Elsevier

World Neurosurgery

Volume 76, Issues 3–4, September–October 2011, Pages 311-317
World Neurosurgery

Peer-Review Report
Giant Olfactory Groove Meningiomas: Extent of Frontal Lobes Damage and Long-Term Outcome After the Pterional Approach

https://doi.org/10.1016/j.wneu.2011.03.021Get rights and content

Objective

The treatment of giant olfactory groove meningiomas (OGMs; maximum diameter ≥ 6 cm) poses special problems and represents a surgical challenge. We discuss the long-term results in a series of 18 patients with giant OGMs and report our experience on a global strategy encompassing the pterional approach to manage the lesion and an extended transbasal approach to treat recurrences.

Methods

Between February 1991 and December 2007, 18 patients with giant OGMs were surgically managed via a pterional craniotomy. Postoperative follow-up imaging was obtained at one, six, and 12 months and then yearly. In preoperative images, data from tumor volume were assessed. The volume of the residual right frontal porencephalic cave (ipsilateral to the operative side) was compared with the volume of the porencephalic cave measured in the left frontal lobe (internal control) in each case. Comparison between porencephalic cave and the original tumor volume for each side was also performed.

Results

At the first operation in 17 of 18 patients (94.4%), the tumor resection was accomplished by a complete macroscopic lesion removal and coagulation of its dural attachment (Simpson grade II). In one patient, a Simpson grade V resection was obtained. The mean follow-up was 93.5 months, ranging from 12 to 214 months. Recurrences were observed in three patients (16.7%) at 103, 102, and 128 months, respectively, from the time of the first operation. These patients were operated on via an extended subfrontal transbasal approach accomplishing a complete (Simpson grade I) resection. No death occurred. The visual deficit improved in seven of 13 patients (53.8%), remained stable in five (38.5%), and worsened in one patient (7.7%). Overall, 17 of 18 patients (94.4%) had a good outcome and returned to their previous occupations. All the tumors presented with a symmetrical growth pattern. The mean meningioma volume was 23.51 ± 1.62 cm3 for the right portion of the tumor and 23.04 ± 1.35 cm3 for the left portion. The mean residual porencephalic volume was significantly smaller in the left frontal lobe (mean value 5.7 mL) than in the right frontal lobe (mean value 16.6 mL; P < 0.05). The mean residual porencephalic volume was significantly smaller than the tumor volume both in the left (P < 0.01) and in the right side (P < 0.05).

Conclusion

The pterional-transsylvian approach provides two major advantages: first, it minimizes morbidity and mortality through an early neurovascular control and by limiting parenchymal damage as demonstrated by a quantitative analysis; second it is associated with low recurrence rate at a long-term follow-up.

Introduction

Olfactory groove meningiomas (OGMs) account for 8%-18% of all intracranial meningiomas (16). They arise in an area of maximal brain compliance, at the level of the cribriform plate and the frontosphenoid suture. Accordingly, they may grow very large before becoming symptomatic and being diagnosed (3).

Since the first successful OGMs removal reported by Durante (28), a safe and radical surgical approach for the treatment of this lesion still remains a matter of controversy. Different strategies have been proposed to achieve satisfactory results. Some authors have advocated an anterior approach by a frontal (uni- or bilateral) craniotomy, with various refinements, to reach the fronto-basal area with minimal brain retraction (8, 16, 20, 24, 26). Others have suggested an anterolateral approach that includes a pterional craniotomy, thus allowing the early and safe management of the neurovascular structures that often are displaced by the posterior portion of the tumor (3, 5, 9, 14, 17, 18, 19, 21, 29). Along with these two basic surgical strategies, more extensive approaches have been recently proposed for the management of OGMs entering into the paranasal sinuses and orbits (11, 15).

In this scenario, the treatment of giant OGMs (maximum diameter ≥6 cm) poses special problems and represents a surgical challenge for the perioperative morbidity and postoperative parenchymal damage. Moreover, the advantages of the different approaches have not been sufficiently evaluated in long-term follow-up studies (spanning longer than five years) with reference to recurrence rate.

Some years ago, we reported a small series of giant OGMs, emphasizing the role of the pterional approach in minimizing surgical morbidity (3). In the present study we discuss the long-term results in a series of 18 patients harboring giant OGMs and report our experience on a global strategy encompassing the pterional approach to manage the lesion and an extended transbasal approach to treat recurrences. To our knowledge, in this report we describe the longest follow-up in a homogeneous series of giant OGMs and analyze the extent of postoperative parenchymal damage in both frontal lobes.

Section snippets

Patient Population

Between February 1991 and December 2007, 18 patients harboring giant OGMs were operated on by the senior author (F.T.) at the Neurosurgical Department of the University of Messina, School of Medicine, Messina, Italy. They were six men and 12 women with a mean age of 59 years (range, 35-74 years). The first six cases have been previously described (3). Clinical records, radiological examinations, operative notes, video recordings of the procedures, and follow-up records were examined

Results

Our experience reports on 18 consecutive patients who underwent giant OGM surgical removal via a pterional approach. Anosmia and a psycho-organic syndrome were the most common presenting symptoms reported by all 18 patients. These disturbances were associated with headache in 13 cases (72.2%) and visual disorder in 13 patients (72.2%). The mean follow-up was 93.5 months, ranging from 12 to 214 months.

At the preoperative neuroradiological investigation, all the tumors presented with a

Discussion

In this paper we report our series of patients with giant OGMs managed by a pterional approach. This series is unique because it includes only patients with OGMs exceeding 6 cm in diameter and a long follow-up (mean follow-up, 93.5 months). In 94.4% of the cases, a radical tumor removal was achieved with low morbidity and no mortality. Volumetric analysis, in which we assessed postsurgical changes between the frontal lobes, showed a significantly smaller mean volume of the porencephalic cave in

Conclusion

The present study further strengthens the usefulness of the pterional-transsylvian approach for the resection of giant sized OGMs. Such a route provides two major advantages: first, it minimizes morbidity and mortality through an early neurovascular control and by limiting parenchymal damage as demonstrated by a quantitative analysis; second, it is associated with low recurrence rate at a long-term follow-up. In this regard, recurrence rate, related to different surgical strategies, should be

References (30)

  • R. Gazzeri et al.

    Giant olfactory groove meningioma: ophthalmological and cognitive outcome after bifrontal microsurgical approach

    Acta Neurochirur (Wien)

    (2008)
  • W. Hassler et al.

    Pterional approach for surgical treatment of olfactory groove meningiomas

    Neurosurgery

    (1989)
  • W. Hassler et al.

    Surgical treatment of olfactory groove meningiomas using the pterional approach

    Acta Neurochir Suppl (Wien)

    (1991)
  • S.J. Hentschel et al.

    Olfactory groove meningiomas

    Neurosurg Focus

    (2003)
  • K. James et al.

    Measuring response in solid tumors: Unidimensional versus bidimensional measurement

    J Natl Cancer Inst

    (1999)
  • Cited by (49)

    • Unilateral Supraorbital Keyhole Craniotomy Avoiding the Frontal Sinus for Large and Giant Olfactory-Groove Meningiomas: A Case Series

      2023, World Neurosurgery
      Citation Excerpt :

      This study, therefore, shows the efficacy of a minimally invasive unilateral keyhole approach for removing large skull base tumors that involve the bilateral anterior cranial fossa, with minimal manipulation of the contralateral hemisphere, as seen with bilateral approaches; avoidance of potential mucoceles, as seen with bifrontal and midline approaches; and reduced risk of CSF leaks, as seen with endoscopic endonasal procedures. Large and giant OGMs have historically been resected via either bifrontal or unilateral pterional approaches.8-11 The bifrontal craniotomy has the benefits of providing the shortest distance to the tumor from the calvarium, maximal working space for dissection and resection, and a large degree of visualization, among others.8,10,12

    • Innovations in the Art of Microneurosurgery for Reaching Deep-Seated Cerebral Lesions

      2019, World Neurosurgery
      Citation Excerpt :

      For these lesions, the pterional route provides a better and wider exposure of the tumor through a transsylvian route, allowing earlier control of the anterior cranial base and critical neurovascular structures located at the posterior pole of the tumor. Furthermore, in a series of patients with giant OGMs for whom long-term follow-up was performed, Grasso and colleagues29 found that the pterional transsylvian approach achieved low rates of morbidity and death, minimal parenchymal damage as assessed by a magnetic resonance imaging–based quantitative analysis, and a low recurrence rate. In a retrospective case series involving 99 patients with OGM, the pterional approach was found to achieve an extent of resection similar to that of the bifrontal approach (Simpson grade I–II: 80% [bifrontal] and 81% [pterional]) and a lower rate of life-threatening complications (e.g., retraction-related brain swelling, bleeding, ischemia).30

    • Complications in anterior cranial fossa surgery

      2019, Complications in Neurosurgery
    View all citing articles on Scopus

    Conflict of interest: This study was supported in part by Grant nos. DM45602, DM46965, and DM48235, funded by the Italian Minister of Education, University and Research.

    Dedicated to Francesco Durante (Letojanni 1844-Rome 1934).

    View full text