Recurrent petroclival meningiomas: clinical characteristics, management, and outcomes

Approach Selection Strategies for Repeat Resection of Brain Cavernous Malformations: Cohort Study

BACKGROUND

Neurosurgical management of cerebral cavernous malformations (CMs) often benefits from using skull base approaches. Although many CMs are cured by resection, residual or recurrent disease may require repeat resection.

OBJECTIVE

To review approach selection strategies for reoperation of CMs to aid decision-making for repeat procedures.

METHODS

In this retrospective cohort study, a prospectively maintained single-surgeon registry was queried for patients with CMs who underwent repeat resection from January 1, 1997, to April 30, 2021.

RESULTS

Of 854 consecutive patients, 68 (8%) underwent 2 operations; 40 had accessible data on both. In most reoperations (33/40 [83%]), the index approach was repeated. In most reoperations using the index approach (29/33 [88%]), that approach was deemed ideal (no equivalent or superior alternative), whereas in some (4/33 [12%]), the alternative approach was deemed unsafe because of conformation of the tract. Among patients with reoperations using an alternative approach (7/40 [18%]), 2 with index transsylvian approaches underwent bifrontal transcallosal approaches, 2 with index presigmoid approaches underwent extended retrosigmoid revisions, and 3 with index supracerebellar-infratentorial approaches underwent alternative supracerebellar-infratentorial trajectory revisions. Among patients with reoperations with an alternative approach considered or selected (11/40 [28%]), 8 of 11 patients had a different surgeon for the index resection than for the repeat resection. The extended retrosigmoid-based approaches were used most often for reoperations.

CONCLUSION

Repeat resection of recurrent or residual CMs is a challenging neurosurgical niche at the intersection of cerebrovascular and skull base disciplines. Suboptimal index approaches may limit surgical options for repeat resection.

Surgical results of 158 petroclival meningiomas with special focus on standard craniotomies

Objective

The goal of this retrospective study is the evaluation of risk factors for postoperative neurological deficits after petroclival meningioma (PCM) surgery with special focus on standard craniotomies.

Materials and methods

One-hundred-fifty-eight patients were included in the study, of which 133 patients suffered from primary and 25 from recurrent PCM. All patients were operated on and evaluated concerning age, tumor size, histology, pre- and postoperative cranial nerve (CN) deficits, morbidity, mortality, and surgical complications. Tumor-specific features—e.g., consistency, surface, arachnoid cleavage, and location—were set in a four-grade classification system that was used to evaluate the risk of CN deficits and tumor resectability.

Results

After primary tumor resection, new CN deficits occurred in 27.3% of patients. Preoperative ataxia improved in 25%, whereas 10% developed new ataxia. Gross total resection (GTR) was achieved in 59.4%. The morbidity rate, including hemiparesis, shunt-dependence, postop-hemorrhage, and tracheostomy was 22.6% and the mortality rate was 2.3%. In recurrent PCM surgery, CN deficits occurred in 16%. GTR could be achieved in three cases. Minor complications occurred in 20%. By applying the proposed new classification system to patients operated via standard craniotomies, the best outcome was observed in type I tumor patients (soft tumor consistency, smooth surface, plane arachnoid cleavage, and unilateral localization) with GTR in 78.7% (p < 0.001) and 11.9% new CN deficits (p = 0.006).

Conclusion

Standard craniotomies as the retrosigmoid or subtemporal/pterional approaches are often used for the resection of PCMs. Whether these approaches are sufficient for GTR—and avoidance of new neurological deficits—depends mainly on the localization and intrinsic tumor-specific features.

Supplementary Information

The online version contains supplementary material available at 10.1007/s11060-022-04105-5.

Retractorless Surgery for Petroclival Meningiomas via the Subtemporal Approach: A Try to Reduce Brain Retraction Injury

Purpose

To present our experience with retractorless surgery for resection of petroclival meningiomas (PCMs) via the subtemporal approach with routine operative instruments.

Methods

Clinical data of patients with PCMs who received surgical treatments via subtemporal approach were retrospectively analyzed. Patient demographics, duration of operation, extent of resection, postoperative brain injury rate, postoperative complication, and surgical outcome were reviewed.

Results

Twenty-nine consecutive patients with retractorless surgery via subtemporal approach performed between November 2018 and November 2021. The gross total resection rate was 82.8% (N = 24). The incidence of postoperative temporal lobe injury was 3.4% (N = 1). All the procedures were completed without fixed retraction or other specialized instruments.

Conclusions

Retractorless surgery via subtemporal approach is a reliable treatment option for PCMs, which can be completed with routine operative instruments.

Surgical resection of petroclival meningiomas of the cerebellopontine angle and/or diaphragma sellae extension via an extended intradural anterior transpetrous approach

OBJECTIVE

This study aimed to describe the extended intradural anterior transpetrous approach (ATPA) and its usefulness for the surgical resection of petroclival meningiomas (PCMs) of the cerebellopontine angle (CPA) and/or diaphragma sellae (DS) extension.

METHODS

Between January 2017 and December 2019, a total of 22 patients with PCMs extending to the CPA/or DS underwent surgery via extended intradural ATPA by the senior author (Xr.X.). We retrospectively analysed the clinical data, radiological findings, surgical treatment, complications, and outcomes of patients and discussed the operative technique.

RESULTS

In 22 patients, the tumours were gross totally removed (Simpson I and II) in 18 patients (81.8%), subtotally (Simpson III) in 3 patients (13.6%), and partially (Simpson IV) in 1 patient (4.5%). One patient died 48 days after the operation, and no recurrence was found in 21 patients during a median follow-up of 26 months. Postoperative complications included in abducens nerve palsy in 12 patients with recovery in 10 patients, facial numbness in 4 patients with recovery in 3 patients, and hemiplegia and oculomotor nerve palsy in 1 patient each with recovery in all patients. The postoperative MRI showed temporal lobe oedema but no clinical symptoms in 3 patients.

CONCLUSION

Extended intradural ATPA is an alternative approach for PCMs of the CPA and/or DS extension. The single approach can expose both the sellar region and the posterolateral area of the IAC, which is advantageous for extended intradural ATPA.

Factors Associated With Abducens Nerve Palsy in Patients Undergoing Surgery for Petroclival Meningiomas

BACKGROUND

During the surgical resection of petroclival meningiomas, preserving the cranial nerves is crucial. The abducens nerve is particularly vulnerable during surgery. However, the preoperative risk factors and postoperative prognosis of abducens nerve palsy (ANP) are poorly understood.

METHODS

We retrospectively analyzed 70 patients who underwent surgery for petroclival meningiomas between May 2010 and December 2019, divided into gross-total resection (GTR) and subtotal resection (STR) groups. The relationship of preoperative clinical factors with the incidence and recovery of postoperative ANP was analyzed.

RESULTS

Postoperative ANP was observed in 23 patients (32.9%). Multivariable logistic regression revealed that the tumor-to-cerebellar peduncle T2 imaging intensity index (TCTI) (P < 0.001) and internal auditory canal invasion (P = 0.033) contributed to postoperative ANP. GTR was achieved in 37 patients (52.9%), and 10 (27.0%) of them showed ANP. STR was achieved in 33 patients (47.1%), and 13 (39.4%) of them showed ANP. Recovery from ANP took a median of 6.6 months (range, 4.5-20.3 months). At 6 months after the operation, recovery of the abducens nerve function was observed in 16 patients (69.0%); of whom, 4 (40.0%) were in the GTR group and 12 (92.3%) were in the STR group (P = 0.025).

CONCLUSIONS

TCTI and internal auditory canal invasion were the risk factors for postoperative ANP. Although intentional STR did not prevent ANP immediately after the operation, recovery of the abducens nerve function after surgery was observed more frequently in the STR group than in the GTR group.

Surgical Treatment and Clinical Outcomes of Petroclival Meningiomas: A Single-Center Experience of 107 Patients

Objective

This study aimed to establish optimal surgical strategies via reviewing the clinical outcomes of various surgical approaches for the pertroclival meningiomas (PCMs).

Methods

This retrospective study enrolled 107 patients with PCMs at the authors’ institution from year 2010 to 2020. Patient demographics, the clinical characteristics, various operative approaches, major morbidity, post-operative cranial nerve deficits and tumor progression or recurrence were analyzed.

Results

The subtemporal transtentorial approach (STA), the Kawase approach (KA), the retrosigmoid approach (RSA) and the anterior sigmoid approach (ASA), namely the posterior petrosal approach (PPA) were adopted for 17 cases, 22 cases, 31 cases and 34 cases respectively. Total or subtotal resection was achieved in 96 cases (89.7%). The incidence of new-onset and aggravated cranial nerve dysfunction were 13.1% (14/107) and 10.4% (15/144), respectively. Furthermore, 14 cases suffered from intracranial infection, 9 cases had cerebrospinal fluid leakage, and 3 cases sustained intracranial hematoma (1 case underwent second operation). The mean preoperative and postoperative Karnofsky Performance Status (KPS) score was 80 (range 60-100) and 78.6 (range 0-100), but this was not statistically significant (P>0.05). After a mean follow-up of 5.1 years (range 0.3- 10.6 years), tumor progression or recurrence was confirmed in 23 cases. Two cases died from postoperative complications.

Conclusions

For the treatment of PCMs, it is still a challenge to achieve total resection. With elaborate surgical plans and advanced microsurgical skills, most patients with PCMs can be rendered tumor resection with satisfactory extent and functional preservation, despite transient neurological deterioration during early postoperative periods.

Petroclival meningiomas: update of current treatment and consensus by the EANS skull base section

BACKGROUND

The optimal management of petroclival meningiomas (PCMs) continues to be debated along with several controversies that persist.

METHODS

A task force was created by the EANS skull base section along with its members and other renowned experts in the field to generate recommendations for the management of these tumors. To achieve this, the task force reviewed in detail the literature in this field and had formal discussions within the group.

RESULTS

The constituted task force dealt with the existing definitions and classifications, pre-operative radiological investigations, management of small and asymptomatic PCMs, radiosurgery, optimal surgical strategies, multimodal treatment, decision-making, and patient's counselling.

CONCLUSION

This article represents the consensually derived opinion of the task force with respect to the management of PCMs.

Can Intraoperative Magnetic Resonance Imaging Be Helpful in the Surgical Resection of Parasellar Meningiomas? A Case Series

OBJECTIVE

The surgery of parasellar meningiomas is crucial. There are only a few reports of the use of intraoperative magnetic resonance imaging (iMRI) for resection of these lesions. We discuss the safety and usefulness of this technique in achieving the planned surgical goal and analyze patients' outcomes.

METHODS

Nineteen cases of parasellar meningioma were treated in our institution using iMRI. We classified the tumors according to their primary location: tuberculum sellae, clinoidal, and cavernous sinus meningiomas. We evaluated the history of previous surgery, outcome, residual (if present) tumor volume, degree of resection, achievement of the surgical goal, and number of iMRI scans.

RESULTS

The preoperative surgical goal was achieved in all patients. In 7 of 19 patients, (37%) further tumor resection was performed after the first iMRI scan. Regarding the cavernous sinus group, the surgical resection was continued after the first iMRI in 56% of patients, obtaining substantial additional volume reduction. No complications were found related to the use of iMRI scan.

CONCLUSIONS

iMRI has been effective in safely increasing the extent of parasellar meningioma resection mainly for recurrent and invasive tumors. Its usefulness has been seen mostly in cavernous sinus lesions, in which it allowed the further safe resection in 56% of cases. Moreover, this tool was particularly useful in recurrent or residual meningiomas with extension in extracranial compartments.

Clinical outcomes and survival analysis for petroclival meningioma patients receiving surgical resection: an analysis of 176 cases

Purpose: The relationship of clinical results and survival analysis of operative patients with petroclival meningioma (PCM) was studied.

Patients and methods: Data from a total of 176 PCM patients receiving surgical resection were retrospectively collected. Follow-up was conducted through outpatient review by reexamination telephone calls and letters. Clinical outcomes, survival, and Karnofsky Performance Scale (KPS) data were analyzed.

Results: Seventy-two percent of patients (127/176) received only surgery, 8.5% (15/176) received surgery and adjuvant radiation therapy (RT) (surgery + RT), and 19.3% (34/176) received surgery and adjuvant gamma knife surgery (GKS) (surgery + GKS). Gross total resection (GTR) was performed in 34.7% of patients (61/176), subtotal resection (STR) in 58.0% (102/176), and partial resection (PR) in 7.4% (13/176). Recent follow-up KPS was higher than preoperative (80 vs 70, P<0.05) and postoperative KPS (80 vs 70, P<0.05). Cumulative survival was the same for 3, 5, 7, and 9 years, ie, 95%, and mean survival time (MST) was (110.83±2.55) months (95% CI: 105.83–115.83). Recurrence/progression (R/P)-free survival was 88.9%, 86.9%, 71.1% and 71.1%, respectively for 3, 5, 7, and 9 years, and MST was (100.58±3.82) months (95% CI: 93.11–108.06). R/P (HR: 5.486, 95% CI: 1.655–18.180), surgery + RT (HR: 0.125, 95% CI: 0.016–0.990) and WHO grade III (HR: 2.766, 95% CI: 1.146–6.676) were independently associated with cumulative survival. Lack of adhesion to and encasement of neurovascular structures was independently associated with R/P-free survival (HR: 2.002, 95% CI: 1.023–3.919).

Conclusion: Surgical treatment was safe and effective for PCM. R/P, surgery + RT, and WHO grade III were independently associated with cumulative survival. Lack of adhesion to and encasement of neurovascular structures was independently associated with R/P-free survival. These factors should be paid attention to in surgical treatment of PCM.

The role of the basal cisterns in the development of posterior fossa skull base meningiomas

Meningiomas account for more than 30% of all intracranial brain tumors, with 25% of them originating somewhere along the skull base and about 20% of these located in the posterior fossa. The intimate relation of these tumors with neural and vascular structures make them difficult to treat, both surgically and nonsurgically. Their treatment is further hampered by the lack of definitive recommendations, which is partially due to the fact that there is no general accepted model of classification. The present report proposes a new concept of classification of posterior fossa skull base meningiomas, one that takes into account the intimate relation of these tumors with arachnoid structures, simplifies the overcrowded landscape of their systematization and can be extended to oher skull base locations.

Surgical management of medium and large petroclival meningiomas: a single institution's experience of 199 cases with long-term follow-up

BACKGROUND

Petroclival meningiomas (PCMs) were once regarded as 'inoperable' due to their complex anatomy and limited surgical exposure. This study aimed to evaluate the long-term outcomes of surgically treated PCMs larger than 2 cm.

METHODS

A series of 199 consecutive patients (137 females, 68.8 %) with PCMs larger than 2 cm from between 1993 and 2003 were included. The clinical charts, radiographs, and follow-ups were evaluated.

RESULTS

Gross total resection (GTR) was achieved in 111 (55.8 %) patients, subtotal resection (STR) in 65, and partial resection (PR) in 23. Cranial nerve dysfunctions were the most common complications and occurred in 133 (66.8 %) cases. The surgical mortality was 2.0 %. The Karnofsky Performance Scale (KPS) scores significantly decreased 1 month after the operations (preoperative KPS = 76.8 and postoperative KPS = 64.8; p = 0.011, Paired-samples t test). Long-term follow-ups were obtained in 142 patients, the follow-up duration was 171.6 months, and the most recent KPS was 83.2. Permanent morbidities remained in 24 patients (18.9 %). Multivariate analysis revealed that brainstem edema and tumors larger than 4 cm in diameter were independent risk factors in terms of outcomes (KPS < 80). The recurrence/progression rates were 14.5, 31.8, and 53.3 % for the GTR, STR, and PR cases, respectively (p = 0.002, Pearson χ (2) test). Gamma Knife radiosurgery for the remnants exhibited good tumor control.

CONCLUSIONS

Favorable outcomes and low mortality were achieved with the microsurgical management of medium and large PCMs; however, the rates of cranial nerves dysfunction remained high. Radically aggressive resection might not be judicious in terms of postoperative morbidity. The preoperative evaluations and intraoperative findings were informative regarding the outcomes. The low follow-up rate likely compromised our findings, and additional consecutive studies were required.