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LETTERS TO EDITOR
Year : 2011  |  Volume : 59  |  Issue : 3  |  Page : 461-463

Optic nerve fenestration in sphenoid wing meningioma


Department of Neuroscience, Division of Neurosurgery, University of Turin, Italy

Date of Submission15-Dec-2010
Date of Decision07-Mar-2011
Date of Acceptance12-Mar-2011
Date of Web Publication7-Jul-2011

Correspondence Address:
P P Panciani
Department of Neuroscience, Division of Neurosurgery, University of Turin
Italy
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.82730

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How to cite this article:
Panciani P P, Crobeddu E, Garbossa D, Ducati A, Fontanella M. Optic nerve fenestration in sphenoid wing meningioma. Neurol India 2011;59:461-3

How to cite this URL:
Panciani P P, Crobeddu E, Garbossa D, Ducati A, Fontanella M. Optic nerve fenestration in sphenoid wing meningioma. Neurol India [serial online] 2011 [cited 2019 Aug 22];59:461-3. Available from: http://www.neurologyindia.com/text.asp?2011/59/3/461/82730


Sir,

Fenestrations of the optic nerve have been described in association with aneurysms of the internal carotid artery. [1],[2],[3],[4],[5],[6],[7] Only one case of de novo fenestration has been described. [8] We report a case of splitting of the optic nerve in a patient operated for a middle sphenoid wing meningioma, probably the first report of such case.

A 46-year-old man presented with decreased vision in his left eye of 2 weeks duration. Goldman perimeter fields demonstrated an enlargement of central scotoma. Brain magnetic resonance imaging (MRI) showed middle sphenoid wing meningioma [Figure 1]. The patient was taken for a left pterional craniotomy. The first step of the procedure was the un-roofing of the optic canal and the falciform ligament cutting. Microsurgical dissection and excision of the tumor was completed. A reddish mass was observed through the optic nerve [Figure 2]. At a high magnification the anomaly was recognize as a possible splitting of the optic nerve [Figure 3]a. The indocyanine green video angiographic study revealed a vessel below the fenestration [Figure 3]b. Postoperative cerebral angiography showed the absence of vascular malformations [Figure 4]. The postoperative course was uneventful and his visual acuity deficit remained unchanged at the 6-month follow-up examination.
Figure 1: Axial T1-weighted enhanced MRI showing a sphenoid wing meningioma

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Figure 2: Intraoperative photograph after unroofing of the optic canal and falciform ligament cutting. The image shows a fenestration of the left optic nerve

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Figure 3: (a) Magnified view of the optic nerve splitting. (b) Indocyanine green video angiographic study reveals a vessel, likely the ophtalmic artery, below the fenestration of the nerve

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Figure 4: Postoperative left carotid angiogram did not show any vascular malformations

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Sphenoid wing meningiomas frequently encase or displace the internal carotid artery and its branches, as well the optic nerve and chiasm. Visual dysfunctions, both defective acuity and visual fields, are often the presenting symptoms. Moreover, a risk of up to 20% of visual deterioration after surgery is reported. [9] In our patient, a defective visual acuity due to an enlarged central scotoma was the initial symptom. We performed an early optic canal unroofing and falciform ligament cutting in order to avoid visual impairment. Intraoperatively, a splitting of the optic nerve was observed [Figure 3]a. The indocyanine green video angiographic study showed an artery below the fenestration [Figure 3]b. The postoperative angiography excluded the presence of aneurysms [Figure 4]. There as no visual deterioration postoperatively.

The presence of a penetrating aneurysm was reported in seven cases with optic nerve fenestration. [1],[2],[3],[4],[5],[6],[7] In the case reported by House [8] the patient presented multiple aneurysms not related to the fenestration [Table 1]. A vascular anomaly is generally proposed to explain the splitting. An embryological vascular remnant or perforating vessels supplying the optic apparatus could be involved in the development of a fenestration in the bundle of nerve fibers. [5] In our patient the angiography excluded vascular diseases. In cases of sphenoid wing and tuberculum sellae meningiomas, the optic nerve frequently shows a discolored band representing the area where it had been squeezed against the proximal edge of the optic canal and falciform ligament. [9] In patients with a congenital predisposition, the pressure point may result in the splitting of the nerve. Intraoperative damage can be avoided through an early nerve decompression. Congenital fenestrations of the optic nerve are extremely rare. In our patient, high pressure below the falciform ligament could explain the splitting of the optic nerve. Early optic canal un-roofing and falciform ligament cutting are recommended to avoid worsening of visual functions.
Table 1: Clinical finding for previously published cases of optic nerve fenestration


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  References Top

1.Beatty RA. Splitting of the optic nerve by a carotid-ophthalmic artery aneurysm: Case report. J Neurosurg 1986;65:560-2.  Back to cited text no. 1
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2.Date I, Akioka T, Ohmoto T. Penetration of the optic chiasm by a ruptured anterior communicating artery aneurysm: Case report. J Neurosurg 1997;87:324-6.  Back to cited text no. 2
[PUBMED]  [FULLTEXT]  
3.Fujita A, Tamaki N, Yasuo K, Nagashima T, Ehara K. Complete penetration of the optic chiasm by an unruptured aneurysm of the ophthalmic segment: Case report. Surg Neurol 2002;57:130-4.  Back to cited text no. 3
[PUBMED]  [FULLTEXT]  
4.House PA, Couldwell WT. De novo fenestration of the optic nerve. Case illustration. J Neurosurg 2005;102:390.  Back to cited text no. 4
[PUBMED]  [FULLTEXT]  
5.Jea A, Baskaya MK, Morcos JJ. Penetration of the optic nerve by an internal carotid artery-ophthalmic artery aneurysm: Case report and literature review. Neurosurgery 2003;53:996-1000.  Back to cited text no. 5
    
6.Joo SP, Kim TS. Splitting of the optic nerve associated with ruptured anterior communicating artery aneurysm. Case report. Neurol Med Chir 2007;47:501-2.  Back to cited text no. 6
    
7.Kanamaru K, Ishida F, Taki W. Splitting and penetration of the optic nerve by an aneurysm arising from the anterior wall of internal carotid artery: Case report. J Neurol Neurosurg Psychiatry 2001;71:525-7.  Back to cited text no. 7
[PUBMED]  [FULLTEXT]  
8.Mathiesen T, Kihlstrom L. Visual outcome of tuberculum sellae meningiomas after extradural optic nerve decompression. Neurosurgery 2006;59:570-6.  Back to cited text no. 8
    
9.Wang YY, Thani NB, Han TF. Optic nerve penetration by a carotico-ophthalmic artery aneurysm. J Clin Neuroscience 2010;17:931-3.  Back to cited text no. 9
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
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