Sphenoid wing meningiomas

Meningiomas arising from the region of the sphenoid wing comprise a significant portion of intracranial and skull base meningiomas and present a diverse array of clinical challenges. These tumors can either be focal (globoid) or diffuse (en plaque) in morphology and present a variety of distinct clinical concerns and surgical challenges depending on the location of the tumor along the sphenoid wing. Clinical presentation is variable but visual symptoms are a prominent concern and a frequent driver of clinical decision-making in the management of these tumors. Surgical resection is the most effective treatment of these lesions and a clear understanding of the relevant surgical anatomy of the sphenoid wing is necessary to minimize surgical morbidity. The frontotemporal craniotomy in combination with an interfascial extracranial dissection technique provides excellent surgical exposure for the resection of most sphenoid wing meningiomas. Lateral sphenoid wing meningiomas are the most readily accessible, but can present challenges related to extracranial tumor invasion or with involvement of the sylvian fissure. Medial or clinoidal tumors are generally more challenging to resect, given their location deep on the sphenoid wing and close association with the optic nerve and the internal carotid artery. The anterior clinoidectomy, via either extradural or intradural approach, is an essential step in safely resecting many of these tumors. En plaque, or spheno-orbital, meningiomas are a unique entity given their diffuse nature, tendency to induce a marked hyperostostic reaction, and frequent extension into the orbit. Resection of spheno-orbital meningiomas can be difficult due to the extent of bony resection often required as well as the management of reconstruction following resection. Radiosurgery can be an important adjuvant treatment modality for these tumors when complete resection is not possible or would result in excessive morbidity. Surgical outcomes for resection of sphenoid wing meningiomas are historically poor, but have improved markedly in recent years with improvement in skull base dissection techniques.