Complication Analysis after Resection of Parasagittal and Superior Sagittal Sinus Meningiomas

Introduction: Parasagittal meningiomas (PSM) present a unique challenge given their intimate relationship with medial bridging veins and involvement of the superior sagittal sinus (SSS). The intraoperative compromise of these might be a source of significant postoperative complications, including catastrophic intraparenchymal hemorrhage (IPH). Although a lack of SSS opacification on preoperative imaging is usually considered suggestive of sinus occlusion and that resection of such a SSS segment is usually presumed to be safe, up to a 10% complication rate has been reported. Over time, less aggressive approaches favoring SSS preservation followed by adjuvant radiotherapy have been adopted by many neurosurgeons. However, in particular in higher grade tumors or in those following a failed prior treatment, an aggressive surgery including SSS sacrifice might be warranted even in the modern era. In this study, we investigated hemorrhagic and non-hemorrhagic complications following PSM surgery and factors associated with complications.

Materials and Methods: We conducted a retrospective review of all patients who underwent resection of PSM from 2012 to 2020 at our tertiary care center. All patients were included if (1) they harbored a pathologically confirmed meningioma; (2) Sindou grade I–VI; (3) had available complete preoperative and postoperative imaging and clinical information.

Results: We included 62 patients, including 24 (38.7%) cases of SSS resection. Postoperative hemorrhage was noted in 8 tumors (12.9%) in 7 patients (11.3%). Hemorrhages ranged from 1 day to 4 years after surgery. There was one case of a catastrophic hemorrhage; one case of bilateral IPH with generalized brain edema requiring decompressive craniectomy; and a patient with a severe postoperative headache, hemiplegia and aphasia without hemorrhage requiring a balloon angioplasty of his preoperatively stenosed SSS with a resolution of all his symptoms. No difference in the patients’ age, preoperative tumor volume or Simpson grade of resection was noted between hemorrhage and non-hemorrhage group (p = 0.216, p = 0.871 and p = 0.2418, respectively). Resection of the SSS was not associated with postoperative IPH (no IPH 54 (87.1%), IPH 8 (12.9%), p = 0.1388), regardless of the segment resected (anterior 1/3, p = 0.7340, middle 1/3, p = 0.2983, posterior 1/3, p = 0.8984). Similarly, involvement of more than one SSS segment was not associated with higher risk of postoperative hemorrhage (p = 0.0938). However, a prior surgery and a higher tumor grade were independently associated with greater risk of postoperative hemorrhage (p = 0.0003, p = 0.007, respectively). Patients with SSS resected with preoperatively stenosed SSS were at increased risk of hemorrhage compared with preoperatively occluded or patent sinus (p = 0.0010 vs. p = 0.2631 and p = 0.6847, respectively). Long-term postoperative holocephalic headaches were reported at the follow-up in 14 (22.58%), positively associated with the resection of the SSS (p = 0.0003). Four (6.56%) patients had CSF diversion procedure noted at the last follow up. Mortality was noted in three out of seven patients who had a postoperative hemorrhage, four patients fully recovered.

Conclusion: Parasagittal meningiomas of higher grades and those previously treated represent a high risk group for postoperative hemorrhage, in particular those with stenosed SSS on preoperative imaging, irrespective of SSS sacrifice.

Publication History

Article published online:
07 February 2025