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Bono BC, Faedo F, Riva M, Pessina F. Microsurgical resection of a large petroclival meningioma through an extended retrosigmoid approach: how I do it. Acta Neurochir (Wien) 2024; 166:178. [PMID: 38625597 DOI: 10.1007/s00701-024-06073-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2024] [Accepted: 04/04/2024] [Indexed: 04/17/2024]
Abstract
BACKGROUND Petroclival meningiomas are challenging tumors. Several skull base approaches have been proposed in the last decades, with variable rates of postoperative morbidity and extent of resection. METHODS We herein reported the step-by-step microsurgical resection of a large petroclival meningioma through an extended retrosigmoid approach. Detailed surgical technique has been accompanied by a 2D operative video. CONCLUSION The extended retrosigmoid approach allowed for a safe gross total resection of the tumor, as confirmed by the postoperative MRI. The patient did not experience any new postoperative deficit, despite a transient diplopia, and was discharged on postoperative day 7.
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Affiliation(s)
- Beatrice C Bono
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, 20090, Milan, Italy.
- Department of Neurosurgery, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, 20089, Milan, Italy.
| | - Francesca Faedo
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, 20090, Milan, Italy
- Department of Neurosurgery, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, 20089, Milan, Italy
| | - Marco Riva
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, 20090, Milan, Italy
- Department of Neurosurgery, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, 20089, Milan, Italy
| | - Federico Pessina
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, 20090, Milan, Italy
- Department of Neurosurgery, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, 20089, Milan, Italy
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Mastronardi L, Campione A, Alomari AA. Posterior cranial fossa meningiomas: Comparison of results between patients older and younger than 70 years. BRAIN & SPINE 2024; 4:102790. [PMID: 38584865 PMCID: PMC10995794 DOI: 10.1016/j.bas.2024.102790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Revised: 03/10/2024] [Accepted: 03/19/2024] [Indexed: 04/09/2024]
Abstract
Introduction Surgical strategy for meningioma resection in the elderly is controversial: diverse studies in the literature have pointed at the age as a negative prognostic factor in terms of postoperative results. Research question The aim of this study is to compare surgical outcomes after resection of posterior fossa meningiomas in <70 and ≥ 70 years-old age groups. Material and methods We reviewed 72 patients affected by posterior fossa meningiomas who underwent surgical treatment at San Filippo Neri Hospital, Rome, Italy between September 2010 and December 2022. We analyzed data regarding tumor size, clinical presentation, extent of resection and complication/mortality. Results The groups consisted of 52 (72,2%) young and 20 (27,8%) elderly patients. Gross total resection rate was significantly higher among youngsters (p = 0,013), mainly for planned subtotal removal in older patients. At 3-month follow-up, clinical improvement was seen in 19 (36,5%) young and 7 (35,0%) elderly patients, which raised at last follow-up, being 84,6% (44) and 80,0% (16), respectively (p = 0,406). Two cases of progression/recurrence among the elderly and 1 among youngsters were observed; one case of mortality among the elderly was reported. Discussion and conclusions Safety data regarding postoperative complications and mortality in our series seem to confirm that there is no significant difference between older and younger patients, as long as older patients are carefully selected. Therefore, if surgery is proposed, it should be radical if gross total resection could be safely attempted.
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Affiliation(s)
| | - Alberto Campione
- Department of Neurosurgery, San Filippo Neri Hospital/ASLRoma1, Rome, Italy
| | - Amer Ahmad Alomari
- Department of Neurosurgery, San Filippo Neri Hospital/ASLRoma1, Rome, Italy
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Pattankar S, Misra BK. Treatment Strategies and Current Results of Petroclival Meningiomas. Adv Tech Stand Neurosurg 2023; 48:251-275. [PMID: 37770687 DOI: 10.1007/978-3-031-36785-4_9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/30/2023]
Abstract
Petroclival meningiomas (PCMs) are complex skull-base tumors that continue to pose a formidable surgical challenge to neurosurgeons because of their deep-seated location/intimate relationship with the brainstem and neurovascular structures. The advent of stereotactic radiosurgery (SRS), along with the shifting of management goals from complete radiological cure to maximal preservation of the patient's quality of life (QOL), has further cluttered the topic of "optimal management" in PCMs. Not all patients with PCM need treatment ("watchful waiting"). However, many who reach the neurosurgeons with a symptomatic disease need surgery. The goal of the surgery in PCMs is a GTR, yet this can be achieved in only less than half of the patients with acceptable morbidity. The remainder of the patients are better treated by STR followed by SRS for residual tumor control or close follow-up. A small subset of patients with PCM may be best treated by primary SRS. In this chapter, we have tried to summarize the scientific evidence pertaining to the management of PCMs (including the senior author's series), particularly those regarding the available treatment strategies and current outcomes, and discuss the decision-making process to formulate an "optimal management" plan for individual PCMs.
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Affiliation(s)
- Sanjeev Pattankar
- Department of Neurosurgery and Gamma Knife Radiosurgery, P D Hinduja Hospital and MRC, Mumbai, India
| | - Basant K Misra
- Department of Neurosurgery and Gamma Knife Radiosurgery, P D Hinduja Hospital and MRC, Mumbai, India.
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Surgical and Functional Outcome after Resection of 64 Petroclival Meningiomas. Cancers (Basel) 2022; 14:cancers14184517. [PMID: 36139677 PMCID: PMC9496694 DOI: 10.3390/cancers14184517] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2022] [Revised: 09/11/2022] [Accepted: 09/14/2022] [Indexed: 11/17/2022] Open
Abstract
Objective: The management of petroclival meningiomas (PCMs) remains notoriously difficult due to their close association with neurovascular structures and their complex anatomy, hence the surgical paradigm change from radical to functional resection in the past. With this study, we aimed to analyze surgical and functional outcomes of a modern consecutive series of patients with PCMs. Methods: We reviewed patient charts and imaging data of 64 consecutive patients from 2006 to 2018 with a PCM resected at our institution and compared surgical and functional outcomes between subgroups stratified by surgical approach. Results: Females comprised 67.2% of patients (n = 43), with a mean age of 55 years (median 56; range 21-84). Follow-up data were available for 68.8% and reached a mean of 42.3 months (range 1-129) with a median of 28.5 months. The mean tumor diameter was 37.3 mm (standard deviation (SD) 15.4; median 37.0). Infiltration of the cavernous sinus was observed in 34 cases (53.1%), and the lesions affected the brain stem in 28 cases (43.8%). Preoperative cranial nerve palsy was observed in 73.4% of cases; trigeminal neuropathy (42.2%), hearing loss (32.8%), and impairment of vision (18.8%) were the most common. A retrosigmoid approach was employed in 47 cases (78.1%), pterional in 10 (15.6%), combined petrosal in 2 (3.1%), and transnasal and subtemporal in 1 (1.6%). Fifteen cases (23.4%) were resected in a two-staged fashion. Gross total resection (GTR) was attempted in 30 (46.9%) cases without cavernous sinus infiltration and was achieved in 21 (70.0%) of these cases. Surgical complications occurred in 13 cases (20.3%), most commonly meningitis (n = 4; 6.3%). Postoperatively, 56 patients (87.5%) developed new cranial nerve palsy, of which 36 (63.6%) had improved or resolved on last follow up. Achieving GTR was not significantly associated with higher rates of surgical complications (chi-square; p = 0.288) or postoperative cranial nerve palsy (chi-square; p = 0.842). Of all cases, 20 (31.3%) underwent postoperative radiation. Tumor progression was observed in 10 patients (15.9%) after a mean 102 months (median 124). Conclusions: Surgical resection remains the mainstay of treatment for PCMs, with perioperative cranial neuropathies exhibiting favorable recovery rates. Most essentially, the preselection of patients with hallmarks of brain stem affection and cavernous sinus infiltration should dictate whether to strive for a functionally oriented strategy in favor of radical resection.
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Di Carlo DT, Capo G, Fava A, Cagnazzo F, Margil-Sànchez M, Champagne PO, Voormolen EHJ, Morganti R, Froelich S, Perrini P. Petroclival meningiomas: the risk of post-operative cranial nerve deficits among different surgical approaches-a systematic review and meta-analysis. Acta Neurochir (Wien) 2020; 162:2135-2143. [PMID: 32424566 DOI: 10.1007/s00701-020-04395-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Accepted: 05/04/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND The surgical resection of petroclival meningiomas (PCMs) remains a challenge. Both the relationship with neurovascular structures and the deep location of the tumor can affect the extent of resection and the rate of post-operative morbidity. METHODS The authors performed a systematic review and meta-analysis of the literature examining the rate of new cranial nerve (CN) deficits after resection of PCM. A systematic search of two databases was performed for studies published between 1990 and 2018. Random-effect meta-analysis was used to pool the rate of post-operative CN deficits, mortality rate, and rate of radical resection. RESULTS We included twelve studies and 334 patients harboring PCM. The overall rate of complete resection was 68% (95% CI 57.9-78.2%; p < 0.01; I2 = 83%). The rate of early and late post-operative CN deficits was the following: 3.8 and 2.7% (III CN), 6.6 and 3% (IV), 7.3 and 5.5% (V CN), 8 and 3.6% (VI CN), 8.9 and 8.9%% (VIII), and 4 and 2.7% (IX-XI CNs) (I2 = 0%, and p < 0.01 for all analyses). The risk of post-operative deficit of the IV CN was higher among the petrosal group (7.6%; I2 = 0% vs 2.1%; I2 = 0%), whereas the impairment of VII CN function was higher among retrosigmoid group (16.6%; I2 = 64.6% vs 11.4%; I2 = 52.8%), but it was transient in the majority of cases. CONCLUSIONS This systematic review and meta-analysis provides a detailed overview of post-operative CN deficits ensuing surgical resection of PCMs. These findings should be acknowledged when counseling patients with PCMs regarding the more appropriate approach for their tumor.
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Affiliation(s)
- Davide Tiziano Di Carlo
- Department of Neurosurgery, Azienda Ospedaliero Universitaria Pisana (AOUP), Via Paradisa 2, 56100, Pisa, Italy.
- Neurosurgical Department, Lariboisière Hospital, Université Paris Diderot, Paris, France.
| | - Gabriele Capo
- Neurosurgical Department, Lariboisière Hospital, Université Paris Diderot, Paris, France
| | - Arianna Fava
- Department of Neurosurgery, Azienda Ospedaliero Universitaria Pisana (AOUP), Via Paradisa 2, 56100, Pisa, Italy
- Neurosurgical Department, Lariboisière Hospital, Université Paris Diderot, Paris, France
| | - Federico Cagnazzo
- Neuroradiology Department, University Hospital Gui-de-Chauliac, CHU de Montpellier, Montpellier, France
| | - Miguel Margil-Sànchez
- Neurosurgical Department, Lariboisière Hospital, Université Paris Diderot, Paris, France
| | | | - Eduard H J Voormolen
- Neurosurgical Department, Lariboisière Hospital, Université Paris Diderot, Paris, France
| | - Riccardo Morganti
- Department of Clinical and Experimental Medicine, Section of Statistics, University of Pisa, Pisa, Italy
| | - Sébastien Froelich
- Neurosurgical Department, Lariboisière Hospital, Université Paris Diderot, Paris, France
| | - Paolo Perrini
- Department of Neurosurgery, Azienda Ospedaliero Universitaria Pisana (AOUP), Via Paradisa 2, 56100, Pisa, Italy
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Isolan GR, Wayhs SY, Lepski GA, Dini LI, Lavinsky J. Petroclival Meningiomas: Factors Determining the Choice of Approach. J Neurol Surg B Skull Base 2017; 79:367-378. [PMID: 30009118 DOI: 10.1055/s-0037-1608654] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2017] [Accepted: 09/30/2017] [Indexed: 10/18/2022] Open
Abstract
Objectives To review a surgical series of petroclival meningiomas and the factors considered in the choice of approach. Design Retrospective review. Setting The study was conducted in a university hospital in southern Brazil. Participants Twenty-two patients with petroclival meningioma originating from the upper two-thirds of the clivus medial to the fifth cranial nerve. Main Outcome Measures Gross-total resection, mortality, major morbidity, new cranial nerve deficits and tumor progression or recurrence. Results Retrosigmoid approach was used in tumors <3 cm and in those at or below the internal auditory meatus. Posterior petrosectomy was performed for tumors extending into the middle fossa. Gross-total resection was performed in 11 patients (50%). The mean follow-up time was 32 months (6-75 months). There were four cases of tumor progression or recurrence, which were treated with radiosurgery. Conclusions Resection of petroclival meningiomas remains challenging. In most cases, the retrosigmoid approach was sufficient, without affecting the degree of tumor resection. Petrosal approaches were reserved for patients with tumor extension into the middle fossa.
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Affiliation(s)
- Gustavo Rassier Isolan
- Graduate Program in Medicine: Surgical Sciences, Universidade Federal do Rio Grande do Sul (UFRGS); Neurotology and Acoustic Neuroma Center (CNNA); Clínica Lavinsky; Hospital Moinhos de Vento - Porto Alegre, Rio Grande do Sul, Brazil.,The Advanced Neurology and Neurosurgery Research Center (CEANNE), Porto Alegre, Rio Grande do Sul, Brazil
| | - Sâmia Yasin Wayhs
- Graduate Program in Medicine: Surgical Sciences, UFRGS, Porto Alegre, Rio Grande do Sul, Brazil
| | - Guilherme Alves Lepski
- Department of Neurology, Division of Neurosurgery, Universidade de São Paulo (USP), São Paulo, São Paulo, Brazil.,Department of Neurosurgery, Eberhard Karls University, Tübingen, Germany
| | - Leandro Infantini Dini
- The Advanced Neurology and Neurosurgery Research Center (CEANNE), Porto Alegre, Rio Grande do Sul, Brazil
| | - Joel Lavinsky
- Hospital Moinhos de Vento, Porto Alegre, Rio Grande do Sul, Brazil.,CNNA; Clínica Lavinsky, Porto Alegre, Rio Grande do Sul, Brazil
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Maurer AJ, Safavi-Abbasi S, Cheema AA, Glenn CA, Sughrue ME. Management of petroclival meningiomas: a review of the development of current therapy. J Neurol Surg B Skull Base 2014; 75:358-67. [PMID: 25276602 PMCID: PMC4176539 DOI: 10.1055/s-0034-1373657] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2013] [Accepted: 02/23/2014] [Indexed: 10/25/2022] Open
Abstract
The surgical management of petroclival meningioma remains challenging, due to the difficulty of accessing the region and the vital structures adjacent to the origin of these tumors. Petroclival meningiomas were originally considered largely unresectable. Until the 1970s, resection carried a 50% mortality rate, with very high rates of operative morbidity if attempted. However, in the past 40 years, advances in neuroimaging and approaches to the region were refined, and results from resection of petroclival meningiomas have become more acceptable. Today, the developments of a multitude of surgical approaches as well as innovations in neuroimaging and stereotactic radiotherapy have proved powerful options for multimodality management of these challenging tumors.
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Affiliation(s)
- Adrian J. Maurer
- Department of Neurosurgery, University of Oklahoma Health Science Center, Oklahoma City, Oklahoma, United States
| | - Sam Safavi-Abbasi
- Department of Neurosurgery, University of Oklahoma Health Science Center, Oklahoma City, Oklahoma, United States
| | - Ahmed A. Cheema
- Department of Neurosurgery, University of Oklahoma Health Science Center, Oklahoma City, Oklahoma, United States
| | - Chad A. Glenn
- Department of Neurosurgery, University of Oklahoma Health Science Center, Oklahoma City, Oklahoma, United States
| | - Michael E. Sughrue
- Department of Neurosurgery, University of Oklahoma Health Science Center, Oklahoma City, Oklahoma, United States
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Ebner FH, Koerbel A, Roser F, Hirt B, Tatagiba M. Microsurgical and endoscopic anatomy of the retrosigmoid intradural suprameatal approach to lesions extending from the posterior fossa to the central skull base. Skull Base 2011; 19:319-23. [PMID: 20190941 DOI: 10.1055/s-0029-1220199] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
This article evaluates the accessibility of the posterior part of the central skull base via the extended retrosigmoid intradural suprameatal approach. In formaldehyde-fixed specimens, the retrosigmoid intradural suprameatal approach was performed, and the feasibility of reaching central skull base structures was analyzed. Microscopic and endoscopic techniques were used. The main outcome measures were digital films and screenshots, which were analyzed regarding quantitative and qualitative aspects of visual structures. By drilling off the suprameatal tubercle and part of the petrous apex, Meckel's cave may be opened, the trigeminal nerve mobilized, and the tentorium divided. Thus the parasellar area may be exposed and the posterosuperior space of the cavernous sinus approached. Using an endoscope-assisted technique and following cisternal anatomy, the sellar and parasellar region may be explored even if the working space is narrow. The retrosigmoid intradural suprameatal approach provides optimal accessibility to medially located central skull base structures, in particular to the posterior part of the cavernous sinus. Use of the endoscope may remarkably optimize the accessibility.
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Affiliation(s)
- Florian H Ebner
- Department of Neurosurgery, Eberhard-Karls-University, Tuebingen, Germany
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Schroeder HWS, Hickmann AK, Baldauf J. Endoscope-assisted microsurgical resection of skull base meningiomas. Neurosurg Rev 2011; 34:441-55. [PMID: 21614425 DOI: 10.1007/s10143-011-0322-9] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2010] [Revised: 03/15/2011] [Accepted: 04/23/2011] [Indexed: 11/25/2022]
Abstract
This study aims to determine the value of endoscope assistance in the microsurgical resection of skull base meningiomas. Fourty-six patients harboring a skull base meningioma underwent an endoscope-assisted microsurgical resection. In 30 patients (65%), tumor parts which could not be visualized under the microscope were detected with the endoscope. In 26 patients (56%), these tumor remnants were removed under endoscopic view. Gross total resection was achieved in 35 patients (76%) and near-total resection in 11 (24%). There was no surgical mortality. The major complication was new cranial nerve deficit. The application of endoscopes was most useful in the small supraorbital craniotomies to look under the ipsilateral optic nerve and internal carotid artery as well as to visualize the diaphragm sellae and olfactory groove. In the retrosigmoid craniotomies, the endoscope was beneficial to inspect the internal auditory canal, to look into Meckel's cave, or to inspect areas hidden behind the jugular tubercle and tentorial edge. There was no obvious complication related to the application of the endoscope. Endoscope assistance is particularly of value when skull base meningiomas are to be removed via small craniotomies to inspect blind corners which cannot be visualized in a straight line with the microscope. In addition, there is a benefit of using endoscopes with various angles of view in standard craniotomies and skull base approaches to look around bony and dural corners or to look behind neurovascular structures, by which the amount of skull base drilling and retraction to expose the tumor can be reduced.
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Affiliation(s)
- Henry W S Schroeder
- Department of Neurosurgery, Ernst Moritz Arndt University, Sauerbruchstr, 17487, Greifswald, Germany.
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Abstract
BACKGROUND AND OBJECTIVE The antero- or persigmoid approach preserves all functional structures of the petrous bone and, therefore, is an alternative to the classic laterobasal approaches for exploring the petroclival region. As high morbidity is assumed and it is a time consuming procedure, this approach is not well known. METHODS AND PATIENTS Initially, a cadaver study using computer assisted surgery was used to determine the surgical workflow before we optimized our surgical procedures. RESULTS In a series of 7 patients with benign tumors growing from the petrous apex to the petroclival region, we were able to resect all tumors completely via the anterosigmoidal surgical corridor using computer assisted surgery. CONCLUSIONS The navigation-guided anterosigmoidal approach is an excellent method, allowing a good overview of the petroclival region. In patients suffering from complex petroclival tumors, it offers a real chance to achieve complete microsurgical tumor resection without functional defects by an interdisciplinary neuro-oto-surgical session.
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Affiliation(s)
- J Schipper
- Universitätsklinik für Hals-, Nasen- und Ohrenheilkunde und Poliklinik, Universitätsklinikum Freiburg.
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