Planum Sphenoidale Meningiomas Research Articles

Surgical Management and Outcome of the Planum Sphenoidale Meningioma: A Single-Center Strobe Compliant Study

BackgroundThe resection of the jugum (planum) sphenoidale meningioma (JSM) is challenging and there is a scarcity of available data in the literature. This study aimed to describe the surgical management and long-term outcome of jugum sphenoidale meningioma. MethodsThis was a retrospective, single-center, cohort study of 91 JSM patients treated in our department from 2005 to 2022. All the included patients have undergone surgical treatment. Clinical, radiological, and surgical data were extracted with specific attention to the age at onset, family history, duration from symptoms to diagnosis, clinical presentation, quality of excision, recurrence, and treatment outcome. ResultsWHO grade I and grade II meningioma were 83.5% (n=76) and 16.5% (n=15) respectively. Fronto-lateral 42.9% (n=39) and pterional approaches 57.1% (n=52) were the two major surgical approaches used for the management of planum sphenoidale meningioma. Twelve patients needed emergency surgical treatment at admission: 4 (4.4%) External CSF Shunt and 8 (8.8%) VP-Shunt. We have found a statistically significant (p=0.032) association between the quality of excision and the risk of recurrence. The GTR (Hazard ratio = 1) of the planum meningioma protects the patient from recurrence within 60 months of follow-up. Post-operative complications encountered were CSF-Leak in 2.2%, Meningitis 4.4%, surgical site infection 2.2%, and surgical site hematoma 3.3%. The overall postoperative favorable outcome was 68.1% (n=62). ConclusionThe pterional approach has allowed the achievement of GTR for jugum sphenoidale meningioma with protective odds from recurrence risk.

Epidemiology, Genetics and Pathophysiology of Pituitary Tumors

Pituitary tumors or tumors of the sella turcica include pituitary neuroendocrine tumors, Rathke's cleft cysts, craniopharyngiomas, tuberculum sellae, planum sphenoidale meningiomas, germ cell tumors, and hypophysitis. In addition, some rare tumors, such as pituicytomas, granular cell tumors, spindle cell oncocytomas, and chordomas or chondrosarcomas, arise from the parasellar regions. The treatment strategy is completely different for each lesion; therefore, accurate diagnosis is essential.

Pterional Approach for Anterior Skull Base Midline Meningiomas against "The More The Merrier" Approach: An Institutional Experience.

Objective Anterior midline skull base meningiomas involving olfactory groove, planum sphenoidale, and tuberculum sellae were usually managed with bifrontal craniotomy until the dawn of advanced microsurgical techniques. With the emergence of microsurgical techniques, midline meningiomas could be tackled solely from a unilateral pterional approach. We present our experience with pterional approach in managing anterior skull base midline meningiomas, including the technical nuances and outcomes. Methods Fifty-nine patients who underwent excision of anterior skull base midline meningiomas through a unilateral pterional craniotomy between 2015 and 2021 were retrospectively analyzed. The surgical technique and patient outcomes in the context of visual, behavioral, olfaction, and quality of life were evaluated during the follow-up. Results A total of 59 consecutive patients were assessed over an average follow-up period of 26.6 months. Twenty-one (35.5%) patients had planum sphenoidale meningioma. Olfactory groove and tuberculum sellae meningioma groups consist of 19 (32%) patients each. Visual disturbance was the predominant symptom with almost 68% of patients presented with it. A total of 55 (93%) patients had complete excision of the tumor with 40 patients (68%) achieving Simpson grade II excision, and 11 (19%) patients had Simpson grade I excision. Among operated cases, 24 patients (40%) had postoperative edema among which 3 (5%) patients had irritability and 1 patient had diffuse edema requiring postoperative ventilation. Only 15 (24.6%) patients had contusion of the frontal lobe and were managed conservatively. Five patients (50%) with seizures had an association with contusion. Sixty-seven percent of patients had improvements in vision and 15% of patients had a stable vision. Only eight (13%) patients had postoperative focal deficits. Ten percent of patients had new-onset anosmia. The average Karnofsky score was improved. Only two patients had recurrence during follow-up. Conclusion A unilateral pterional craniotomy is a versatile approach for the excision of anterior midline skull base meningioma, even for the larger lesions. The ability of this approach in the visualization of posterior neurovascular structures at the earlier stages of surgery while avoiding the opposite frontal lobe retraction and frontal sinus opening makes this approach more preferable over the other approaches.

Suprasellar Meningioma Classification: Endoscopic Transnasal Perspective

Abstract Objectives Midline suprasellar meningiomas include planum sphenoidale, tuberculum sellae, and diaphragma sellae meningiomas. Multiple classifications have been previously documented; however, they come with controversies and limitations, including those with surgical implications. The aim of this study was to classify suprasellar meningiomas based on their behavior toward the underlying bone and neurovascular structures. Methods Patients with newly diagnosed suprasellar meningiomas that underwent extended endoscopic transnasal approach between 2015 and 2021 were included in this study. The following parameters were evaluated: chiasmatic sulcus length, location of the optic chiasm and nerves, optic canal involvement, and vascular displacement. Results We identified 40 cases of midline suprasellar meningiomas, 1 diaphragma sellae meningioma (type A), 10 tuberculum sellae meningiomas (type B), 9 chiasmatic sulcus meningiomas (type C), and 10 planum sphenoidale meningiomas (type D). Asymmetrical visual complaints were most common in chiasmatic sulcus meningiomas, followed by tuberculum sellae meningiomas (66 and 50%, respectively). Chiasmatic sulcus meningiomas showed increased separation between the optic chiasm and the A1/A2 complex (8.9 mm) compared with tuberculum sellae (2.7 mm) and planum sphenoidale (1.9 mm) meningiomas. Compared with other types, increased chiasmatic sulcus length was observed in chiasmatic sulcus meningiomas. Conclusions Preoperative evaluation of bone involvement and tumor relation to neurovascular structures can be used to classify suprasellar meningiomas. Chiasmatic sulcus meningioma is a distinct subtype of suprasellar meningiomas. Its unique behavior toward nearby neurovascular structures could be of surgical value during tumor resection.

Supraorbital Keyhole Approach—A Minimally Invasive Versatile Approach to Skull Base Lesions

Abstract Context Over the last two decades, there have been development of approaches that are minimally invasive but achieve maximum effective results with minimal morbidity. The supraorbital keyhole approach (SOKHA) through the transciliary incision is minimally invasive approach that permits effective management of skull base lesions with minimal injury to the soft tissue and surrounding brain. Aims The aim of this study was to evaluate the efficacy and safety of SOKHA for skull base lesions. Settings and Design This is a prospective study in a tertiary neurosurgical teaching institute in a metropolitan city. Materials and Methods Twenty-one patients of various pathology were operated using the SOKHA through the “eye-brow incision.” The pathologies included pituitary adenoma, craniopharyngioma, epidermoid, tuberculum sella, and planum sphenoidale meningioma. The authors describe in detail the surgical approach employed by them for these various pathologies. Results All neoplastic lesions in this series could be addressed effectively with near total or total excision. No fresh postoperative deficits were noted except a case who developed ipsilateral anterior cerebral artery infarction that resulted in lower limb weakness. One patient developed postoperative abscess requiring surgical excision. At follow-up, all patients revealed a cosmetic scar hidden by the eye brow. Conclusions The SOKHA is an effective minimally invasive procedure with proven safety for the management of anterior, selected middle skull base lesions and to provide excellent cosmesis with minimal trauma to the adjacent brain. The authors, however, feel that it is technically demanding and surgeons should employ a stepwise progression from simple to more complex lesions.

Case report – Complete visual recovery in a case of planum sphenoidale meningioma

Reporting a case of a 57-year-old male with progressive visual and field loss diagnosed with planum sphenoidale meningioma after further investigation. The patient initially had difficulty in near work, which further progressed to severe visual loss in the left eye and almost a complete field defect in the right eye after which he underwent imaging. A planum sphenoidale meningioma was reported on imaging, and the patient underwent an excision surgery. At five-month follow-up postsurgery, a complete visual recovery was seen which was maintained at one-year follow-up as well. Thus, early recognition and timely management of planum sphenoidale meningiomas can lead to full visual recovery.

Endonasal transsphenoidal surgery for planum sphenoidale versus tuberculum sellae meningiomas.

The aim of this study was to determine if the distinction between planum sphenoidale (PS) and tuberculum sellae (TS) meningiomas is clinically meaningful and impacts the results of the endoscopic endonasal approach (EEA). A consecutive series of patients who were 18 years of age or older and underwent EEA for newly diagnosed grade I PS meningiomas (PSMs) and TS meningiomas (TSMs) between October 2007 and May 2021 were included. The PS and TS were distinguished by drawing a line passing through the center of the TS and perpendicular to the PS on postcontrast T1-weighted MRI. Probabilistic heatmaps were created to display the actual distribution of tumor volumes. Tumor volume, extent of resection (EOR), visual outcome, and complications were assessed. The 47 tumors were distributed in a smooth continuum. Using an arbitrary definition, 24 (51%) were PSMs and 23 (49%) were TSMs. The mean volume of PSMs was 5.6 cm3 compared with 4.5 cm3 for TSMs. Canal invasion was present in 87.5% of PSMs and 52% of TSMs. GTR was achieved in 38 (84%) of 45 cases in which it was the goal, slightly less frequently for PSMs (78%) compared with TSMs (91%), although the difference was not significant. Th mean EOR was 99% ± 2% for PSMs and 98% ± 11% for TSMs. Neither the suprasellar notch angle nor the percentage of tumor above the PS impacted the rate of GTR. After a median follow-up of 28.5 months (range 0.1-131 months), there were 2 (5%) recurrences after GTR (n = 38) both of which occurred in patients with PSMs. Forty-two (89%) patients presented with preoperative impaired vision. Postoperative vision was stable or improved in 96% of patients with PSMs and 91% of patients with TSMs. CSF leakage occurred in 4 (16.6%) patients with a PSM, which resolved with only lumbar drainage, and in 1 (4.3%) patient with a TSM, which required reoperation. PSM and TSMs arise in a smooth distribution, making the distinction arbitrary. Those classified as PSMs were larger and more likely to invade the optic canals. Surgical outcome for both locations was similar, slightly favoring TSMs. The arbitrary distinction between PSMs and TSMs is less useful at predicting outcome than the lateral extent of the tumor, regardless of the site of origin.

Management of an Internal Carotid Artery Injury During Open Skull Base Surgery With a Crushed Muscle Patch - Technical Note and Lessons Learned.

Iatrogenic internal carotid artery (ICA) injury is a catastrophic complication in open skull base surgery. There is a lack of information regarding the most appropriate techniques on how to manage this complication. To highlight the difficulties encountered when an ICA injury arises intraoperatively and discuss the role and the potential pitfalls of the crushed muscle patch in the management of an ICA injury during open skull base surgery. In this technical video, we demonstrate the management of intraoperative ICA injury, which occurred during the resection of a diffuse planum sphenoidale meningioma via a left pterional craniotomy. When isolation of the defect with temporary clips failed, we opted for a crushed muscle graft to plug the defect. Hemostasis was achieved, but because of prolonged pressure application and "overpacking," the parent vessel was occluded. The crushed muscle patch can be easily applied; however, care must be taken not to "overpack" and occlude the ICA.

3D Printing-Assisted Skull Base Tumor Surgeries: An Institutional Experience.

Three-dimensional (3D) printing technology in neurosurgery has gained popularity nowadays. Skull base contains many major neurovascular structures in a confined space, along with anatomical variations making surgical approaches to this region challenging. 3D-printed model of skull base tumors consists of the patient's bony skull base, actual tumor dimensions, and surrounding major neurovascular structures. We included a total number of five patients with skull base tumors (one case of planum sphenoidale meningioma, two cases of sellar tumor with suprasellar extension, and two cases of cerebellopontine angle tumor) and 3D-printed tumor model of each of them. These models were used for preoperative simulation and served as very true to life training tool. These help in increasing the efficacy of the surgeon, improves surgical safety and ergonomics. They were also used for patient counselling, educating about the disease, the surgical procedure, and associated risks.

Olfactory Outcomes after Resection of Tuberculum Sella and Planum Sphenoidale Meningiomas via a Transcranial Approach.

Objectives Controversy exists surrounding the optimal approaches to tuberculum sella meningioma (TSM) and planum meningioma (PM). Olfaction is infrequently considered within this context but is nonetheless an important quality of life measure. The evolution of olfactory outcomes following contemporary transcranial surgery remains unclear. This study reviews olfactory outcomes after supraorbital craniotomy for TSM or PM and defines temporal trends in its recovery. Study Design A prospective study of a patients who underwent a minimally invasive supraorbital craniotomy for TSM or PM was conducted at a single neurosurgical center. Participants & Main Outcome Measures All patients were questioned about olfaction at presentation 3 months postoperatively, 12 months postoperatively, and annually thereafter (median follow-up = 37 months). The olfactory status of patients was categorized as normosmia, anosmia, hyposmia, parosmia, (altered perception of odours), or phantosmia, (olfactory hallucinations). Results Twenty-two patients were included in the study analysis, (range = 27-76). Precisely, 3 months after surgery, seven patients had normal olfaction (32%). Six patients were anosmic, (27%) four hyposmic, (18%), three parosmic, (14%), and two were phantosmic (9%). At 1-year follow-up, almost half of patients (10; 48%) were normosmic, while two patients (9.5%) were anosmic. There were no further improvements in olfaction between 1 year and long-term follow-up. Conclusion Subfrontal transcranial approaches for TSM or PM appear to be associated with changes in olfaction that can improve with time; these improvements occur within the first year after surgery. Impacts upon olfaction should be considered when selecting a surgical approach and patients counseled appropriately.

Planum Sphenoidale Meningioma: A Rare Location of Skull Base Meningioma

Background: Meningioma is common primary central nervous system tumors. Twenty-five percent of all meningioma consist of skull base meningioma. Planum sphenoidale meningiomas are rare. Planum sphenoidale meningiomas can extend into adjacent areas. Approximately two thirds of patients complain of failing vision in one eye as the first symptom.
 Case Report: A 32-year-old woman presented with 6-month history of progressively worsening blurred of both of vision. She also complained her smell ability was reduced for 3 months. She had headache for 6 months. The pain was worsening in the morning. She is conscious. A neurologic examination revealed bilateral hyposmia and visual deficits but no weakness. Visus of oculo dextra was 1/300 and visus of oculo sinistra was no light perception. Magnetic resonance imaging (MRI) intravena contrast of brain revealed a large extra-axial mass measured ±6,2x5,9x6 cm centred on planum sphenoidale displacing both frontal lobes. She had an operation of tumor removal with cranio-orbito-zygotomy approach. The tumor, which measured ±7cmx7cmx6 cm, was succesfully removed completely. She gets improvement of smell ability and both visual postoperatively. The histopathology of the tumor revealed meningioma WHO grade I.
 Discussion: Planum sphenoidale meningiomas present a frequently encountered pathology of the anterior skull base. These meningiomas give rise to an early visual disturbance with relatively slow progression. Displacement of the olfactory tracts and optic chiasm occur when the meningioma extends into the paranasal sinuses and nasal cavity. Clinical presentation and diagnosis often occur in the late stage. Anosmia is one of common finding on physical examination. Postoperative improvement of visual symptoms depends on the preoperative duration of those symptoms.

Abnormal ECG in a Structurally Normal Heart

A 63-year-old woman presented with an abnormal electrocardiogram (ECG) triggered by a murmur on physical examination. The ECG showed low atrial ectopic rhythm at rate 46 bpm with diffuse abnormal T wave and prolonged QTc at 546 milliseconds (Fig. 1). She was completely asymptomatic. She had a history of hypertension with no other cardiovascular risk factors along with normal laboratory values. Coronary angiography revealed normal coronary arteries and normal left ventricle (LV) contractility. An ECG demonstrated normal LV size and systolic function, and cardiac magnetic resonance imaging (MRI) revealed normal LV size and function with no evidence of myocardial edema, necrosis, fibrosis, or acute myocardial tissue injury of the LV. Right ventricular size and systolic function were also normal. The main differential diagnosis of inverted T waves includes ischemia, hypertrophy, and intracranial abnormalities. As such, we did proceed with computed tomography head that showed evidence of 3.7 cm mass most consistent with planum sphenoidale meningioma. A subsequent MRI confirmed a broad-based dural mass measuring 34 × 35 × 27 mm centred in the anterior cranial fossa with a significant superolateral mass effect on the overlying bilateral frontal lobes with vasogenic edema (Fig. 2, A and B ). Dynamic ECG changes have been observed in patients with subarachnoid haemorrhage or stroke. Cerebrovascular masses may also increase sympathetic activity and a-adrenergic stimulation with subsequent ECG changes such as ST-segment depression, profound T-wave inversion, and QTc interval prolongation.1Hersch C. Electrocardiographic changes in head injuries.Circulation. 1961; 23: 853-860Crossref PubMed Scopus (86) Google Scholar, 2Kopikkar S. Baranchuk A. Guzman J.C. Morillo C.A. Stroke and ventricular arrhythmias.Int J Cardiol. 2013; 168: 653-659Abstract Full Text Full Text PDF PubMed Scopus (35) Google Scholar, 3Kukla P. Jastrzębski M. Kurdzielewicz W. et al.Dynamic ECG changes in a patient with subarachnoid haemorrhage.Kardiol Pol. 2014; 72: 473-475Crossref PubMed Scopus (1) Google Scholar Our patient presented with ECG changes secondary to the meningioma mass effect. The patient was referred to neurosurgery and is planned for surgical excision of the mass.

The extended pterional approach for midline anterior skull base meningiomas

Background: Various surgical approaches for the management of midline anterior skull base meningiomas exist in the literature. The main surgeon target is proper selection the appropriate approach that achieves total removal of the lesion without causing morbidity or mortality and facilitates safe effective removal of the tumour.
 Objectives: To evaluate the role of the extended pterional approach for excision of midline anterior skull base meningiomas as regarding the effectiveness, extent of resection and surgical outcome.
 Patients and methods: This retrospective study involved 23 cases with midline anterior skull base meningiomas resected through the extended pterional approach. Patients' clinical data, operative notes, imaging studies and clinical follow-up data were analyzed and evaluated.
 Results: Tumors studied were 9 olfactory groove meningiomas, 8 tuberculum Sellae meningiomas, 4 planum sphenoidale meningiomas and 2 diaphragma sellae meningiomas. Gross total resection tumour excision in 15 cases (64.5%), subtotal excision in 5 cases (21.5%) and partial excision in 3 cases (14%). Complications were diabetes insipidus (2 cases 8.6%), CSF rhinorrhea (3 cases 12.9%) and visual deterioration (3 cases 12.9%). We had two cases of mortality.
 Conclusion: The extended pterional approach allows safe and effective removal of midline anterior skull base meningiomas. It expands the exposure offered by the classic pterional approach and minimizing the necessity for applying fixed brain retraction with good cosmetic outcome and less approach-related morbidities in comparison with the extensive skull base approaches.

Surgical challenges and outcome of endoscopic endonasal approaches in the management of recurrent pituitary adenomas

Background: Various surgical approaches for the management of midline anterior skull base meningiomas exist in the literature. The main surgeon target is proper selection the appropriate approach that achieves total removal of the lesion without causing morbidity or mortality and facilitates safe effective removal of the tumor.
 Objectives: To evaluate the role of the extended pterional approach for excision of midline anterior skull base meningiomas as regard the effectiveness, extent of resection and surgical outcome.
 Patients and methods: This retrospective study involved 23 cases with midline anterior skull base meningiomas resected through the extended pterional approach. Patients' clinical data, operative notes, imaging studies and clinical follow-up data were analyzed and evaluated.
 Results: Tumors studied were 9 olfactory groove meningiomas, 8 tuberculum Sellae meningiomas, 4 planum sphenoidale meningiomas and 2 diaphragma sellae meningiomas. Gross total resection tumor excision in 15 cases (64.5%), subtotal excision in 5 cases (21.5%) and partial excision in 3 cases (14%). Complications were diabetes insipidus (2 cases 8.6%), CSF rhinorrhea (3 cases 12.9%) and visual deterioration (3 cases 12.9%). We had two cases of mortality.
 Conclusion: The extended pterional approach allows safe and effective removal of midline anterior skull base meningiomas. It expands the exposure offered by the classic pterional approach and minimizing the necessity for applying fixed brain retraction with good cosmetic outcome and less approach related morbidities in comparison with the extensive skull base approaches.

Endoscopic Endonasal Transsphenoidal Approach for Resection of Tuberculum Sella and Planum Sphenoidale Meningiomas: A Snapshot of Our Institutional Experience.

Introduction:Meningiomas of the tuberculum sellae and planum sphenoidale represent a subgroup of anterior skull base tumors that comprise approximately 5%–10% of all intracranial meningiomas. Most of the patients report with failing vision, so early surgical decompression either transcranial and/or endonasal approach is recommended. The endonasal route allows for direct coagulation of the tumor meningeal supply and extensive resection of dural attachments, and importantly, provides an inferior to superior access to the infrachiasmatic region that facilitates complete tumor removal without encountering the optic nerve. This article describes our institutional experience for the endonasal resection of tuberculum sellae and planum sphenoidale meningiomas.Materials and Methods:We retrospectively analyzed eight cases of tuberculum sellae and planum sphenoidale meningiomas who selectively underwent endoscopic endonasal transsphenoidal resection between 2015 and 2018. All patients had ophthalmological, endocrinological, and radiological evaluation both preoperatively and postoperatively.Results:Among the study group, we found age range 22–68 years, male:female 1:2. Among the radiological findings, there were five cases of tuberculum sellae meningioma, while three cases were of planum sphenoidale meningioma. In tumor resection status, we found gross total resection in six cases and debulking in two cases. Postoperative analysis of visual outcome revealed improvement in four cases, constant in three cases, and worsening in one case. We also found the post of nasal complications in four cases, cerebrospinal fluid leak in two cases and transient diabetes insipidus in one case.Conclusion:In this study, we highlighted our experience of a very small group of patients with anterior fossa meningioma specific to tuberculum sella and planum sphenoidale origin.

Left Planum Sphenoidale Transitional Meningioma -Simpson Grade-1

Planum sphenoidale meningiomas are rare slow growing tumours that impair cognition and lead to behavioural changes. Other common presentations of this condition include persistent headache followed by vision diminution. Dismissing cognitive impairment and behavioural changes as part of dementia, depression or aging might lead to loss of opportunity to treatment. The common symptoms manifested in sphenoid (spheno-orbital) wing meningioma is bulging of the eyes which may be painless, visual impairment and ocular paresis. Headache is also a common symptom, in addition to ptosis. Variants of the clinical syndrome include the following: Eye swelling and hearing loss, optic atropy, Kennedy syndrome and mental changes. Patient had severe headache for which he went for the eye checkup, where the loss of vision in the left eye was confirmed, through the field test. The MRI confirmed the tumour presence. Though the diagnosis was informed it took one year to convince the patient for the surgery. Hence, the author wishes to emphasise the role of tumour support systems. Physician’s serve as patients’ first point of entry into the health care system and as the continuing focal point for all necessary health care services along with their team they play a vital role in convincing patients from postdiagnosis to surgery and recovery.

A dry pineapple slice like lesion in the anterior skull base

We read with much great interest the article of Salunke et al.[[1]] Bone formation in meningiomas can be scattered, focal (eccentric or centrally). The latter is the case in our patient, a 50-year-old male who was referred for magnetic resonance imaging (MRI) from the temporal bone because of daily head pressure and tinnitus. MRI showed an incidental high-density lesion with central calcification and moderate perilesional edema at the right border of the lesion, most probably a planum sphenoidale meningioma [[Figure 1]].

Tailored approach for the resection of planum sphenoidale meningiomas

Background and importance. Planum sphenoidale meningiomas are relatively rare tumours that can grow to a considerable size before determining noticeable symptoms. Modern imaging techniques can detect these tumours of varying size. Surgical resection of planum sphenoidale meningiomas can be performed by adapting the approach to the size of the tumour.Clinical presentation. A 56-year-old woman presented with a small (2 cm in diameter) planum sphenoidale meningioma that was resected through a frontal craniotomy performed with a 4,5 cm trephine at the level of the frontal sinus. The second case is that of a 55-year-old woman that presented with a large planum sphenoidale meningioma (5,6 cm in the antero-posterior plane and 5,5 cm cranio-caudally) extending to the tuberculum sellae and sellar diaphragm, reaching the anterior wall of the third ventricle. In this case, a bifrontal craniotomy was performed with frontal sinus cranialization and resection of falx cerebri, achieving a Simpson II resection. Both cases presented a favourable postoperative evolution, without any deficits and an excellent cosmetic result.Conclusion. The approach for tumours of the anterior skull base must be tailored to the size of the tumour. A minimally invasive approach through the frontal sinus should not be avoided in cases with small tumours.

Yield of screening blood work and MRI of the brain and orbits in the work-up of unilateral chronic optic neuropathy.

No guidelines exist for the investigation of treatable causes of chronic optic neuropathy, including sarcoidosis, lupus, and syphilis. The purpose of this study was to determine the diagnostic yield of screening blood work (ACE (Angiotensin Converting Enzyme)for sarcoidosis, Antinuclear Antibodies (ANA) for lupus, CMIA(chemiluminescence microparticle enzyme immunoassay) for syphilis) and contrast-enhanced MRI brain and orbits in atypical unilateral chronic optic neuropathy. Retrospective review from February 2012 to June 2018 at a neuro-ophthalmology practice. Six hundred and eighty-three consecutive charts with optic neuropathy were reviewed. Inclusion criteria were unilateral chronic optic neuropathy and a work-up including contrast-enhanced MRI brain and orbits, CBC, ESR, CRP, ANA, CMIA, and ACE. Exclusion criteria were optic nerve swelling in either eye on initial assessment or an established cause of optic neuropathy. The main outcome measure was diagnostic yield. Fifty-seven patients were included. One patient had elevated ACE, seven had positive ANA titers, and three had positive CMIA. Zero patients were diagnosed with sarcoidosis, one patient was diagnosed with lupus-related optic neuropathy, and one patient was diagnosed with syphilitic optic neuropathy. The diagnostic yield of ACE was 0%, ANA was 1.75%, and CMIA was 1.75%. MRI revealed planum sphenoidale meningioma causing compressive optic neuropathy in one patient, giving it a diagnostic yield of 1.82%. Routine screening blood work (ACE, ANA, CMIA) and MRI brain and orbits for chronic idiopathic unilateral optic neuropathy has low diagnostic yield, especially if clinical suspicion for syphilis, lupus, and sarcoidosis is low. MRI should still be performed in all cases in order to rule out compressive lesions.

Small Extended Bifrontal Approach for Midline Anterior Skull Base Meningiomas: Our Experience with 54 Consecutive Patients

To describe the technique of a small extended bifrontal approach and review the clinical outcome of patients with midline anterior skull base (MASB) meningiomas treated using this technique. The small extended bifrontal craniotomy extends inferiorly to the nasofrontal suture without entering the orbit, superiorly 3 cm above the supraorbital rim, and laterally 3 cm to the midline on both sides. A review of a prospectively acquired database was performed of 54 consecutive patients with MASB meningiomas who underwent this craniotomy. Twenty-nine patients with olfactory groove meningiomas, 2 with planum sphenoidale meningiomas (PSMs), and 23 with tuberculum sellae meningiomas (TSMs) were treated using this technique. Gross total resection was achieved in all patients. Of 29 patients with olfactory groove meningiomas, 12 (41.4%) had normal olfaction at presentation and 8 had preservation of olfaction postoperatively. Of 25 patients with TSMs/PSMs, 23 (92.0%) had preoperative visual impairment, with 13 showing improved vision (56.5%), 8 unchanging (34.8%), and 2 deteriorating (8.7%) after surgery. The most common complications were anosmia and hyposmia, which occurred in 5 patients (20.0%) and 3 patients (12.0%) with TSMs/PSMs, respectively. No mortality was reported. There was no recurrence in all patients after a mean follow-up of 39.5 months (range, 16-64 months). The small extended bifrontal approach is a safe and effective technique for resection of MASB meningiomas, which provides adequate surgical exposure with less approach-related morbidity. It is an excellent alternative for surgeons who favor the bifrontal approach and its extended variations.