Hyperostosing meningiomas of the cranial vault wit

Authors: Andrea Talacchi Francesco Corsini Massimo Gerosa

Publish Date: 2010/10/15

Volume: 153, Issue: 1, Pages: 53-61

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Abstract

This study represents the first clinical series in the reported literature exclusively concentrating on the clinicoradiological features of nonsphenoidal hyperostosing meningiomas It attempts to identify the factors that may have an impact on the surgical strategy and results of this unique subgroup of meningiomasIn the vault we distinguished between meningiomas with and without tumor mass according to their thickness 15 vs ≥15 cm and between convexity lateral and calvarial midline meningiomas according to their location The clinical radiological surgical and prognostic characteristics of the tumors were examinedOver a 10year period we observed 24 cases 18 of which in the convexity nine without and nine with tumor mass and six calvarial one without and five with tumor mass Six patients presented with neurological signs while the majority showed bony hyperostosis n = 19 Brain edema n = 7 was found only in cases with tumor mass in all neurologically impaired patients and only in one intact patient Total removal was obtained in 92 patients Small residual tumors attached to the superior sagittal sinus and perisinusal dura were coagulated in situ and not excised Morbidity occurred in three symptomatic patients with tumor mass and brain edema mental confusion in one case and hemiparesis in two cases Mortality was nil After a mean followup of 48 years three cases relapsed all of which had initially presented with atypical meningiomasThe rare hyperostosing cranial vault meningiomas may be classified as being with and without tumor mass A number of categorical differences exist in their distribution pattern of hyperostosis surrounding arachnoidal plane and their prognosis Careful preoperative planning aimed at tailoring the extent of tumor removal and reconstruction in the neighboring infiltrated structures enables a good outcome to be achievedThe colleagues from Verona present their unique series of 24 nonsphenoidal hyperostosing meningiomas of the cranial vault Bony hyperostosis was the presenting symptom in as many as 19/24 cases 18 lateral tumors nine without and nine with a tumor mass vs six midline one without and five with a tumor mass tumors three of 24 atypical grade II meningiomas unexpectedly 1311 male–female ratio and amazingly median age of only 45 years For Cushing a slowly enlarging bony bulge under the scalp was an important sign of meningioma 1 but such patients still pop up in our populations covered with CT and MRI scanningThe authors rightly call for an individually tailored tumor removal and reconstruction of tissue defects A technical detail with the patient’s upper body elevated this commentator prefers to make a lot of burr holes in two rows around the hyperostosis in CT scans immediately cover all holes from a fistful of bone wax to prevent bleeding and air embolism remove first the bony ring only and open the exposed dura in the circular bony defect to remove the hyperostotic part in one piece—all this not to manipulate the underlying cortex and veins Cranioplasty options include intraoperative hammering of titanium mesh to cover the defect or placing a large piece of artificial cranioplasty material of standard convex form or commercially produced from the patient’s preoperative CT dataThe mechanisms by which meningiomas induce hyperostosis are unknown—and will remain so as long as residents prefer other pleasures of life than research Molecular genetics of increased bone formation may give a clue—TGFbeta signaling Camurati–Engelman disease osteopoikilosis Wnt pathway endosteal hyperostosis sclerosteosis van Buchem disease high bonemass syndrome osteopathia striata eicosanoid pathway Ghosal syndrome pachydermoperiostosis 2 Another mystery is why the sphenoid bone is particularly prone to overwhelming hypertosis with orbital consequences

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