Journal of Neuro-Ophthalmology, March 2003, Volume 23, Issue 1

Visual Outcome in Surgically Treated Suprasellar Meningiomas

OBJECTIVE To determine long-term (>10 years) visual outcome in patients with suprasellar meningiomas.METHODS Retrospective case series.RESULTS Among 18 patients who underwent surgery for suprasellar meningioma (1 patient died postoperatively), 1 experienced initial improvement in vision in both eyes, 8 experienced improvement in vision in one eye and maintained stable vision in the other eye, 2 experienced improvement in vision in one eye and worsening of vision in the other, 3 experienced worsening of vision in one eye and stable vision in one eye, and 4 maintained stable visual acuity in both eyes. No patient experienced postoperative worsening of vision in both eyes. During 10 years or more of follow-up, 10 of the patients (56%) maintained stable vision in both eyes, 6 patients (33%) experienced loss of vision in one eye while maintaining stable vision in the other, and 2 patients (11%) experienced loss of vision in both eyes. During this period, 7 of the 18 patients (39%) developed neuroimaging evidence of tumor growth or recurrence, with a mean time of 10.7 years. Four of these patients were thought to have had gross total resection of their tumor. Patients who experienced worsening of vision during the follow-up period were more likely to have developed neuroimaging evidence of growth or recurrence (five patients) than patients without such evidence (two patients), and such patients did not regain vision following subsequent surgery or radiation therapy. Nevertheless, at final examination, 13 patients (72%) had visual acuity of 20/40 or better in at least one eye.CONCLUSIONS The long-term visual prognosis for patients who undergo surgery for suprasellar meningioma is excellent, although tumor recurrence is common, even in patients thought to have undergone gross total removal of their tumor, and often occurs more than 10 years after surgery. Patients who develop tumor recurrence are likely to lose vision in at least one eye and are unlikely to achieve improvement in vision with subsequent surgery or radiation therapy. Thus, patients with suprasellar meningiomas believed to have been completely resected should undergo long-term, serial postoperative clinical examinations and neuroimaging to allow detection and further treatment of recurrences as early as possible. Postoperative radiation therapy should be considered for patients whose suprasellar meningiomas have been incompletely resected.

ORIGINAL CONTRIBUTION Visual Outcome in Surgically Treated Suprasellar Meningiomas Carlos Filipe Chicani, MD, and Neil R. Miller, MD Obj ective: To determine long- term (> 10 years) visual out­come in patients with suprasellar meningiomas. Methods: Retrospective case series. Results: Among 18 patients who underwent surgery for suprasellar meningioma ( 1 patient died postoperatively), 1 experienced initial improvement in vision in both eyes, 8 experienced improvement in vision in one eye and main­tained stable vision in the other eye, 2 experienced improve­ment in vision in one eye and worsening of vision in the other, 3 experienced worsening of vision in one eye and stable vision in one eye, and 4 maintained stable visual acu­ity in both eyes. No patient experienced postoperative wors­ening of vision in both eyes. During 10 years or more of follow- up, 10 of the pa­tients ( 56%) maintained stable vision in both eyes, 6 pa­tients ( 33%) experienced loss of vision in one eye while maintaining stable vision in the other, and 2 patients ( 11%) experienced loss of vision in both eyes. During this period, 7 of the 18 patients ( 39%) developed neuroimaging evi­dence of tumor growth or recurrence, with a mean time of 10.7 years. Four of these patients were thought to have had gross total resection of their tumor. Patients who experi­enced worsening of vision during the follow- up period were more likely to have developed neuroimaging evidence of growth or recurrence ( five patients) than patients without such evidence ( two patients), and such patients did not re­gain vision following subsequent surgery or radiation therapy. Nevertheless, at final examination, 13 patients ( 72%) had visual acuity of 20/ 40 or better in at least one eye. Conclusions: The long- term visual prognosis for patients who undergo surgery for suprasellar meningioma is excel­lent, although tumor recurrence is common, even in patients thought to have undergone gross total removal of their tu­mor, and often occurs more than 10 years after surgery. Pa­tients who develop tumor recurrence are likely to lose vision in at least one eye and are unlikely to achieve improve­ment in vision with subsequent surgery or radiation therapy. From the Neuro- Ophthalmology Unit, Wilmer Eye Institute, The Johns Hopkins Hospital, Baltimore, Maryland. Address correspondence to Neil R. Miller, MD, Maumenee B- 109, Johns Hopkins Hospital, Baltimore, MD 21287, USA; nrmiller@ jhmi. edu Thus, patients with suprasellar meningiomas believed to have been completely resected should undergo long- term, serial postoperative clinical examinations and neuroimag­ing to allow detection and further treatment of recurrences as early as possible. Postoperative radiation therapy should be considered for patients whose suprasellar meningiomas have been incompletely resected. ( JNeuro- Ophthalmol 2003; 23: 3- 10) eningiomas arising from the tuberculum sellae, also called suprasellar meningiomas, are generally be­nign, well- circumscribed, and slow growing ( 1- 5). They usually are asymptomatic until they damage the anterior visual system ( 6), at which time they produce visual loss in one or both eyes. In addition, they may encase major blood vessels, thus compromising the potential for total removal ( 3). Since the classic monograph by Cushing and Eisen-hardt ( 7) in 1938, many large series have established the role of surgery in the treatment of suprasellar meningiomas. Although attempted removal of these tumors was initially associated with significant mortality and morbidity, a num­ber of factors, including advanced microsurgical tech­niques, intraoperative electrophysiologic monitoring of cranial nerve function, improved neuroanesthesia regi­mens, and postoperative supportive care in specialized in- patient units have reduced operative and postoperative mortality and morbidity ( 8- 12). Nevertheless, although su­prasellar meningiomas are thought to respond well to sur­gical treatment, little information exists regarding long-term visual prognosis associated with these tumors. The aim of the current study was to evaluate the efficacy of treatment of suprasellar meningiomas with respect to long-term visual outcome. METHODS The database of the Neuro- Ophthalmology Unit of the Wilmer Eye Institute at the Johns Hopkins Hospital was searched for all cases with the diagnoses of suprasellar or tuberculum sellae meningioma examined between July 1975 and December 2000. Fifty- four cases were identified, Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. J Neuro- Ophthalmol, Vol. 23, No. 1, 2003 3 JNeuro- Ophthalmol, Vol. 23, No. 1, 2003 Chicani and Miller and the charts of these patients were reviewed. Thirty pa­tients were alive but had follow- up of less than 10 years and were therefore excluded from further evaluation. Of the re­maining 24 patients with follow- up of at least 10 years, complete records were available for 21 ( 87.5%), 19 of whom had undergone treatment of their tumors. All 19 charts were reviewed, and the following data were re­corded: age at presentation, gender, presenting symptom, and time intervals from onset of symptoms to diagnosis, onset of symptoms to treatment, and diagnosis to treatment. The type of treatment, occurrence of tumor progression or recurrence, time from treatment to progression or recur­rence of tumor, and years of follow- up were also recorded. Ophthalmologic findings were noted at the time of diagno­sis, following treatment, and at the most recent examina­tion. The most recent visual status of each patient was de­termined by examination or by telephone interviews with the patients, their relatives, their physicians, or a by combi­nation of these methods, and compared with the patient's status at the time of diagnosis. For purposes of analysis, improvement in visual acuity ( VA) was defined as two or more lines of improvement of Snellen acuity or a change from no light perception ( NLP) to light perception ( LP), LP to hand movements, hand movements to finger counting, finger counting to 20/ 400 vision, or 20/ 25 to 20/ 20 vision. Decreased VA was defined as worsening by two or more lines of Snellen acuity or a change from 20/ 400 to counting fingers, counting fingers to hand movements, hand move­ments to LP, or LP to NLP. The presence of optic neurop­athy was determined by evaluation of several measures of optic nerve function, including visual acuity, color vision, pupillary responses to light stimulation, visual field find­ings, and appearance of the optic disc. An optic neuropathy was considered to be present if more than one parameter was consistently abnormal and could not be explained by another cause, such as amblyopia, cataract, retinal disease, or congenital color blindness. RESULTS Patient Demographics Table 1 depicts the characteristics of the patients. There were 11 women ( 58%) and 8 men ( 42%). The age at presentation ranged from 29 to 71 years, with a mean age at presentation of 49.1 years ( 48.2 years for women; 50.4 years for men) and a median age of 48 years. The interval between the onset of symptoms and diagnosis, treatment, or both could be determined in 16 of the 19 patients ( 84%). The mean time to diagnosis was 22 months ( range of 6 months to 4 years). The mean time from diagnosis to treat­ment was 78 days ( range of 1 to 360 days). One of the pa­tients died shortly after surgery. The length of ophthalmo­logic follow- up for the remaining 18 patients ranged from 10 to 37 years, with a mean of 16.8 years and a median of 14 years. Presenting Symptoms Among the presenting symptoms ( available in all 19 patients), decreased vision was present in all patients. It was monocular in 10 patients ( 53%) and binocular in 9 ( 47%). Headache was present in 3 patients ( 16%). Three patients ( 16%) had noted visual field defects, and 1 patient ( 3%) complained of periocular pain in the eye with decreased vi­sion. Double vision was not a presenting complaint. Presenting Signs At presentation, 17 ( 89.5%) of the 19 patients had V A less than 20/ 20 in one or both eyes related to the effects of the tumor on the optic nerves. One patient (# 1) had VA of 20/ 20 OU associated with bitemporal field defects, and a second patient (# 9) had VA of 20/ 15 OU associated with bitemporal field defects. Eighteen of the 19 patients ( 95%) had VA of 20/ 40 or better in at least one eye. Color vision deficits were present in all eyes with reduced visual acuity, with the severity of the color vision deficit often greater than the severity of visual loss. Visual field defects were also present in all eyes with reduced visual acuity from op­tic nerve involvement as well as in several eyes with normal visual acuity. The visual field defects included arcuate, al-titudinal, and hemianopic defects, as well as central scoto­mas and peripheral constriction. The appearance of the op­tic discs was recorded for 18 ( 95%) patients at presentation. Three patients ( 17%) had bilaterally normal optic discs; 8 patients ( 44%) had one normal disc and one pale disc; 7 ( 39%) patients had pallor of both discs. Overall, 12 ( 63%) patients had evidence of a unilateral optic neuropathy; 7 ( 37%) had evidence of a bilateral optic neuropathy. No patient had other cranial neuropathies ( including ocular motor nerve or trigeminal nerve). Diagnosis All patients underwent at least one neuroimaging study. Patients evaluated between 1975 and 1980 under­went skull radiographs, computed tomographic scanning, cerebral angiography, or a combination. Patients evaluated after 1980 underwent computed tomographic scanning, magnetic resonance imaging, cerebral angiography, or a combination. Treatment Table 1 shows the treatment of each patient, as well as treatment complications and recurrences in the 19 patients. All 19 patients underwent attempted surgical removal of their tumors. Fourteen ( 74%) had a single procedure. Of the remaining five patients, four underwent two operations, the Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. 4 © 2003 Lippincott Williams & Wilkins SURGICALLY TREATED SUPRASELLAR MENINGIOMAS JNeuro- Ophthalmol, Vol. 23, No. 1, 2003 TABLE 1. Pt number/ Gender/ Age at diagnosis l/ M/ 29 2/ F/ 30 3/ M/ 33 4/ F/ 33 5/ F/ 42 6/ F/ 45 7/ F/ 45 8/ F/ 46 9/ M/ 47 10/ M/ 48 1 l/ F/ 49 12/ F/ 55 13/ M/ 57 14/ M/ 58 15/ F/ 58 16/ M/ 60 17/ F/ 63 18/ F/ 64 19/ M/ 71 Patient information Extent of surgical resection Gross total Subtotal Subtotal Gross total Gross total Gross total Gross total Gross total Subtotal Gross total Gross total Gross total Gross total Gross total Subtotal Gross total Gross total Gross total Gross total CF, counting fingers; left eye. Nonvisual mortality and morbidity Died in perioperative period None CSF leak ( after 4t h surgery) None None None None Bone flap infection ( after 2n d surgery) None None None Bone flap infection ( after 2n d surgery) None None None None None None None Preoperative visual acuity OD 20/ 20 LP 20/ 50 20/ 40 CF2' 20/ 30 20/ 20 20/ 70 20/ 15 20/ 20 20/ 30 20/ 30 20/ 40 20/ 20 NLP 20/ 20 20/ 80 20/ 40 20/ 40 OS 20/ 20 20/ 20 20/ 15 20/ 70 20/ 100 NLP 20/ 70 20/ 30 20/ 15 20/ 300 20/ 30 NLP 1/ 400 20/ 400 20/ 15 NLP 20/ 40 20/ 200 20/ 20 Initial postoperative visual acuity ( 6 weeks) OD N/ A 20/ 30 20/ 15 20/ 40 20/ 400 20/ 80 20/ 20 20/ 20 20/ 20 20/ 20 20/ 20 20/ 20 20/ 20 20/ 20 NLP 20/ 20 20/ 70 NLP NLP OS N/ A 20/ 15 20/ 20 20/ 20 NLP NLP 20/ 25 CF1' 20/ 20 20/ 50 20/ 20 NLP CF2' 20/ 400 20/ 20 NLP 20/ 25 20/ 80 20/ 20 Final long. • term visual acuity ( years after surgery) OD N/ A NLP NLP 20/ 40 4/ 400 NLP 20/ 20 20/ 15 20/ 20 20/ 15 20/ 20 20/ 20 20/ 25 20/ 20 NLP 20/ 20 20/ 200 NLP NLP OS N/ A 20/ 15 ( 19) NLP ( 20) 20/ 40 ( 18) NLP ( 10) NLP ( 37) 20/ 25 ( 14) NLP ( 36) 20/ 20 ( 14) 20/ 50 ( 11) 20/ 20 ( 19) NLP ( 17) NLP ( 11) 20/ 400 ( 11) 20/ 20 ( 10) NLP ( 13) 20/ 100 ( 11) 20/ 100 ( 13) 20/ 20 ( 10) F, female; HM, hand motions; LP, light perception; M, male; NA, not applicable; NLP, Time to tumor recurrence ( years) N/ A 8 4 N/ A N/ A 17 N/ A 18 N/ A N/ A N/ A 13 N/ A N/ A 5 N/ A 10 N/ A N/ A Subsequent interventions N/ A None 1. 7 further operations 2. Conventional RT ( 36 Gy) 3. Stereotactic radiosurgery ( 1 Gy) None Conventional RT ( 50 Gy) 1 further operation None 1 further operation Conventional RT ( 50 Gy) 3 months after surgery None None 1 further operation None None Conventional RT ( 50 Gy) at time of recurrence None 1 further operation None None no light perception; OD, right eye; OS, Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. 5 JNeuro- Ophthalmol, Vol. 23, No. 1, 2003 Chicani and Miller second in each case being performed after clinical or neu-roimaging evidence of recurrence. One patient (# 3) under­went eight operations over 29 years and died after the last one. Thus, the 19 patients underwent a total of 30 surgi­cal procedures. No patient received radiation therapy as a primary treatment; four ( 19%) initially treated with surgery received radiation therapy later. Patients # 5 and # 9 received conven­tional fractionated radiation therapy ( 5040 cGy and 5400 cGy, respectively) shortly after initial craniotomy and sub­total removal of their tumors. Patient # 3 received stereotac­tic radiosurgery ( 1000 cGy) after a third craniotomy ( per­formed 11 years after the first procedure) and underwent conventional fractionated radiation therapy ( 3600 cGy) af­ter the fifth surgery ( 28 years after the first one). Patient # 15 received conventional fractionated radiation therapy ( 5400 cGy) after recurrence of the tumor 5 years after initial cra­niotomy. Patient # 2 declined a recommendation for surgery followed by radiation or radiation alone after clinical and neuroimaging findings suggested recurrence of the tumor 8 years after the first surgery. Postoperative Mortality and Nonvisual Morbidity Thirteen of the 19 patients ( 68%) in this series expe­rienced neurologic complications related to surgery ( Table 1). Mortality One patient (# 1) died shortly after surgery from the effects of a large intracranial hemorrhage with secondary cerebral edema. A second patient (# 3) died after the eighth surgery for tumor recurrence. Morbidity Two patients ( 11%) experienced a postoperative bone- flap infection (# 8 and # 12). In one patient, the infec­tion was controlled with systemic antibiotics; in the second, the flap required removal after intravenous antibiotics failed to control the infection. One patient (# 3) had a cere­brospinal fluid leak after his fourth surgery. The leak was treated successfully with a duraplasty. Initial Postoperative Visual Outcome Table 1 indicates the preoperative visual acuity for all 19 patients in this series, the visual acuity 6 weeks follow­ing treatment of the 18 patients who survived the initial operation (" initial postoperative visual acuity"), and the vi­sual acuity at final examination (" long- term visual acuity") 10 years or longer after initial surgery ( see Long- Term Vi­sual Outcome). Of the 36 eyes of 18 surviving patients, visual acuity improved in the initial postoperative period in 13 ( 36%), remained stable in 16 ( 44%), and worsened in 7 ( 19%) ( Fig. 1). All but one of the eyes with worse vision after surgery were completely blind. Initial Postoperative Visual Outcome ( Eyes) Eyes : - / - ,--. i Visual Acuity Status FIG. 1. Initial postoperative visual outcome ( at 6 weeks) compared with preoperative visual status ( eyes). With respect to patients, one ( 6%) had improvement in vision in both eyes, four ( 22%) had the same visual acuity in both eyes after surgery as before surgery, seven ( 39%) experienced improvement in vision in one eye and main­tained stable vision in the opposite eye, four ( 22%) experi­enced improvement in vision in one eye and worsening of vision in one eye, and two ( 11 %>) experienced postoperative worsening of vision in one eye and maintained stable vision in the opposite eye ( Fig. 2). No patient in this series expe­rienced worsening of vision in both eyes in the first 6 weeks following surgery. Thus, 12 patients ( 67%) experienced ini­tial postoperative improvement in visual acuity in at least Initial Postoperative Visual Outcome ( Patients) a of Patients T * 6- 4-" 3 2- 1 ru - - - i - ? Better SamcOU Worse OU on in, ivi si. wi Visual Acuity Status FIG. 2. Initial postoperative visual outcome ( at 6 weeks) compared with preoperative status ( patients). B = better visual acuity; S = same visual acuity; W = worse visual acuity; B1, S1 = better visual acuity in one eye and the same visual acuity in the other; B1 , W1 = better visual acuity in one eye and worse visual acuity in the other; S1, W1 = same visual acuity in one eye and worse visual acuity in the other. Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. 6 © 2003 Lippincott Williams & Wilkins SURGICALLY TREATED SUPRASELLAR MENINGIOMAS JNeuro- Ophthalmol, Vol. 23, No. 1, 2003 one eye, and six patients ( 33%) experienced worsening of vision in one eye. Among the patients who underwent treatment within 1 year of symptom onset, 50%> of eyes retained 20/ 20 vision or experienced postoperative improvement in vision, 27.8% of eyes retained stable vision, and 22.2% o of eyes experienced worsening of vision. On the other hand, among the patients who underwent treatment more than 1 year after symptom onset, 28.5%> experienced postoperative improve­ment in vision, 21.5% had stable vision, and 50% o experi­enced worsening of vision. Thus, almost 80% o of eyes in patients treated within 1 year of symptom onset improved or remained stable following surgery, whereas 70% o of eyes in patients treated more than 1 year after symptom onset either worsened or remained stable. In general, the worse the preoperative visual function, the worse the postopera­tive visual function. Long- Term Visual Outcome During the follow- up period, visual acuity remained stable in 26 eyes ( 72%) and worsened in 10 ( 28%) as com­pared with initial postoperative visual acuity ( Fig. 3). No eyes improved during the follow- up period. All eyes that were blind after surgery remained blind during the follow-up period. With respect to patients, 10 ( 56%) maintained stable vision in both eyes, six ( 33 %) experienced worsening of vision in one eye while maintaining stable vision in the other, and two ( 11%) experienced worsening of vision in both eyes. ( Fig. 4). Of the eight patients who experienced worsening of vision in one or both eyes during the follow-up period, five ( 62.5%) (# 2, # 3, # 6, # 8, and # 17) were among the seven patients in this series who had neuroimag-ing evidence of tumor growth or recurrence during the Long- Term Visual Outcome Compared To Initial Postoperative Visual Outcome ( By Eyes) ffnf Eyes 31) IS 20 15 ] 0 J 0 ..-' - Visual Acuity Status FIG. 3. Long- term visual outcome compared with initial postoperative visual outcome ( eyes). Note that no eye ex­perienced late improvement in visual acuity during the fol­low- up period. Long- Term Visual Outcome Compared To Initial Postoperative Visual Outcome ( By Patients) (?) Patients , n s J ( 1) Hj t \) f J > v {•>) - V Better Same Worse U1. S1 M, W1 S1. W1 OU OU OL Visual Acuity Status () Patients with recurrent tumors FIG. 4. Long- term visual outcome compared with initial postoperative outcome ( patients). B = better visual acuity; S = same visual acuity; W = worse visual acuity; B1 , S1 = better visual acuity in one eye and the same visual acuity in the other; B1, W1 = better visual acuity in one eye and worse visual acuity in the other; SI , W1 = same visual acuity in one eye and worse visual acuity in the other. follow- up period. Four of these five patients underwent fur­ther surgery, radiation therapy, or both, but none experi­enced subsequent improvement in visual function. Among the three patients who experienced worsening of vision in one or both eyes during the follow- up period, but who had no evidence of tumor growth or recurrence by neuroimag-ing (# 4, # 5, and # 13), the degree of visual loss was rela­tively minor. One of these patients (# 4) had reduction in the vision of one eye from 20/ 20 to 20/ 40 over a period of 18 years, one (# 5) had reduction of vision in one eye from 20/ 400 to 4/ 400 over a follow- up period of 10 years, and one (# 13) had reduction of vision from 20/ 20 to 20/ 25 in one eye and from counting fingers to NLP in the other eye over a period of 11 years. None of these three patients un­derwent re- exploration. Overall, 16 of the 18 patients ( 89%) had stable vision in at least one eye during the follow- up period, and at final examination, 17 of 36 eyes ( 47%) had visual acuity of 20/ 40 or better, and 13 of the 18 patients ( 72%) had visual acuity of 20/ 40 or better in at least one eye ( Figs. 5 and 6). DISCUSSION All but one patient in this series presented with uni­lateral or bilateral visual loss and had evidence of a unilat­eral or bilateral optic neuropathy. The one patient who had no evidence of an optic neuropathy had a typical optic chi­asmal syndrome. Although the preponderance of visual manifestations might be attributed to bias of ascertainment, Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. 7 JNeuro- Ophthalmol, Vol. 23, No. 1, 2003 Chicani and Miller Long- Term Visual Outcome ( Eyes) ffof h. ves ^ ^ 20.' 5 « - 20; 20a FIG. Vis a j I Acuity 5. Long- term visual acuity ( eyes). Note that almost half the eyes of patients in the series had visual acuity of 20/ 40 or better. these findings are consistent with those of numerous other authors, including neurosurgeons ( 1,13,14). Patients with these tumors do not tend to have other symptoms or signs. In contrast to patients with parasellar or cavernous sinus memngiomas ( 15), patients with suprasellar memngiomas do not complain of diplopia or facial sensory symptoms and do not have evidence of single or multiple ocular motor nerve pareses or trigeminal neuropathy. Duration of symptoms prior to treatment is thought to be an important factor in the visual outcome of patients with suprasellar meningiomas. Indeed, most authors emphasize that the shorter the duration of symptoms is prior to treat­ment, the better the outcome will be ( 6,13,16,17). For ex­ample, Rosenberg and Miller ( 6) concluded that patients treated within 1 year of symptom onset had a better short-term visual prognosis than patients whose symptoms were present for more than 1 year before treatment. The long-term visual results in this series confirm these findings. Our finding that patients with poor preoperative visual acuity tended to have poor postoperative visual acuity is also in agreement with that of several other authors ( 7,18,19). Two of the 19 patients in this series who underwent surgery ( 10.5%) died in the perioperative period, one after initial surgery and one after an eighth operation for recur­rent tumor. These results are consistent with surgical mor­tality rates ranging from 0% to 7% in other series drawn from the same time period ( 11,13,20,21). The major neurologic morbidity in patients who un­dergo resection of suprasellar meningiomas results from postoperative seizures, infection, cerebrospinal fluid leak, and strokes in the territory of the internal carotid, middle cerebral, anterior cerebral, or anterior communicating arter­ies ( 13,14,22). Most series quote a rate of 20% to 40% ( 11,13,14,20- 22). In our series, there was no major or permanent neurologic morbidity; however, two patients ex­perienced bone- flap infections and one experienced a cere­brospinal fluid leak ultimately requiring a duraplasty. Our rate of neurologic morbidity was thus 15.8%. The most common complication of surgery to remove suprasellar meningiomas is loss of vision. This complica­tion may occur in an eye that already has decreased visual function from the tumor or in an eye that had normal visual function before surgery. Our finding that six of our patients ( 33%) had worse vision in at least one eye after initial surgery is slightly higher than the 20% to 30% rates of visual loss reported in other series ( 6,13,16,17,22- 25). More importantly, there was no late visual improvement in any eye in this series during long- term follow- up. Thus, when worsening of vision occurs after surgery, it is likely to be permanent. Recurrence rates for suprasellar meningiomas range from 5% to more than 30%, the rate increasing with longer follow- up ( 3,26- 28). Factors thought to contribute to recur­rence include extent of tumor removal, strength and extent of dural attachment of the tumor, tumor size, tumor loca­tion, severity of bleeding, and duration of the surgery ( 26). In our series, 39% of the patients experienced neuroimaging evidence of growth or recurrence of tumor over a mean time of 10.3 years. Although four of these patients were known to have had subtotal resections, three were thought by the neurosurgeon to have had a gross total resection. Thus, it is clear that there is a significant risk of recurrence of supra­sellar memngiomas even after gross total resection of the lesion and that the longer the patient is followed, the more likely it is that the tumor will recur. Short- term visual results after removal of suprasellar meningiomas vary considerably among series, with rates of Long- Term Visual Outcome ( Patients) Patients l- f L I ' S-- t>- 4' ! • • tf + n_ ifcirjcr- i 1 -•• 10: 40 20/ 50- 20' 100 < lt)! 2t} 0 Visual Acuity ( Better Eye) * TncLudes 4 pniients vrtNi recmrent tumor ** IiL£ lLidi; 5 1 ptLlitiit with recurrent tumor Ttliluxlea 2ualieiL^ WLl. h recLHreri I. IJTIOT FIG. 6. Long- term visual acuity ( patients). Note that the majority of patients had visual acuity in their better eye of 20/ 40 or better, including four patients with recurrent tumor. Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. 8 © 2003 Lippincott Williams & Wilkins SURGICALLY TREATED SUPRASELLAR MENINGIOMAS JNeuro- Ophthalmol, Vol. 23, No. 1, 2003 improvement ranging from 30% to 70% ( 6,16,17,22, 23,25). In our series, visual acuity at final examination 10 years or more after surgery was at least as good as preop-eratively in 69% of eyes and in 89% of patients ( Table 1), consistent with those series reporting relatively high rates of visual improvement. Indeed, at final examination, 72% of patients had visual acuity of 20/ 40 or better in at least one eye ( Fig. 6). Thus, the long- term prognosis for visual func­tion in patients who undergo resection of a suprasellar me­ningioma appears to be excellent. Although surgery remains the treatment of choice for most patients with meningiomas, there is increasing evi­dence that techniques such as three- dimensional stereotac­tic ( conformal) fractionated radiation therapy and stereo­tactic radiosurgery may reduce the risk of tumor growth or recurrence. In our series, 21% of patients underwent con­ventional fractionated radiation therapy following tumor resection. Two of these patients underwent radiation shortly after initial resection of their tumors, whereas the other two patients received radiation therapy at the time of tumor re­currence. The two patients who received radiation therapy shortly after removal of their tumors had better visual func­tion at final examination than the two patients who received radiation at the time of tumor recurrence. Although these numbers are small, they are consistent with the findings of most short- term studies that report better visual results when patients are treated with radiation shortly after initial surgery ( 2,3,8,29- 37). Although conventional radiation therapy has significant potential risks, including death, loss of vision, pituitary dysfunction, and the development of secondary neoplasms ( 33,34), we believe that the potential benefit of radiation therapy, particularly when stereotactic focusing techniques are used, may outweigh the risks and that postoperative radiation should be considered in all pa­tients with suprasellar meningiomas, particularly when the tumor is subtotally resected. CONCLUSIONS The visual prognosis for patients with suprasellar me­ningiomas who undergo resection of their tumor is excel­lent. Most patients experience short- term stabilization or improvement in one or both eyes and long- term stable vi­sion unless there is recurrence or growth of residual tumor. Because recurrences tend to occur more than 10 years fol­lowing surgery, patients who undergo apparently success­ful gross total removal of their tumors should be counseled regarding the need for continued clinical and neuroimaging follow- up, and postoperative radiation therapy should be considered for patients in whom the tumor can be only sub-totally resected. REFERENCES 1. Al- Mefty O, Holoubi A, Rifai A, et al. Microsurgical removal of suprasellar meningiomas. Neurosurgery 1985; 16: 364- 72. 2. Miralbell R, Linggood R M, de la Monte S, et al. The role of radio­therapy in the treatment of subtotally resected benign meningiomas. JNeurooncol 1992; 13: 157- 64. 3. Mirimanoff RO, Dosoretz DE, Linggood RM, et al. Meningioma: analysis of recurrence and progression following neurosurgical re­section. 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