- Department of Neurosurgery and Skull Base Surgery, Hospital Ernesto Dornelles, Brazil
- Department of Pathology and Radiation, Pontifical Catholic University of Rio Grande do Sul – PUCRS, Porto Alegre/RS, Brazil
- Service of Hand Surgery and Reconstructive Microsurgery, Pontifical Catholic University of Rio Grande do Sul – PUCRS, Porto Alegre/RS, Brazil
Carlos Eduardo da Silva
Service of Hand Surgery and Reconstructive Microsurgery, Pontifical Catholic University of Rio Grande do Sul – PUCRS, Porto Alegre/RS, Brazil
DOI:10.4103/2152-7806.124978Copyright: © 2014 da Silva CE. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
How to cite this article: da Silva CE, da Silva VD, da Silva JL B. Convexity meningiomas enhanced by sodium fluorescein. Surg Neurol Int 14-Jan-2014;5:3
How to cite this URL: da Silva CE, da Silva VD, da Silva JL B. Convexity meningiomas enhanced by sodium fluorescein. Surg Neurol Int 14-Jan-2014;5:3. Available from: http://sni.wpengine.com/surgicalint_articles/convexity-meningiomas-enhanced-by-sodium-fluorescein/
Background:The resection of the meningiomas surrounding the dura is an important goal during the removal of a convexity meningioma. The authors present the first application of sodium fluorescein (SF) as a tool for tumor and dural tail identification in convexity meningiomas.
Methods:Five frontal convexity meningiomas operated on between December 2012 and April 2013 were included. After initial dissection a dose of 1 g of the SF, 20% was injected into a peripheral vein. Tumor and dural tail were removed using the correlation between magnetic resonance imaging (MRI) findings and transoperative SF enhancement.
Results:Simpson Grade 1 removal was obtained in three cases, grade 2 in one atypical meningioma and grade zero in one case. SF dural tail enhancement was positive in all cases and histologic analysis evidenced involvement of the dura by tumors.
Conclusion:SF enhancement was evident in meningiomas and dura surrounding the lesions. Histologic analysis confirmed dural involvement. SF could represent an universally available fluorescent tool for meningioma surgery.
Keywords: Fluorescent marker, grade zero removal, meningioma, surgical resection
The recognition of the meningiomas and surrounding dural tail limits is one of the most challenging goals during a meningioma resection. Further, the possibility of better tumor control depends on the extension of the tumor to be removed and includes the dura around the mass. Sodium fluorescein (SF) was first used for the identification of different types of brain tumors in 1948.[
A 72-year-old male with recurrence of an atypical meningioma, involving both frontal convexity and superior sagittal sinus (SSP). A partial removal of the bifrontal mass with residual tumor in the SSP, with transoperative SF administration, showed strong evidence of dural and tumoral dye enhancement [Figures
A 62-year-old male with headache and seizures, presenting a large left frontal cystic meningioma on magnetic resonance imaging (MRI) went through a radical removal, with SF transoperative tumor and surrounding dura enhancement. Histological analysis showed evidence of meningothelial meningioma and the dural surrounding area was negative, even with SF irregular enhancement. The patient was discharged without neurological abnormalities.
A 60-year-old female with headaches showing a meningioma in the left motor area on MRI. Transoperative SF administration was used, as described below, with positive tumor and a surrounding dura enhancement [
A 37-year-old female with headaches showing a meningioma in the right frontal lobe on MRI. Transoperative SF administration enhanced tumor and a surrounding dura [Figures
A 57-year–old female with headache and a meningioma in the right frontal lobe on MRI. Trans-operative SF administration enhanced tumor and dural tail [
Transoperative SF administration
The initial dissections were performed, and after exposure of the tumors and their relative positioning within the cortical and vascular structures, a dose of 1 g of the SF 20% was injected into a peripheral vein and included pictures were obtained 10 min after SF administration. Digital photos were taken using digital camera MediLive Carl Zeiss 1 CCD. The light source of the pictures was the same as the microsurgical field, manual white balance was proceeded, capturing images visualized by the surgeon at the microscope without any special filters.
SF enhanced all convexity meningiomas. Dural tail as indicated by MRI findings correlated with transoperative SF dural enhancement was also positive according to the histologic analysis.
The work of Simpson, seminal, which was undertaken during the second half of the last century, taught that the objective and goal for surgically treated meningiomas was to achieve the most radical removal possible.[
Considering the aspects in some cases of convexity meningiomas, those in which the resection could be enlarged with no compromise of the quality of life, and applying the original concept of extensive resection for better disease control, we research a new application of SF in this introductory series.
Fluorescent markers have been used to improve identification of the tumor limits, especially during the resection of gliomas.[
The present study about the application of SF in convexity meningioma surgery was the first investigation of the fluorescent marker for such lesions. Actually, it represents an extension of the previous experience using this substance in skull base tumors.[
The dural tail was the most relevant aspect observed in the present study, in order to achieve radical removal. This could be influenced by SF enhancement. All cases presented SF enhancement of the dura around the meningiomas, in an irregular fashion. Surgical resection was oriented by SF enhancement and MRI preoperative images and histological analysis was evident to the dural involvement by the tumor in all cases [Figures
The transoperative dural SF enhancement helped the radical removal. The only exception was in the case 1, a recurrent atypical meningioma, with invasion of a patent superior sagital sinus, which was preserved [
This introductory series points to a relationship between dural enhancement by SF around the mass and the presence of meningioma in histopathology. In contrast, it is possible that distant portions of dura, which were not enhanced by SF, could be involved by tumor also. The limits of any markers and the understanding of what they are enhancing should be considered when analyzing the applicability of fluorescent methods. Kubben et al. presented an interesting study about the correlation between contrast enhancement in an intraoperative MRI and histopathology in GBM, where they concluded that the absence of contrast enhancement was a bad predictor for the absence of tumor.[
The concern about important dural sinuses, venous channels and eloquent areas involvement during convexity meningiomas dissection is also a reason for researching the applicability of SF. In cases where dural sinuses were supposed to be invaded by the tumors, as the case 1 included in the present study, SF could help as an auxiliary method for transoperative investigation and decisions. In the case illustrated, meningioma was enhanced in the wall of the superior sagital sinus and the preservation of the sinus was helped by the dye [
SF staining during brain tumor surgery is probably related to blood– brain barrier (BBB) disruption.[
In convexity meningiomas with pial invasion and edema surrounding the lesions, BBB disruption permitted a strong enhancement of the tumor [
In the original work of Moore black light was used to enhance the fluorescein penetration.[
The study presents the limitation of small number of patients. Also, we prefer to use standard white light instead of black light or special filters. The fluorescence could be improved with such devices. In fact, a recent study tested the SF guided removal of malignant tumors under YELLOW 560 nm surgical microscope filter with interesting results and lower doses of SF.[
The use of SF is very simple. The substance is safe, presents low cost, and it is a universally available option. The method presented does not require any special techniques or devices, which includes SF as a considerable fluorescent tool for convexity meningiomas surgery.
The initial results of the enhancement by SF of convexity meningiomas and surrounding dura were positive. Further larger studies should evaluate the dye as an alternative for fluorescence-guided convexity meningiomas surgery in order to improve the radical removal.
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