (8) that the surgical experience with intraventricular meningiomas (IM) is rare in the literature and sparsely reported, and several surgical approaches exist.
CT scan and MRI showed a giant tumor localized in the right trigone with extension to the whole body of lateral ventricle and temporal and occipital horn (75 mm wide, 80 mm in length, 60 mm height) (Figure 1) The brain MRI revealed a large, isodense, intraventricular mass in the right lateral ventricle. On T1-weighted images the mass enhanced homogeneously with loculated enlargement of the temporal horn, suspect for an intraventricular meningioma.
W
Surgical approaches to the trigone of the lateral ventricle are challenging because of the eloquent nature of the surrounding anatomy (1, 2, 7, 9). The trigone of the lateral ventricle has an intimate relationship with the fibers of the internal capsule, the optic radiations, and the striate cortex (1, 2, 7-9, 11, 12). The surgical approach cannot be standardized because the specific location, size, and vascularization of these deep-seated tumors touch fundamental elements (1, 4, 6, 8, 9, 11, 12). The computerized tomography (CT) scan and the magnetic resonance imaging (MRI) features were similar to other meningiomas, except for the lack of dural attachment (2, 4). Furthermore, IMs pose a surgical challenge as they often remain asymptomatic until they become very large (1-6, 8), are in close proximity to vital and highly functional structures, and, during surgery, its devascularization is usually achieved only after significant tumor debulking (1, 3, 4, 6, 8-12). Their benign nature and large size makes them unsuitable for any treatment other than surgical excision. In addition, as Ma
This huge tumor was removed through a right transcorticaloccipito-parietal approach. Because of the high tumor vascularization, during the operation there was significant blood loss (1500 mL), which required blood transfusion. A ventricular drain was left in place and removed after 10 days. The histologic diagnosis confirmed a World Health Organization grade I meningothelial meningioma. The postoperative course was characterized by a deep hemorrhage in the surgical field that resolved without surgery, and transitory worsening of left motor hemiparesis associated with swallowing problems, which resolved after 30 days. The early postoperative CT scan showed total removal (Figure 1).
Marco Giulioni and Matteo Martinoni IRCCS Institute of Neurological Sciences, Section of Neurosurgery, Bellaria Hospital, Bologna, Italy To whom correspondence should be addressed: Marco Giulioni, M.D. [E-mail: [email protected]] Published online 19 August, 2014; http://dx.doi.org/10.1016/j.wneu.2014.08.039.
REFERENCES 1. Delfini R, Acqui M, Oppido PA, Capone R, Santoro A, Ferrante L: Tumors of the lateral ventricles. Neurosurg Rev 14:127-133, 1991. 2. Fornari M, Savoiardo M, Morello G, Solero CL: Meningiomas of the lateral ventricles. Neuroradiological and surgical considerations in 18 cases. J Neurosurg 54:64-74, 1981. 3. Kashiwazaki D, Takaiwa A, Nagai S, Akioka N, Kurosaki K, Noguchi K, Kuwayama N, Kuroda S: Reversal of cognitive dysfunction by total removal of a large lateral ventricle meningioma: a case report with neuropsychological assessments. Case Rep Neurol 6:44-49, 2014. 4. Kim EY, Kim ST, Kim HJ, Jeon P, Kim KH, Byun HS: Intraventricular meningiomas: radiological findings and clinical features in 12 patients. Clin Imaging 33:175-180, 2009. 5. Liu JK: Microsurgical resection of giant intraventricular meningioma. Neurosurg Focus 34(1 Suppl):Video 2, 2013. Figure 1. Axial (A), sagittal (B), and Coronal (C) T1- weighted magnetic resonance imaging after gadolinium contrast injection showing a right large intraventricular meningioma determining mass effect without perilesional edema. Postoperative computerized tomography scan (D) confirmed the total removal of the lesion and showed the temporary external ventricular derivation left during surgery.
WORLD NEUROSURGERY 82 [5]: e657ee669, NOVEMBER 2014
6. Lunardi P, Conti C, Corinaldesi R, Ghetti G: An unusual growth of an intraventricular meningioma: a case report. Neurol Sci 32:669-671, 2011. 7. Lyngdoh BT, Giri PJ, Behari S, Banerji D, Chhabra DK, Jain VK: Intraventricular meningiomas: a surgical challenge. J Clin Neurosci 14:442-448, 2007.
www.WORLDNEUROSURGERY.org
e657
CORRESPONDENCE
8. Ma J, Cheng L, Wang G, Lin S: Surgical management of meningioma of the trigone area of the lateral ventricle. World Neurosurg 82:757-769, 2014. 9. Nayar VV, DeMonte F, Yoshor D, Blacklock JB, Sawaya R: Surgical approaches to meningiomas of the lateral ventricles. Clin Neurol Neurosurg 112:400-405, 2010. 10. Okechi H, Albright AL: Intraventricular meningioma: case report and literature review. Pediatr Neurosurg 48:30-34, 2012. 11. Ødegaard KM, Helseth E, Meling TR: Intraventricular meningiomas: a consecutive series of 22 patients and literature review. Neurosurg Rev 36:57-64 [discussion 64], 2012. 12. Wang X, Cai BW, You C, He M: Microsurgical management of lateral ventricular meningiomas: a report of 51 cases. Minim Invasive Neurosurg 50: 346-349, 2007.
Postoperative Rhinorrhea without Intraoperative Cerebrospinal Fluid Leak After Endoscopic Transnasal Transphenoidal Surgery for Pituitary Macroadenomas LETTER: the pituitary literature, we find that cerebrospinal R eviewing fluid (CSF) leakage is a common and major complication of transphenoidal surgery. Rates of postoperative CSF rhinorrhea increase with surgery for macroadenomas, transphenoidal reoperation, and intraoperative leak (3, 5). Several techniques of sellar
floor reconstruction have been described for the reduction of rate of postoperative CSF rhinorrhea after the occurrence of an intraoperative leak (1, 4), whereas simple closure after transphenoidal surgery has been proposed in the absence of an intraoperative CSF leak. We present 3 patients from our early series subjected to endoscopic transnasal transphenoidal removal of pituitary macroadenomas. During surgery and after a thorough endoscopic visual inspection and induction of Valsalva maneuver, there was no evidence of CSF leak. After removal of the macroadenoma, a layer of SURGICEL (Ethicon, Bridgewater, New Jersey, USA) was left over the tumor bed for hemostasis. Postoperatively, CSF rhinorrhea was noticed, and all patients were successfully managed with the placement of CSF lumbar drainage. Couldwell et al. (2), in their technical note, report no incidence of postoperative CSF rhinorrhea if no intraoperative leak is encountered during transphenoidal surgery. Furthermore, all procedures were performed without reconstruction of the sellar floor, and no late CSF leak was observed. The results of the aforementioned study raised concerns about the possible causative factors that led to postoperative rhinorrhea in our 3 patients. Enlarged sella from a macroadenoma leads to expansion and possible incompetence of diaphragma sellae and exposed arachnoid membrane. With meticulous surgical technique, the integrity of arachnoid can be preserved and a Valsalva maneuver can elicit a subtle leak. However, either the constant force applied to the weakened diaphragma sellae from the continuous pulsatile flow of CSF or tearing of a herniated (Figure 1) diaphragma sellae through the sella opening from bony chips could explain postoperative CSF leak in this scenario. An autologus fat graft harvested from the lower abdomen or the lateral thigh can be inserted in the emptied sella after removal of a macroadenoma buttressed in place with multiple layers of surgicel or a fascia graft. With this technique the incompetent diaphragma sellae is reinforced and also prevented from herniation through the opened sellar floor. We now routinely use this technique in every case of macroadenoma surgery with occurrence of herniation of the diaphragma sellae through the opened sellar floor and negative inspection for intraoperative CSF leak after Valsalva maneuver, with excellent results in our late series.
Figure 1. Endoscopic image of herniation of the diaphragma sellae through the sellar floor opening that occurred after Valsalva maneuver during the final stages of a pituitary macroadenoma removal. This rare condition could potentially predispose to postoperative cerebrospinal fluid rhinorrhea, unless the diaphragma is buttressed back into place with the insertion in the emptied sella of autologus fat graft.
e658
www.SCIENCEDIRECT.com
Use of autologus fat or fascia graft is suggested for the sellar floor reconstruction in cases of intraoperative CSF leak during transphenoidal removal of pituitary macroadenomas. Furthermore, no reconstruction at all is proposed in cases where no intraoperative CSF leak is noted. Nevertheless, postoperative CSF rhinorrhea without intraoperative leakage, although rare, is not uncommon. Insertion of autologus fat graft in the sella turcica can be a feasible and effective surgical method for the prevention of postoperative CSF rhinorrhea in the setting of endoscopic transanal transphenoidal removal of pituitary macroadenomas without intraoperative leak, especially when herniation of the
82 [5]: e657ee669, NOVEMBER 2014 WORLD NEUROSURGERY
