J Neurosurg 73:840-849,1990

Clinoidal meningiomas
OSSAMA AL-MEFTY, M.D.
Department of Neurosurgery, University of Mississippi Medical Center, Jackson, Mississippi

~" Anterior clinoidal meningiomas are frequently grouped with suprasellar or sphenoid ridge meningiomas,
masking their notorious association with a high mortality and morbidity rate, failure of total removal, and
recurrence. To avoid injury to encased cerebral vessels, most surgeons are content with subtotal removal.
Without total removal, however, recurrence is expected. Recent advances in cranial-base exposure and
cavernous sinus surgery have facilitated radical total removal.
The author reports 24 cases operated on with vigorous attempts at total removal of the tumor with involved
dura and bone. This experience has distinguished three groups (I, II, and III) which influence surgical difficulties,
the success of total removal, and outcome. These subgroups relate to the presence of interfacing arachnoid
membranes between the tumor and cerebral vessels. The presence or absence of arachnoid membranes depends
on the origin of the tumor and its relation to the naked segment of carotid artery lying outside the carotid
cistern. Total removal was impossible in the three patients in Group I, with postoperative death occurring in
one patient and hemiplegia in another. Total removal was achieved in 18 of the 19 patients in Group II, with
one death from pulmonary embolism. In the two patients in Group III, total removal without complications
was easily achieved.

KEY WORDS ~ meningioma 9 anterior clinoid 9 carotid cistern 9 cavernous sinus 9

sphenoid wing

C
USHING and EisenhardP 7 clearly distinguished
meningiomas of the anterior clinoid as "those
of the deep or clinoidal third," and concur-
rently, Vincent referred to them as "sphenocavernous
meningiomas. ''18 Despite this early recognition, these
meningiomas are frequently grouped with suprasellar
meningiomas or with meningiomas of the sphenoid
ridge, 6Aj'23"24~41`3jmasking their ominous course. They
are second only to clival meningiomas in surgical mor-
tality and morbidity rates, failure of total removal, and
high rate of recurrence. Acknowledging that the best
chance for cure comes through radical total removal,
most authors, both pioneer and modern, have been
content with subtotal removal to avoid the devastating
sequelae of injury to the encased cerebral vessels; 6'9A7"
22,31.43,51.56hence, repeated surgery and radiation therapy
are frequently required. However, unless total removal
is achieved, detrimental regrowth is expected in the
majority of patients.l'~5~17'3747
Recent advances in cranial-base and cavernous si-
nus surgery have facilitated total removal, allowing re-
spectable mortality and morbidity rates for these
t u m o r s . 3"5"2~ This report describes 24 cases of
clinoidal meningiomas operated on over a period of 7
years, from November, 1981, to October, 1988, with
vigorous attempts at total removal (including tumor,
dura, and bone) during the first operation. According
to the classification system of Simpson, 47 the extent
of tumor excision was either Grade I (complete mac-
roscopic removal of the tumor, with excision of its du-
ral attachment, and abnormal bone) or Grade II (com-
plete macroscopic removal of the t u m o r and of its
visible extensions, with coagulation of its dural at-
tachment). Our experience with intraoperative anatom-
ical observation led us to distinguish three categories of
this tumor (Groups I, II, and III), each with a marked in-
fluence on the surgical difficulties, ability to achieve total
removal, and outcome. These groups relate to the pres-
ence of interfacing arachnoid membranes between the
tumor and the cerebral vessels. The presence or absence
of this arachnoid membrane depends on the origin
of the tumor and its relation to the small intradural
carotid artery segment lying outside the carotid cistern.
Anatomical Considerations and Classification
As the carotid artery emerges from the cavernous
sinus inferomedial to the anterior clinoid, it enters the
subdural space to be vested in the carotid cistern. This
cistern is bordered superiorly by the dura over the
anterior clinoid process and the frontal lobe, and infe-
riorly by the dura covering the superior aspect of the
cavernous sinus. The arachnoid does not follow the
internal carotid artery into the cavernous sinus space,

840 J. Neurosurg. / Volume 73/December, 1990

Clinoidal meningiomas
nor is it attached to the anterior clinoid process. A 1-
or 2-mm segment of naked internal carotid artery lies
between the investment of the carotid cistern and the
dura of the cavernous sinus, s9 This segment is not to
be confused with the extradural segment which lies
between the two rings anchoring the carotid artery as it
exits the cavernous sinus space. 2~ Medially, the carotid
cistern shares a wall with the chiasmatic cistern and is
bounded laterally by the medial temporal lobe and the
free margin of the tentorium. The inferior part of the
carotid cistern and the superior part of the interpedun-
cular cistern are in apposition, creating a single Lilie-
quist membrane.

Group I
If the meningioma's origin is proximal to the end of
the carotid cistern (Group I), as is the case with a
meningioma originating from the inferior aspect of the
anterior clinoid, the tumor will enwrap the carotid ar-
tery, directly adhering to the adventitia in the absence
of an intervening arachnoid membrane (Figs. 1 and 2).
As the tumor grows, this direct attachment to the vessel
wall continues to the carotid bifurcation and along the
middle cerebral artery, advancing the arachnoid mem-
brane ahead of it. This situation makes dissecting the
tumor from the carotid artery and the middle cerebral
artery branches impossible and explains why some au-
thors describe tumors invading the arterial wall. 2~
Group H
Tumors of Group II originate from the superior and/
or lateral aspect of the anterior clinoid above the seg-
ment of the carotid invested in the carotid cistern. Thus,
as the tumor grows, an arachnoid membrane of the
carotid cistern and, distally, of the sylvian cistern sep-
arates the tumor from the arterial adventitia. Although
the tumor engulfs the vessels, this arachnoid membrane
F~G. 1, Artist's drawing of a Group I meningioma. The
tumor encases the carotid artery and its branches, with direct
attachment to the adventitia. The optic nerve maintains an
arachnoid plane from the chiasmatic cistern.
remains intact, making microsurgical dissection feasible
despite total encasement of the vessels (Figs. 3 and 4).
This observation correlates with reports in the literature
concerning the feasibility of tumor dissection despite
total vascular encasement. 4'2336
The optic chiasm and the optic nerves in both Group
I and II tumors are wrapped in the arachnoid mem-
brane of the chiasmatic cistern, and dissecting them
free from the tumor is relatively easy with a microsur-
gical technique. In patients having undergone previous
surgery, the arachnoid membrane may be violated;
subsequently, the dissection plane is lost and the tumor
will be in direct contact with the adventitia. In this case,
the difficulty in Group II becomes similar to that in
Group I.

FIG. 2. A Group I meningioma. Left: Preoperative computerized tomography appearance. During sur-
gery, no arachnoid membrane was found and dissection of the middle cerebral and carotid arteries was
impossible. Right: Lateral carotid arteriogram demonstrating narrowing of the carotid and middle cerebral
arteries by the encasing tumor.

J. Neurosurg. / Volume 73/December, 1990 841

 O. A1-Mefty

FlG. 3. A Group II meningioma. Left: Artist's drawing showing the tumor encasing the carotid artery
and its branches. An arachnoid membrane of the carotid cistern separates the tumor from the adventitia,
rendering dissection possible. The optic nerve maintains an arachnoid membrane from the chiasmatic cistern.
Right: Retouched operative photograph showing the optic nerve (II), the anterior cerebral artery (A1), the
middle cerebral artery (M~), and part of the internal carotid artery (C) dissected free from the encasing tumor
(T). Dissection continues on the proximal carotid artery and into the cavernous sinus. The dissection is
relatively easy, owing to the presence of the arachnoid membrane of the carotid cistern. R = retractor on the
frontal lobe.

Group I I I the superior temporal line on the opposite side. This

Tumors in Group III originate at the optic foramen, results in the superficial temporal artery coursing pos-
extending into the optic canal and the tip of the anterior terior to the incision while the branches of the facial
clinoid process. These tumors are usually small. The nerve are located anteriorly. Preservation of the super-
arachnoid membrane is present between the vessels and ficial temporal artery is important since the artery may
tumor but may be absent between the optic nerve and be needed for extracranial-intracranial (EC-IC) anasto-
the tumor (Figs. 5 and 6). mosis. The frontal branches of the facial nerve are
preserved by intrafascial dissection, as described previ-
ously by Ya~argil, et al. 6~
Operative Technique
Early in this series, the pterional approach was used Bone Removal
in seven patients and subfrontal approach in three. The zygomatic arch is dissected in subperiosteal fash-
Since 1985, we have exclusively used the orbitocranial ion, sectioned at the most anterior and posterior ends,
approach described elsewhere 2'3 for removal of these and displaced downward along with its attachment to
tumors. This approach provides the following advan-
tages: 1) it brings the surgeon closer to the deep-seated
lesion, allowing dissection over the shortest possible
distance; 2) it permits a surgical attack via multiple
routes: subfrontal, transsylvian, and subtemporal; 3) it
consists of a single bone flap, eliminating the need for
reconstruction and associated functional and anatom-
ical or cosmetic deficits; 4) its low basilar approach
alleviates brain retraction; and 5) it allows early inter-
ception of the tumor's blood supply through the sphe-
noid ridge, thus minimizing blood loss.

Positioning and Scalp Incision

The patient is placed supine and a spinal drainage
needle is inserted. The head is rotated 30* to 40 ~ to the
opposite side, dropped toward the floor, tilted 5~ to 10",
and fixed in the Mayfield headrest. The scalp incision
is begun 1 cm anterior to the tragus, proceeding in a
curvilinear fashion behind the hairline to the level of
FIG. 4. A Group II meningioma. Computerized tomogra-
phy scan (left) and arteriogram, anteroposterior view (right).
Notice the arterial narrowing by the encasing tumor. Dissec-
tion and tumor removal were facilitated by the presence of an
intervening arachnoid membrane.

842 J. Neurosurg. / Volume 73/December, 1990

Clinoidal meningiomas

FIG. 5. A Group III meningioma. Left: Artist's drawing showing the tumor originating in the optic
foramen. The tumor is small, separated from the carotid by the carotid cistern, but it extends into the optic
canal. Right: Retouched operative photograph showing the carotid cistern intact. The tumor (T) is small and
extends into the optic canal. II = optic nerve; C = carotid artery; R = retractor on the frontal lobe.

the masseter muscle. This maneuver allows a more of the olfactory nerve deters excessive frontal lobe re-
basal approach to the floor of the middle fossa, obvi- traction, otherwise resulting in avulsion of the olfactory
ating obstruction by the bulky temporal muscle. The nerve.
temporal muscle is retracted posteriorly and inferiorly,
exposing the junction of the zygomatic, sphenoidal, Tumor Debulking
and frontal bones. Removal of the orbitocranial flap Under the operating microscope, a plane of dissec-
then proceeds as described elsewhereY The sphenoid tion is established between the tumor and the frontal
ridge is drilled using a high-speed air drill. Drilling is and temporal lobes. Ultrasonic aspiration is used to
continued to completely remove the sphenoid ridge, debulk large tumors. Caution is used not to carry de-
unroofing the superior orbital fissure and removing the bulking close to the carotid artery or the middle cere-
anterior clinoid extradurally. This maneuver intercepts bral artery branches. Tumor removal around this area
the arterial feeders coming from branches of the middle is continued using only microsurgical dissection with
meningeal artery. It also assures removal of the involved bipolar coagulation and careful piecemeal removal by
bone at the insertion and prepares for exposure of the microdissection.
internal carotid upon entry to the cavernous sinus.
Arterial Dissection
Dural Opening and Tumor Exposure Once the tumor is debulked, the distal branches of
The dura mater is opened with a semicircular incision the middle cerebral artery are identified under high
centered on the pterion; an extension from the main magnification and, using microdissection, the tumor
incision is directed posteriorly and inferiorly to the floor capsule is removed from the arterial wall. Despite total
of the temporal fossa. Opening the dura under the
microscope provides a transitional adjustment of the
surgeon's dexterity from bone work to fine microsur-
gical dissection.
When the dura is opened, brain relaxation is achieved
by partial drainage of cerebrospinal fluid (CSF) through
the lumbar catheter. The arachnoid over the sylvian
fissure is opened, allowing separation of the temporal
and frontal lobes. The arachnoid opening is made and
extended on the frontal side to preserve the superficial
middle cerebral veins when possible. The relaxed frontal
lobe is held by a self-retaining retractor. Elevation of
the frontal lobe should be minimal - - a distance of 1.5
cm or less is adequate for tumor resection. The olfactory
nerve is located and preserved by dissecting it for some FIG. 6. Computerized tomography scan of a Group Ill me-
distance from the base of the frontal lobe. Preservation ningioma (arrow).

J. Neurosurg. / Volume 73/December, 1990 843


encasement of these vessels, a tfiickened arachnoid
membrane separated the tumor from the adventitia in
Group II tumors. Dissection is carried to the bifurcation
of the carotid artery, removing the tumor from the
anterior cerebral artery. Careful dissection under high
magnification is continued to free the ventriculostriate
arteries, the perforator of the anterior cerebral artery,
and the internal carotid artery branches to the optic
apparatus. Dissection becomes easier along the poste-
rior communicating artery and the anterior choroidal
artery, since these two arteries have their own vesting
arachnoid membranes? 9 Dissection of the third nerve
segment, prior to its entry in the lateral wall of the
cavernous sinus space, also becomes easier.
When hemorrhage ensues from a tear in a cerebral
vessel, as it did in five of our cases, temporary vascular
clips (30 gm/mm) are applied distal and proximal to
the bleeding point, and the arterial wall is stitched with
fine 10-0 sutures. Since the tumor may be supplied by
arterial twigs from the cerebral artery, the surgeon first
confirms that they are tumor feeders and not hypotha-
lamic perforators or the optic nerve blood supply. Thus,
each arterial branch is dissected and followed to ascer-
tain its course. Particular attention is paid to spare the
artery of Heubner and the vital branches of the stria-
tum. The Liliequist membrane was intact in all of our
cases of Group II tumors; consequently, removal of the
tumor from the interpeduncular fossa and the posteri-
orly displaced basilar artery was usually easy.
Optic Nerve Dissection
The optic nerves in these tumors are displaced in
several different ways. The optic nerve may be pushed
inferiorly and medially or elevated by the bulk of the
tumor coming between the carotid artery and the optic
nerve. In seven of our cases, the optic nerve was totally
engulfed, but in all cases the optic nerve maintained its
arachnoid barrier formed by the wall of the chiasmatic
cistern. When the optic nerve is engulfed, it is easier to
begin the dissection from the chiasm and continue
forward toward the optic canal. Frequently, the tumor
extends a bud into the optic canal, requiring unroofing
of the optic canal and careful dissection of the tumor.
The arterial supply to the optic nerve and chiasm is
preserved by the same method of dissection. Particular
attention is paid to preserve the inferior group of arter-
ies, which are the sole blood supply to the decussating
fibers in the central chiasm. 8 Since occasional observa-
tions of visual recovery after total blindness have been
reported, 4'33 the optic nerve was never sacrificed in our
patients to obtain better exposure of the tumor, even
in a totally blinded eye.
Dissection of the Pituitary Stalk
The pituitary stalk is easily recognized by its distinc-
tive color and vascular network. It is usually displaced
backward and to the opposite side. Arachnoidal cleav-
age is present and careful dissection under the micro-
scope is successful.
844
O. A 1 - M e f t y
Cavernous Sinus Involvement
When the tumor extends into the cavernous sinus,
as it did in nine of our cases, proximal and distal control
of the carotid artery is necessary. Early in this series,
proximal control was achieved by exploring the inter-
nal carotid artery in the neck. More recently, this was
accomplished by exposing the intrapetrous segment of
the carotid artery. The anterior clinoid is already re-
moved, facilitating exposure of the superior aspect of
the cavernous sinus. The tumor is then removed
through the superior or lateral wall of the cavernous
sinus, as reported elsewhere?
After gross tumor removal, the dura around the
anterior clinoid is evaporated with the CO2 laser. Any
further bone hyperostosis is drilled with the diamond
bit of a high-speed drill. Frequently, this change in the
bone is actually invasion by the tumor. 9'~9 To avoid
postoperative CSF leakage through the extended eth-
moidal cell, a piece of fascia is applied over this area.
The dura is then closed in a watertight fashion, the
single bone flap positioned in place, and the skin closed
in two layers.
Summary of Cases
Case Material
Twenty-four cases qualifying as clinoidal meningi-
omas were operated on over a 7-year period, from
November, 1981, through October, 1988. There were
four other patients with the same pathology who did
not have surgery. We excluded from the study me-
ningiomas with origins (as described intraoperatively)
on the tuberculum sellae, diaphragma sellae, planum
sphenoidale, and middle and lateral sphenoid ridge, as
well as hyperostosing en plaque meningiomas. Of the
24 patients studied, 14 have been described in previous
publications. 4'5 Seventeen were operated on at King
Faisal Specialist Hospital in Riyadh, Saudi Arabia,
between November, 1981, and December, 1985, and
seven were operated on at the University of Mississippi
Medical Center between January, 1986, and November,
1988. The patients ranged in age from 26 to 76 years
(mean 52 years); there were seven men and 17 women.
The symptoms of two women presented during preg-
nancy. Four patients had previously undergone surgery
on their tumors.
Clinical Presentation
Visual disturbances were present in 84% of cases,
similar to the typical findings described for tumors at
this site (initial unilateral visual loss). Five patients
experienced loss of vision on one side only; nine expe-
rienced optic atrophy, and six had papilledema. Fos-
ter Kennedy syndrome was documented in only one
case. Four patients had impairment of the oculomo-
tor or trigeminal nerve, while seizure was present in
three patients. Two patients were admitted in a coma-
tose state with giant tumors, and underwent emergen-
cy surgery. Visual loss preceded diagnosis by 2 to 44
J. Neurosurg. / Volume 73/December, 1990
Clinoidal meningiomas
months (average 25 months); headache preceded sur-
gery by an average of 68 months.
Radiographic Findings
Computerized tomography (CT) scans in all cases
revealed the presence of tumor and its extensions. Mag-
netic resonance (MR) imaging with gadolinium en-
hancement was used in the last three cases. All patients
underwent cerebral angiography to delineate the anat-
omy of the cerebral circulation, arterial displacement,
encasement of major vessels, and blood supply. Angi-
ography revealed an associated internal carotid artery
aneurysm in one patient. According to the classification
mentioned above, 47 there were three Group I tumors,
19 Group II tumors, and two Group III tumors.
The carotid, middle cerebral, and anterior cerebral
arteries, as well as the optic apparatus, were all inti-
mately involved with the tumor, being displaced, ad-
herent, or totally engulfed. The carotid artery was totally
encased in 11 patients, the branches of the middle
cerebral artery were encased in seven, the anterior ce-
rebral artery was encased in three, and the optic nerve
was encased in seven. Cavernous sinus invasion oc-
curred in nine patients.
Operative Results
Total removal (tumor, dura, and bone), as judged by
intraoperative inspection and confirmed by postopera-
tive CT scans (Fig. 7), was achieved in 18 of the 19
patients with Group II tumors; in the one exception a
small nub of tumor was left in the cavernous sinus.
There was one death 9 days postoperatively, due to
pulmonary embolism, in a patient who was in excellent
condition and was ready to be discharged. One patient
lost vision in one eye in which she had been able to
count fingers preoperatively from 1 ft. Preoperative
visual impairment improved in only two patients. One
patient had permanent third cranial nerve palsy. Two
patients had transient diabetes insipidus, and one pa-
FIG. 7. Contrast-enhanced computerized tomography
scans of a patient with a Group II clinoidal meningioma.
Left: Preoperative scan. Right: Scan obtained after total
removal of the tumor including intracavernous and optic
canal extensions. Notice the resection of the anterior clinoid.
J. Neurosurg. / Volume 73/December, 1990
tient had permanent diabetes insipidus. One patient
was readmitted for repair of a CSF leak, and one
required a CSF shunt for hydrocephalus. One other
patient had a pulmonary embolism. The one semico-
matose and one fully comatose patient at admission
both made impressive recoveries postoperatively.
The postoperative follow-up period ranged from 1 to
7 years (average 57 months). There was only one asymp-
tomatic recurrence which was observed to be without
change on a CT scan 3 years later in the one Group II
patient with subtotal removal. Two patients in this
group had a second meningioma remote from the first
(in the convexity), separated from the first operation by
3 and 6 years, respectively. These were removed surgi-
cally.
Only partial but extensive removal was possible in
all three Group I patients. One patient developed de-
layed postoperative vasospasm 7 days postoperatively,
which was confirmed by angiography, with a deterio-
rating ischemic neurological condition and eventual
death 4 months later. The second patient had postop-
erative hemiplegia and was treated for pulmonary em-
bolism. A gradual increase in tumor size over a 3-year
period was documented by CT scanning. Radiation
therapy was administered upon the patient's refusal of
a second operation. The third patient showed some
recovery of extraocular movement and received radia-
tion therapy, showing no changes on an M R image 24
months later.
The two patients in Group III had no complications
and showed neither clinical changes nor recurrence 7
months and 46 months postoperatively, respectively,
according to the last available follow-up report of De-
cember, 1985.
Discussion
Distinguishing Clinoidal Meningiomas
To subclassify anterior clinoidal meningiomas into
three groups may be surprising since many authors find
it difficult to distinguish clinoidal meningiomas from
those with more lateral attachment on the sphenoid
ridge, and prefer the notion of wide or small attach-
ment. 23-2s Stern 4~ has even advocated the concept of an
anatomical continuum of all meningiomas involving
the cranio-orbital junction.
In a discussion of meningiomas of the "clinoidal
third," Cushing and EisenhardP 7 stated, "it is not easy,
with certainty, to identify these cases in the literature."
This statement is still true today. Only a thorough re-
view of the literature can extract cases of anterior cli-
noidal meningiomas (Table 1). An analysis of these
cases leads to recognition of clinoidal meningiomas as
a separate entity with distinguishing clinical, radiologi-
cal, and surgical considerations. Cushing's series is a
typical example: of the 13 patients with anterior clinoi-
dal meningiomas, two were operated on transsphenoi-
dally in 1912 and 19 13, resulting in one operative death.
There was one other operative death. Only three pa-
845
 O. A1-Mefty
TABLE 1
S u m m a r y of major surgical series of anterior clinoid meningiomas*

No. of Partial or Total Operative Recurrence + Known Symptomatic

Authors & Year
Cases Subtotal Removal Removal Death Eventual Death Recurrence
Cushing & Eisenhardt, 1938 1 l+(2)t 8 3 1+(1)# 5
Uihlein & Weyand, 1953 52 17 5
Holub, 1956 19 6 9
Olivecrona, 1967 47 15 32 11 3
Guyot, et al., 1967 13
Cook, 1971 11 3
Fischer, et al., 1973 6 2
Ugrumov, et al., 1979 16 14 2 4
Cophignon et al., 1979 6 4 2 0
Konovalov, et al., 1979 70 13
MacCarty & Taylor, 1979 47
Bonnal, et al., 1980 7 7 3
Pompili, et al., 1982 10 5
Ojemann, 1985 16 0 1
Hakuba, et aL, 1986 7 0
Jan, et al., 1986 19 6
Sekhar, et al., 1989 16 3 13 0
A1-Mefty, 1990 24 4 21 2
* Only available information is entered.
# Two patients were operated on transsphenoidally in 1912 and 1913, one of whom was an operative death.

tients had total removal. Recurrence with eventual
death occurred in five patients.
Bonnal, et al., 9 described a similar series, with only
subtotal removal possible in all seven patients and three
operative deaths. Pompili, e t a / . , 44 reported that only
two of their nine patients with inner sphenoid ridge
meningiomas (five of which were globus tumors) had
excellent results, defined as total removal combined
with complete clinical remission and no clinical or ra-
diological sign of recurrence. A striking difference in
mortality and morbidity rates, failure of total removal,
and recurrence is apparent whenever clinoidal menin-
giomas are compared with middle and lateral sphenoid
tumors or with tuberculum sellae t u m o r s . 9A7'26'29'41'44'52
Recognizing these differences, Bonnal, et al.,9 classi-
fied sphenoid ridge meningiomas into five groups (A to
E), with Group A in their classification representing the
meningiomas discussed in this report. They described
clinoidal or sphenocavernous meningiomas en m a s s e
as: "extended upward into the cranial cavity from the
dura of the cavernous sinus, of the anterior clinoid
process, and of the internal part of the sphenoidal
wings. They were in close contact with the internal
carotid artery and its branches, which were shifted,
stretched, or embedded, and with the optic nerve and
tract. Bone was not involved, except for the anterior
clinoid process, nor were the craniofacial cavities."
They conceded that total removal of these meningi-
omas is difficult even with the help of magnification
and ultrasonic aspiration. This group is similar to the
first category of Ojemann's sphenoid ridge menin-
gioma. 4~
Although meningiomas of the anterior clinoid invade
the cavernous sinus, there exist meningiomas that are
strictly intracavernous, originating from within the cav-
ernous s i n u s . 1~ The latter present with symptoms
and signs of cavernous sinus syndrome, and form a
separate entity; thus, we have excluded them from this
discussion.
T o t a l vs. S u b t o t a l R e m o v a l
The surgical mortality rate associated with anteri-
or clinoidal meningiomas has remained unacceptably
high. Uihlein and Weyand 53 reported a mortality rate
of 32% in 1953, comparable to a 42% mortality rate in
the series of Bonnal, et al., 9 in 1980. Repeatedly, the
operative cause is injury to the major cerebral ves-
sels, 9'17'23'41'43'53 a risk that has forced an overwhelming
number of surgeons to accept and recommend subtotal
removal.6,9,~ L 17,22,23,31,45,51,52,56
Most neurosurgeons have had the experience of care-
fully observing slow-growing tumors, and there have
been reports of patients who remain in satisfactory
condition for years after partial removal of their tu-
mors. 9'3~ On the other hand, the extent of surgical
removal is clearly the most determining factor in tumor
recurrence and progression. 1,37.47,48In the series of Mir-
imanoff, et al., 37 sphenoid ridge meningiomas (with a
28% rate of total resection in all sphenoid ridge loca-
tions) recurred or progressed with a probability at 5 and
10 years of 34% and 54%, respectively. A second op-
eration carries a significantly higher mortality and fail-
ure r a t e . 35'37
Uihlein and Weyand 53 have stated that "total re-
moval of these tumors is necessary to prevent recur-
rence." Cophignon, et al.,~5 stated the point clearly: "to
cure a patient from a spheno-orbital meningioma one
has to remove the entire intradural tumor, all the

846 J. Neurosurg. / Volume 7 3 / D e c e m b e r , 1990

Clinoidal meningiomas
involved dura, the orbital tumor, and all the so-called
hyperostosis, opening the facial and intracranial sinuses,
if necessary."
Recent advances in skull-base exposure, anesthesia,
cerebral protection, microsurgical techniques, imaging,
and surgery of the cavernous sinus have assisted in
overcoming many of the formidable tasks in dissecting
and preserving the vital neural and vascular structures
involved with these tumors. Embedded carotid and
middle cerebral artery branches can be dissected free
under magnification by means of microsurgical tech-
niques. 42~ Extensions into the cavernous sinus
can be removed with preservation of the intracavernous
carotid artery and the cranial nerves. 4'2~ Involved
bone can be extensively drilled away. T M Revasculari-
zation can be performed by EC-IC anastomosis, 38 a
saphenous vein graft, 5~ or direct reconstruction of the
carotid artery using an interposed venous graft 46 (T
Fukushima, personal communication, 1989), providing
a means to alleviate ischemia should injury beyond
repair occur to major cerebral vessels. Delayed throm-
bosis of the internal carotid and middle cerebral arteries
leading to stroke has been reported after surgery of
these tumors, z343 We do not believe, however, that this
potential risk is frequent enough to be a deterrent to
arterial dissection.
Olivecrona4~ reported no recurrences in 26 surviving
patients after complete removal of their medial ridge
meningiomas, with a postoperative follow-up period
of up to 25 years. Reviewing his long-term results in
patients with medial sphenoid ridge meningiomas, Oli-
vecrona concluded, "in the group where the tumor was
completely removed the functional results in the sur-
vivors were highly satisfactory, whereas in the incom-
pletely removed groups some patients lived for many
years but the rate of recurrence was high and the results
of secondary operation far from encouraging." Hence,
the controversy surrounding pursuit of total removal
does not question its value, but reveals the potentially
high price in risk of mortality and morbidity.
The microsurgical technique has clearly improved
the incidence of operative mortality and morbidity and
the chance of total removal. 43233"4551 This is because
the surgeon is able to dissect adherent or encased struc-
tures due to the cleavage of the arachnoid membrane,
which is recognizable under the microscope. Hence, our
classification has a deep impact on surgical decision-
making and outcome. When this membrane was absent
(Group I in our classification), dissection was impossi-
ble; none of the tumors was removed totally and the
outcome was a disappointment. In contrast, despite
total encasement of arteries and nerves, total removal
was possible in Group II, with minimal morbidity.
Unlike other suprasellar meningiomas, recovery of vis-
ual deficits in clinoidal meningiomas is poor. ~4~ This
implicates ischemia as the cause of visual loss in clinoi-
dal meningiomas rather than mere optic nerve com-
pression.
J. Neurosurg. / Volume 73/December, 1990
S m a l l M e n i n g i o m a s o f the Anterior Clinoid
Cushing and Eisenhardt ~7 cited an early example of
a small anterior clinoidal meningioma found at autopsy
and depicted in 1910 by Frotscher. Several cases of
these small meningiomas at the anterior clinoid (Group
III in our classification) can be found. We were able to
isolate 14 such c a s e s 9A6"21"4~ in addition to 22 others
mentioned by Konovalov, et al. 32 These meningiomas
are characterized by severe loss of vision with optic
atrophy on one side, Prior to high-resolution CT and
MR imaging, radiological studies were frequently nor-
mal and the tumor was usually found upon exploration
for unexplained visual loss. This group of tumors is
frequently reported to extend into the optic canal. They
are easily removed; however, visual prognosis remains
guarded because of the ischemic nature of the optic
nerve deficit. These tumors are similar in clinical find-
ings and surgical consideration to intracanalicular me-
ningiomas, which have recently been reviewed by Wil-
son, et al. 57
The Role o f Radiation Therapy
The role of radiation therapy cannot be left unad-
dressed in a discussion of clinoidal meningiomas in
which subtotal removal or recurrence are prominent
features. Waga, et al.,54 were unable to establish whether
prophylactic radiation therapy was effective in prevent-
ing recurrence of benign meningiomas, while Yama-
shita, et al., 58 concluded that irradiation of recurrent
meningiomas is of little value, although it might occa-
sionally be beneficial. Recent reports, however, have
advocated the effectiveness of radiotherapy in conjunc-
tion with subtotal surgical excision. 7Az'55Hence, radia-
tion therapy is a viable adjuvant in treating nonremov-
able residual or recurring tumors. For smaller residual
tumors, stereotactic radiotherapy is an attractive alter-
native awaiting long-term results.
Acknowledgments
The author is grateful to Julie Hipp for help in preparing
the manuscript and to Michael P. Schenk for the drawings.
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Manuscript received January 16, 1990.
Accepted in final form March 30, 1990.
Address reprint requests to: Ossama A1-Mefty, M.D., De-
partment of Neurosurgery, University of Mississippi Medical
Center, 2500 North State Street, Jackson, Mississippi 39216-
4505.
849