23-year review of spheno-orbital meningioma: clinical, radiological, and pathological insights from 100 cases.

BACKGROUND: Spheno-orbital meningioma (SOM) represents a unique variant of sphenoid wing meningiomas, distinguished by its propensity for bone infiltration and cranio-orbital involvement. SOM exhibits a considerable incidence of misdiagnosis and recurrence. PURPOSES: To elucidate the clinical, radiological, and pathological characteristics of SOM. METHODS: Review of electronic medical records, histopathology, radiological images and follow-up information of 100 SOM patients. RESULTS: Of the 100 patients (28 males, 72 females) with SOM, mean age was 46.8 ± 12.6 years and prevalent symptoms were proptosis (99%). All the CT scans showed hyperostosis with 89.3% of the hyperostosis having an irregular edge. In MRI scans, dural tail sign was observed across all patients and the cranio-orbital tumors often penetrated temporal muscle (74.1%), extraocular muscle (74.1%) and lacrimal gland (63%). All the 100 patients underwent surgical intervention, and among them, 62 individuals received postoperative radiotherapy. Grade I resections had a lower recurrence rate(16.7%), which further decreased with the addition of radiotherapy(13.9%). In contrast, all patients with grade II or higher grade resections without radiotherapy experienced recurrence, indicating a higher risk associated with less complete tumor removal. The pathological examination revealed that intraorbital sections exhibited comparable tumor density to intraorbital SOM tumors, along with increased fibrous density but decreased vascular distribution. CONCLUSIONS: Radiological characteristics of SOM included cranio-orbital tumors, hyperostosis of the sphenoid wing with an irregular edge, and dural tail sign. Combination of gross total resection and adjuvant radiotherapy was recommended to minimize recurrence rate. Intracranial SOM tumors tended to be softer and more bleed-prone than intraorbital sections, necessitating surgical precision.

Anatomical features of the sphenoid ridge in the pediatric population.

PURPOSE: To describe the relation of the sphenoid ridge (SR) with the surrounding anatomical structures in healthy children when approaching the anterior and middle fossae. METHODS: Computed tomography of 180 pediatric patients (90 males / 90 females), aged 1-18 years were included the study. The size of the lesser wing (LW) and the distances of the LW to certain landmarks were measured. RESULTS: The LW length was 28.48 ± 8.15 mm. The LW widths at the midline and the midpoint and lateral point of the SR were 7.78 ± 1.74 mm, 2.84 ± 0.81 mm, and 1.91 ± 0.64 mm, respectively. The distance between the midpoint of the SR and the crista galli was 28.22 ± 5.56 mm, and the distance between the crista alaris and internal auditory meatus was 51.73 ± 5.79 mm. The linear function was calculated as y = 18.748 + 1.024 × age for SR length, y = 6.046 + 0.182 × age for the midline width of SR, y = 2.367 + 0.050 × age for the midpoint width of SR, y = 1.249 + 0.069 × age for the crista alaris width, y = 21.727 + 0.683 × age for the distance between the SR midpoint and the crista galli, and y = 43.614 + 0.855 × age for the distance between the crista alaris and internal auditory meatus. CONCLUSION: All measured parameters increased irregularly with advancing age. Furthermore, our regression equations representing the growth dynamics of SR may be used to estimate these parameters.

Langerhans cell histiocytosis of the sella in a pediatric patient: case report with review of the literature.

PURPOSE: Langerhans cell histiocytosis (LCH) is a rare condition arising from the monoclonal expansion of myeloid precursor cells, which results in granulomatous lesions that characteristically express CD1a/CD207. We report a case of LCH in a 3-year-old male involving the sphenoid bone with extension into the sellar/suprasellar region. CASE REPORT: A 3-year-old male presented with progressively worsening headaches and associated night sweats, neck stiffness, and fatigue over the previous 4 weeks. Magnetic resonance imaging (MRI) revealed a 2.4-cm lytic lesion within the basisphenoid, exerting mass effect upon the pituitary gland. A biopsy was performed to determine the etiology of the lesion. Postoperatively, the patient developed an intralesional hematoma with visual complications requiring emergent surgical resection via endoscopic endonasal approach. Final pathology confirmed LCH. The patient had improvement in his vision long term. CONCLUSIONS: LCH extending into the sella is a rare but important diagnosis to consider in pediatric patients presenting with lesions in this region. We presented a case of a pediatric patient presenting with LCH of the sphenoid bone extending into the sella, with subsequent apoplexy and vision loss. Review of the literature showed varying treatment options for these patients, including purely surgical and non-surgical treatments. Early intervention may be necessary to avoid potentially devastating neurologic sequelae.

Computed tomography based evaluation of the association between sphenoid sinus pneumatization patterns and variations of adjacent bony structures in relation to age and gender.

Many studies revealed that the sphenoid sinus pneumatization (SSP) affects the protrusion/dehiscence of adjacent structures including optic canal (OC), foramen rotundum (FR), vidian canal (VC), and carotid canal (CC). Knowledge of this relationship bears vital importance to identify the safest surgical route during transsphenoidal procedures. Therefore, we aimed to determine the individualized prevalence of the protrusion/dehiscence of adjacent structures based on sagittal and coronal SSP (SSSP and CSSP) patterns. Computed tomography images of 300 patients were analysed to identify the SSSP and CSSP types, and the protrusion/dehiscence of adjacent structures was determined. The relationship between the variables was examined using statistical analysis in terms of age, gender, and laterality. The most prevalent SSSP type was postsellar (62.7%), followed by sellar (30%), presellar (6.6%), and conchal (0.7%). In 71.3% of patients, five types of CSSP were observed, with 23.6% and 21.7% exhibiting Type IV and V, respectively. Our results indicated that postsellar type, Type IV and V CSSP associated with the highest likelihood of protrusion/dehiscence of OC, FR, VC, and CC. Furthermore, no significant correlation was observed between these qualitative variables and gender, with the exception of the VC dehiscence, the protrusion of OC and CC. No notable differences were identified with respect to laterality. Also, the probability of having postsellar type, Type IV and V CSSP, as well as the protrusion of OC, VC, and CC, decreased with increasing age. Further detailed analysis of this association is required to predict the size of the surgical window and to prevent neurovascular injury.

The effects of pterygomaxillary disjunction in surgically assisted rapid maxillary expansion: A systematic review and meta-analysis.

OBJECTIVE: This study aims to assess the expansive effects of pterygomaxillary disjunction (PMD) in surgically assisted rapid maxillary expansion (SARME) surgery using a meta-analysis approach. MATERIALS AND METHODS: The study conducted a comprehensive literature search across five databases: PubMed, Scopus, Medline, Embase, and Cochrane, adhering to the PRISMA 2020 guidelines. Dental alterations were assessed using either cone-beam computed tomography (CBCT) or dental casts, while skeletal changes were exclusively measured from CBCT scans. We analysed the dentoskeletal changes between PMD +/- groups and conducted a within-group comparison. The primary focus of the results was on the mean differences observed in pre- and post-operative measurements. RESULTS: Dental expansion was larger in the PMD+ group but not statistically significant. Skeletal expansion showed a significantly larger expansion in the posterior region in the PMD+ group (P = .033). Without PMD, anterior palatal expansion was significantly larger (P = .03), and the buccal tipping of posterior teeth was also significantly larger (P = .011) to achieve acceptable dental expansion outcomes. CONCLUSIONS: Both PMD +/- groups of SARME surgery can achieve satisfactory dental expansion outcomes. However, bone expansion and tooth inclination are also important factors that influence orthodontic treatment and post-expansion stability. By reducing the bony resistance with PMD, larger posterior palatal expansion and more parallel bony expansion are observed. In contrast, without PMD, there is smaller palatal expansion and greater tooth inclination in the posterior region. This could potentially lead to compromised periodontal conditions following expansion.

Feasibility of spheno-occipital synchondrosis fusion stages as an indicator for the assessment of maxillomandibular growth: A mixed longitudinal study.

OBJECTIVES: This study aimed to assess the relative growth rates (RGRs) of the maxilla and mandible at varying fusion stages of the spheno-occipital synchondrosis (SOS), thereby elucidating the potential of SOS stages in predicting maxillomandibular growth. MATERIALS AND METHODS: A total of 320 subjects (171 boys and 149 girls), aged 6 to 18 years, were retrospectively included. Each subject had a minimum of two longitudinal cone-beam computed tomography (CBCT) images, with no more than one interval of SOS fusion stage change between the two scans. Subjects were categorized based on their SOS fusion stages and genders. The RGRs of the maxilla and mandible at various SOS fusion stages were measured and compared using longitudinal CBCT images. RESULTS: Significant statistical differences were observed in maxillomandibular RGRs across various SOS fusion stages. In girls, the sagittal growth of the maxilla remained stable and active until SOS 3, subsequently exhibited deceleration in SOS 4-5 (compared to SOS 3-4, P < .05) and continued to decrease in SOS 5-6. Whereas in boys, the sagittal growth of the maxilla remained stable until SOS 4, and a deceleration trend emerged starting from SOS 5 to 6 (P < .01 compared to SOS 4-5). Mandibular growth patterns in both genders exhibited a progression of increasing-accelerating-decelerating rates from SOS 2 to 6. The highest RGRs for total mandibular length were observed in SOS 3-4 and SOS 4-5. CONCLUSION: Spheno-occipital synchondrosis fusion stages can serve as a valid indicator of maxillomandibular growth maturation.

Combined open surgery and endovascular embolization for a ruptured sphenoid wing dural arteriovenous fistula.

BACKGROUND: The sphenoid wing dural arteriovenous fistula (AVF) is rare, and can manifest with severe symptoms, particularly in cases classified as greater sphenoid wing type. Endovascular therapy is generally employed, however, open surgical intervention could be warranted in cases with complex fistula. METHOD: We present a case with ruptured greater sphenoid wing dural AVF (Cognard type IV), in which endovascular embolization using liquid material was performed, followed by open surgery to concurrently disconnect the fistula and evacuate the hematoma. CONCLUSION: The sphenoid wing dural AVFs may be effectively cured by open surgery for fistula disconnection in conjunction with endovascular embolization.

Anterior clinoidectomy in low lying internal carotid artery-posterior communicating artery aneurysm.

BACKGROUND: At times, a regulation internal carotid artery-posterior communicating artery junction (ICA-P-Comm) aneurysm becomes a surgical hurdle owing to its close proximity to the anterior clinoid process, an immovable ICA and a concealed dominant P-Comm artery arising from the aneurysm neck. METHOD: A 70 year old patient with a low lying ICA-P-Comm aneurysm underwent a "tailored" intradural clinoidectomy for aneurysm clipping. CONCLUSION: A tailored anterior clinoidectomy to expose "just enough" allows a proximal ICA control in a suitable area, mobility of an atherosclerotic ICA and exposes the P-Comm artery origin which are essential in safe clipping of these aneurysms.

An Unusual Case of an Intradiploic Arachnoid Cyst of the Orbit.

This study reported a case of an arachnoid cyst of the sphenoid bone causing orbital signs and symptoms in a 58-year-old man with progressive proptosis and nonspecific discomfort in the OS. Orbital MRI showed a 3-cm homogeneous cyst within the left greater wing of the sphenoid bone. To the best of our knowledge, this is the first report of an intradiploic arachnoid cyst in the sphenoid bone with atypical radiological features, causing clinical symptoms, and managed through an eyelid approach, achieving a complete resolution with no complications.

Radiologic evaluation of the Vidian canal in the pediatric population.

PURPOSE: This examination aimed to display the size and topographic position of the Vidian canal (VC) in normal children. METHODS: 180 pediatric subjects aged 1-18 years were included this computed tomography examination. The distances of VC to certain landmarks, and VC length were measured. The locations of VC according to the sphenoid sinus, and the medial plate of pterygoid process were classified as three types, separately. RESULTS: The distances of VC to the vomerine crest, midsagittal plane, round foramen, and the superior wall of sphenoid sinus were measured as 12.68 ± 3.17 mm, 10.76 ± 2.52 mm, 8.62 ± 2.35 mm, and 14.16 ± 5.00 mm, respectively. The length and angle of VC were measured as 12.00 ± 2.52 mm, and 16.60 ± 9.76°, respectively. According to the sphenoid bone, VC location was identified as Type 1 in 113 sides (47.5%), as Type 2 in 70 sides (29.4%), and as Type 3 in 55 sides (23.1%). According to the medial plate of pterygoid process, VC location was identified as Type A in 274 sides (76.1%), as Type B in 55 sides (15.3%), and as Type C in 31 sides (8.6%). VC location types correlated with pediatric ages, but not sex or side. CONCLUSION: With advancing pediatric age, the protrusion of VC into the sphenoid sinus increases, and VC shifts from medial to lateral side of the medial plate of pterygoid process.

The sphenopterygoid canal and pterygoid foramen.

BACKGROUND: In human anatomy, there are well-known the foramina of the greater sphenoidal wing, the foramen rotundum, the foramen ovale, the foramen spinosum, as well as the inconstant sphenoidal emissary foramen of Vesalius and the foramen of Arnold. Different canals are found in several species of rodents, such as the alisphenoid and sphenopterygoid (SPC) canals. METHOD: It was re-explored an archived computed tomography angiogram of a 60 y.o. female case. RESULTS: Bilateral superior recesses of the pterygoid fossae (SRPF) and a right SPC were found. The SRPF on each side penetrated the non-lamellar pterygoid root and superiorly reached the sphenoidal sinus wall. Upper fibres of medial pterygoid muscles were inserted into each SRPF. An unexpected SPC was found on the right side. It opened superiorly on the lateral side of the foramen rotundum and inferiorly at a pterygoid foramen in the superior end of the posterior margin of the lateral pterygoid plate. A sphenoidal emissary vein traversed that SPC to drain into the pterygoid plexus. CONCLUSION: The SRPF and SPC could also be found in humans. As the sphenoidal emissary veins are surgically relevant, they should not be further regarded as exclusively crossing the foramen of Vesalius but also the SPC.

Paraclinoid aneurysms clipping through an extradural sphenoid ridge keyhole approach.

BACKGROUND: Paraclinoid aneurysms represent a challenge for neurosurgeons due to the anatomical complexity of this region. Then, innovative techniques such as the extradural sphenoid ridge approach are suitable for a safe microsurgical clipping. METHOD: A description of the surgical technique was made by the senior author, a vascular neurosurgeon experienced with the use of this approach in the management of paraclinoid aneurysms exemplified through a clinical case. CONCLUSION: Microsurgical clipping through an extradural sphenoid ridge keyhole approach for small and midsize paraclinoid aneurysms is an excellent treatment modality with good clinical and surgical results.

How I do it: micro-neurosurgical resection of spheno-orbital meningioma with customized orbit reconstruction technique.

BACKGROUND: Spheno-orbital meningioma (SOM) is a rare intracranial pathology with intraosseous hypertrophy and intraorbital extension. METHOD: We described a middle-aged female with SOM who was managed in a micro-neurosurgical manner. The titanium implant was customized and applied to rebuild the orbital wall to prevent postoperative enophthalmus. CONCLUSION: Despite technical demands, favorable cosmetic, and clinical outcomes without complications can be achieved by meticulous surgical technique following radical resection. CLINICAL TRIAL REGISTRATION: NA.

Endoscopic endonasal transsphenoidal surgery in acromegaly with conchal sphenoid sinus.

BACKGROUND: A conchal non-pneumatized sphenoid sinus tends to be considered as unfavorable for transsphenoidal surgery because of procedural difficulties. Especially in acromegalic patients, the proportion of the conchal type of sphenoid sinus is potentially high compared with that of other patients who have a pituitary tumor. This report investigates the characteristics and surgery of the conchal type of sphenoid sinus in acromegaly along with the internal bone properties. CLINICAL PRESENTATION: A 70-year-old man with acromegaly underwent endoscopic endonasal transsphenoidal surgery. Intraoperatively, the anterior wall of the non-pneumatized sphenoid was cortical, however, the cancellous bone was very soft, included fatty tissue, and was easily removed by suction. The sellar lesion could be reached without any problems, and finally, total tumor resection was achieved. CONCLUSION: Based on this surgical case, the conchal sphenoid sinus of acromegaly is not always homogeneous solid bone but may contain soft fatty tissue. Therefore, although the sphenoidal characteristics may have an impact on the surgical procedures, precise assessment pre- and intraoperatively can make transsphenoidal surgery with conchal sphenoid sinus feasible.

Morphologic and Morphometric Measurements of the Foramen Ovale: Comparing Digitized Measurements Performed on Dried Human Crania With Computed Tomographic Imaging. An Observational Anatomic Study.

The foramen ovale (FO) of the sphenoid bone is clinically important for the interventional treatment of trigeminal neuralgia. Percutaneous procedures applied to treat the chronic pain condition typically involve the cannulation of this oval-like foramen located at the base of the skull. Anatomic variations of the FO have been reported to contribute to difficulties in the cannulation of this structure. Computed tomography (CT) can help the surgeon improve the accuracy and safety of the intervention. However, even with navigation technology, unsuccessful cannulation of the FO has been reported. The aim of this observational anatomic study was to define morphometric and morphologic data of the FO and to investigate for potential differences between measurements taken on dried human crania and digitized measurements of the FO measured on CT images. One hundred eighteen FOs were evaluated. Twenty FOs underwent CT scanning. The mean length of the foramen was 7.41±1.3 mm on the left side and 7.57±1.07 mm on the right. The mean width of the foramen was 4.63±0.86 mm on the left side and 4.33±0.99 on the right. The mean area on the left side was 27.11±7.58 and 25.73±6.64 mm 2 on the right. No significant left-right differences were found for any of these dimensions. The most important conclusion that we can draw is that the measurements can indeed be performed on CT images to obtain an accurate picture of the morphology. Considering the surgical importance of the FO and taking into consideration the limitations this study added to scientific knowledge, this study was constructive as far as neurosurgeons and anatomists are concerned.

Morphological and Metrical Relationships Between Sphenoid Sinus and Sella Turcica: Possible Applications in Transnasal Transsphenoidal Surgery.

INTRODUCTION: Transsphenoidal surgeries imply the risk of intraoperative lesions to the neurovascular structures surrounding the sphenoid sinus (SS). Aim of the present study is to assess the metrical and morphologic relationships existing between SS and sella turcica (ST). MATERIALS AND METHODS: Two hundred computed tomography-scans of patients were selected. For each patient volumes of SS were calculated from their 3-dimensional models segmented through ITK-SNAP program. Variants of SS in pneumatisation and sellar diameters [antero-posterior (AP) diameter, depth, and length] were evaluated on each computed tomography-scan. Correlations among different measurements were assessed through Spearman test ( P <0.01), whereas associations between sellar parameters and presence of pneumatisation variants were assessed through Mann-Whitney test ( P <0.01). RESULTS: In males, pneumatization of the greater wings was related to smaller AP diameter ( P <0.01) and depth of ST ( P <0.01), whereas in females lower values of depth were found in patients with pneumatization of the pterygoid processes ( P <0.01). In both sexes, a positive correlation was found between AP diameter and, respectively, length and depth of ST ( P <0.01), together with a negative correlation between volume of SS and depth of ST ( P <0.01). Lastly, in females a positive correlation was found between age and, respectively, length and depth of ST ( P <0.01). CONCLUSIONS: The present study highlighted new metrical and morphologic relationships between volume and pneumatisation of SS and diameters of ST. Knowledge of these correlations allows to understand more clearly, in the preoperative setting, the surgical working space. Further studies are needed, especially for what concerns the relationship between sellar measurements and age in females.

Clinical Characteristics and Prognostic Analysis of Osteolytic and Hyperostosis Sphenoid Orbital Meningiomas: A Single-Center Experience.

Reactive hyperostosis of spheno-orbital meningiomas (SOMs) often occurred in the sphenoid wing, while osteolytic SOMs (O-SOMs) were rarely discussed. This study preliminarily evaluated the clinical characteristics of O-SOMs and analyzed prognostic factors affecting the recurrence of SOMs. We retrospectively analyzed the medical records of consecutive patients who underwent surgery for a SOM between 2015 and 2020. According to the bone changes of sphenoid wing, SOMs were divided into O-SOMs and hyperostosis SOMs (H-SOMs). A total of 31 procedures were performed in 28 patients. All cases were treated by pterional-orbital approach. It was confirmed that 8 cases were O-SOMs and the other 20 cases were H-SOMs. Total tumor resection was performed in 21 cases. There were 19 cases with Ki 67 ≥3%. The patients were followed up for 3 to 87 months. Proptosis improved in all patients. All O-SOMs had no visual deterioration, while 4 H-SOMs cases had visual deterioration. There was no significant difference in clinical outcomes between the two types of SOM. The recurrence of SOM was related to the degree of resection, but not to the type of bone lesions, invasion of cavernous sinus and Ki 67.

Timing of Spheno-Occipital Synchondrosis Closure in Cleft Lip and Palate Patients in Iranian Population.

This study aimed to evaluate the chronological age range associated with each stage of spheno-occipital synchondrosis (SOS) fusion in patients with cleft lip and palate compared to the noncleft group, using cone-beam computed tomography (CBCT) images.In this study, the degree of SOS fusion was assessed using a 4-stage scoring system on CBCT images of 190 individuals (92 patients with cleft lip and palate, 98 noncleft individuals). A χ2 test was performed to assess the correlation between age and fusion stage. The independent sample t tests were used to evaluate the differences in the mean values of the samples of each group and each sex, as well as the mean value of each stage (P < .05).The results showed that there was no significant difference in the timing of the SOS fusion stages between the patients with cleft palate and the noncleft group. Although the fusion process of SOS begins about one year earlier in females, the complete ossification occurs at the mean age of 18.5 for both sexes in the experimental group and the mean age of 19.0 in the noncleft group.The present study found no differences in the fusion stages of the spheno-occipital synchondrosis between patients with cleft lip and palate and healthy individuals.

Comparison of three-dimensional maxillary growth across spheno-occipital synchondrosis maturation stages.

BACKGROUND: This study aimed to three-dimensionally compare the maxillary growth among the spheno-occipital synchondrosis (SOS) maturation stages in both genders. METHODS: This is a cross-sectional study of a retrospective type in which cone-beam computed tomography (CBCT) images of 500 patients aged 6 to 25 years (226 males and 274 females) were analyzed. The SOS was evaluated using the four-stage scoring system; completely open, partially fused, semi-fused, or completely fused. The SOS scoring and three-dimensional cephalometric measurements were analyzed by Invivo 6.0.3 software. Descriptive and analytical statistics were performed and a P-value < 0.05 was considered statistically significant. RESULTS: There was a statistically significant difference in maxillary measurements among SOS maturation stages in both genders (P < 0.05). The mean differences in the maxillary growth among the SOS maturation stages between SOS stages 2 and 3 were higher than those between stages 1and 2 and stages 3 and 4 for maxillary length and height in both genders. However, the mean difference in the maxillary width was higher between SOS stages 1 and 2 than those stages 2 and 3 and stages 3 and 4. On other hand, there may be lesser maxillary growth between SOS stages 3 and 4 for maxillary width, length (in males), and height. The growth curves showed high active growth of the maxilla as the SOS was still fusing (especially stage 2 and 3) than those of the fused (stage 4). Moreover, the acceleration of growth occurred earlier in females than males regarding chronological age but not for SOS maturation stages. CONCLUSIONS: The SOS maturation stages are valid and reliable maxillary skeletal maturation indicators for three-dimensional maxillary growth in both genders.

Anatomy and Diseases of the Greater Wings of the Sphenoid Bone.

The greater wings of the sphenoid bone (GWS) comprise the components of the sphenoid bone that make up most of the posterior orbital wall and form the anterior and medial parts of the floor of the middle cranial fossa. Many important skull base foramina, which transmit vital neurovascular structures, are present in these paired wings on either side of the central body of the sphenoid bone. A wide variety of diseases can affect the GWS, ranging from benign osseus lesions to malignant primary and secondary bone abnormalities. The complex three-dimensional curved (winged) shape of the GWS and the wide array of pathologic entities that affect this bone can make it challenging for the radiologist to report the imaging findings accurately, especially in relation to the important skull base foramina. The authors describe a systematic approach to understanding the three-dimensional anatomy of the GWS and review important diseases, with the aid of imaging examples. Useful imaging "pearls" that can help in making specific diagnoses are provided throughout the article. ©RSNA, 2022.