Proptosis, Orbital Pain, and Long-Standing Monocular Vision Loss Resolved by Surgical Resection of Intraosseous Spheno-Orbital Meningioma: A Case Report and Literature Review

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Abstract

Background and Importance We present a case of a patient with a residual intraosseous sphenoid wing meningioma presenting with proptosis, orbital pain, and monocular vision loss for 8 months who underwent decompression of the optic canal, orbital contents, and orbital reconstruction resulting in significant improvement in her vision loss with full resolution of proptosis and orbital pain.

Clinical Presentation A 43-year-old female presented with a 1 year history of headache, peri-orbital pain, proptosis, and severe vision loss. She had previously undergone subtotal resection of a large Simpson Grade 1 spheno-orbital meningioma 3 years prior at an outside institution. Workup at our institution revealed hyperostosis of the left greater wing of the sphenoid bone and narrowing of the optic canal along with bony enhancement concerning for residual tumor. The patient was given the recommendation from outside institutions for radiation, presumably due to the chronicity of her visual loss. Our institution recommended resection of the residual osseous tumor with orbital reconstruction. Less than 2 weeks after surgery, the patient noted significant improvement in orbital pain and vision. At 3 months, she had regained full and symmetric orbital appearance with no orbital pain. Her visual acuity improved to 20/30 with full visual fields.

Conclusion Surgical decompression of the optic canal and orbital contents for tumor related sphenoid wing hyperostosis should be strongly considered, despite an extended duration of visual change and loss. This case report shows that vision can be significantly restored even after symptoms have been present for greater than 6 months.

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Most cited references 17

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Primary extradural meningiomas: a report on nine cases and review of the literature from the era of computerized tomography scanning.

F. DeMonte, Frederick F. Lang, O Macdonald … (2000)

Primary meningiomas arising outside the intracranial compartment (primary extradural meningiomas [PEMs]) are rare tumors. To develop a better understanding of these tumors and to establish a comprehensive classification scheme for them, the authors analyzed a series of patients treated at the M. D. Anderson Cancer Center (MDACC) and reviewed all cases reported in the English-language literature since the inception of the use of computerized tomography (CT) scanning. Clinical records, results of radiographic studies, and histological slides were reviewed for all cases of PEM at MDACC. Demographic features, symptoms, tumor location, histological grade, and patient outcome were assessed in all cases. A comprehensive literature search identified 168 PEMs in 142 patients reported during the CT era. These reports were also analyzed for common features. Tumors for both data sets were classified as purely extracalvarial (Type I), purely calvarial (Type II), and calvarial with extracalvarial extension (Type III). Type II and Type III tumors were further categorized as convexity (C) or skull base (B) lesions. The incidence of PEMs at MDACC was 1.6%, which was consistent with the rate reported in the literature. In both data sets, the male/female ratio was nearly 1:1. The most common presenting symptom was a gradually expanding mass. The age of patients at diagnosis of PEM was bimodal, peaking during the second decade and during the fifth to seventh decades. In all MDACC cases and in 90% of those reported in the literature the PEMs were located in the head and neck. The majority of tumors originated in the skull (70%). In the MDACC series and in the literature review, the majority (67% and 89%, respectively) of tumors were histologically benign. Although fewer PEMs were malignant or atypical (33% at MDACC and 11% in the literature), their incidence was higher than that observed for primary intracranial meningiomas. Distant metastasis was not a common feature reported for patients with PEMs (6% in the literature). Outcome data were available in 96 of the cases culled from the CT-era literature. The combination of the MDACC data and the data obtained from the literature demonstrated that patients with benign Type IIB or Type IIIB lesions were more likely to experience recurrence than patients with benign Type IIC or Type IIIC tumors (26% compared with 0%, p < 0.05). The more aggressive atypical and malignant tumors were associated with a statistically significant higher death rate (29%) relative to benign tumors (4.8% death rate, p < 0.004). Defining a tumor as a PEM is dependent on the tumor's relation to the dura mater and the extent and direction of its growth. Classification of PEMs as calvarial or extracalvarial and as convexity or skull base lesions correlates well with clinical outcome.

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Microsurgical technique and results of a series of 63 spheno-orbital meningiomas.

C Cedzich, Johannes Schramm, Florian Ringel … (2007)

For this study, spheno-orbital meningiomas (SOMs) are defined as intraosseus meningiomas at the base of the anterior and middle cranial fossa, involving the sphenoid wing and orbit associated with a carpet-like, soft tissue component. We describe a surgical series of 63 SOMs, including surgical technique, complications, and recurrences. For this retrospective series, patient charts of those who underwent operation for SOM by or under the supervision of the senior author (JS) at two institutions were identified and reviewed. Follow-up data was collected for up to 17 years (median, 4.5 yr). Between 1983 and 2003, 63 patients with a mean age of 51 years underwent operation for SOM. The most common preoperative sign was proptosis (79%), followed by visual acuity deficits (27%). Preoperative symptoms included a visual acuity below 0.8 (47%) and visual field deficits of 32%. Bony resection included the lesser sphenoid wing, the lateral orbital wall, the orbital roof, the optic canal, and the middle fossa base. Periorbital tumor infiltration led to intraorbital resection in 32 cases, and five cases presented a solid intraorbital tumor. After surgery, proptosis improved in 77% of the patients; 64% of the patients had improved visual acuity, and 58% of the patients with preoperative deficits had improved visual fields. Postoperatively, 12 patients showed temporary oculomotor deficits, and eight patients showed permanent oculomotor deficits. Temporary (n = 9) and persisting (n = 2) ptosis was observed. The median follow-up period was 4.5 years. Seventy-six percent of patients had tumor residuals, of which 61% were stable and 39% were progressive. Eleven tumor residuals were operated and four were treated by radiation. Complete surgical resection of SOMs is frequently impossible because the involvement of delicate structures of the orbital cone is common. Although some persisting neurological deficits are possible, proptosis and other visual deficits are often relieved. Two-thirds of tumor rests remained stable during the follow-up period. Consequently, the surgical aim should be the relief of leading symptoms rather than radical resection.

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Surgical management of tuberculum sellae meningiomas: involvement of the optic canal and visual outcome.

U Schick, W Hassler (2005)

To present a large series of surgically treated tuberculum sellae meningiomas with particular regard to involvement of the optic canal and visual outcome. A retrospective analysis was done on 53 patients (40 female) with meningiomas originating from the tuberculum sellae who underwent surgery between 1991 and 2002. The standard surgical approach consisted of pterional craniotomy. Sixteen meningiomas extended posteriorly onto the diaphragma sella, 29 anteriorly to the planum sphenoidale, and 19 to the anterior clinoid process. Thirty seven tumours involved the optic canal, three bilaterally. Follow up ranged from 6 to 108 months (mean 29.9 months). Total macroscopic resection was achieved in 48 patients. Median tumour size was 2.6 cm. Postoperatively, visual acuity improved in 20 patients and deteriorated in seven. Preoperative and postoperative visual acuity worsened with increasing duration of preoperative symptoms and with increasing age. Extension into the intraconal space was a negative predictor. However, tumour size did not influence visual acuity. Recurrence occurred in two cases (21 and 69 months postoperatively). Two patients died from causes unrelated to the tumour. In the majority of patients with tuberculum sellae meningiomas, total resection may be achieved through a pterional approach with minimal complications.

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Author and article information

Journal

Journal ID (nlm-ta): J Neurol Surg Rep

Journal ID (iso-abbrev): J Neurol Surg Rep

Journal ID (doi): 10.1055/s-00000182

Title: Journal of Neurological Surgery Reports

Publisher: Georg Thieme Verlag KG (Stuttgart · New York )

ISSN (Print): 2193-6358

ISSN (Electronic): 2193-6366

Publication date (Print): January 2020

Publication date (Electronic): 31 March 2020

Volume: 81

Issue: 1

Pages: e28-e32

Affiliations

[1 ]Department of Neurological Surgery, Carolinas Medical Center, Charlotte, North Carolina, United States

[2 ]Carolina Neurosurgery and Spine Associates, Charlotte, North Carolina, United States

Author notes

Address for correspondence Vinay Deshmukh, MD, FACS Carolina Neurosurgery and Spine Associates 225 Baldwin Ave, Charlotte, NC 28204United States vinay.deshmukh@ 123456cnsa.com

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Jonathan M. Parish http://orcid.org/0000-0002-9634-6406

Article

Publisher ID: 190016

DOI: 10.1055/s-0040-1708845

PMC ID: 7108951

PubMed ID: 32257766

SO-VID: aafee45e-6936-4ae6-a86a-582cffa54387

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This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives License, which permits unrestricted reproduction and distribution, for non-commercial purposes only; and use and reproduction, but not distribution, of adapted material for non-commercial purposes only, provided the original work is properly cited.

Proptosis, Orbital Pain, and Long-Standing Monocular Vision Loss Resolved by Surgical Resection of Intraosseous Spheno-Orbital Meningioma: A Case Report and Literature Review

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Hearing Loss and Restoration

Most cited references 17

Primary extradural meningiomas: a report on nine cases and review of the literature from the era of computerized tomography scanning.

Microsurgical technique and results of a series of 63 spheno-orbital meningiomas.

Surgical management of tuberculum sellae meningiomas: involvement of the optic canal and visual outcome.

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