Dural Sinus Invasion in Meningiomas and Repair

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CHAPTER 25 Dural Sinus Invasion in Meningiomas and Repair image

Marc P. Sindou, Jorge E. Alvernia

INTRODUCTION

Surgery of meningiomas involving the major dural sinuses leaves the surgeon confronted with a difficult dilemma: leave the fragment invading the sinus in place and have a higher risk of recurrence, or attempt a total removal and expose the patient to a greater operative danger. The controversy of what constitutes the best treatment is still in debate.1 Some claim that leaving the intraluminal fragment in place is the best treatment, and others that attempt at total gross removal with venous reconstruction is preferable. The latter is our preference, based on a 20-year experience corresponding to a series of 100 meningiomas that were studied and then reported in 2006.2 The effects, in terms of recurrence rate and morbidity and mortality, of attempting complete removal including the invaded portion of the dural sinus, and in addition the consequences of restoring or not the venous circulation were studied. Our series consisted of 100 consecutive patients who underwent surgery between January 1980 and January 2001 (Table 25-1). Meningiomas originated at the superior sagittal sinus in 92 of the cases (28 in the anterior, 48 in the middle and 16 in the posterior third), the transverse sinus in 5, and the confluence of sinus in 3. A simplified classification scheme based on the degree of dural sinus involvement was applied:

Type I: Lesion attachment to the outer layer of the sinus wall
Type II: Tumor fragment inside the lateral recess
Type III: Invasion of the ipsilateral wall
Type IV: Invasion of the lateral wall and roof
Types V and VI: Complete sinus occlusion, with or without the contralateral wall free, respectively

TABLE 25-1 Analysis of 100 surgically treated meningiomas with major cerebral venous sinus invasion

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Lesions with type I invasion were treated by peeling the outer layer of the sinus wall. In cases of tumor sinus invasion types II to VI, two strategies were employed: a “nonreconstructive” (coagulation of the residual fragment or global resection) and a “reconstructive” one (suture, patch, or bypass).

Gross tumor removal was achieved in 93% of the cases and reconstruction of the sinus was attempted in 45 (65%) of the 69 cases with wall and lumen invasion. The overall recurrence rate in the study was 4%, with a follow-up ranging from 3 to 23 years (mean 8 years). The mortality rate was 3%, all cases due to brain swelling after en bloc resection of a type VI meningioma without venous restoration. Eight patients who harbored a lesion in the middle third portion of the superior sagittal sinus had permanent neurologic aggravation, likely due to local venous infarction. Six of these patients had not undergone a venous repair procedure. Venous reconstruction did not increase the morbidity–mortality rate in our series. From this study we concluded the following: (1) the relatively low recurrence (4%) favors attempts at complete removal, including the portion invading the sinus; (2) because the subgroup of patients without venous reconstruction displayed statistically significant clinical deterioration after surgery compared with the other subgroups (P = 0.02), venous flow restoration seems justified when not too risky.2

CLASSIFICATION OF SINUS INVASION

Different classifications of sinus invasion have been proposed by different authors, especially Krause (quoted by Merrem3) and Bonnal and Brotchi.4–7 For surgical purpose, we developed a simplified classification that we believe is easy to remember. This classification, developed for the sagittal sinus location shown in Figure 25-1, may also be applied to meningiomas involving the torcular and the transverse sinus.2

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FIGURE 25-1 Classification of meningiomas according to sinus invasion. Type I, meningioma attached to the outer layer of the sinus wall; type II, lateral recess invaded; type III, ipsilateral wall invaded; type IV, both ipsilateral wall and roof invaded; type V, sinus totally occluded, but contralateral wall free of invasion; type VI, sinus totally invaded including all three walls.

(From Sindou M, Alvernia, J. Results of attempted radical tumor removal and venous repair in 100 consecutive meningiomas involving the major dural sinuses. J Neurosurgery 2006;105(4):514–25).

PREOPERATIVE INVESTIGATIONS

Computed tomography (CT) and magnetic resonance imaging (MRI) with and without contrast medium provide the key of diagnosis. MRI (T1-weighted sequences with and without gadolinium injection and T2 sequences) is more effective in delineating the tumor and differentiating it from surrounding structures: in particular, it can determine the feasibility of dissection. Gadolinium enhancement of the invaded dura allows the site of exposure to be predicted. However, it must be kept in mind that enhancement of the dura adjacent to the main tumor mass may indicate actual tumor invasion or may simply indicate hyperemia. Venous MR offers additional useful information on venous system involvement. MR angiography does not succeed in providing a reliable exploration of the tumor vascularization and hemodynamics. Therefore, angiography through the transfemoral route is still of value before establishing the detailed surgical strategy.

Selective bilateral internal and external carotid subtraction angiographies as well as vertebral angiography serve to determine the dural and cortical–pial supply ipsilateral or contralateral to the tumor. The arterial phase is useful to predict the difficulty of dissection of the capsule from the cortex. As we have shown in prior publications, dissection entails neurologic risk when a pial vascular supply is identified.8 When meningeal supply is important, preoperative embolization may be of some value in producing tumor necrosis and decreasing the operative risks to the patient by diminishing the blood loss that accompanies resection of these tumors.

The late venous phases with bilateral filling of the sagittal sinus are required for the exact evaluation of sinus patency and collateral venous pathways. Oblique views can depict the superior sagittal sinus (SSS) throughout its entire course. Various degrees of sinus occlusion can be observed from simple compression with narrowing of the sinus lumen to intraluminal defect to total occlusion. Complete occlusion may be assumed from no visualization of segments of the sinus and from collateral venous channel development. The pattern of venous drainage and venous collateral channels must be established preoperatively to determine the surgical approach (Fig. 25-2).

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FIGURE 25-2 (Top) Type III parasagittal meningioma in mid-third of SSS. A, Preoperative coronal gadolinium-enhanced T1-weighted MR image showing a right middle third parasagittal meningioma with type III invasion of the lateral wall of the sagittal sinus. B, Preoperative venous-phase angiogram, lateral view, demonstrating a patent sinus and tumor blush (*). C, Postoperative coronal gadolinium-enhanced T1-weighted MR image exhibiting no evidence of tumor remnant. The lateral sinus wall was resected and patched. D, Postoperative venous phase angiogram, lateral view, showing sinus patency (arrows). (Bottom) Steps of the patching technique. A, Lateral view of the sagittal sinus (right side) after removal of the tumor outside the sinus; the invaded lateral mass is visible (type III). B, The invaded portion of the wall has been resected; venous bleeding is controlled by pledgets of Surgicel inserted into the sinus lumen (proximal and distal). C, Venous reconstruction performed using an autologous patch (fascia temporalis in this case). F, Falx cerebri; LW, lateral wall of SSS; R, roof; P, patch; S, Surgicel; O, venous ostia in contralateral wall.

(From Sindou M, Alvernia, J. Results of attempted radical tumor removal and venous repair in 100 consecutive meningiomas involving the major dural sinuses. J Neurosurgery 2006;105(4):514–25).

SURGICAL TECHNIQUE

General Principles

Positioning

Placing the patient in the semi-sitting (lounging) position allows a good venous return without increased intracranial pressure. Air embolism, although possible, is not a frequent risk because of the relatively high level of the intracranial venous pressure in these patients. The problem can be avoided or safely controlled in experienced surgical hands.

Exposure and initial steps

1. The operative exposure should be as extensive as possible. The skin flap and craniotomy should extend across the midline to permit visualization of both sides of the sinus and about 3 cm outside the margins of the occluded sinus. However, such a large access should be reconsidered if there are scalp, pericranial, or diploic collateral venous pathways, which may be impaired during the approach.
2. Afferent tumor arteries within the dura should be coagulated or clipped before being cut.
3. The dura is incised in a circumferential manner around the margin of the tumor insertion on the dura of the convexity and along the border of the corresponding portion of the superior sagittal sinus.
4. The microscope is installed.
5. The attachment of the meningioma to the lateral wall of the sinus and to the neighboring falx is detached from the structures by using the cutting mode of the bipolar coagulation forceps, thus cutting off the tumor’s meningeal supply.
6. Then, intracapsular debulking is performed so that the remaining capsule of the tumor can be easily mobilized from the underlying cortex. Under the microscope an extra-arachnoidal plane of dissection must be carefully searched. If it is absent, the plane of dissection becomes subpial because of pia mater incorporation into the tumor capsule (Fig. 25-3).
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FIGURE 25-3 Right (type V) parasagittal meningioma of posterior third. Surgical steps: A, Exposure of the meningioma. B, After removal of the tumor outside the superior sagittal sinus (SSS). One can see the right wall is invaded. C, After opening of the lateral wall one can see that lumen is totally blocked. D, After removal of the intraluminal fragment the ostia of two afferent veins entering the SSS through the left wall are visible. E, Repair of the resected right wall by means of a patch made of fascia temporalis and sutured with two running sutures.

Sinus surgery procedure

7. Because there are frequent discrepancies between images and anatomic findings, the sinus should be explored through a short incision to disclose any intrasinus fragment.
8. Temporary control of venous bleeding from the sinus and afferent veins is easily obtained by packing small pledgets of hemostatic material (Surgicel, Johnson Medical, Viroflay, France) in the lumen and at the ostia of afferent veins. Balloons should not be used because they do not pass easily through the sinus septa and may injure the sinus endothelium. Vascular clamps and aneurysm clips should be avoided as much as possible because they may injure the sinus walls and afferent veins (see Figs. 25-2 and 25-3).
9. Bridging veins, especially in the rolandic outflow area, should be preserved by dissecting them free from adjacent brain and tumor.
10. Venous reconstruction is performed using patches or bypasses, with two hemirunning sutures (Prolene 8.0 Laboratoire ETHNOR, Neuilly/Seine, France). Although the autologous vein would appear as the most suitable material for use as a patch, vein harvesting seems excessive for patching only. The locally situated dura mater, fascia temporalis, and pericranium can be used; however, we favor the use of fascia temporalis when possible because of it more rigid structure. When a bypass is performed the graft should not be compressed by any surrounding structure and measures to decrease the intracranial pressure should be taken to prevent it from kinking or stenosis (Figs. 25-4 and 25-5).
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FIGURE 25-4 Type VI parasagittal meningiomas totally invading and occluding the anterior half of the posterior third of superior sagittal sinus. A, Drawing of the tumor. B, Total removal of the meningioma together with the totally invaded portion of the sinus and proximal and distal temporary sinus lumen occlusion with Surgicel pledgets. C, Venous circulation restored with a venous autologous graft harvested from the (external) jugular vein and mounted as a bypass of end to end type at both anastomoses. D, Operative microsurgical view (taken from the intraoperative videotape) after completion of the venous bypass. Proximal (P) and distal (D) end to end anastomoses. Bypass is patent and circulating (arrow flow).

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FIGURE 25-5 Schematic drawing of Sinojugular bypass. A, A transverse–jugular bypass between right transversal sinus and external jugular vein, exposed superficially to sternocleidomastoid and trapezius muscles (for a bilaterally occluded sigmoid sinus). B, A sagitto–jugular bypass between the sagittal sinus and the external jugular vein (for an occluded sagittal sinus-torcular at its posterior third by meningioma). C, Postoperative control (at two weeks) by digital substraction angiography of a patent sino–(sagittal) jugular (external) bypass performed with a greater internal saphenous vein graft (arrowheads), right side, in a patient with a totally occluded (type VI) sagittal sinus (posterior third), by a meningioma, and suffering severe intracranial pressure syndrome. D, Distal; J, external jugular vein; P, proximal; S, superior sagittal sinus; VB, venous bypass patent.

(From Sindou M, Alvernia, J. Results of attempted radical tumor removal and venous repair in 100 consecutive meningiomas involving the major dural sinuses. J Neurosurgery 2006;105(4):514–25).

Postoperative care

11. To facilitate bypass patency after surgery, blood pressure, volume, and viscosity must be carefully monitored. Heparin therapy (two times control value) is recommended for at least 21 days to prevent the reconstructed sinus from becoming clotted, and 3 months of an aspirin regimen are recommended to allow sinus wall endothelialization.

Surgery of the Dural Sinus, According to the Degree of Invasion

Type I: Excision of outer layer, leaving a clean and glistening dural surface, and coagulation of dural attachment.
Type II: Removal of intraluminal fragment through the recess, then repair of the dural defect by resuturing the access or by closing it with a patch, or, provided it is not stenosing, sealing of the opening with aneurysm clip.
Type III: Resection of sinus wall and repair with a patch.
Type IV: Resection of both invaded walls and reconstruction of the two resected walls by a patch.
Type V: The opposite wall to the tumor side is free of tumor. Thus we think that it is preferable to reconstruct with a patch the two invaded walls after their resection, rather than to perform a bypass. This type can be distinguished from type VI only by direct surgical exploration of the sinus lumen.
Type VI: Removal of involved portion of sinus and restoration by venous bypass. The site of the bypass is on the sagittal sinus for meningiomas involving the sagittal sinus (SS), between the SS and the external jugular vein for meningiomas totally occluding the posterior third and the torcular, and between the transverse sinus (TS) and the external jugular vein for meningiomas involving the TS (see Fig. 25-5).

CONSIDERATIONS FROM THE LITERATURE REVIEW

Surgical Venous Damage

All authors dealing with meningiomas invading dural sinuses agree on the importance of preserving the afferent (bridging) veins to the sinus, especially the ones of the central group in the middle third portion of the sagittal sinus, as well as those located at the transversus sinus and corresponding to the inferior cerebral veins of Labbé.

Avoiding the interruption of a partially occluded sagittal sinus is a matter of strong consensus. The safety of resecting a totally occluded portion of a sinus, although classically accepted, is disputable; brain swelling, venous infarction, and cerebrospinal fluid (CSF) collection may occur when venous collateral circulation is impaired. In Hoessly and Olivecrona’s series,9 which included 196 parasagittal meningiomas, treated without venous reconstruction, morbidity amounted to 12.3%, with half of the cases involving venous damages. Their 10% mortality corresponded to 14 (12.8%) of the 109 tumors located in the middle, 3 (9.7%) of the 31 lesions in the posterior third, and 3 (5.3%) of the 56 lesions in the anterior third. In Bonnal and Brotchi’s study including 21 cases, one patient (4.8%) died after an en bloc resection of the tumor mass without venous restoration.5 In a recent article documenting the cooperative experience of 8 surgeons and the grouping of 108 cases, Di Meco and colleagues mentioned the occurrence of severe brain swelling in 3 (10%) of the cases treated with en bloc resection without venous reconstruction. Also, persistent subgaleal fluid collection likely corresponding to a default in CSF reabsorption and/or persistent postoperative high intracranial pressure from venous origin was observed in 11 of their patients (10%).10 In our series, morbidity and mortality related to venous damage and/or absence of venous flow reconstruction were estimated at 8% and 3%, respectively. Perhaps these patients would have had a better outcome if they had undergone venous repair, or perhaps shaving of the tumor outside the sinus with secondary stereotactic radiation would have been harmless, but we do not know the answer.

Dural Sinus Reconstruction

Reconstructions in the venous system are not new. Different techniques of dural sinus repair were reported long ago,11–33 and encouraging results of anastomosing cortical veins to the sinus venous graft have been reported more recently.34–38

First Bonnal and Brotchi5 and then Hakuba and colleagues,13–16 Bederson and colleagues,11 Sekhar and associates,37 Steiger and colleagues,38 and Schmid-Elsaesser and colleagues39 reported satisfactory experiences patching with pieces of dura or autologous venous graft. In our series 13 (86.6%) of the 15 repairs with dura or fascia, confirmed angiographically, were patent.2 Harvesting autologous veins, theoretically the best material for patching the venous system, seemed too excessive for patching. According to our experience, the most appropriate material is the thin and glossy fascia temporalis. For performing bypasses, the internal saphenous vein for a long graft and the external jugular vein for a short graft were used in 12 patients. Eight (72.7%) of the 11 angiographically controlled bypasses were patent (Table 25-2; Fig. 25-6).

TABLE 25-2 Patency of sinus after various manipulations.

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FIGURE 25-6 Type V torcular meningioma. A, Preoperative axial computed tomography (CT) with contrast medium (upper row) and anteroposterior view of venous phase of digital substraction angiography (DSA) showing the torcular meningioma occluding totally the right transverse sinus and subtotally the left one (arrow, lower row). B, Postoperative axial CT showing complete removal of the tumor (upper row) and postoperative DSA (after 2 weeks) demonstrating patency of both right (arrowhead) and left (arrow) transverse sinuses (lower row).

(From Alvernia J, Sindou M, Torcular. Transverse and Sigmoid Sinus Meningiomas. In: Lee J, editor. London; Springer; 2009. p.477).

When a synthetic graft (i.e., a GORE-TEX® tube) was used (six cases), none were patent despite the use of anticoagulation, and thus we do not recommend synthetic grafts on the venous system.

When temporary occlusion of the sinus is required, the use of small pledgets of Surgicel within the lumen and at the ostia of the tributary afferent veins makes the process simple. This technique has been found much more preferable than using aneurysm clips or balloons. In fact, aneurysms clips or even temporary clamps are too aggressive for sinus walls, and balloons together with silicone tubes as shunts are not convenient because they cannot fit inside the sinus lumen given the presence of the septa, especially in the middle portion of the sagittal sinus. Moreover, all entail the risk of damaging or even avulsing the endothelium, which is known to be susceptible to secondary thromboses.

Whether a bypass is justified every time a total resection is attempted, or in only in selected cases with proven high venous pressure, remains a debatable issue. We are rather prone to conducting the procedure systematically, especially because performing a bypass in the extradural space involves little additional risk. The fact that all of the patients who had a graft that thrombosed (with the exception of one with a GORE-TEX® tube) remained asymptomatic does not mean that venous reconstruction was useless. One can postulate that the bypass gave time for compensatory venous pathways to develop until occlusion occurred. Importantly, the three patients who died of brain swelling all had meningiomas with type VI sinus invasion that had been totally resected without venous flow restoration.

CONCLUSIONS

The low recurrence rate in our series supports resecting not only the tumor portion outside the sinus but also the fragment invading the sinus. Ultimately, a decision must be made after weighing the benefits and risks. When attempt at radical removal is decided venous reconstruction is mandatory; when the sinus is incompletely occluded we find it potentially useful, even in cases of complete occlusion, to restore the flow that might be compromised by impaired compensatory channels. Achieving radical removal requires opening the sinus, exploring its lumen, and (temporarily) interrupting its circulation. The process can be performed easily with pledgets of Surgicel. Resected walls should be repaired with patching; a graft harvested from adjacent dura, fascia lata, or preferably the thin fascia temporalis appears adequate. For performing bypasses, only autologous grafts should be utilized: the external jugular vein for short grafts and the internal saphenous vein for longer ones. Postoperative anticoagulation is mandatory for at least 3 months, until reendothelialization occurs; this strategy does not increase hemorrhagic complications.

References

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