The role of postoperative irradiation in the management of sphenoid wing meningiomas. A preliminary report.

PURPOSE: To determine whether postoperative radiation therapy decreases recurrence rates in subtotally excised and recurrent sphenoid wing meningiomas. METHODS: Patients with primary subtotally excised and recurrent sphenoid wing meningiomas who underwent surgery between 1981 and 1994 (n = 105) were prospectively followed for recurrence. Postoperative radiation was not recommended in patients who had complete excision; therefore, their recurrence rates were not evaluated in this study. Patients with malignant meningiomas also were excluded from analysis. Recurrence was defined as evidence of tumor growth on neuroimaging with or without clinical symptoms. RESULTS: Follow-up information was available for 86 patients; 69 had primary subtotally excised tumors and 17 had recurrent tumors. Follow-up information was unavailable in the remaining 19 patients. Tumor location and histopathology, type of surgery performed, and patient sex and age were similar in the irradiated and nonirradiated subgroups. Postoperative irradiation was delivered to 31 patients with primary tumors and 11 with recurrent tumors; none of these 42 patients had recurrence during a mean observation period of 4.2 and 3.5 years, respectively. The nonirradiated group consisted of 38 patients with primary tumors and 6 with recurrent tumors; 16 of 18 patients who had primary meningiomas had a recurrence and 5 of 6 who had recurrent tumors had another relapse (mean interval between resection and recurrence, 4.4 years and 14 months, respectively). CONCLUSIONS: Postoperative radiation appeared to delay recurrence in subtotally excised and recurrent sphenoid wing meningiomas during the time frame of this study.

The management of optic nerve sheath meningiomas.

Thirty-eight patients (39 eyes) with optic nerve sheath meningiomas were entered into a treatment plan and were followed up for at least three years. Eighteen eyes were simply observed because they had minimal functional deficit or the eye was blind. Radiation was used on six eyes with documented progressive visual loss that still had useful vision. Surgery was initially used in an attempt to remove optic nerve sheath meningiomas but was abandoned except in exceptional cases. Total surgical removal of the tumor was carried out in ten eyes with loss of vision and in which the meningioma was growing. Surgery for subtotal or complete removal of the tumor followed by radiation was carried out in five eyes exhibiting aggressive growth of the tumor. This treatment plan has helped us to treat patients with optic nerve sheath meningiomas in an orderly way.

Surgical approaches to orbital tumors.

Three approaches as used with modern technology, magnification with an operating microscope, and self-retained retraction have been presented. These approaches have allowed satisfactory exposure of difficult retrobulbar orbital areas from the various directions and have allowed us to more comfortably microdissect and remove orbital tumors. They also provide good exposure for the use of the carbon dioxide laser, which has been an aid in removing the intraorbital extensions of meningiomas, plexiform neurofibromas, and difficult lymphangiomas that occupy the intraconal compartments of the orbit. These approaches should only be undertaken by a skilled ophthalmic orbital surgical team in the case of the anterior medial and lateral approach, and definitely by a well-experienced neurosurgical/ophthalmic orbital team for tumors involving the orbital cranial junction and the superior orbital compartment. Experience gained over 17 years has convinced us that a team approach is mandatory for the difficult deep intraorbital tumors, even with the anterior medial or lateral approach.

Terson's syndrome--significance of ocular findings.

Ocular findings of three patients with Terson's syndrome are presented. Two patients had a ruptured intracranial aneurysm, and one had a subdural hematoma. Ocular findings included retinal, preretinal, and vitreous hemorrhages. Vitreous hemorrhage may be delayed in onset and may require vitrectomy if persistent. The eye findings are characteristic but not pathognomonic of this syndrome. The authors emphasize the diagnostic and prognostic importance of ocular findings in patients with spontaneous intracranial hemorrhages. Some of the primary theories of the syndrome are reviewed.