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Méndez Rosito D, Borrayo-Dorado S, Zorrilla-Madera E, Sánchez-Gallardo JF, Gallardo-Ceja D, Ríos FJ, Cárdenas Y, Palmisciano P, Forbes JA, Abdala-Vargas NJ. The M-Point A Novel Landmark in Middle Fossa Surgery: A Cadaveric Morphometric Study. World Neurosurg 2024; 181:e67-e74. [PMID: 37385439 DOI: 10.1016/j.wneu.2023.06.098] [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: 02/13/2023] [Revised: 06/19/2023] [Accepted: 06/20/2023] [Indexed: 07/01/2023]
Abstract
BACKGROUND The arcuate eminence (AE) is an anatomically consistent bony protrusion located on the upper surface of the petrous bone that has been previously studied as a reference for lateral skull base approaches. There is a paucity of information in the neurosurgical literature seeking to improve the safety of the extended middle cranial fossa (MCF) approach using detailed morphometric analysis of the AE. OBJECTIVE To evaluate the use of the AE as an anatomical landmark to help with early identification of the internal acoustic canal (IAC) in MCF approaches by means of a cadaveric study, using a new morphometric reference termed the "M-point." METHODS A total of 40 dry temporal bones and 2 formalin-preserved, latex-injected cadaveric heads were used. The M-point was established as a new anatomic reference by identifying the intersection of a line perpendicular to the alignment of the petrous ridge (PR), originating from the midpoint of the AE, with the PR itself. Subsequent anatomical measurements were performed to measure the distance between M-point and IAC. Additional distances, including PR length and the anteroposterior and lateral AE surfaces, were also measured. RESULTS The mean distance between the M-point and the center of the IAC was 14.9 mm (SD ± 2.09), offering a safe drilling area during an MCF approach. CONCLUSIONS This study provides novel information on identification of a new anatomic reference point known as the M-point that that can be used to improve early surgical identification of the IAC.
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Affiliation(s)
- Diego Méndez Rosito
- Laboratorio de Base de Cráneo, Centro Médico Nacional 20 de Noviembre, ISSSTE, Mexico City, Mexico.
| | - Sheila Borrayo-Dorado
- Laboratorio de Base de Cráneo, Centro Médico Nacional 20 de Noviembre, ISSSTE, Mexico City, Mexico
| | - Elias Zorrilla-Madera
- Laboratorio de Base de Cráneo, Centro Médico Nacional 20 de Noviembre, ISSSTE, Mexico City, Mexico
| | | | - David Gallardo-Ceja
- Laboratorio de Base de Cráneo, Centro Médico Nacional 20 de Noviembre, ISSSTE, Mexico City, Mexico
| | - Francisco J Ríos
- Department of Anatomy, Escuela Superior de Medicina, IPN, Mexico City, Mexico
| | - Yolanda Cárdenas
- Department of Anatomy, Escuela Superior de Medicina, IPN, Mexico City, Mexico
| | - Paolo Palmisciano
- Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Jonathan A Forbes
- Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Nadin J Abdala-Vargas
- Laboratorio de Base de Cráneo, Centro Médico Nacional 20 de Noviembre, ISSSTE, Mexico City, Mexico; Department of Neurological Surgery, Fundación Universitaria de Ciencias de la Salud (FUCS), Hospital de San José, Bogotá, Colombia
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Troude L, Avinens V, Farah K, Boucekine M, Balossier A, Regis J, Baucher G, Roche PH. Surgical management of large cerebellopontine angle meningiomas: long-term results of a less aggressive resection strategy. J Neurosurg 2023; 138:1630-1639. [PMID: 36208440 DOI: 10.3171/2022.8.jns221329] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Accepted: 08/18/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Cerebellopontine angle (CPA) meningiomas present many surgical challenges depending on their volume, site of dural attachment, and connection to surrounding neurovascular structures. Assuming that systematic radical resection of large CPA meningiomas carries a high risk of permanent morbidity, the authors adopted an alternative strategy of optimal resection followed by radiosurgery or careful observation of the residual tumor and assessed the efficiency and safety of this approach to meningioma treatment management. METHODS This single-center retrospective cohort study included 50 consecutive patients who underwent surgery for meningioma between January 2003 and February 2020. RESULTS The most common main dural attachments of the meningiomas were posterior (42%) and superior (26%) to the internal auditory meatus. The suboccipital retrosigmoid route was the most routinely used (92%). At the last follow-up examination, 93% of the patients with normal preoperative facial nerve (FN) function retained good House-Brackmann (HB) grades of I and II, whereas 3 patients (7%) displayed intermediate HB grade III FN function. Hearing preservation was achieved in 86% of the patients who presented with preoperative serviceable hearing, and recovery after surgery was achieved in 19% of the patients experiencing preoperative hearing loss. In order to preserve all cranial nerve function, gross-total resection was obtained in 26% of patients. Of the 35 patients who had undergone subtotal resection, 20 (57%) had been allocated into a wait-and-rescan treatment approach and 15 (43%) underwent upfront Gamma Knife surgery (GKS). The mean postoperative tumor volume was 1.20 cm3 in the upfront GKS group and 0.73 cm3 in the wait-and-rescan group (p = 0.08). Tumor control was achieved in 87% and 55% of cases (p < 0.001), with a mean follow-up of 85 and 69 months in the GKS and wait-and-rescan groups, respectively. The 1-, 5-, and 7-year tumor progression-free survival rates were 100%, 100%, and 89% in the GKS group and 95%, 59%, and 47% in the wait-and-rescan group, respectively (p < 0.001). CONCLUSIONS Optimal nonradical resection of large CPA meningiomas provides favorable long-term tumor control and functional preservation. Adjuvant GKS does not carry additional morbidity and appears to be an efficient adjuvant treatment.
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Affiliation(s)
- Lucas Troude
- 1Department of Neurosurgery, North University Hospital, APHM-Aix-Marseille Université (AMU), Marseille
| | - Valentin Avinens
- 1Department of Neurosurgery, North University Hospital, APHM-Aix-Marseille Université (AMU), Marseille
| | - Kaissar Farah
- 2Department of Neurosurgery, Timone University Hospital, APHM-AMU, Marseille; and
| | - Mohamed Boucekine
- 3Department of Statistical Analysis, Faculté des Sciences Médicales et Paramédicales, AMU, Marseille, France
| | - Anne Balossier
- 2Department of Neurosurgery, Timone University Hospital, APHM-AMU, Marseille; and
| | - Jean Regis
- 2Department of Neurosurgery, Timone University Hospital, APHM-AMU, Marseille; and
| | - Guillaume Baucher
- 1Department of Neurosurgery, North University Hospital, APHM-Aix-Marseille Université (AMU), Marseille
| | - Pierre-Hugues Roche
- 1Department of Neurosurgery, North University Hospital, APHM-Aix-Marseille Université (AMU), Marseille
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Donofrio CA, Badaloni F, Riccio L, Morandini A, Bertuccio A, Generali D, Calbucci F, Servadei F, Fioravanti A. Posterior Petrous Meningiomas: Surgical Classification and Postoperative Outcomes in a Case Series of 130 Patients Operated via the Retrosigmoid Approach. World Neurosurg 2023; 171:e301-e308. [PMID: 36509329 DOI: 10.1016/j.wneu.2022.12.022] [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: 11/24/2022] [Accepted: 12/05/2022] [Indexed: 12/14/2022]
Abstract
OBJECTIVE A standardized definition and classification of primary posterior petrous meningiomas (PPMs) is lacking, with consequent challenges in comparing different case series. This study aimed to provide an anatomical description and classification of PPMs analyzing a homogeneous series of patients operated via the retrosigmoid approach. METHODS PPMs originate laterally to the petro-occipital fissure within the venous ring composed of the superior petrosal, sigmoid, inferior petrosal, and cavernous sinuses. We proposed a classification based on tumor site of origin, direction of growth relative to the internal acoustic meatus, and cranial nerves' displacement. Four types of PPMs were defined: retromeatal (type A), meatal (type B), premeatal (type C), and broad-based (type D). We performed a retrospective analysis of 130 consecutive patients with PPMs who underwent surgery as first-line treatment. RESULTS The PPM classification predicted clinical presentation, postoperative morbidity, and resection rates. Headache, hydrocephalus, and cerebellar deficits were more common in type A (59.0%, 37.7%, 49.2%) and type D (66.7%, 66.7%, 33.3%). Hypoacusia/anacusia was more common in type B (87.5%), while trigeminal hypoesthesia/anesthesia was more common in type C (85.0%). After surgery, patients with type A and D PPMs were at higher risk to develop cerebellar deficits (11.5%-22.2%), whereas patients with type B and C PPMs presented with hypoacusia/anacusia (12.5%) and trigeminal deficits (10.0%), respectively. The near-total resection rate was higher in type A (91.8%), followed by types B (82.5%), C (80.0%), and D (77.8%) PPMs. CONCLUSIONS The PPM surgical classification has an operative and prognostic relevance. In expert hands, the retrosigmoid approach represents a safe and effective approach to remove PPMs.
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Affiliation(s)
- Carmine Antonio Donofrio
- Department of Neurosurgery, ASST Cremona, Cremona, Italy; Division of Biology and Genetics, Department of Molecular and Translational Medicine, Faculty of Medicine, University of Brescia, Brescia, Italy.
| | - Filippo Badaloni
- Department of Neurosurgery, IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Lucia Riccio
- Department of Neurosurgery, ASST Cremona, Cremona, Italy
| | | | - Alessandro Bertuccio
- Department of Neurosurgery, Santi Antonio e Biagio e Cesare Arrigo Alessandria Hospital, Alessandria, Italy
| | - Daniele Generali
- Medical Oncology and Translational Research Unit, ASST Cremona, Cremona, Italy; Department of Medicine, Surgery and Health Sciences, Cattinara Hospital, University of Trieste, Trieste, Italy
| | - Fabio Calbucci
- Department of Neurosurgery, Maria Cecilia Hospital, Cotignola, Italy
| | - Franco Servadei
- Humanitas Clinical and Research Center-IRCCS, Humanitas University, Rozzano, Milano, Italy
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Sykopetrites V, Taibah A, Piras G, Giannuzzi AL, Mancini F, Sanna M. The otologic approach in the management of posterior petrous surface meningiomas. Eur Arch Otorhinolaryngol 2022; 279:5655-5665. [PMID: 35767053 DOI: 10.1007/s00405-022-07442-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2022] [Accepted: 05/09/2022] [Indexed: 01/04/2023]
Abstract
PURPOSE Report our experience in the management of posterior petrous surface meningiomas (PPSMs), and identify features that affect hearing, facial nerve (FN) function, and control of the disease. METHODS Retrospective case series of 131 patients surgically managed for PPSMs. FN status, hearing and tumour radicality were assessed and compared between patients with tumours of different locations (Desgeorges classification) and internal auditory canal involvement (IAC). RESULTS At the time of surgery 74.8% of patients had a hearing loss. Hearing was mostly unserviceable in tumors attached to the meatus. Pure tone audiometry did not correlate to IAC extension, while speech discrimination scores were statistically worse when the tumor occupied the IAC (unpaired t test, p = 0.0152). Similarly, extrameatal tumors undergoing removal by otic preserving techniques maintained postoperative hearing, whereas hearing worsened significantly in tumors involving the IAC (paired t test, p = 0.048). The FN was affected preoperatively in 11.4% of cases. Postoperative FN palsy was significantly correlated to the IAC involvement (Fisher's exact test, p = 0.0013), while it was not correlated to tumor size. According to the Desgeorges classification, a postoperative FN palsy complicated the majority of anteriorly extending tumors and, two-fifths of meatus centred tumors. 75% of posterior located tumors had a postoperative FN grade I HB. CONCLUSIONS Since the involvement of the IAC by the tumor affects both hearing and FN function, the IAC is of primary importance in PPSMs and should be studied and addressed as much as the tumor location in the CPA.
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Affiliation(s)
- Vittoria Sykopetrites
- Department of Otology and Skull Base Surgery, Gruppo Otologico and Mario Sanna Foundation, Piacenza, Rome, Italy. .,Casa di Cura "Piacenza" S.P.A., Via Emmanueli 42, 29121, Piacenza, Italy.
| | - Abdelkader Taibah
- Department of Otology and Skull Base Surgery, Gruppo Otologico and Mario Sanna Foundation, Piacenza, Rome, Italy.,Casa di Cura "Piacenza" S.P.A., Via Emmanueli 42, 29121, Piacenza, Italy
| | - Gianluca Piras
- Department of Otology and Skull Base Surgery, Gruppo Otologico and Mario Sanna Foundation, Piacenza, Rome, Italy.,Casa di Cura "Piacenza" S.P.A., Via Emmanueli 42, 29121, Piacenza, Italy
| | - Anna Lisa Giannuzzi
- Department of Otology and Skull Base Surgery, Gruppo Otologico and Mario Sanna Foundation, Piacenza, Rome, Italy.,Casa di Cura "Piacenza" S.P.A., Via Emmanueli 42, 29121, Piacenza, Italy
| | - Fernando Mancini
- Department of Otology and Skull Base Surgery, Gruppo Otologico and Mario Sanna Foundation, Piacenza, Rome, Italy.,Casa di Cura "Piacenza" S.P.A., Via Emmanueli 42, 29121, Piacenza, Italy
| | - Mario Sanna
- Department of Otology and Skull Base Surgery, Gruppo Otologico and Mario Sanna Foundation, Piacenza, Rome, Italy.,Casa di Cura "Piacenza" S.P.A., Via Emmanueli 42, 29121, Piacenza, Italy
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Lee WJ, Hong SD, Woo KI, Seol HJ, Choi JW, Lee JI, Nam DH, Kong DS. Endoscopic endonasal and transorbital approaches to petrous apex lesions. J Neurosurg 2021; 136:431-440. [PMID: 34416715 DOI: 10.3171/2021.2.jns203867] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2020] [Accepted: 02/08/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The petrous apex (PA) is one of the most challenging areas in skull base surgery because it is surrounded by numerous critical neurovascular structures. The authors analyzed the clinical outcomes of patients who underwent endoscopic endonasal approach (EEA) and transorbital approach (TOA) procedures for lesions involving PA to determine the perspectives and proper applications of these two approaches. METHODS The authors included patients younger than 80 years with lesions involving PA who were treated between May 2015 and December 2019 and had regular follow-up MR images available for analysis. Patients with meningioma involving petroclival regions were excluded. The authors classified PA into three regions: superior to the petrous segment of the internal carotid artery (p-ICA) (zone 1); posterior to p-ICA (zone 2); and inferior to p-ICA (zone 3). Demographic data, preoperative clinical and radiological findings, surgical outcomes, and morbidities were reviewed. RESULTS A total of 19 patients with lesions involving PA were included. Ten patients had malignant tumor (chondrosarcoma, chordoma, and osteosarcoma), and 6 had benign tumor (schwannoma, Cushing's disease, teratoma, etc.). Three patients had PA cephalocele (PAC). Thirteen patients underwent EEA, and 5 underwent TOA. Simultaneous combined EEA and TOA was performed on 1 patient. Thirteen of 16 patients (81.3%) had gross- or near-total resection. Tumors within PA were completely resected from 13 of 16 patients using a view limited to only the PA. Complete obliteration of PAC was achieved in all patients. Postoperative complications included 2 cases of CSF leak, 1 case of injury to ICA, 1 fatality due to sudden herniation of the brainstem, and 1 case of postoperative diplopia. CONCLUSIONS EEA is a versatile surgical approach for lesions involving all three zones of PA. Clival tumor spreading to PA in a medial-to-lateral direction is a good indication for EEA. TOA provided a direct surgical corridor to the superior portion of PA (zone 1). Patients with disease with cystic nature are good candidates for TOA. TOA may be a reasonable alternative surgical treatment for select pathologies involving PA.
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Affiliation(s)
| | | | - Kyung In Woo
- 3Ophthalmology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
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Anania P, Mirapeix-Lucas R, Zona G, Prior A, Cortes CA, Muñoz Hernandez F. Middle Cranial Fossa Approach: Anatomical Study on Skull Base Triangles as a Landmark for a Safe Anterior Petrosectomy. J Neurol Surg B Skull Base 2019; 82:202-207. [PMID: 33777635 DOI: 10.1055/s-0039-1696957] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2019] [Accepted: 07/28/2019] [Indexed: 10/26/2022] Open
Abstract
Objective The Kawase approach provides access to the petroclival and posterior cavernous sinus regions, cerebellopontine angle, and upper basilar artery territory. Nevertheless, it remains one of the most challenging approach for neurosurgeons, due to the considerable related morbidity and mortality. The goal of this study was to evaluate the relationship between anatomical landmarks and their possible variations, and to measure the extension of the Kawase space, to define the reliability of these landmarks while performing an anterior petrosectomy. Design Using eight cadaveric specimens (15 sides), an anatomical dissections and extradural exposure of the Kawase area were performed. Settings A two-step analysis of the distances between the mandibular branch of the trigeminal nerve (V3) and the structures at risk of iatrogenic damage was performed. Main outcome measures We measured the distance between V3 and the basal turn of the cochlea, and between V3 and the internal acoustic canal (IAC), analyzing the limits of bone resection without causing hearing damage. Results We analyzed eight cadaveric (15 sides) formalin-fixed heads injected with colored silicone: four males and four females of Caucasian race (mean age: 73.83 years). We found a mean distance of 10.46 ± 1.13 mm between the great superficial petrous nerve (GSPN) intersection with V3 and the basal turn of the cochlea, and of 11.92 ± 1.71 mm between the origin point of V3 from the Gasserian ganglion and the fundus of the IAC. Conclusion The knowledge of the safe distance between the most applicable anatomic landmarks and the hearing structures is a practical and useful method to perform this approach reducing related comorbidity.
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Affiliation(s)
- Pasquale Anania
- Neurosurgery, Department of Neurosciences (DINOGMI), Policlinico San Martino, University of Genoa, Genova, Italy.,Neurosurgery, Hospital de la Santa Creu I Sant Pau, Autonomous University of Barcelona, Barcelona, Spain
| | - Rosa Mirapeix-Lucas
- Department of Anatomy and Embryology, School of Medicine, Autonomous University of Barcelona, Spain
| | - Gianluigi Zona
- Neurosurgery, Department of Neurosciences (DINOGMI), Policlinico San Martino, University of Genoa, Genova, Italy
| | - Alessandro Prior
- Neurosurgery, Department of Neurosciences (DINOGMI), Policlinico San Martino, University of Genoa, Genova, Italy
| | - Carlos Asencio Cortes
- Neurosurgery, Hospital de la Santa Creu I Sant Pau, Autonomous University of Barcelona, Barcelona, Spain
| | - Fernando Muñoz Hernandez
- Neurosurgery, Hospital de la Santa Creu I Sant Pau, Autonomous University of Barcelona, Barcelona, Spain
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Tawfik-Helika M, Mertens P, Ribas G, Cusimano MD, Catala M, Kirollos R, Jacquesson T. Understanding Anatomy of the Petrous Pyramid-A New Compartmental Approach. World Neurosurg 2019; 124:e65-e80. [PMID: 30620892 DOI: 10.1016/j.wneu.2018.11.234] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2018] [Revised: 11/24/2018] [Accepted: 11/26/2018] [Indexed: 11/26/2022]
Abstract
BACKGROUND Learning surgical anatomy of the petrous pyramid can be a challenge, especially in the beginning of the training process. Providing an easier, holistic approach can be of help to everyone with interest in learning and teaching skull base anatomy. We present the complex organization of petrous pyramid anatomy using a new compartmental approach that is simple to understand and remember. METHODS The surfaces of the petrous pyramid of two temporal bones were examined; and the contents of the petrous pyramid of 8 temporal bones were exposed through progressive drilling of the superior surface. RESULTS The petrous pyramid is made up of a bony container, and its contents were grouped into 4 compartments (mucosal, cutaneous, neural, and vascular). Two reference lines were identified (mucosal and external-internal auditory canal lines) intersecting at the level of the middle ear. The localization of contents relative to these reference lines was then described, and 2 methods of segmentation (the X method and the V method) were then proposed. This description was then used to describe middle ear relationships, facial nerve anatomy, and air cell distribution. CONCLUSIONS This new compartmental approach allows a comprehensive understanding of the distribution of petrous pyramid contents. Dividing it into anatomic compartments, and then navigating this mental map along specific reference points, lines, spaces, and segments, could create a useful tool to teach or learn its complex tridimensional anatomy.
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Affiliation(s)
- Mamdouh Tawfik-Helika
- Department of Neurosurgery, Beaujon University Hospital, Assistance publique hopitaux de Paris, Clichy, France.
| | | | - Guilherme Ribas
- Department of Surgery, University of São Paulo Medical School, São Paulo, Brazil
| | - Michael D Cusimano
- Division of Neurosurgery, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Martin Catala
- Sorbonne Université, CNRS UMR 7622, INSERM ERL 1156, IBPS, Paris, France
| | - Ramez Kirollos
- Senior Consultant, National Neuroscience Institute, Singapore
| | - Timothée Jacquesson
- Department of Anatomy, University of Lyon 1, Lyon, France; Skull Base Multi-disciplinary Unit, Department of Neurosurgery B, Neurological Hospital Pierre Wertheimer, Hospices Civils de Lyon, Lyon Cedex, France
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Tomasello F, Angileri FF, Conti A, Scibilia A, Cardali S, La Torre D, Germanò A. Petrosal Meningiomas: Factors Affecting Outcome and the Role of Intraoperative Multimodal Assistance to Microsurgery. Neurosurgery 2018; 84:1313-1324. [DOI: 10.1093/neuros/nyy188] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2017] [Accepted: 04/19/2018] [Indexed: 11/13/2022] Open
Affiliation(s)
| | | | - Alfredo Conti
- Department of Neurosurgery, University of Messina, Messina, Italy
- Depart-ment of Neurosurgery, Charité Univer-sitätsmedizin, Berlin, Germany
| | | | | | | | - Antonino Germanò
- Department of Neurosurgery, University of Messina, Messina, Italy
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Differences in clinical presentation, intraoperative findings and outcome between petroclival and lateral posterior pyramid meningioma. Clin Neurol Neurosurg 2016; 141:122-8. [PMID: 26826961 DOI: 10.1016/j.clineuro.2016.01.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2015] [Revised: 12/29/2015] [Accepted: 01/05/2016] [Indexed: 11/20/2022]
Abstract
OBJECTIVE The goal of this study was to determine the impact of the location of the most frequent skull base meningioma of the posterior fossa, i.e. petroclival (PCM) and lateral posterior pyramid meningioma (LPPM) on clinical presentation, surgical treatment and treatment results. PATIENTS AND METHODS We retrospectively reviewed a consecutive series of patients operated on for PCM (n=46) and LPPM (n=32). Uni- and multivariate analyses were performed to identify differences in clinical presentation, surgical treatment and pre-, intra- and postoperative factors of influence upon the outcome parameters: Complications rate, mortality, tumour recurrence/progress, hospital stay, Karnofsky Performance Score (KPS). RESULTS At Presentation, the rate of dizziness was higher in LPPM (56% vs. 7%, p<0,001) and trigeminal nerve impairment was more frequent in PCM (50% vs. 3%, p<0,001). Complete tumour resections were more often achieved (91% vs. 39%, p<0,001), and surgery lasted shorter (median: 247 min vs. 500 min, p<0,001) with less blood loss (median: 525 ml vs. 1000 ml, p<0,001) in LPPM compared to PCM. The overall complication rates (73% vs. 31%, p<0,001) as well the rate of irreversible complications (57% vs. 9%, p<0,004) were higher in PCM than in LPPM. The most frequent complications of PCM surgery were eye movement (46% vs. 6%, p<0,001), facial nerve (28% vs. 3%, p<0.02) and swallowing impairments (21% vs. 3%, p<0.02). The perioperative mortality was 11% in PCM and 0% in LPPM patients. In the multivariate analyses, KPS at discharge correlate positively with age (p=0.034) and preoperative KPS (p=0.0048) in LPPM and positively with staged resection (p=0.056) and negatively with the occurrence of surgical complications (p=0,0427) in PCM. Hospitalization time correlated with the blood loss (p<0,001) for PCM, negatively with the preoperative KPS (p=0.0002) for PCM and LPPM and positively with tumour diameter (p=0.0001) and non-surgical complications rate (p=0.0001) for LPPM. CONCLUSION As compared to LPPM, surgical treatment of PCM is associated with higher morbidity and mortality. The outcome of LPPM was primarily influenced by preoperative factors: Patients age, tumour size, preoperative KPS. The outcome of PCM was primarily influenced by intraoperative factors like: blood loss, surgery duration, staged tumour resection and the surgical complications rate.
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Jacquesson T, Berhouma M, Tringali S, Simon E, Jouanneau E. Which Routes for Petroclival Tumors? A Comparison Between the Anterior Expanded Endoscopic Endonasal Approach and Lateral or Posterior Routes. World Neurosurg 2015; 83:929-36. [PMID: 25700970 DOI: 10.1016/j.wneu.2015.02.003] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2014] [Revised: 01/30/2015] [Accepted: 02/02/2015] [Indexed: 12/21/2022]
Abstract
OBJECTIVE Petroclival tumors remain a surgical challenge. Classically, the retrosigmoid approach (RSA) has long been used to reach such tumors, whereas the anterior petrosectomy (AP) has been proposed to avoid crossing cranial nerves. More recently, the endoscopic endonasal approach has been "expanded" (i.e., EEEA) to the petroclival region. We aimed to compare these 3 approaches to help in the surgical management of petroclival tumors. METHODS Petroclival approaches were performed on 5 specimens after they were prepared with formaldehyde colored via latex injection. RESULTS The EEEA provides a simple straightforward route to the clivus, but reaching the petrous apex requires the surgeon to circumvent the internal carotid artery either via a medial transclival, an inferior transpterygoid, or a lateral variant through the Meckel's cave. In contrast, the AP offers a narrow direct superolateral access to the petroclival region crossed by the trigeminal nerve. Finally, the RSA provides a wide simple and quick exposure of the cerebellopontine angle, but access to the petroclival region needs the surgeon to deal with the V(th) to XI(th) cranial nerves. DISCUSSION/CONCLUSION The EEEA should be preferred for extradural midline tumors (chordomas, chondrosarcomas) or for cystic lesions when drainage is essential. The AP could be optimal for the radical removal of intradural vascularized tumors (meningiomas) with intrapetrous or supratentorial extensions. The RSA retains an advantage for small or cystic tumors near the internal acoustic meatus. The skull base surgeon has to master all of these routes to choose the more appropriate one according to the surgical objective, the tumor characteristics, and the patient's medical status.
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Affiliation(s)
- Timothée Jacquesson
- Skull Base Multidisciplinary Unit, Department of Neurosurgery, Neurological Hospital Pierre Wertheimer, Lyon Cedex, France; Department of Anatomy, University of Lyon, Lyon, France.
| | - Moncef Berhouma
- Skull Base Multidisciplinary Unit, Department of Neurosurgery, Neurological Hospital Pierre Wertheimer, Lyon Cedex, France
| | - Stéphane Tringali
- Skull Base Multidisciplinary Unit, Department of Neurosurgery, Neurological Hospital Pierre Wertheimer, Lyon Cedex, France; Department of Otorhinolaryngology, Pierre Benite, France
| | - Emile Simon
- Department of Anatomy, University of Lyon, Lyon, France
| | - Emmanuel Jouanneau
- Skull Base Multidisciplinary Unit, Department of Neurosurgery, Neurological Hospital Pierre Wertheimer, Lyon Cedex, France
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Abstract
BACKGROUND AND PURPOSE The aim of the study is to present our experience in the surgical treatment of posterior petrous meningiomas in regard to clinical presentation, surgical anatomy, complications and long-term functional postoperative results. MATERIAL AND METHODS A series of 48 consecutive patients operated on for posterior petrous meningiomas at the authors' institution between 2002 and 2011 is reported. The main symptom on first admission was hypoacusis, impairment of the fifth cranial nerve and cerebellar ataxia. The tumour was found to be attached to the premeatal dura in 46%, the inframeatal dura in 29% and the postmeatal dura in 25% of cases. Tumour resection was categorized as grade I in 16 patients, grade II in 29 patients, grade III in 1 patient and grade IV in 2 patients, according to the Simpson classification system. The petrosal approach and retrosigmoid approach were suitable for posterior petrous meningiomas. RESULTS Postoperative facial nerve dysfunction appeared in 8 and further deteriorated in 2 patients. Hearing function deteriorated after surgery in 8 and improved in 2 cases. Perioperative death occurred in two patients. Tumour recurrence was observed in two patients, and both underwent a second operation and postoperative stereotactic radiotherapy. CONCLUSIONS Surgical treatment of posterior petrous meningiomas has become increasingly safe but these tumours still remain a surgical challenge because of the relatively high incidence of permanent complications associated with their removal. The site of displacement of the cranial nerves depending on the dural origin of the tumour has the most influence on the related difficulties in its removal.
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