Department of Neurological Sciences, Section of Neurosurgery, Federico II University School of Medicine, Naples, Italy.
Acta Neurochir (Wien). 2013 Jan;155(1):77-84. doi: 10.1007/s00701-012-1485-z. Epub 2012 Sep 4.
To define from a series of surgically treated suprasellar, anterior clinoid, and sphenoid wing meningiomas, an unequivocal criterion for performing optic canal deroofing in patients with basal meningiomas with deteriorated vision.
One hundred-fifty consecutive patients with suprasellar and parasellar meningiomas (44 tuberculum sellae, 46 clinoidal, and 60 spheno-orbital) who underwent surgery between 1988 and 2008 are retrospectively analyzed. The rate of preoperative visual deficit, the incidence of optic canal involvement, the related surgical management, and its influence on visual outcome are reviewed in all tumor localizations.
All 44 patients with tuberculum sellae meningiomas had variable preoperative visual impairment. All were operated on by transcranial approach. Unroofing of the optic canal was performed in the two cases with intracanalar tumor extension. Postoperatively, the visual function improved in 27 patients (61.4 %) and was unchanged in 17 (25 %). Among 46 patients with clinoidal meningiomas, visual dysfunction was found in 30 (65.2 %). The first 32 patients were operated on by classical pterional approach, with selective opening of the optic canal in six cases (group A), whereas all the last 14 underwent routine anterior clinoidectomy and opening of the optic canal (group B). The visual function improved postoperatively in 17 among 30 patients (56.7 %), with a significantly higher rate in group B cases (80 % versus 45 %). Among 60 patients with spheno-orbital meningiomas, 36 (60 %) had visual dysfunction and 43 (71.6 %) involvement of the optic canal. The visual function improved in 18 cases (50 %), was unchanged in 13 (36 %), and worsened in 5 (14 %). Lateral tumors had the lowest rate of optic canal involvement and a 100 % rate of visual improvement; on the other hand, all orbital apex and diffuse tumors had concentric invasion of the optic canal with a 18.6 % rate of visual worsening.
UOC seems to be a safe procedure not associated with immediate postoperative impairment of the vision. We recommend routine deroofing of the optic canal coupled with extradural anterior clinoidectomy in all clinoidal meningiomas in order to obtain early and complete exposure of both intradural and extradural segments of the optic nerve. For tuberculum sellae meningiomas, we advise to open the optic canal only in cases with intracanalar tumor extension. Finally, for spheno-orbital meningiomas, we recommend UOC through a cranio-orbital approach in almost all cases, except for lateral meningiomas, where the involvement of the lateral wall of the optic canal is rare and may be successfully managed through a lateral orbitotomy without craniotomy.
从一系列经手术治疗的鞍上、前颅窝和蝶骨翼脑膜瘤中，确定一种明确的标准，用于对视力恶化的基底脑膜瘤患者施行视神经管减压术。
回顾性分析 1988 年至 2008 年间手术治疗的 150 例鞍上和鞍旁脑膜瘤（44 例鞍结节、46 例蝶骨嵴内 1/3 和 60 例蝶骨-眶）患者。分析所有肿瘤部位患者术前视力障碍的发生率、视神经管受累的发生率、相关手术治疗及其对视功能预后的影响。
所有 44 例鞍结节脑膜瘤患者均有不同程度的术前视力障碍。所有患者均采用经颅入路手术。2 例有管内肿瘤延伸的患者行视神经管减压术。术后，27 例（61.4%）视力功能改善，17 例（25%）无变化。46 例蝶骨嵴内脑膜瘤患者中，30 例（65.2%）有视力障碍。前 32 例患者采用经典翼点入路，6 例（A 组）选择性开放视神经管，后 14 例患者采用常规前床突切除术和视神经管开放术（B 组）。30 例患者中，17 例（56.7%）术后视力功能改善，B 组患者的改善率明显较高（80%比 45%）。60 例蝶骨-眶脑膜瘤患者中，36 例（60%）有视力障碍，43 例（71.6%）视神经管受累。18 例（50%）视力改善，13 例（36%）无变化，5 例（14%）恶化。外侧肿瘤视神经管受累率最低，视力改善率为 100%；另一方面，所有眶尖和弥漫性肿瘤均有视神经管的同心性侵犯，视力恶化率为 18.6%。
UOC 似乎是一种安全的手术，不会导致术后即刻视力损害。我们建议在所有蝶骨嵴内脑膜瘤中常规行视神经管减压术，并联合硬膜外前床突切除术，以获得视神经颅内段和颅外段的早期和完全暴露。对于鞍结节脑膜瘤，我们建议仅在管内肿瘤延伸的情况下开放视神经管。最后，对于蝶骨-眶脑膜瘤，我们建议在几乎所有病例中通过颅眶入路行 UOC，但外侧脑膜瘤除外，因为外侧壁视神经管受累罕见，可通过外侧眶切开术成功治疗，而无需开颅。
