Meningioma of the Jugular Foramen: Glomus Jugulare Mimic and Surgical Challenge

Surgical results, technical notes and complications of jugular foramen lesions via retroauricular infratemporal fossa approach

OBJECTIVE

The objective of this study was to evaluate the clinical effect and safety of the postauricular infratemporal fossa approach (ITFA) in resecting jugular foramen lesions.

METHODS

All 25 patients undergoing microsurgery via postauricular ITFA from March 2015 to May 2023 in the Department of Neurosurgery, Tangdu Hospital, Air Force Military Medical University were included. The clinical and radiological data were retrospectively analyzed. Regular follow-up was carried out.

RESULTS

The mean age of all patients was 50.5±8.9 years, and 14 of them were female and 11 were male. Among the cases, lower cranial nerve schwannoma accounted for 60 % (15/25) of all tumors, jugular foramen paraganglioma accounted for 20 % (5/25), and the remaining 20 % included meningioma, chondrosarcoma, plasmacytoma, and salivary gland tumors. Total tumor resection was performed in 18 cases, subtotal tumor resection in 7 cases and partial resection in 1 case. Seven patients underwent gamma knife radiotherapy after surgery. Transient lower cranial nerve dysfunction occurred in 8 patients, and permanent lower cranial nerve dysfunction occurred in 2 patients after surgery. One patient developed facial paralysis, and one patient presented hearing loss.

CONCLUSIONS

The postauricular ITFA achieved a relatively high total tumor resection rate and a lower incidence of neurological functional disorders. It is an alternative and suitable surgical approach for resecting jugular foramen lesions. Maximizing the preservation of neurological function is preferred, especially when radical resection cannot be achieved. Stereotactic radiotherapy could be used for residual tumors.

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.

Low-Grade Fibromyxoid Sarcoma of the Lateral Skull Base: Presentation of Two Cases

Low-grade fibromyxoid sarcoma (LGFMS) is a rare slow-growing malignant tumour with a deceptively benign histologic appearance. Herein, we report two cases of LGFMS with variable clinical presentations. The first case was a 17-year-old female who referred to our department due to deaf ear on the right together with ipsilateral gag reflex impairment and globus sensation in the pharynx. The second case was a 35-year-old female with recurrent LGFMS, suffering from headaches, vertigo, and episodes of loss of consciousness. LGFMS of the temporal bone is a rare pathology, and to the best of our knowledge, no such cases have been reported before.

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.

Jugular Tubercle Meningioma with Hemorrhagic Conversion Mimicking a Ruptured Thrombosed Giant Vertebrobasilar Aneurysm

BACKGROUND

Hemorrhagic meningiomas, although relatively uncommon, represent a distinct clinical entity. In some cases, these meningiomas can closely mimic a thrombosed aneurysm. We present a case of a jugular tubercle meningioma whose radiographic and clinical picture initially suggested a ruptured, thrombosed vertebrobasilar aneurysm. This case serves to highlight several key differences between these 2 pathologies that can assist in diagnosis.

CASE DESCRIPTION

A 54-year-old woman presented to an outside hospital with a severe, sudden onset headache along with new-onset horizontal diplopia. On examination, she was noted to have a left sixth nerve palsy. A computerized tomography scan was performed and demonstrated a mass in the region of the left jugular foramen. A subsequent lumbar puncture was suggestive of subarachnoid hemorrhage. Frozen section was suggestive of meningioma and our patient underwent a successful gross total resection with no permanent neurological sequelae.

CONCLUSIONS

Hemorrhagic meningiomas can have a clinical and radiologic picture that closely resembles a ruptured, thrombosed cerebral aneurysm. Based on our single case, we suggest several important diagnostic differentiators between these 2 entities. We found the hemorrhagic meningioma to exhibit eggshell-like rim calcification, thick, irregular peripheral enhancement, and a central cystic component. This can be contrasted to the classic appearance of a thrombosed aneurysm with mixed T₁-, T₂-weighted signal intensity, and occasional regular, thin peripheral enhancement.

Optimal treatment of jugular foramen schwannomas: long-term outcome of a multidisciplinary approach for a series of 29 cases in a single institute

BACKGROUND

The goal of treatment for jugular foramen schwannomas (JFSs) is to achieve complete tumor removal with cranial nerve preservation. However, achieving this goal remains a challenge despite the advances in microsurgical techniques. The aim of this study was to determine optimal treatment strategies for JFSs based on a review of a series of 29 surgical cases in our institute.

MATERIALS AND METHODS

Between 1997 and 2013, 29 patients with JFSs underwent surgical treatment by multidisciplinary otoneurosurgical approaches. We retrospectively evaluated various clinical outcomes including the extent of tumor resection, postoperative cranial nerve deficits, and the recurrence rate. Tumor extension was classified using the Kaye and Pellet classification (KPC) system, and the extent of tumor resection was graded as gross total resection (GTR), near total resection (NTR), and subtotal resection (STR). We utilized the House-Brackmann facial nerve grading system (HBFNGS), the average pure-tone audiometry and speech audiometry (PTA/SA) tests, and the American Speech-Language-Hearing Association National Outcome Measurement System (ASHA NOMS) swallowing scale (ASHA level) for assessment of functional outcomes.

RESULTS

The extent of tumor resection was not related to the degree of immediate postoperative cranial nerve deficits. However, the surgical approach was significantly related to postoperative hearing status and immediate postoperative facial function. Also, among the ten patients who were below the level of acceptable facial function immediately postoperatively, nine patients (90%) recovered to acceptable facial function by the last follow-up. Concerning postoperative swallowing status, all 21 patients recovered swallowing function by the last follow-up. Postoperative Gamma Knife stereotactic radiosurgery (GKRS) was performed for three recurrent and seven residual tumors, and recurrence was not observed in the mean 36-month follow-up period.

CONCLUSIONS

A surgical strategy should be tailored to the individual case, and clinicians should consider the possibility of recurrence and further adjuvant treatment.

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.

Strategies and long-term outcomes in the surgical management of tympanojugular paragangliomas

BACKGROUND

The purpose of this study was to share our review of surgical strategies and long-term outcomes in the management of tympanojugular paragangliomas.

METHODS

This was a retrospective study with a literature review. The records of 184 patients with 185 tympanojugular paragangliomas were analyzed for tumor class, surgical procedure, preoperative vascular management, and perioperative sequelae.

RESULTS

Of class C1, C2, C3, and C4 tumors, we found 46 (24.9%), 95 (51.3%), 41 (22.2%), and 3 (1.6%), respectively. One hundred four (56.2%) tumors had intracranial extensions and 8 (4.3%) involved the vertebral artery. A single-stage procedure was adopted in 158 (85.4%) tumors. The infratemporal fossa type A approach was used in all cases. In 17 patients (9.7%), an intra-arterial stenting of the internal carotid artery was performed. Gross-total tumor removal was achieved in 166 cases (89.7%) and 4 (2.4%) among them developed a recurrence.

CONCLUSION

A thorough understanding of skull base techniques and a logical decision-making process in the management of tympanojugular paragangliomas can achieve a high rate of success in terms of recurrences and complications. © 2015 Wiley Periodicals, Inc. Head Neck 38: 871-885, 2016.

Lesions involving the jugular foramen: clinical characteristics and surgical management

CONCLUSION

Lesions involving the jugular foramen (JF) present as various diagnoses. Pulsatile tinnitus is more common in glomus jugulare (GJ) tumors, whereas otalgia and facial nerve paresis are more prevalent in temporal bone malignancies (TBMs). Preoperative facial nerve electroneurography (ENoG) was significantly correlated with postoperative facial nerve function.

OBJECTIVE

To describe the diagnosis and surgical management of lesions involving the JF.

METHODS

The charts were reviewed for 38 patients who had lesions involving the JF, including 14 patients with TBMs, 11 with GJ tumors, 7 with cholesteatomas, 2 with facial nerve schwannomas, 2 with JF schwannomas, and 2 with cholesterol granulomas. The follow-up data were recorded.

RESULTS

The most frequent symptoms included hearing loss (89.47%), followed by otorrhea (47.37%) and pulsatile tinnitus (39.47%). With respect to TBMs, 57.14% of patients complained of otorrhea and otalgia, and 50.00% presented with facial nerve paresis. Among the 13 patients with facial nerve paresis, 53.85% were diagnosed with TBMs. Regarding GJ tumors, 81.82% had pulsatile tinnitus and hearing loss. Among the 25 patients with normal preoperative facial nerve function, the mean facial nerve ENoG reduction was 29.48 ± 29.15%, and the mean postoperative facial nerve score was 77.48 ± 33.13. The correlation coefficient was -0.973 (p = 0.000).

Subtotal Resection for Management of Large Jugular Paragangliomas with Functional Lower Cranial Nerves

Objectives

To evaluate tumor control following subtotal resection of advanced jugular paragangliomas in patients with functional lower cranial nerves and to investigate the utility of salvage radiotherapy for residual progressive disease.

Study Design

Case series with planned chart review.

Setting

Tertiary academic referral center.

Subjects and Methods

Patients who presented with advanced jugular paragangliomas and functional lower cranial nerves were analyzed. Primary outcome measures included extent of resection, long-term tumor control, need for additional treatment, and postoperative lower cranial nerve function.

Results

Twelve patients (mean age, 46.2 years; 7 women, 58.3%) who met inclusion criteria were evaluated between 1999 and 2013. The mean postoperative residual tumor volume was 27.7% (range, 3.5%-75.0%) of the preoperative volume. When the residual tumor volume was less than 20% of the preoperative volume, no tumor growth occurred over an average of 44.6 months of follow-up ( P < .01). Four tumors (33.3%) demonstrated serial growth at a mean of 23.5 months following resection, 2 of which were treated with salvage stereotactic radiotherapy providing control through the last recorded follow-up. No patient experienced permanent postoperative lower cranial neuropathy as a result of surgery.

Conclusion

Subtotal resection of jugular paragangliomas with preservation of the lower cranial nerves is a viable management strategy. If more than 80% of the preoperative tumor volume is resected, the residual tumor seems less likely to grow.

Middle ear meningiomas: a case series reviewing the clinical presentation, radiologic features, and contemporary management of a rare temporal bone pathology

Meningiomas are the most common extra-axial intracranial neoplasm and frequently develop in the parasagittal region. Rarely, meningiomas may involve the middle ear and mastoid, resulting from contiguous spread of adjacent intracranial tumor, or less commonly as an isolated primary tumor of the middle ear. Patients with primary middle ear meningiomas (MEMs) often present with non-specific otologic complaints including hearing loss, otorrhea and otalgia thereby mimicking common chronic otitis media, while secondary lesions more frequently manifest sensorineural hearing loss, cranial neuropathy and other neurologic symptoms from the associated intracranial component. The radiological appearance of MEMs often overlaps with other tumors of the temporal bone. Therefore, a correct diagnosis cannot always be made prior to surgical biopsy. While gross total resection with preservation of existing neurological function is possible with smaller lesions, complete tumor removal may be extremely morbid with more extensive or adherent MEMs. In such cases, aggressive subtotal resection with close radiologic follow-up should be considered. Given the rarity of the studied condition, the literature addressing MEMs is sparse. The current study reviews ten additional cases of MEMs, highlighting the clinicopathologic and radiological features that distinguish meningiomas from other middle ear and mastoid pathology.

The lower cranial nerves: IX, X, XI, XII

The lower cranial nerves innervate the pharynx and larynx by the glossopharyngeal (CN IX) and vagus (CN X) (mixed) nerves, and provide motor innervation of the muscles of the neck by the accessory nerve (CN XI) and the tongue by the hypoglossal nerve (CN XII). The symptomatology provoked by an anomaly is often discrete and rarely in the forefront. As with all cranial nerves, the context and clinical examinations, in case of suspicion of impairment of the lower cranial nerves, are determinant in guiding the imaging. In fact, the impairment may be located in the brain stem, in the peribulbar cisterns, in the foramens or even in the deep spaces of the face. The clinical localization of the probable seat of the lesion helps in choosing the adapted protocol in MRI and eventually completes it with a CT-scan. In the bulb, the intra-axial pathology is dominated by brain ischemia (in particular, with Wallenberg syndrome) and multiple sclerosis. Cisternal pathology is tumoral with two tumors, schwannoma and meningioma. The occurrence is much lower than in the cochleovestibular nerves as well as the leptomeningeal nerves (infectious, inflammatory or tumoral). Finally, foramen pathology is tumoral with, outside of the usual schwannomas and meningiomas, paragangliomas. For radiologists, fairly hesitant to explore these lower cranial pairs, it is necessary to be familiar with (or relearn) the anatomy, master the exploratory technique and be aware of the diagnostic possibilities.

Extracranial Intraluminal Extension of Atypical Meningioma within the Internal Jugular Vein

Meningiomas represent the most common benign intracranial neoplasms, and may spread by direct extension into nearby venous sinuses, but gross spread to the extracranial venous system is uncommon. We report the case of a patient with extracranial intraluminal spread of meningioma within the internal jugular vein to level III of the neck. Review of the preoperative assessment and management is also presented.

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.

Jugular foramen tumors: clinical characteristics and treatment outcomes

OBJECTIVE

To describe the diagnosis, management, and treatment outcome of jugular foramen (JF) tumors.

STUDY DESIGN

Retrospective chart review.

METHODS

Charts of the 83 patients diagnosed with JF tumors between January 1997 and May 2008 were reviewed. Presenting symptoms, otologic and neurotologic examination, audiologic thresholds, treatment procedure, surgical technique, tumor size and classification, and postoperative complications were recorded. Facial nerve function was graded using the House-Brackmann scale. Extent of tumor removal was determined at time of surgery, followed by routine radiographic follow-up.

RESULTS

The mean age of patients with JF tumors was 48.5 years (standard deviation, 16.3 yr), and women (79.5%) outnumbered men (20.5%). Most had glomus jugulare (GJ) tumors (n = 67, 80.7%); 9 patients had lower cranial nerve schwannomas (10.8%), and 7 patients had meningiomas (8.4%). The most frequent initial symptoms included pulsatile tinnitus (84.3%), conductive hearing loss (75.9%), and hoarseness (34.9%). Sixty-one patients (73.5%) underwent surgery, 18.1% had radiotherapy, and 8.4% were observed. Total tumor removal was achieved in 81% of surgery cases. New lower cranial nerve (CN) deficits occurred after surgery in 18.9% of GJ, 22.2% of schwannoma, and 50% of the 4 meningiomas. At last follow-up, 88.1% of surgical patients had normal or near-normal (House-Brackmann I or II) facial function.

CONCLUSION

Total resection of GJ tumors, meningiomas, and lower CN schwannomas can be a curative treatment. However, subtotal removal may be required to preserve CN function, vital vascular structures, and the brainstem. Postoperative radiotherapy is used to control residual tumor. When postoperative complications develop in patients, early rehabilitation is important to decrease mortality and morbidity. Therefore, patients should be closely followed.

A comparative review of multidetector CT angiography and MRI in the diagnosis of jugular foramen lesions

AIM

To compare the efficiency of multidetector computed tomography (MDCT) and magnetic resonance imaging (MRI) in the diagnosis of jugular foramen lesions.

MATERIALS AND METHODS

The imaging of 15 patients with tumours predominantly occurring at the jugular foramen was retrospectively reviewed, with postoperative pathology data available for 11 patients. MDCT was performed at arterial phase and MRI with standard sequences and contrast enhancement. All imaging was blindly re-reported by an experienced neuroradiologist.

RESULTS

Pathology reported six glomus jugulare tumours and five neuromas, which were all correctly diagnosed using MDCT. A confident diagnosis was also made in the remaining four cases based on the pattern of enhancement. Only glomus tumours enhanced in the arterial phase. Overall, MRI was used to make a confident diagnosis in eight patients. One showed no enhancement and was correctly diagnosed as a neuroma, and seven demonstrated the tumour flow voids characteristic of a glomus tumour. The remaining seven cases all showed a similar enhancement pattern and could not be confidently differentiated between a neuroma or a glomus tumour. MDCT angiography enabled a confident assessment of the jugular vein in all cases, but MRI was inconclusive in a third of cases. Also, in the nine cases of glomus tumour diagnosed using MDCT, an enlarged feeding artery was identified in eight patients.

CONCLUSION

MDCT is more accurate than MRI in diagnosing glomus tumours, and in particular, neuromas. It also offers valuable preoperative vascular information to the surgeon.

Meningioma with dural venous sinus invasion and jugular vein extension

Meningiomas represent the most common benign intracranial neoplasm in adults, with a considerably lower incidence in children. The authors present the case of an intracranial meningioma with invasion of, and intraluminal extension into, the transverse and sigmoid sinuses, jugular bulb, and internal jugular vein, resulting in venous occlusion in a 14-year-old girl. Computed tomography scanning, MR imaging, and conventional angiography were performed preoperatively. The patient underwent a 2-stage resection: the supratentorial component was resected first, and the infratentorial and venous sinus and jugular vein components were subsequently removed using a combined skull base approach. Gross-total resection was achieved by opening the lateral dural sinus and removing the meningioma from within the transverse and sigmoid sinuses, the jugular bulb, and the internal jugular vein. The patient remained neurologically intact after the staged tumor resections. Postoperative imaging confirmed the gross-total resection. This case illustrates the unusual property of an intracranial meningioma to invade the intrasinusoidal space and extend into the jugular vein without adherence to the underlying venous endothelium of the jugular vein.

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.

Transpetrosal approaches for meningiomas of the posterior aspect of the petrous bone

OBJECTIVE

To assess outcome following excision of meningiomas of the posterior aspect of the petrous bone through transpetrosal approaches.

MATERIAL AND METHOD

We carried out a retrospective case-series study in a multidisciplinary tertiary care center on all patients who underwent meningiomas removal from January 1989 to September 2005. Surgical approaches were transpetrosal: widened retrolabyrinthine, translabyrinthine, transotic and transcochlear, occasionally combined with a subtemporal transtentorial approach. Epidemiology, symptoms, preoperative evaluation, surgery, postoperative complications and facial and auditory results were analyzed using standardized grading systems. The Desgeorges and Sterkers classification was used to assess tumor size and location.

RESULTS

Forty women and three men underwent surgery (mean age: 56.7). Medium-sized tumors stages 2 and 3 (84%) and AM and P localization (34% and 20.4%) predominated. In 65% of cases, the tumor extended beyond the CPA. Main presenting symptoms were balance disorders (72%) and sensorineural hearing loss (53.5%). Mortality was nil. A preoperative facial nerve paresis was present in 14% of patients. Tumor removal was complete in 79.1% of cases. At 1-year post-op, 73% of patients had a normal or subnormal facial function and 55% had serviceable hearing. A cerebrospinal fluid leakage occurred in 6.9%.

DISCUSSION

Posteriorly attached meningiomas are less symptomatic and of better prognosis than medially inserted ones. Transpetrosal approaches are reliable for the removal for all types and sizes of such tumors, and can be easily combined in the same procedure with a subtemporal transtentorial approach to remove extensions to the clivus and tentorium. They offer low morbidity and a high proportion of facial nerve and hearing preservation.

Jugular foramen fibromatosis in a 3-month-old male

A 3-month-old male with a chief complaint of episodic choking with feeds and a hoarse cry is presented. Left eye ptosis and asymmetric soft palate elevation were detected on physical examination. Fiberoptic examination showed a left vocal fold paresis and pooling of secretions in the pyriform sinuses. MRI demonstrated an ill-defined lesion at the left jugular foramen extending into the left carotid sheath. A fine needle biopsy revealed spindle shaped cells consistent with fibromatosis. The histopathology of fibromatosis and the differential diagnosis of jugular foramen masses in children will be described. To our knowledge, this represents the earliest reported case of fibromatosis in the jugular foramen.

Jugular foramen chordoid meningioma

Chordoid meningioma (CM) is a rare histological variant of meningioma and is classified as an atypical meningioma on pattern alone. Herein is described the first case of CM occurring in the jugular foramen. The patient was a 45-year-old woman with a 2 year history of progressive right hearing loss. Magnetic resonance imaging (MRI) demonstrated a large, dumbbell-shaped, homogenously gadolinium-enhanced mass in the right jugular foramen, extending medially to the cerebellopontine angle and caudally into the upper carotid space. Angiographic findings supported a diagnosis of schwannoma. Intraoperatively, the tumor appeared to involve the right glossopharyngeal nerve completely and the vagus nerve incompletely, and was incompletely resected. Microscopically, the tumor consisted predominantly of cords and nests of medium-sized cells with bland cytological features, surrounded by a pale basophilic mucin. Immunohistochemically, the tumor cells demonstrated reactivity for epithelial membrane antigen (membranous) and vimentin, with negative staining for S-100 protein, cytokeratin, CD34, glial fibrillary acidic protein (GFAP), synaptophysin, and chromogranin A. Based on the chordoid histology, an organoid lobular arrangement of the tumor cells, and the location of the tumor (jugular foramen), the differential diagnosis included not only a chordoma but also a paraganglioma (glomus jugulare tumor). Histological identification of typical meningotheliomatous areas, plus selective immunohistochemical panel, is important to establish the correct diagnosis.

Differentiating imaging findings in primary and secondary tumors of the jugular foramen

The preoperative diagnosis of a jugular foramen tumor may be challenging, since a large variety of unusual lesions may be located in this region. These tumors may be classified as primary lesions (which are located in the jugular foramen or extend from the jugular foramen into the surrounding structures) and as secondary lesions (that extend from the surrounding structures into the jugular foramen). Primary tumors include glomus jugulare tumors, schwannomas, meningiomas and peripheral primitive neuroectodermal tumors, while secondary tumors comprise chordomas, chondrosarcomas, chondroblastomas, giant-cell tumors, cholesterol granulomas, giant cholesterol cyst, endolymphatic sac tumors, reactive myofibroblastic tumors, temporal bone carcinomas and metastases. Accurate preoperative radiological suspicion is of great value for preoperative patient counseling and has a direct impact on the surgical planning in these cases. The present study describes and discusses the main differentiating imaging features of lesions involving the jugular foramen, whose accurate preoperative radiological evaluation is essential for proper surgical planning.

Meningiomas of the jugular foramen

Primary meningiomas of the jugular foramen are extremely rare. There is controversy regarding the management of these tumors. The objective of this article is to analyze the treatment and results in a series of ten cases. From a series of 107 patients that had been operated on for jugular foramen tumors between 1987 and 2005, ten had meningiomas. The clinical, histological and imaging findings, as well as the outcome of these cases, were reviewed. A high incidence of malignant or aggressive tumors (six cases) was found. Gross total resection (Simpson I and II) was achieved in five patients. Four patients with meningotheliomatous meningiomas are alive, with a mean follow-up time of 71.8 months (6.5 years). Two patients (one with anaplastic type and one with papillary type) died in the immediate postoperative period. Four patients (two with papillary type, one with microcystic type and one with anaplastic type) died because of disease progression, with a mean survival time of 35 months. Radical removal of benign jugular foramen meningiomas is possible. The incidence of postoperative deficit of cranial nerves is higher than in other benign tumors of the jugular foramen. A high incidence of aggressive (malignant) tumors was observed in this series.

Vascular masses of the head and neck

The classification, clinical presentation, natural history and imaging appearances of vascular masses of the head and neck are reviewed. The radiological appearances of congenital vascular masses (infantile haemangiomas and other congenital vascular tumours, high-flow and low-flow vascular malformations), acquired vascular masses (benign and malignant tumours, non-neoplastic lesions) and other hypervascular masses are described and illustrated, together with consideration of image-guided interventions.

Jugular Foramen Schwannomas: Diagnosis, Management, and Outcomes

OBJECTIVES/HYPOTHESIS

To describe the presentation, radiographic findings, and surgical management of seven patients who have been diagnosed and treated with jugular foramen schwannomas at the University of Utah.

STUDY DESIGN

Retrospective chart review.

METHODS

The charts of seven patients diagnosed with jugular foramen schwannomas were reviewed for presentation symptoms, radiographic findings, and physical examination findings. For the six who underwent surgical excision, the surgical procedure used, cranial nerve function results, audiometric results, perioperative complications, and other follow-up data are presented.

RESULTS

Seven patients were identified from ages 24 to 69 years. Six of the seven underwent surgical excision. Primary presentation symptoms included dizziness, hearing loss, dysphagia, diplopia, tongue paresis, and hoarseness. The choice of surgical approach was based on the size and location of the tumor. All patients had complete excision of their tumors. The nerve of origin included the glossopharyngeal, vagus, and spinal accessory nerves. Preoperative cranial nerve dysfunction continued postoperatively for lower cranial nerves but resolved in patients who were noted to have preoperative dysfunction of cranial nerve V and VI. The rate of new lower cranial nerve injury was 15% and was only seen in the cranial nerves that were determined to be the nerve of origin. In two cases, a temporary feeding tube was required. No recurrences have been noted to date.

CONCLUSIONS

Jugular foramen schwannomas can be successfully diagnosed preoperatively with computed tomography and magnetic resonance imaging. These tumors can be successfully managed with surgery and low morbidity.

Jugular foramen papillary meningioma: A case report

Jugular foramen meningioma is very rare. Papillary meningioma, the histological aspects and clinical behavior of which are highly malignant, is also very rare. Only 55 cases of jugular foramen meningioma have been reported in the literature. To our knowledge, this is the first report of a jugular foramen papillary meningioma. A 25-year-old woman presented with hoarseness and right hearing disturbance. Neurological examination showed deficits of the right hypoglossal and vagus nerves with palsy. Magnetic resonance imaging (MRI) revealed a mass on the right jugular foramen extending intracranially and extracranially, with weak contrast enhancement. The intracranial tumor was removed via the right lateral suboccipital approach. Histopathological examination confirmed the diagnosis of papillary meningioma. We report here the first case of jugular foramen papillary meningioma. No completely effective treatment for papillary meningiomas exists at present, with the exception of surgery.