Meningiomas of the jugular foramen

Intraforaminal Dural Septations of the Jugular Foramen: A Cadaveric Study

OBJECTIVE

The aim of this study was to define the types, prevalences, and diameters of dural septations (DSs) on the inner surface of the jugular foramen (JF) and to describe the distances between the JF, the glossopharyngeal nerve (cranial nerve [CN] IX), vagus nerve (CN X), and accessory nerve (CN XI), the internal acoustic meatus, and nearby surgical landmarks on cadaveric heads.

METHODS

Seventeen adult (9 men and 8 women) formalin-fixed cadaveric heads were used to analyze the types and prevalence of DS bilaterally. Diameters and distances between the DS and the adjacent CNs (CN IX-XI) were measured by digital microcaliper. The multiple t test (SPSS version 25) was used to analyze the comparison between both sides via diameters, numbers, distance, length, and thickness of DS.

RESULTS

The most frequent type of DS was type I (62.5%, right; 56.3%, left), followed by type II (18.8%, right; 25%, left), type III (12.5%, right; 6.3%, left), and type IV (6.3%, right; 12.5%, left). The mean diameter of the septum was 0.6-1 mm, and the mean length of the dural septa was 4.01 mm (right) and (3.83 mm) left. The difference in the length and thickness of the DS between the genders was statistically significant on both sides (P < 0.05). The DS-CN X and DS-JF distances of women were greater than those of men on the right side (P < 0.05).

CONCLUSIONS

The significant differences between dural septum types on the 2 sides of the body may indicate asymmetric location or a variant emerging site of CNs in the same individual.

Natural history of intracranial meningiomas

We know that the extent of resection is the greatest predictor of long-term survival. However, the potential tradeoff for gross total resection in difficult locations is diminished quality of life. Benign subtotally resected or small incidentally discovered meningiomas may be followed clinically especially in the elderly. In addition, radiosurgery plays a role in the treatment of meningiomas as a primary treatment modality, or as a salvage therapy. Decisions regarding management should be made with an understanding of the natural history and rate of growth. In this chapter we review the known meningioma epidemiology as well as the growth patterns of meningiomas based upon location.

Function-Preserving Multimodal Treatment for Jugular Foramen Meningiomas

Objectives  Despite being pathologically benign, jugular foramen meningioma (JFM) may be locally aggressive and spread in three compartments. Because of the complex anatomical location, radical removal of JFM usually causes serious morbidity through lower cranial nerve (LCN) deficits. To accomplish long-standing tumor control with good functional outcomes, we report function-preserving multimodal treatment (FMT) for JFM, comprising the combination of intradural tumor removal with the preservation of LCN function and stereotactic radiosurgery (RS) for the residual tumor. Materials  This study investigated six JFM patients (five women, one man). Preoperatively, five patients showed no LCN sign. Results  All patients underwent function-preserving retrosigmoid intradural tumor removal, and no patient developed new LCN deficit. Three patients underwent RS for the residual tumor at 8 to 12 months after surgery. After RS, all three tumors were controlled. No patients showed tumor recurrence or new LCN deficits in the follow-up period (2 months to 8 years). Conclusion  FMT for JFMs can accomplish long-standing tumor control with excellent functional outcomes.

Dumbbell-Shaped Jugular Foramen Tumors Extending to the Neck: Surgical Considerations Based on Imaging Findings

OBJECTIVE

Dumbbell-shaped jugular foramen tumors (DSJFTs) extending to the neck present diagnostic and management difficulties because of their rarity, various pathologies, and multidisciplinary involvement. Accurate imaging findings are of great importance for surgical planning and clinical outcomes. However, few articles have discussed this issue to date.

METHODS

Thirty-one patients with DSJFTs extending to the neck were surgically treated in a single stage at our institute. Their clinical and radiologic features, operative procedures, and outcomes were retrospectively reviewed.

RESULTS

Preoperative correct diagnosis of DSJFTs extending to the neck was made in all cases of benign tumor and in only 3 cases of malignant tumors in this series. All tumors were removed via a craniocervical approach by a multidisciplinary skull base team because of both their intracranial and neck extensions. Total removal was achieved in 26 patients (83.9%). Preoperative symptoms were improved in 18 patients, whereas new or worsening lower cranial nerve deficits occurred in 4 patients postoperatively. Follow-up (1-132 months, mean 64.4 months) was available in 90.3% of the patients. No clinical or radiologic signs of tumor recurrence were observed.

CONCLUSIONS

Preoperative radiologic evaluation of DSJFTs extending to the neck is essential for differential diagnosis, patient selection, and surgical planning. Favorable surgical outcomes can be achieved via a craniocervical approach, and some detailed imaging findings are helpful to increase the safety of tumor resection and reduce the morbidity of lower cranial nerve deficits and cerebrospinal fluid leakage.

Surgical Resectability of Skull Base Meningiomas

With recent advances in surgical technology such as preoperative imaging, neuro-monitoring, and surgical instruments, the surgical resectability of intracranial meningiomas has increased over the last two decades. This study reviewed clinical articles regarding the surgical treatment of meningiomas to clarify the role of surgical excision, with a focus on skull base meningiomas. We sub-classified clinical articles about skull base meningiomas into two categories (anterior and middle fossa meningiomas; and posterior fossa meningiomas) and reviewed papers in each category. In cases with anterior and middle fossa meningiomas, surgical resectability has reached a sufficient level to maximize functional preservation. In cases of posterior fossa meningioma, however, surgical respectability remains insufficient even with full use of recent surgical modalities. Continuous refining of operative procedures is required to obtain more satisfactory outcomes, especially for posterior fossa meningioma. In addition, recent long-term outcomes of stereotactic radiosurgery (SRS) were acceptable for controlling the skull base meningiomas. Therefore, combination with surgical excision and SRS should be considered in complicated skull base meningiomas.

Microsurgical management of primary jugular foramen meningiomas: a series of 22 cases and review of the literature

This study summarized clinical manifestations, surgical management, histological grading, and long-term outcome of jugular foramen meningiomas (JFMs). Retrospective study was performed in 22 consecutive patients with primary JFMs from January 2004 to October 2010, enrolling 10 men and 12 women with average age of 39.4 (14-57 years). The most common initial symptom is hearing disorder, followed by lower cranial nerve dysfunctions. The tumor was classified into type I (intracranial) in 1, type II (intracranial) in 15, type IV (intracranial-extracranial) in 6, and none type III (extracranial). Surgical approaches mainly included retrosigmoid in 7, far lateral in 10, and juxtacondylar in 5, with some variations. The gross total resection was achieved in 15 cases and subtotal resection in 7. Fourteen patients (63.6 %) developed new or worse neurological deficits immediately after operation, of whom 11 (78.6 %) got alleviation. Postoperatively, keeping airway patency and prevention from aspiration pneumonia is very important. Nasotracheal intubation is much more tolerated than orotracheal intubation for postoperative patient management. WHO grade 2 was found in four cases (18.2 %) and grade 3 in one. During the average time of follow-up in 83.2 months, only one (grade 3) died of tumor regrowth 20 months after surgery and radiosurgery. Five of 17 patients of grade 1 developed tumor regrowth. Radiosurgery provides a good tumor control for tumor regrowth in grade 1, or postoperative grade 2 tumor. In conclusion, JFMs has a favorable long-term overall survival; however, neurological preservation is still challenging, especially low cranial nerves.

Papillary meningioma of the jugular foramen: A case report

Papillary meningioma (PM) is a rare histological variant of intracranial meningioma, which displays an aggressive behavior and its management is difficult. The present study reported the case of a 21-year-old male patient, who presented with headaches and dizziness. Upon neurological examination, left hypoglossal nerve palsy and left cerebellar signs were observed. Computed tomography and magnetic resonance imaging scans of the brain revealed a high-density mass in the left jugular foramen area. Following an uneventful complete surgical resection of the tumor, a definitive diagnosis of Grade III PM was determined based on the histopathological findings, according to the World Health Organization classification. CT scanning one day after surgery confirmed that the tumor had been completely resected, and after four years of follow-up, no evidence of transformation or recurrence was observed.

Multi-size, Multi-angle Microbipolar Forceps for Skull Base Surgery: Technical Note

Objective Hemorrhage control in skull base surgery is critical but hindered by the lack of instruments suitable for coagulating structural curves and corners. The main impediment is that most of the instruments currently used are right-angled and unsuitable because anatomical and pathologic structures are three-dimensional objects having complex curves and corners. In this article, we present a solution: the use of angled bipolar microforceps having a range of small diameters and angles for dissection and coagulation.

Methods Utilizing modern design software and up-to-date synthetic and metallic materials, a variety of nonstick bipolar microforceps with different angles and very fine tips (0.2–1.2 mm) were designed and constructed for use on different anatomical and pathologic curves. The tips of the forceps were made very fine to improve coagulation precision as well as to improve microdissection dexterity. The blades were made long and thin to improve visibility during coagulation and dissection procedures. As a result, these multi-size, multiangle micro instruments can be used not only for coagulation but also for microdissection or tumor removal in most anatomical areas accessed during the course of skull base surgery

Results The research, design, and construction of a new bipolar microforceps with different angles and sizes represents a technical innovation that can lead to improved surgical outcomes.

Conclusion The new micro-instruments enhance the quality and quantity of tumor and tissue resection and dissection in skull base surgery and open the possibility of new surgical approaches to microscopic tumor resection and hemorrhage coagulation in the anatomical areas of the skull base.

Surgical treatment of jugular foramen meningiomas

OBJECT

We present our experience with surgery of jugular foramen meningiomas with special consideration of clinical presentation, surgical technique, complications, and outcomes.

METHODS

This retrospective study includes three patients with jugular foramen meningiomas treated by the senior author between January 2005 and December 2010. The initial symptom for which they sought medical help was decreased hearing. In all of the patients there had been no other neurological symptoms before surgery. The transcondylar approach with sigmoid sinus ligation at jugular bulb was suitable in each case.

RESULTS

No death occurred in this series. All of the patients deteriorated after surgery mainly due to the new lower cranial nerves palsy occurred. The lower cranial nerve dysfunction had improved considerably at the last follow-up examination but no patient fully recovered. Two of three patients with preoperatively impaired yet functional hearing deteriorated after surgery with no subsequent cranial nerve VIII function improvement. In one case postoperative stereotactic radiosurgery was performed due to non-radical tumour resection (Simpson Grade IV) and tumour remnant proved stable in the 4-year follow-up. None of the patients have shown signs of tumour recurrence in the mean follow-up period of 56 months.

CONCLUSIONS

Jugular foramen meningiomas represent one of the rarest subgroups of meningiomas and their surgical treatment is associated with significant risk of permanent cranial nerve deficits.

Nonvascular lesions of the jugular foramen: the gruppo otologico experience

Tumors other than paragangliomas in the jugular foramen are uncommon. Of these, schwannomas and meningiomas predominate. Little clinical data are available in the literature on these tumors at this site. The purpose of this article is to review our experience at the Gruppo Otologico of the management of these tumors. A retrospective series is presented of 32 consecutive patients affected by jugular foramen schwannomas and meningiomas in which their clinical and radiological signs, together with surgical techniques and outcomes, were reviewed. A single-stage resection was possible for the majority of patients when the petro-occipital trans-sigmoid (POTS) approach was used. This allowed resection of both intra- and extradural components of the tumor with hearing preservation and avoidance of facial nerve transposition. No deaths occurred. Lower cranial nerve palsies constituted the major cause of morbidity, but none of the patients required an adjunctive procedure such as vocal cord medialization, tracheostomy, or percutaneous gastrostomy.

Contemporary surgical outcome for skull base meningiomas

Although surgical excision of meningioma and its dural base is the most common primary management, skull base meningiomas are quite different, and contemporary management usually consists of multimodal treatment with the aim of achieving the best possible functional outcome and quality of life (QOL) for these patients. As surgery plays an important role in the treatment of skull base meningiomas, it is crucial for neurosurgeons to appreciate the surgical outcome and QOL after meningioma surgery. Outcome is usually measured for meningiomas in terms of morbidity, mortality, time to recurrence, and QOL. The extent of resection, tumor grade, proliferative markers, and tumor location are significant factors in predicting the surgical outcome. Therefore, we address each of these factors in detail in this review. Advances in recent decades in microsurgical techniques, neuroimaging modalities, neuroanesthesia, and perioperative intensive care have substantially improved the surgical outcome; therefore, most surgical outcomes discussed in this review are cited from contemporary literature (2000 to the present) in order to depict the surgical outcome of contemporary microsurgery.

Surgical Management of Jugular Foramen Meningiomas: A Series of 13 Cases and Review of the Literature

OBJECTIVE

Primary meningiomas occurring within the jugular foramen are exceedingly rare lesions presumed to originate from arachnoid-lining cells situated within the jugular foramen. The objective of this study is to analyze the management and outcome in a series of 13 primary jugular foramen meningiomas collected at a single center.

STUDY DESIGN

Retrospective study.

SETTING

Quaternary referral otology and skull base private center.

METHODS

Charts belonging to 13 consecutive patients with pathologically confirmed jugular foramen meningioma surgically treated between September 1991 and May 2005 were examined retrospectively. The follow-up of the series ranged from 12 to 120 (mean, 42.8 +/- 27.5) months.

RESULTS

Four (28.5%) patients underwent single-stage tumor removal through the petro-occipital transigmoid (POTS) approach. In two patients with preoperative unserviceable hearing, a combined POTS-translabyrinthine approach was adopted. Two patients underwent a combined POTS-transotic approach because of massive erosion of the carotid canal. A modified transcochlear approach type D with posterior rerouting of the facial nerve and transection of the sigmoid sinus and jugular bulb was performed in two patients with a huge cerebellopontine angle tumor component with extension to the prepontine cistern together with massive involvement of the petrous bone and middle ear and encasement of the vertical and horizontal segments of the intrapetrous carotid artery. In one patient with evidence of a dominant sinus on the site of the tumor, a subtotal tumor removal via an enlarged translabyrinthine approach (ETLA) was planned to resect the intradural component of the tumor. Two patients in our series underwent a planned staged procedure on account of a huge tumor component in the neck. One of these patients underwent a first-stage infratemporal fossa approach type A to remove the tumor component in the neck; the second-stage intradural removal of the tumor was accomplished via an ETLA. The last patient underwent a first-stage modified transcochlear type D approach to remove the intradural tumor component followed by a second-stage transcervical procedure for removal of the extracranial component. Gross total tumor removal (Simpson grade I-II) was achieved in 11 (84.6%) cases. Subtotal removal of the tumor was accomplished in two patients. Good facial nerve function (grades I and II) was achieved in 46.1% of cases, whereas acceptable function (grade III) was achieved in the remaining cases 1 year after tumor removal. Hearing was preserved at the preoperative level in all four patients who underwent surgery via the POTS approach. After surgery, no patient recovered function of the preoperatively paralyzed lower cranial nerves. A new deficit of one or more of the lower cranial nerves was recorded in 61.5% of cases.

CONCLUSIONS

Surgical resection is the treatment of choice for jugular foramen meningiomas. Among the various surgical techniques proposed for dealing with these lesions, we prefer the POTS approach alone or combined with the translabyrinthine or transotic approaches. Despite the advances in skull base surgery, new postoperative lower cranial nerve deficits still represent a challenge.