Al-Azhar Neurosurgery

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Case 8

Case 8 Sphenoid wing meningioma

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Figure 8.1: MRI of the patient axial T1 with contrast and sagittal with contrast.

Clinical presentation

  • A 70-year-old female patient presented to the ER with a decreased level of consciousness (DCL) from two days ago, initially having a Glasgow Coma Scale (GCS) score of 12/15 upon admission. After dehydrating measures, her GCS improved to 14/15. •
  • History of Demnetia and Recent memory loss from 1 year
  • Additionally, she has a history of headache and blurring of vision dating back three months and experienced a generalized tonic-clonic seizure one year ago.
  • Fundoscopic examination showed right-sided papilledema grade 2 and left-sided papilledema grade 3.
  • Q1: What are the grades of papilledema?
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Figure 8.2: Grades of papilledema.

  • Q2: What are the different types of globoid meningioma based on the sphenoid wing?
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Figure 8.3: (a) Art illustration of the different anatomical segments of the sphenoid wing. (b) MRI T1 with gadolinium axial (top) and coronal (bottom) views showing the surgical types of sphenoid wing meningioma. https://link.springer.com/chapter/10.1007/978-3-030-99321-4_17/figures/9

  • Q3: What is the classification of clinoidal meningioma?
  • Type I clinoidal meningiomas are believed to originate from the subclinoidal dura at the most proximal intradural entry point of the internal carotid artery, just before it enters the arachnoidal cisternal space. Al-Mefty noted that these tumors are extraarachnoidal, making them more adherent to the internal carotid artery and difficult to surgically remove, often resulting in higher rates of subtotal resection and recurrence.
  • Type II clinoidal meningiomas are thought to arise from the superolateral aspect of the anterior clinoid process. As these tumors grow, they are enveloped by the arachnoid layers around the carotid cistern, which prevents significant adherence of the tumor to the adventitia of the internal carotid artery wall, facilitating easier surgical dissection and more complete resections.
  • Type III clinoidal meningiomas originate from the region of the optic foramen and extend into the optic canal. Due to their growth pattern within the optic canal region, these tumors tend to become symptomatic early and are diagnosed at smaller sizes compared to Types I and II.

Figure 8.4: (Bony anatomy of the anterior clinoid process region. (Left) The course of the optic nerve (straight arrow) and the course of the internal carotid artery (curved arrow). OC, optic canal; ACP, anterior clinoid process; PCP, posterior clinoid process. (Right) The origin of the different types of clinoidal meningiomas.

  • Q4 : How can the location of a sphenoid wing meningioma affect the clinical presentation of the patient?
  • Depending on the location, the lateral type of sphenoid wing meningioma can present with irritative symptoms such as fits. The middle type can present with temporal lobe epilepsy or frontal symptoms due to subfrontal extension, while the medial type is typically presented by visual symptoms due to compression of the optic nerve. In the case presented, the patient’s symptoms coincide with the middle type. The bilateral presentation of papilledema is due to the mass effect, which increases the intracranial pressure.