Modified Transpetrosal–Transtentorial Approach for Resection of Large and Giant Petroclival Meningioma: Technical Nuance and Surgical Experiences

Abstract Background Meningiomas arising from the petroclival area remain a challenge for neurosurgeons. Various approaches have been proposed to achieve maximum resection with minimal morbidity and mortality. Also, some articles correlated preservation of adjacent veins with less neurologic deficits. Objective To describe the experiences in using a new technique to achieve maximal resection of petroclival meningiomas and preserving the superior petrosal veins (SPVs) and the superior petrosal sinus (SPS). Methods A retrospective analysis of 26 patients harboring a true petroclival meningioma with a diameter ≥25 mm and undergoing surgery with the modified transpetrosal–transtentorial approach (MTTA) was performed. Results Fifty-four percent of 22 patients complained of severe headache at presentation. There was also complaint of cranial nerve (CN) deficit, with CN VII deficit being the most common (present in 42% of patients). The average tumor size (measured as maximum diameter) was 45.2 mm, and most of the tumors compressed the brainstem. Total resection was achieved in 12 patients (46.2%), whereas the others were excised subtotally (54.8%). Most of the patients had WHO grade I (96.1%) meningioma; only one had a grade II (3.8%) meningioma. In addition, clinical improvement and persistence of symptoms were observed in 17 (65.4%) and 8 (30.7%) patients, respectively, and postoperative permanent CN injury was observed in 3 (11.5%) patients. Conclusion Using the MTTA, maximal resection with preservation of the CNs and neurovascular SPV-SPS complex can be achieved. Therefore, further studies and improvements of the technique are required to increase the total resection rate without neglecting the complications that may develop postoperatively.

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Preservation of the superior petrosal sinus during the petrosal approach

Journal of Neurosurgery ◽

10.3171/2010.6.jns091461 ◽

2011 ◽

Vol 114 (5) ◽

pp. 1294-1298 ◽

Cited By ~ 22

Author(s):

Ahmad Hafez ◽

Remi Nader ◽

Ossama Al-Mefty

Keyword(s):

Effective Means ◽

Senior Author ◽

Venous Anatomy ◽

Total Resection ◽

Petroclival Meningioma ◽

Trigeminal Schwannoma ◽

Anatomical Basis ◽

Superior Petrosal Sinus ◽

A New Technique ◽

Good Access

Object The petrosal approach is based on sectioning the superior petrosal sinus (SPS) and the tentorium. However, the venous anatomy in certain situations forbids this maneuver. The authors have derived a technique that enables the SPS to be spared during the performance of the petrosal approach. They describe the anatomical basis of this technique and report on 2 cases in which the technique was applied. Methods Five alcohol-preserved cadaveric heads injected with colored silicone were used for bilateral dissection and demonstration of the technique. The described method was thoroughly investigated in these cadavers to assess its advantages, variabilities, and limitations. Subsequently, the technique was applied during the resection of petroclival tumors in 2 patients. Results The authors were able to demonstrate that the approach provides good access to the petroclival area through both the middle and posterior fossa in cadavers. By deriving a new technique of applying the combined petrosal approach without cutting the SPS, the senior author (O.A.M.) managed to achieve total resection of a dumbbell-shaped trigeminal schwannoma in a 19-year-old woman and of a petroclival meningioma in a 49-year-old man. Conclusions This modification of the petrosal approach involving sparing of the SPS or cutting of the tentorium is an effective means for cases in which the venous anatomy mandates preservation of these structures.

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Evolution of Surgical Approaches in the Treatment of Petroclival Meningiomas: A Retrospective Review

Operative Neurosurgery ◽

10.1227/01.neu.0000303218.61230.39 ◽

2007 ◽

Vol 61 (suppl_5) ◽

pp. ONS202-ONS211 ◽

Cited By ~ 36

Author(s):

Nicholas C. Bambakidis ◽

U. Kumar Kakarla ◽

Louis J. Kim ◽

Peter Nakaji ◽

Randall W. Porter ◽

...

Keyword(s):

Survival Rates ◽

Progression Free Survival ◽

Surgical Approaches ◽

Single Institution ◽

Short Term ◽

Total Resection ◽

Free Survival ◽

Petroclival Meningioma ◽

Petroclival Meningiomas

Abstract Objective: We examined the surgical approaches used at a single institution to treat petroclival meningioma and evaluated changes in method utilization over time. Methods: Craniotomies performed to treat petroclival meningioma between September of 1994 and July of 2005 were examined retrospectively. We reviewed 46 patients (mean follow-up, 3.6 yr). Techniques included combined petrosal or transcochlear approaches (15% of patients), retrosigmoid craniotomies with or without some degree of petrosectomy (59% of patients), orbitozygomatic craniotomies (7% of patients), and combined orbitozygomatic-retrosigmoid approaches (19% of patients). In 18 patients, the tumor extended supratentorially. Overall, the rate of gross total resection was 43%. Seven patients demonstrated progression over a mean of 5.9 years. No patients died. At 36 months, the progression-free survival rate for patients treated without petrosal approaches was 96%. Of 14 patients treated with stereotactic radiosurgery, none developed progression. Conclusion: Over the study period, a diminishing proportion of patients with petroclival meningioma were treated using petrosal approaches. Utilization of the orbitozygomatic and retrosigmoid approaches alone or in combination provided a viable alternative to petrosal approaches for treatment of petroclival meningioma. Regardless of approach, progression-free survival rates were excellent over short-term follow-up period.

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Combined Presigmoid and Retrosigmoid Approach to Petroclival Meningiomas

Journal of Neurological Surgery Part B Skull Base ◽

10.1055/s-0038-1669965 ◽

2018 ◽

Vol 79 (S 05) ◽

pp. S402-S403

Author(s):

Marcio Rassi ◽

Johnni Zamponi ◽

Duarte Cândido ◽

Jean Oliveira ◽

Gustavo Passos ◽

...

Keyword(s):

Skull Base ◽

Venous Drainage ◽

Clinical History ◽

Jugular Bulb ◽

Retrosigmoid Approach ◽

Limiting Factor ◽

Posterior Aspect ◽

Petroclival Meningioma ◽

Petroclival Meningiomas ◽

Transtentorial Approach

Introduction The management of petroclival meningiomas is among the most intimidating in neurosurgery, due to its difficult accessibility and close relationship with vital structures; therefore, an appropriate exposure is mandatory. We present a surgical video demonstrating a presigmoid transtentorial approach, associated with the opening of the retrosigmoid dura to a petroclival meningioma, performed by the senior surgeon (L.A.B.B.), along with its indications and pitfalls. Approach Decision The patient's clinical history is summed to the tumor's radiological features as its extension, vascularization, and venous drainage, when selecting the appropriate approach. The presigmoid transtentorial approach offers a wide exposure of the petroclival area along with the tumor's attachment. Its association with the retrosigmoid route allows the surgeon to freely work through multiple paths, and parallel to the skull base, reducing the traction in the temporal lobe. Clinical Case This is a 39-year-old female presenting with trigeminal neuralgia. Imaging depicted a petroclival meningioma, extending from the posterior aspect of the cavernous sinus to the cerebellopontine angle, extending inferiorly to the jugular bulb. A Simpson II resection was achieved through a combined presigmoid and retrosigmoid approach, and the patient was discharged with no complications or new deficits. Conclusion Petroclival meningiomas are a formidable and surgically treatable disease. The appropriate approach is design to each patient and should not be the limiting factor for total tumor removal, which is truly given by the absence of a dissection plane between the tumor and the brainstem, nerves and vascular structures of the skull base.The link to the video can be found at: https://youtu.be/MFjqZvElBSo.

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Diagnosis and Predictors of Treatment Outcomes in Meningiomas with Atypical or Anaplastic Histology

JBNC - JORNAL BRASILEIRO DE NEUROCIRURGIA ◽

10.22290/jbnc.v27i2.751 ◽

2018 ◽

Vol 27 (2) ◽

pp. 100-104 ◽

Cited By ~ 1

Author(s):

Gustavo Simiano Jung ◽

Ricardo Ramina ◽

Erasmo Barros Da Silva Jr ◽

Maurício Coelho Neto

Keyword(s):

Treatment Outcomes ◽

Treatment Options ◽

Gross Total Resection ◽

Total Resection ◽

Who Grade ◽

Grade Ii ◽

Anaplastic Histology ◽

Biological Nature

Atypical and anaplastic meningiomas (WHO grade II and III) are uncommon tumors with poorer prognosis than benign meningiomas. They represent a small and heterogeneous subgroup of meningiomas that has more aggressive biological nature and higher frequency of recurrence. Treatment of these tumors remains challenging and recurrence is common even after gross total resection. We report five year experience of an experienced neurosurgical center (INC) reviewing treatment options and predictor of treatment outcomes for malignant meningiomas.

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Comparative Analysis of the MRI Characteristics of Meningiomas According to the 2016 WHO Pathological Classification

Technology in Cancer Research & Treatment ◽

10.1177/1533033820983287 ◽

2020 ◽

Vol 19 ◽

pp. 153303382098328

Author(s):

Juan Yu ◽

Fan-fan Chen ◽

Han-wen Zhang ◽

Hong Zhang ◽

Si-ping Luo ◽

...

Keyword(s):

Signal Intensity ◽

Tumor Grade ◽

World Health ◽

Maximum Diameter ◽

Who Grade ◽

Pathological Classification ◽

Adc Values ◽

Grade Ii ◽

Health Organization ◽

Mri Characteristics

Objects: To evaluate the performance of preoperative magnetic resonance imaging (MRI) in evaluating diagnoses, operation methods and recurrence of meningiomas according to the World health organization (WHO) pathological classification. Methods: MRI characteristics of 127 meningioma patients were retrospectively analysed according to pathological results (WHO grade) and their association with Simpson’s grades (resection) and recurrence. Results: The T1-weighted imaging (T1WI) signal intensity of WHO grade I meningiomas was slightly hypointense or isointense gray, while the T2-weighted imaging (T2WI) signal intensity was isointense or slightly hyperintense. The T1WI and T2WI signal intensity in WHO grade II and III meningiomas was isointense gray. The enhancement degree and patterns, lobulation, flowing voids, dural tail, maximum diameter, peritumoural oedema, ADC values and margin were significantly different between any 2 grades (P < 0.05). The ADC values were higher for WHO grade I tumors than for WHO grade II and III tumors (P < 0.001). Among all the analyzed characteriscs, ADC values, peritumoural oedema, and margin effectively predicted the diagnosis according to the WHO classification. The operation method and surgical resection were different between WHO grade Ⅰ and WHO grade Ⅱ/Ⅲ meningiomas (P < 0.05). The recurrence rate increased with tumor grade, but there was no statistical difference among the 3 types(P> 0.05). Conclusions: WHO grades and pathological subtypes of meningiomas can generally be determined based on their MRI characteristics. In addition, MRI provides significant guidance for the grading of surgical success and prognosis.

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Posterior petrosal approach for microsurgical resection of petroclival meningioma: 3-Dimensional operative video

Surgical Neurology International ◽

10.25259/sni_270_2021 ◽

2021 ◽

Vol 12 ◽

pp. 324

Author(s):

Guilherme Henrique Weiler Ceccato ◽

Rodolfo Frank Munhoz da Rocha ◽

Anderson Matsubara ◽

Luis Alencar Biurrum Borba

Keyword(s):

Lateral Position ◽

Jugular Foramen ◽

Neurological Deficits ◽

Preoperative Imaging ◽

Neurophysiological Monitoring ◽

Petroclival Meningioma ◽

Petroclival Meningiomas ◽

Close Relationship ◽

Superior Petrosal Sinus ◽

Microsurgical Resection

Background: Petroclival meningiomas are challenging lesions considering their deep location and close relationship with many vital neurovascular structures.[1-8] Case Description: We present the case of a 54-year-old male presenting a history of headache, dizziness, and tinnitus on the left side, associated with left facial hypoesthesia. Preoperative imaging depicted a lesion highly suggestive of a petroclival meningioma with important compression of the brainstem. Considering worsening of symptoms, size, and location of this lesion, microsurgical resection was indicated. A left posterior petrosal approach was employed with aid of neurophysiological monitoring. The patient was placed in a true lateral position and an arciform incision was done. First, the mastoidectomy was performed and then the craniotomy around encompassing both posterior and middle cranial fossae. Middle and posterior fossa dural incisions were connected through coagulation of the superior petrosal sinus. Then tentorium was all the way cut to the incisura. After that, sigmoid sinus can be mobilized posteriorly, increasing exposure of presigmoid space. The area since jugular foramen up to the supratentorial region was fully exposed, allowing safe total resection of the lesion. Postoperative imaging demonstrated complete tumor removal. Patient presented improvement of symptoms, with no new neurological deficits on follow-up. Conclusion: The posterior petrosal approach provided a shorter pathway and direct angle of attack to the tumor attachment, allowing successful resection.[1,6] Extensive laboratory training is essential to get familiarized with the complex anatomical relationships in that area. Informed consent was obtained from the patient for the procedure and publication of this operative video.

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Microsurgical Gross Total Resection of a WHO Grade II Cerebellopontine Angle Ependymoma in an Adult

Journal of Neurological Surgery Part B Skull Base ◽

10.1055/s-0038-1669969 ◽

2018 ◽

Vol 79 (S 05) ◽

pp. S426-S427

Author(s):

Sima Sayyahmelli ◽

Melih Ucer ◽

Mustafa Baskaya

Keyword(s):

Cerebellopontine Angle ◽

Residual Disease ◽

Posterior Inferior Cerebellar Artery ◽

Cranial Nerves ◽

Choroid Plexus Papilloma ◽

Gross Total Resection ◽

Direct Stimulation ◽

Total Resection ◽

Who Grade ◽

Grade Ii

Infratentorial ependymomas that arise in the fourth ventricle and extend into the cerebellopontine angle (CPA) through the foramina of Luschka are well described. However, a primary CPA location of an ependymoma is distinctly uncommon. In this video, we present a 46-year-old man with episodes of dizziness, left-sided tinnitus, imbalance, double vision, and nausea. An magnetic resonance imaging (MRI) scan of the head showed a large mass lesion centered in the CPA with heterogenous enhancement. Differential diagnosis included ependymoma, meningioma, schwannoma of the vestibular nerve, or lower cranial nerves, and choroid plexus papilloma. He underwent microsurgical gross total resection of the tumor via a retrosigmoid approach. Direct stimulation of the cranial nerves was performed throughout the case and there was no attachment of the tumor to any cranial nerve to suggest that this might be a schwannoma. The tumor encased important vasculature, including the posterior-inferior cerebellar artery. The histopathology was a grade II ependymoma. The patient tolerated the surgery well and his postoperative course was uneventful. He remained neurologically intact. He received radiation therapy and there was no recurrent or residual disease on follow-up studies. This video demonstrates important steps of the surgical approach and microsurgical resection techniques for this type of challenging tumor.The link to the video can be found at: https://youtu.be/KK-y6EYh888.

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Adjuvant radiation versus observation with salvage radiation after gross-total resection of WHO grade II meningiomas: a propensity score–adjusted analysis

Journal of Neurosurgery ◽

10.3171/2021.4.jns21559 ◽

2021 ◽

pp. 1-8

Author(s):

Arbaz A. Momin ◽

Pranay Soni ◽

Jianning Shao ◽

Amy S. Nowacki ◽

John H. Suh ◽

...

Keyword(s):

Regression Analysis ◽

Cox Regression ◽

Adjuvant Radiation ◽

Newly Diagnosed ◽

Total Resection ◽

Who Grade ◽

Free Survival ◽

Cox Regression Analysis ◽

Initial Recurrence ◽

Grade Ii

OBJECTIVE After gross-total resection (GTR) of a newly diagnosed WHO grade II meningioma, the decision to treat with radiation upfront or at initial recurrence remains controversial. A comparison of progression-free survival (PFS) between observation and adjuvant radiation fails to account for the potential success of salvage radiation, and a direct comparison of PFS between adjuvant and salvage radiation is hampered by strong selection bias against salvage radiation cohorts in which only more aggressive, recurrent tumors are included. To account for the limitations of traditional PFS measures, the authors evaluated radiation failure-free survival (RFFS) between two treatment strategies after GTR: adjuvant radiation versus observation with salvage radiation, if necessary. METHODS The authors performed a retrospective review of patients who underwent GTR of newly diagnosed WHO grade II meningiomas at their institution between 1996 and 2019. They assessed traditional PFS in patients who underwent adjuvant radiation, postoperative observation, and salvage radiation. For RFFS, treatment failure was defined as time from initial surgery to failure of first radiation. To assess the association between treatment strategy and RFFS while accounting for potential confounders, a multivariable Cox regression analysis adjusted for the propensity score (PS) and inverse probability of treatment weighted (IPTW) Cox regression analysis were performed. RESULTS A total of 160 patients underwent GTR and were included in this study. Of the 121 patients who underwent observation, 32 (26.4%) developed recurrence and required salvage radiation. PFS at 3, 5, and 10 years after observation was 75.1%, 65.6%, and 45.5%, respectively. PFS at 3 and 5 years after salvage radiation was 81.7% and 61.3%, respectively. Of 160 patients, 39 received adjuvant radiation, and 3- and 5-year PFS/RFFS rates were 86.1% and 59.2%, respectively. In patients who underwent observation with salvage radiation, if necessary, the 3-, 5-, and 10-year RFFS rates were 97.7%, 90.3%, and 87.9%, respectively. Both PS and IPTW Cox regression models demonstrated that patients who underwent observation with salvage radiation treatment, if necessary, had significantly longer RFFS (PS model: hazard ratio [HR] 0.21, p < 0.01; IPTW model: HR 0.21, p < 0.01). CONCLUSIONS In this retrospective, nonrandomized study, adjuvant radiation after GTR of a WHO II meningioma did not add significant benefit over a strategy of observation and salvage radiation at initial recurrence, if necessary, but results must be considered in the context of the limitations of the study design.

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