Spinal epidural meningiomas

Summary Two cases of a spinal epidural meningiomas, one localized in the upper thoracic and the other in the cervico-thoracic region are presented. In the second case the tumour originated from the dural sac, i.e. the inner membrane of the developmentally double-layered spinal dura mater.In the first case, however, the tumour appeared to have arisen from the outer layer of the spinal dura mater covering the wall of the vertebral canal. The rarity of this tumour and its mode of origin, which seems to be divergent from the usual one have been emphasized. The relevant literature is reviewed.

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Zusammenfassung Bericht über 2 Fälle mit spinalem epiduralem Meningiom, von denen eines im oberen Thorakalbereich und das andere in der zerviko-thorakalen Übergangsregion lokalisiert waren. Im zweiten Fall ging der Tumor vom Duralsack aus, d. h. von der Innenschicht der entwicklungsgeschichtlich zweischichtigen spinalen Dura mater.Im ersten Fall dagegen schien der Tumor von der äußeren Schicht der spinalen Dura mater, die den Rand des Wirbelkanals bedeckt, ausgegangen zu sein. Die Seltenheit dieses Tumors und seiner Ursprungsart, die von der Regel abweicht, wird hervorgehoben. Die einschlägige Literatur wird dargestellt.

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Resumen Informe sobre 2 casos de meningioma espinal epidural, uno de ellos localizado en la zona torácica superior y el otro en la región de transición cérvico-toracal. En el segundo caso partió el tumor del saco dural, es decir de la hoja interna de las hojas embriológicas de la dura madre espinal.En el primer caso, por el contrario, parece ser que el tumor partió de la hoja externa de la dura madre espinal, la cual cubre el borde del canal vertebral. Se resalta la rareza de estos tumores y de su naturaleza de origen, la cual se desvia de la regla. Se expone la literatura especial al tema.

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Résumé Deux cas de méningiome spinal épidural, un localisé dans la région thoracique supérieure et l'autre dans la région cervico-thoracique sont présentés. Dans le second cas, la tumeur a pour origine le sac durai, c'est-à-dire la membrane interne de la dure-mère spinale développée en deux couches.Dans le premier cas, cependant, la tumeur semblait naître de la couche externe de la dure-mère spinale recouvrant le mur du canal vertébral. La rareté de cette tumeur et de ses modes d'origine, qui semble être différent des cas habituels a été soulignée. La littérature correspondante a été revue.

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Riassunto Vengono presentati due casi di meningiomi epidurali spinali, uno localizzato nella regione toracica alta e l'altro in quella cervicotoracica.Nel secondo caso il tumore prendeva origine dal sacco durale, cioè dalla membrana interna della dura madre spinale che ontogeneticamente è composta da due strati.Nel primo caso tuttavia il tumore era sviluppato dallo strato esterno della dura madre che ricopre la parete del canale vertebrale.Viene messa in risalto la rarità in tale tumore del suo modo di origine, che sembra essere diverso dall'usuale.La letteratura sul tema viene riportata.

     

Spinal neurinomas and meningiomas in children

Summary The literature on spinal neurinomas (N) and meningiomas (M) in children is reviewed, and five personal cases of N are added (one in the context of Recklinghausen's disease). The cases of N totalled 151, and of M 69, accounting respectively for 10.9% and 4.3% of childhood spinal tumours and 2.6% and 1.3% of spinal N and M of all ages. Sixty-one cases of N (16 in the context of Recklinghausen's disease) and 26 cases of M (5 in the context of Recklinghausen's disease) are analyzed in detail. N occurs chiefly between ages 9 and 15 years, the sex ratio is 3 2, all levels of the spinal canal are equally affected, and extradural N or conditions with an extradural component (48%) are more frequent than in adults (26.9%). M occurs chiefly between 12 and 15 years, the sex ratio is 3 2, the prevalence of the thoracic segment (47.8%) is less marked than in adults (81%), and the frequency of the extradural site (10.6%) is close to the sum of the extradural and dumb-bell lesions in adults (11.1%). In children vertebral signs,i.e., spinal rigidity and tenderness, and spasm of paravertebral muscles, are more intense, earlier, and more frequent than in adults, and the clinical history is shorter. The chances of recovery from neurological deficits are greater, as are those of malignant degeneration.     

Spinal meningiomas: a 20-year review

The long-term outcome of 78 patients with spinal meningiomas operated on over 20 years at a single neurosurgical unit was analysed. Age, sex and tumour location were similar to those reported by others. Overall, 95% of our patents were independently mobile postoperatively, despite 25% of the group being unable to walk before operation, including four paraplegic patients. Only two tumours were entirely extradural, and a further two were both intra- and extradural. In all cases, tumour exposure was by posterior laminectomy, without recourse to more complex approaches. Complete tumour resection was achieved in 77 (98%) of cases. The dural attachment was excised in 20 cases and diathermy was applied in 58. There was one recurrence, 14 years after the original surgery. Complex and technically challenging surgical approaches are unnecessary to obtain complete removal even for anteriorly placed tumours. Excision of the dural base would seem unnecessary to attain a low recurrence rate.     

Spinal meningiomas: evaluation of 41 patients

AIM: Spinal meningiomas are relatively frequent intraspinal tumors. They constitute 25-46% of all primary spinal neoplasms. METHODS: Forty-one patients with spinal meningiomas surgically treated between 1986 and 2001 are reviewed in this report. There were 32 females and 9 males, aged 16 to 73 years old. Tumor location was cervical in 7 cases and thoracic in 34 cases. All tumors were intradural. All of the patients were operated by laminectomy in prone position. RESULTS: Total excision was achieved in 40 (98%) patients and subtotal excision in 1(2%). The majority of the tumors were meningothelial (42%) or psammomatous (25%). There was no surgical mortality. Four patients (10%) suffered from morbidity: One patient with CSF fistula, 1 deep venous thrombosis, 1 case with paraparesis and 1 wound infection was seen. Neither multiple meningiomas nor malign meningiomas were seen in our series. CONCLUSIONS: Spinal meningiomas are benign tumors and should be excised totally. If the preoperative neurological status is not complicated, fairly good outcome can be achieved.     

Spinal meningiomas: review of 174 operated cases

The long-term results obtained in a series of 174 patients operated on for spinal meningiomas are critically analyzed. This series was similar to those of other authors with regard to age, sex, location of the tumors, and clinical presentation. Before surgery, about 70% of the patients were included in Groups I and II (mild neurological impairment), and about 30% of the patients were classified in Groups III and IV (significant to severe neurological impairment, up to paraplegia). Complete tumor removal was achieved in 96.5% of the patients, and surgical mortality was about 1%. Microsurgical technique, which was adopted in the last 29 cases, proved to be very effective in reducing undue damage to the spinal cord and in minimizing the postoperative neurological deficits. Of the 174 patients who underwent surgery, 156 underwent late follow-up study for an average of 15 years (2 patients died in the immediate postoperative period, and 16 patients were lost to follow-up). Twenty-nine patients died of causes unrelated to the spinal meningioma; of the remaining 126 patients, 92% were categorized in Groups I and II, and only 8% in Groups III and IV. The rate of recurrence was 6% (9 patients) among the 150 patients who had complete tumor removal, and the rate of regrowth was 17% (1 patient with anaplastic meningioma) among the 6 patients treated by subtotal removal. The early diagnosis of the disease and the use of microsurgical technique appeared as the most relevant factors for further improvement of the surgical results.     

Spinal meningiomas: critical review of 131 surgically treated patients

This study was undertaken to analyze the functional outcome of surgically treated spinal meningiomas and to determine factors for surgical morbidity. Between January 1990 and December 2006 a total of 131 patients underwent surgical resection of a spinal menigioma. There were 114 (87%) female and 17 (13%) male patients. Age ranged from 17 to 88 years (mean 69 years). The mean follow-up period was 61 months (range 1–116 months) including a complete neurological examination and postoperative MRI studies. The pre- and postoperative neurological state was graded according to the Frankel Scale. Surgery was performed under standard microsurgical conditions with neurophysiological monitoring. In 73% the lesion was located in the thoracic region, in 16% in the cervical region, in 5% at the cervico-thoracic junction, in 4.5% at the thoraco-lumbar junction and in 1.5% in the lumbar region. Surgical resection was complete in 127 patients (97%) and incomplete in 4 patients (3%). At the last follow-up the neurological state was improved or unchanged in 126 patients (96.2%) and worse in 4 patients (3%). Permanent operative morbidity and mortality rates were 3 and 0.8%, respectively. Extensive tumour calcification proved to be a significant factor for surgical morbidity (P < 0.0001). Radical resection of spinal meningiomas can be performed with good functional results. Extensive tumor calcification, especially in elderly patients proved to harbor an increased risk for surgical morbidity.     

Spinal neurofibromas: a report of 66 cases and a comparison with meningiomas

A series of 66 spinal cord neurofibromas was analyzed for history, signs, surgical approach, and outcome. The tumors presented primarily with sensory symptoms. Plain films were abnormal in 1/2 of cases and 1/2 had a complete block. They were primarily intradural, and primarily thoracic. A conservative exam system was used for follow-up and 85% with pain had complete relief; 50% with motor loss had normal motor function, and 88% had normal sensation who had prior sensory loss. In comparison to meningiomas, the principal differences were that neurofibromas had an even sex distribution, a lower incidence of cord signs and symptoms, more frequent findings on plain x-rays, and higher cerebrospinal fluid protein. Surgical outcome was similar. Sacrifice of the involved root during removal usually did not produce a deficit. The series is compared with a similar series of meningiomas from the same institution over the same time period.     

Parasagittal meningiomas

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1. Three cases of successfully operated parasaggital meningioma are described. Their characteristics, (1) early involvement of overlying Bone, and (2) the late development or total absence of neurologic symptoms, are stressed.     

Olfactory meningiomas

Summary The clinical features of 25 cases of olfactory groove meningiomas operated between 1950 and 1970 are presented, discussed and compared with earlier series. Particular attention is focused on early symptoms and diagnostic studies that might lead to earlier recognition of these tumors. The surgical mortality rate was 12 per cent. However, this improvement of operative results over some of the previously reported series does not seem to be related to earlier recognition of the tumors; most of them were very large at the time of operation and the average patients complaints extended over a long period of time before the correct diagnosis was established. Although radioactive brain scanning and carotid angiography are very helpful in outlining these tumors, early surgical treatment is still prevented by the lack of careful and timely evaluation of patients who present the initial symptoms of anosmia, mental abnormalities or visual deterioration.     

Clinoidal meningiomas

Anterior clinoidal meningiomas are frequently grouped with suprasellar or sphenoid ridge meningiomas, masking their notorious association with a high mortality and morbidity rate, failure of total removal, and recurrence. To avoid injury to encased cerebral vessels, most surgeons are content with subtotal removal. Without total removal, however, recurrence is expected. Recent advances in cranial-base exposure and cavernous sinus surgery have facilitated radical total removal. The author reports 24 cases operated on with vigorous attempts at total removal of the tumor with involved dura and bone. This experience has distinguished three groups (I, II, and III) which influence surgical difficulties, the success of total removal, and outcome. These subgroups relate to the presence of interfacing arachnoid membranes between the tumor and cerebral vessels. The presence or absence of arachnoid membranes depends on the origin of the tumor and its relation to the naked segment of carotid artery lying outside the carotid cistern. Total removal was impossible in the three patients in Group I, with postoperative death occurring in one patient and hemiplegia in another. Total removal was achieved in 18 of the 19 patients in Group II, with one death from pulmonary embolism. In the two patients in Group III, total removal without complications was easily achieved.     

Cystic meningiomas

Five cases of meningiomas associated with cysts are reported. In a review of the literature the authors stress the importance and difficulty of the preoperative accurate diagnosis and the differential diagnosis from other cystic tumours to avoid misdiagnosis.     

Asterion meningiomas

Asterion meningiomas arise from the posterior petrous ridge at the junction of the transverse and sigmoid sinuses (sinodural angle). The authors retrospectively reviewed the charts of seven patients with asterion meningiomas who underwent a Simpson I tumor resection by either the petrosal or suboccipital approach. Patients presented with headaches, dizziness, ataxia, or seizures. Preoperative angiograms and intraoperative observations confirmed occlusion of the transverse and sigmoid sinuses by tumor, thrombus, or both in four of the patients. In all cases, tumor infiltrated the sinuses and the sinuses were ligated without adverse sequelae. Temporal bone invasion was seen in one patient who had the only tumor recurrence. Postoperatively, there were two transient CSF leaks. Asterion meningiomas can be completely resected with a low incidence of major morbidity. In this small series, a patent transverse/sigmoid sinus was resected in three patients without sequelae. We believe that in young patients with asterion meningiomas a nondominant transverse/sigmoid sinus should be resected if the torcula is patent. More research is needed to determine the safety of resecting a patent dominant transverse/sigmoid sinus.     

Intraventricular meningiomas

Intraventricular meningiomas are most often seen in the lateral ventricles of adults, more often on the left than on the right. A variety of surgical approaches can be selected depending on patient and tumor factors as well as on surgeon preference. Some of these approaches are complex and demand a thorough understanding of the ventricular and periventricular anatomy. When successful, surgery can be curative in most cases of total removal.