Sphenoorbital meningioma: surgical series and design of an intraoperative management algorithm

Current surgical removal of sphenoorbital meningiomas (SOM) mainly aims at reduction of proptosis and restoration of visual function; some stages of the surgical technique are controversial. In this study, we aim to present a surgical decision-making algorithm for SOM. A retrospective study of 27 patients who underwent resection of SOM in our center (2005-2014) was conducted. The primary outcomes evaluated were postoperative visual function and radiological exophthalmos. In our study, clinical proptosis was the most common presenting sign (92%), followed by visual loss (37%). Our surgical algorithm includes (1) extracranial stage; (2) extradural stage, including removal of the anterior clinoid process only in cases of tumor invasion (22% of our cases); (3) intradural stage; (4) intraorbital stage, including opening of the periorbita only in the presence of resectable intraorbital tumor; and (5) reconstruction, including rigid orbital reconstruction only if the periorbita was violated (22%) and placement of a fat graft in the epidural space in most cases (85%). Complete tumor resection was achieved in 51.8%. The extent of resection was limited mainly due to invasion to the cavernous sinus (61.5%) and the superior orbital fissure (84%). Surgery achieved significant visual improvement in 80% and exophthalmos reduction in 77% of the patients. Preoperative visual deficit (P = 0.0001) and optic canal involvement (P = 0.04) appeared to predict postoperative improvement of visual function. Surgical complications were mainly transient cranial nerve deficits. Based on our results, we concluded that the proposed surgical algorithm leads to successful visual, cosmetic, and oncologic outcomes.