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Table of Contents    
ORIGINAL ARTICLE
Year : 2018  |  Volume : 66  |  Issue : 2  |  Page : 407-415

Mobilization of the outer cavernous membrane decreases bleeding and improves resection in spheno-clinoidal meningiomas without cavernous sinus extension: A randomized controlled trial


1 Department of Neurosurgery, Faculty of Medicine, Kasr Al-Ainy Medical College, Cairo, Egypt
2 Department of Neurosurgery, The National Ribat University, Khartoum, Sudan
3 Department of Neurosurgery, Montefiore Medical Center, Albert Einstein College of Medicine, New York, USA

Date of Web Publication15-Mar-2018

Correspondence Address:
Dr. Arundhati Biswas
Department of Neurosurgery, Montefiore Medical Center, Albert Einstein College of Medicine, New York
USA
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.227306

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 » Abstract 


Objective: The aim of this study was to determine whether adding mobilization of the outer cavernous sinus membrane as a part of the approach, in large spheno-clinoidal meningiomas without cavernous sinus extension, would reduce bleeding and increase the extent of resection.
Methods: This prospective randomized controlled trial was held between February 2016 and April 2017 at Cairo University Hospitals. The study recruited 94 patients with spheno-clinoidal meningiomas without cavernous sinus involvement. Patients were randomly assigned (by a computer based randomization system) into two groups; the treatment group, in which the patients received mobilization of the outer layer of the lateral wall of the cavernous sinus, prior to opening of the dura; and, the control group, in which the patients were operated by a direct opening of the dura without cavernous sinus dissection. The primary outcome of this study was the difference in the amount of blood lost during surgery between both groups of patients. The secondary outcome variables were the estimated blood loss (EBL) calculated according to Mercurelli's formula, the extent of tumor resection and the amount of blood transfused.
Results: The amount of blood loss and estimated blood loss (EBL) were significantly less in the “with mobilization group” with the P value being 0.00 and 0.013, respectively. Additionally, the amount of residual tumor was compared between both the groups and it showed that the group of patients who have received mobilization of the outer cavernous sinus membrane had a higher rate of radical resection as expressed by a lower volume of residual tumor (P value 0.005).
Conclusion: In large spheno-clinoidal meningiomas without cavernous sinus involvement, routine mobilization of the outer cavernous sinus membrane reduces bleeding. This helps in a better visualization of cranial nerves in a relatively avascular field as it enables the performance of neurovascular dissection in an earlier phase of surgery. It also enables a more radical resection.


Keywords: Bleeding, cavernous sinus, spheno-clinoidal meningioma
Key Message: In spheno-clinoidal meningiomas without cavernous sinus involvement, mobilization of the outer cavernous sinus membrane reduces bleeding, advances the stage of the neurovascular dissection and permits a more radical resection of the tumor. However, there is a steep learning curve associated with the procedure.


How to cite this article:
Hegazy A, Al-Shami H, Ali MF, Fathallah M, Salah A, Mohamed H, Ahmed EI, Mohammed Osman HH, Biswas A. Mobilization of the outer cavernous membrane decreases bleeding and improves resection in spheno-clinoidal meningiomas without cavernous sinus extension: A randomized controlled trial. Neurol India 2018;66:407-15

How to cite this URL:
Hegazy A, Al-Shami H, Ali MF, Fathallah M, Salah A, Mohamed H, Ahmed EI, Mohammed Osman HH, Biswas A. Mobilization of the outer cavernous membrane decreases bleeding and improves resection in spheno-clinoidal meningiomas without cavernous sinus extension: A randomized controlled trial. Neurol India [serial online] 2018 [cited 2019 Oct 14];66:407-15. Available from: http://www.neurologyindia.com/text.asp?2018/66/2/407/227306




Bleeding in large spheno-clinoidal meningiomas is a challenge because it prevents the obtaining of a clean surgical field for a comfortable neurovascular dissection.[1] This, in addition to other factors, affects the extent of resection.[2],[3],[4] The source of this bleeding is mainly the middle meningeal artery and the meningio-hypophyseal trunk.[5],[6],[7] An early surgical interruption of these vessels requires mobilization of the outer cavernous membrane. This approach is standard for spheno-cavernous meningiomas, where the outer cavernous membrane divides the tumor into an intra-dural resectable part, and an intra-cavernous part.[8] However, mobilization of the outer cavernous membrane for cases without cavernous sinus involvement is not a common practice. The aim of this study was to determine whether or not an additional mobilization of the outer cavernous sinus membrane as part of the surgical approach, in large spheno-clinoidal meningiomas without cavernous sinus extension, would decrease bleeding and increase the extent of resection.


 » Methods Top


The study was approved by the Institutional Review Board of the Faculty of Medicine, Cairo University [Protocol code N-44-2016, registered on Clinicaltrial.gov (NCT02863484)] and conducted as a randomized controlled single blinded trial, with a 1:1 allocation, according to the ethical guidelines of the declaration of Helsinki.

Inclusion and exclusion criteria

Only adult patients (≥18 years) with large (≥ 4 cm in maximum diameter) spheno-clinoidal meningiomas, without cavernous sinus involvement, were included in the study. Malignant or recurrent meningiomas, neurofibromatosis, small tumors (<4 cm in maximum diameter), or tumors with evidence of cavernous sinus involvement, were not included in the study. Also, tuberculum sella and olfactory groove meningiomas were not included in the study. The patients who suffered an intra-operative vascular injury were not included in the study.

Prior to commencement of the trial (pilot study)

13 patients (7 in the treatment group and 6 controls) were operated to explore and standardize the technique and size of the skin incision, craniotomy, and the amount of blood loss before dural opening.

Randomization strategy

Allocation was based on a computer generated random number protocol. Randomization numbers were concealed in closed opaque envelops.

This study recruited 94 cases. In 35 cases (37.22%), the tumors were located at the medial sphenoid wing (clinoidal meningiomas); in 12 (12.8%) cases, at the lateral sphenoid wing; and, in 38 (40.4%) cases, at the middle sphenoid wing. In 9 cases (9.6%), an en-plaque meningioma was present.

Surgical technique

Both groups were operated upon by a single surgeon to reduce the operator dependent variability in terms of surgical skills and techniques. Both groups underwent a fronto-temporal craniotomy. In the study group, mobilization of the outer cavernous sinus membrane was performed before opening of the dura; while, the control group was operated upon by opening the dura without mobilization of the outer cavernous membrane, as has been described previously.[2],[8],[9] In the patients in whom mobilization of the outer layer of the lateral wall of the cavernous sinus was performed, the operative technique included resection of the lesser wing of the sphenoid bone. This was followed by performance of an orbitotomy using a high-speed drill. After the orbitotomy, the periorbita was exposed and dissected bluntly from the outer surface of the greater wing of the sphenoid bone [Figure 1] and [Figure 2]. Using a small bone nibbler, the greater wing of the sphenoid bone was removed along with the remaining part of the lesser wing of the sphenoid bone, down to the level of the base of the anterior clinoid process. This opened the superior orbital fissure and exposed the meningeal-orbital fold. Using sharp dissection, the tentorial fold was divided, and, using blunt dissection, the dura of the outer layer of the lateral wall of the cavernous sinus was peeled away, exposing the oculomotor and trochlear nerves, followed by the ophthalmic division of the trigeminal nerve, then the maxillary division, and finally, the mandibular division. At this stage, the foramen spinosum was reached, and the main trunk of the middle meningeal artery was coagulated and divided [Figure 3] and [Figure 4]. Finally, the dura was elevated off the apex of the petrous bone with dissection of the greater petrosal nerve [Figure 5]. In the cases showing extension into the posterior fossa, the apex of the petrous bone was drilled away, the superior petrosal sinus was ligated and the tentorium was divided all the way to the tentorial incisura taking care not injure the trochlear nerve. After completion of the extra-dural phase of the procedure, the tumor was detached from the basal temporal dura forming the outer layer of the lateral wall of the cavernous sinus and excised with it. The avascular tumor in the middle cranial fossa was then removed all the way to the free border of the tentorium. The Sylvian fissure was then split, utilizing a lateral to medial trajectory, and then from inside to outside, a process that was facilitated by the relaxation that had been achieved at the base of the brain by the removal of the middle-fossa part of the tumor. At this stage, the avascular field facilitated the sharp dissection in the subarachnoid plane between the tumor and the middle cerebral artery. The plane was then maintained proximally to the carotid bifurcation, and finally to the internal carotid artery [Figure 6] and [Figure 7]. After securing the major vessels, the medial part of the tumor was dissected to expose the optic nerve, and the optico-carotid triangle was cleared of the tumor. In the cases who showed no evidence of a good plane of dissection, a piece of tumor was left attached to the vessel in question. In cases who showed evidence of extension of the tumor into the optic canal, the anterior clinoid process was drilled away extradurally, and the falciform ligament was divided, followed by opening of the dura propria with mobilization of the optic nerve and exposure of the ophthalmic artery with removal of the tumor from the optic canal. Reconstruction of the basal temporal dura was done using pericranium, and, after securing hemostasis, the wound was closed in layers.
Figure 1: 1. Orbital roof seen during performance of the orbitotomy; 2. Middle fossa

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Figure 2: 1 Orbitotomy; 2. Orbitomeningeal fold after opening the superior orbital fissure by removing the remainder of the lesser as well as the greater wing of the sphenoid all the way down to the base of anterior clinoid process; 3. Temporal dura; 4. Frontal dura; 5. Base of the anterior clinoid process

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Figure 3: 1. V1 branch of trigeminal nerve; 2. Gelfoam between V1 and V2 branches of the trigeminal nerve (in the anterolateral triangle); 3. V2 branch of the trigeminal nerve; 4. Coagulated and divided main stem of the middle meningeal artery; 5. V3 branch of the trigeminal nerve. 6. Orbital fat; 7. Temporal dura; 8. Plexiform part of the Gasserian ganglion

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Figure 4: 1. Trochlear nerve; 2. V1 nerve; 3. Gelfoam between V1 and V2 nerves; 4. V2 nerve; 5. V3 nerve; 6. Petrous apex; 7. Middle meningeal artery; 8. Frontal dura; 9. Temporal dura; 10. Orbital roof. A part of obital roof has been drilled during the performance of the orbitotomy, with exposed orbital fat. * Superior orbital fissure

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Figure 5: 1. V1 nerve; 2. V2 nerve; 3. V3 nerve; 4. Gelfoam (at the anterolateral triangle) between V1 and V2 nerves. Bipolar coagulation of the basal temporal dura forming the outer cavernous membrane which serves as the basal attachment of the tumor

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Figure 6: 1. Avascular tumor dissection; 2. Middle cerebral artery; 3. Optic nerve

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Figure 7: Following complete tumor removal, there is an unobstructed view of all the neurovascular structures at the base of the brain. 1. Optic nerve; 2. Internal carotid artery; 3. Anterior cerebral artery; 4. Anterior choroidal artery; 5. Posterior communicating artery; 6. Middle cerebral artery

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Outcomes

The primary outcome of this study was the difference in the amount of blood lost during surgery between both groups of patients. Blood loss was calculated as the sum of the numerical value of the net weight of the sponges used during surgery, and the numerical value of the difference in the amount of fluid estimated to be present in the aspiration compartment and the total amount of irrigation fluids administered. The numbers of blood units given were also determined.

The secondary outcome variables were the estimated blood loss (EBL) calculated according to Mercurelli's formula,[10] the extent of tumor resection and the amount of blood transfusion.

Follow-up

Radiological follow up was performed 6 weeks after surgery.

49 patients underwent mobilization of the outer cavernous sinus membrane (constituting the group termed as 'with mobilization' [WM]) prior to proceeding with the tumor removal; and. 45 patients underwent direct removal of the tumor, without mobilization of the outer cavernous sinus membrane (constituting the group termed as 'no mobilization' [NM]). The number of patients, the location of tumors, and the surgical approaches adopted, are shown in [Table 1].
Table 1: General characteristics of all the patients included in the study

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Statistical analysis

All statistical analyses were done using the Statistical Package for the Social Sciences (SPSS 23, IBM Inc.). For testing of hypothesis, the unpaired t-test was used and a P< 0.05 was considered significant.


 » Results Top


121 patients were assessed for eligibility. 15 patients were not included (9 not meeting the inclusion criteria, 3 refused to participate in the randomization, and 3 were not included for other reasons). 106 patients were randomized, with 52 patients being allocated to the mobilization arm, and 54 being allocated to the non-mobilization arm. 3 patients were lost to follow up in the WM group, and 9 patients were lost to follow up in the NM group. Thus, the study finally included 49 patients in the WM group, and 45 patients in the NM group.

72 (76.6%) cases were female, and 22 (23.4%) were male patients. 13 (13.8%) patients were less than 35 years of age, 56 (59.6%) patients were between 35 and 55 years of age, and 25 (26.6%) patients were above the age of 55 years [Table 1].

In the beginning, the estimated blood volume (EBV), hemoglobin% (HGB), red blood cell count (RBC), tumor size and hematocrit (HCT) were compared in both the groups using the T-test for two independent groups. This was done to determine that both groups were comparable. There was no statistically significant difference between both the groups regarding: EBV, HGB and RBC, tumor size and hematocrit (with a P value of 0.657, 0.1, 0.089, 0.085 and 0.373, respectively). [Figure 8] shows the mean values for each of the variables compared in both the groups.
Figure 8: A bar diagram compares the mean values for EBV (1), HGB(2) and RBC(3), tumor size(4) and hematocrit [HCT] (5) for two independent groups and shows the resultant P value for each comparison. The “Y” axis represents the mean value for each variable in both the groups, each with its own unit of measurement represented on the scale shown. For all variables P > 0.05

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Secondly, for each tumor location, both groups were assessed to determine that a comparable percentage-distribution of cases were included in each group. For each location, there was a relatively good similarity, as shown by the Kolmogorov-Smirnov (KS) test (P = 0.917). [Figure 9] shows the percentage distribution of tumors at different locations compared between both the groups.
Figure 9: The bar chart compares the percentage distribution for tumors at different locations in both the groups, with the “Y” axis showing the percentage of cases and the “x” axis showing the various tumor locations. (P = 0.971 then >0.05)

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Generally, both groups were comparable, as shown by the results of the homogeneity tests performed.

Thirdly, the amount of blood loss and estimated blood loss (EBL) were compared in both the groups using the T-test for two independent samples, as mentioned in [Table 2]. This showed the amount of blood loss and estimated blood loss to be significantly less in the WM group (with the P values being 0.00 and 0.013, respectively).
Table 2: Difference in blood loss (as measured by blood loss and EBL, and blood transfusion between both the groups. Data are expressed as ml of blood

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Fourthly, the amount of residual tumor remaining following the surgical excision was compared between both the groups to determine the group in which a higher rate of radical resection was possible, as showed in [Table 3]. The comparison was done using the T-test for two independent samples. It showed that the group of patients who have received mobilization of the outer cavernous sinus membrane had a higher rate of radical resection, as expressed by a lower volume of residual tumor (P = 0.005).
Table 3: Differences between both the groups regarding the amount of residual tumor: Data are expressed as cubic centimeters

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Assessment of complications

The complications that occurred in our study are illustrated in [Table 4]. Postoperative cranial nerve paralysis was the sole statistically significant variable between both the groups, with an incidence of 26.5% versus 8.8 in the WM and the NM groups, respectively. In the majority of cases, third cranial nerve palsy was the most common deficit found. Almost all cranial nerve deficits resolved spontaneously within the first 3-6 months after surgery with conservative treatment. Facial nerve paralysis was reported in one case (associated with traction on the geniculate ganglion) and resolved after 6 weeks postoperatively. Facial paresthesia was also predominant in the mobilization group; however, this was not a permanent problem in any of the cases.
Table 4: Assessment of complications comparing both the groups

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 » Representative Cases Top


Case 1

A 45-year old male patient presented with gradually progressive headache and diminution of vision on the right side. He also had epileptic attacks, which were not controlled by medical treatment. He was kept on phenytoin 100 mg TDS. On examination, his vision was 20/100 on the right side and 20/28 on the left side. Fundus examination revealed a pale optic disc on the right side. Visual field examination showed a homonymous hemianopia on the affected side. The patient was operated upon with mobilization of the outer layer of the lateral wall of the cavernous sinus. The operative blood loss was 400 cc of blood. In spite of the tumor completely encircling the internal carotid artery, the arachnoidal plane could be established with a sharp dissection permitting a complete tumor resection. Post-operative recovery was uneventful. During the follow up period, the patient showed an improvement in his visual condition on the right side. However, the attacks of epilepsy continued in the form of complex partial seizures, inspite of complete tumor removal. The histopathological diagnosis was a meningiothelial meningioma World Health Organization grade I. [Figure 10], [Figure 11], [Figure 12], [Figure 13], [Figure 14] demonstrate the pre- and postoperative images of the patient.
Figure 10: Patient 1: Preoperative axial T2 weighted MR image

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Figure 11: Patient 1: Preoperative coronal T1 weighted image showing tumor extension with complete encasement of the ICA on the involved side

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Figure 12: Patient 1: Postoperative coronal T1 weighted MR image with contrast showing complete tumor removal

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Figure 13: Patient 1: Postoperative axial T1 weighted MR image with contrast showing complete tumor removal

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Figure 14: Patient 1: Postoperative axial T1 weighted MR image with contrast showing complete tumor excision

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Case 2

A 49-year old female patient presented with headache and blurring of vision. Additionally, this patient had cognitive dysfunction and epileptic attacks. Her neurological examination revealed no abnormality apart from bilateral papilledema grade 4. Neuroimaging showed a clinoidal meningioma.

A standard pterional approach was undertaken. The dura was opened in a C-shaped fashion based on the sphenoid wing. De-bulking of the tumor was then carried out. Although the dissection started at the dural base after coagulation of the tumor tail, yet the tumor was still vascular and bled excessively during its removal. The blood loss during the operation was significant and the patient needed a blood transfusion of 6 units. The post-operative period was stormy as the patient developed cerebral salt wasting syndrome, internal jugular vein thrombosis and communicating hydrocephalus. However, following the successful management of these conditions, the patient was discharged with an improvement in her neurological condition. Her cognitive deficits had improved but never returned to the normal levels. The histopathological diagnosis was a meningiothelial meningioma, World Health Oganisation grade I [Figure 15], [Figure 16], [Figure 17], [Figure 18], [Figure 19], [Figure 20].
Figure 15: Patient 2: Preoperative coronal T1 weighted MR image with contrast showing the tumor extensions

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Figure 16: Patient 2: Preoperative sagittal T1 weighted MR image with contrast

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Figure 17: Patient 2: Preoperative CT angiography showing extensive tumor vascularity

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Figure 18: Patient 2: Postoperative coronal T1 weighted image with contrast showing near total tumor resection with a very small residual tumor remaining

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Figure 19: Patient 2: Postoperative axial T1 weighted image with contrast

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Figure 20: Patient 2: Postoperative axial T1 weighted image with contrast.

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 » Discussion Top


The results of this study indicate that in the two comparable (with respect to tumor size, location and pre-operative hematological features) groups of patients, patients who received mobilization of the outer cavernous membrane showed a significantly lower blood loss, estimated blood loss (EBL), and a better rate of resection.

The better resection obtained in the group of patients who received mobilization of the outer cavernous membrane, reflects an improved ability to perform neurovascular dissection, created by an avascular surgical field. This facilitates a direct excision of the tumor, circumventing the need for a continuous bipolar coagulation at the base of the tumor. Another advantage of mobilization of the outer cavernous membrane was that the procedure helped in advancing the steps of neurovascular dissection during surgery to an earlier phase, in which the neurosurgeon, who was not tired and was in a better state of mind, was better equipped to deal with this critical part of surgery.

Large spheno-clinoidal meningiomas that are associated was a large scale intraoperative bleeding, can be removed by a variety of approaches, but the fronto-temporal approach or its modification is the approach most widely used. Mobilization of the outer cavernous membrane is performed as a standard part of the procedure in spheno-cavernous meningiomas, where this step divides the tumor into an extra-cavernous part and an intra-cavernous part. For the cases, where the tumor exists without a cavernous sinus extension, mobilization of the outer cavernous membrane is not a common practice, and its effect on bleeding and resection has not been proven by a controlled clinical trial.[11],[12]

Bleeding from the cavernous sinus may be encountered during mobilization of the outer cavernous membrane if an anatomically deficient part of the lateral wall of the cavernous sinus is encountered; however, the cavernous sinus bleeding is easily controllable and usually has not reflected on the overall blood loss. The effectiveness of the technique proposed in this article emanates from the interruption of the end-artery feeders to the tumor only, and not the main-branch vessels (as occlusion of the latter vessels may compromise important collateral vessels). This technique is particularly helpful in controlling tumor feeders emerging from the lateral wall of the cavernous sinus, which originate in the meningio-hypophyseal trunk and represent the main blood supply to spheno-clinoidal meningiomas.[1] Additionally, the division of the middle meningeal artery interrupts an important source of blood supply to the tumor.

Embolization is the method most commonly used to reduce bleeding in meningiomas. To be effective, a complete embolization of all the feeding vessels to the tumor should be undertaken, and this is rarely possible. Additionally, 9-21% of cases develop permanent neurological deficits with a 1% mortality.[13],[14] Most of the complications occur during the process of interrupting the feeders from the internal carotid artery, particularly from the meningio-hypophyseal trunk. Accordingly, the value of embolization in meningiomas present in the spheno-clinoidal region is questionable.[7],[15]

Injecting hydrogen peroxide into the meningioma is another method of reducing bleeding. It is simple, feasible, cost-effective and safe but not always effective. Ultrasonic-aspiration, laser, or microwave thermo-coagulation are other methods that can be used to reduce bleeding in meningioma surgery; however, they are not regularly effective in reducing bleeding and may be associated with a risk of physical or chemical injury.[16],[17] Unlike these methods mentioned, mobilization of the outer cavernous sinus membrane is not associated with the risk of physical or chemical injury.

The complications reported in this series included aggravation of pre-existing visual deficits; the development of weakness or dysphasia, post-craniotomy syndrome, epilepsy, wound infection, cranial nerve palsy; as well as cerebrospinal fluid (CSF) accumulation leading communicating hydrocephalus requiring a CSF diversion procedure.[16] There were no significant differences in the incidence of complications between both the groups, except for the higher incidence of post-operative cranial nerve deficits. This was significantly higher in the group that received mobilization of the outer cavernous membrane. The commonest postoperative cranial nerve deficit was in the form of third cranial nerve paralysis. However, in all the patients, this deficit resolved spontaneously during the follow-up period, usually within the first 3-6 months after surgery. One patient developed a temporary seventh nerve paralysis due to traction on the geniculate ganglion, but this resolved spontaneously within the first 6 weeks after surgery. No patients suffered from any vascular injury due to the mobilization of the outer cavernous membrane. Other studies describing the same approach have also alluded to similar complications.[17],[18],[19]

The actual estimation of the intra-operative blood loss is always associated with an element of inaccuracy;[10] however, the most important factor that determines the usefulness of a particular operative maneuver is the ability to obtain a better resection. The main limitation encountered during the mobilization of the outer cavernous membrane is the need for a specialized training to perform the procedure. This is because the operative technique requires the skill to mobilize the outer cavernous membrane without entering the cavernous sinus or the intra-dural compartment and can be only be perfected after repeated practice in the microsurgical cadaveric lab. This makes the performance of the approach by the neurosurgeon in training (who is usually the one doing the craniotomy) difficult. However, the significance of the approach and the benefits obtained from its execution, should urge future skull base surgeons to practice the technique and acquire the necessary training to perform this complex approach.


 » Conclusion Top


In spheno-clinoidal meningiomas without cavernous sinus involvement, routine mobilization of the outer cavernous sinus membrane reduces bleeding. It also helps in cranial nerve dissection (as it advances the stage of the neurovascular dissection during surgery) and permits a more radical resection.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
 » References Top

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Li MH, Zhao JL, Li YY, Zeng CH, Xu GS, Hong T. Extradural transcavernous approach to cavernous sinus cavernous hemangiomas. Clin Neurol Neurosurg 2015;136:110-5.  Back to cited text no. 8
    
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Abbassy M, Woodard TD, Sindwani R, Recinos PF. An overview of anterior skull base meningiomas and the endoscopic endonasal approach. Otolaryngol Clin North Am 2016;49:141-52.  Back to cited text no. 11
    
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Ruzevick J, Raza SM, Recinos PF, Chaichana K, Pradilla G, Kim JE, et al. Technical note: Orbitozygomatic craniotomy using an ultrasonic osteotome for precise osteotomies. Clin Neurol Neurosurg 2015;134:24-7.  Back to cited text no. 12
    
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Hirohata M, Abe T, Morimitsu H, Fujimura N, Shigemori M, Norbash AM. Preoperative selective internal carotid artery dural branch embolisation for petroclival meningiomas. Neuroradiology 2003;45:656-60.  Back to cited text no. 13
    
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Yoon YS, Ahn JY, Chang JH, Cho JH, Suh SH, Lee BH, et al. Pre-operative embolisation of internal carotid artery branches and pial vessels in hypervascular brain tumours. Acta Neurochir 2008;150:447-52.  Back to cited text no. 14
    
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Dowd CF, Halbach VV, Higashida RT. Meningiomas: The role of preoperative angiography and embolization. Neurosurg Focus. 2003;15:E10.  Back to cited text no. 15
    
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Lichtenbaum R, de Souza AA, Jafar JJ. Intratumoral hydrogen peroxide injection during meningioma resection. Neurosurgery 2006;59(4 Suppl 2):ONS470-3  Back to cited text no. 16
    
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Verma SK, Sinha S, Sawarkar DP, Singh PK, Gupta D, Agarwal D, et al. Medial sphenoid wing meningiomas: Experience with microsurgical resection over 5 years and review of literature. Neurol India 2016;64:464-74.  Back to cited text no. 17
    
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Patil M, Mahore A, Sathe P, Chagla A. Bilateral mirror image sphenoid wing meningiomas. Neurol India 2017;65:677-9.  Back to cited text no. 18
[PUBMED]  [Full text]  
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Ammirati M, Lamki TT, Pillai P, Powers C. Intra-tumoral ultrasonic aspirator delivery of H2O2-a novel approach to resecting highly vascularized intracranial tumors. Technical note and case report. Clin Neurol Neurosurg 2013;115:1891-3.  Back to cited text no. 19
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13], [Figure 14], [Figure 15], [Figure 16], [Figure 17], [Figure 18], [Figure 19], [Figure 20]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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