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

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.

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

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.

Presigmoid transpetrous approach (partial petrosectomy) combined with subtemporal transtentorial approach for petroclival meningioma

Introduction: Petroclival meningiomas constitute 3 to 10% of meningiomas of the posterior fossa, they originate in the petroclival fissure, in the upper part of the clivus, petrosal apex, and medial to the trigeminal nerve. Resection of these tumors is a neurosurgical challenge. The combined partial petrosectomy approach associated with a sub-temporal approach is a technique described by various authors; however, its performance is considered highly complex. We report the case of a petroclival meningioma operated successfully in our hospital using a combined presigmoid and subtemporal transtentorial transpetrosal approach. Clinical case: 33-year-old female patient with a clinical picture of headache, nausea, and gait disturbance. Brain magnetic resonance imaging showed a large right petroclival tumor (4.2x3.9x3.8cm) that displaced the brainstem and secondary hydrocephalus. The hydrocephalus was treated with a ventricular peritoneal shunt. Then, the tumor was resected using a combined presigmoid and subtemporal transpetrosal approach, a technique that allowed adequate exposure of the tumor, achieving complete resection, without intraoperative complications. Postoperative evolution was favorable, with no sequelae. Conclusion: The combined presigmoid and transtentorial subtemporal transpetrous approach for petroclival meningiomas is an effective and feasible technique to perform in our environment. The support of technology such as Neuronavigation, the ultrasonic aspirator, intraoperative monitoring, and adequate experience in skull base surgery are fundamental factors for the success of this surgery. Keywords: Meningioma, Skull Base Neoplasms, Craniotomy, Neurosurgical Procedures. (Source: MeSH NLM)

An Overview of Definition and Approaches to Petroclival Meningioma

Meningiomas account for 20 to 25% of all intracranial tumors and 10% are seen in the posterior fossa. Petroclival tumors are defined as arising from the upper two thirds of the clivus, medial to the trigeminal nerve at the petroclival junction. Brain CT scan and MRI are routinely used to evaluate tumor anatomy. The petrous temporal bone is a hindrance to resection of these tumors. Oftentimes neurosurgeons are unskilled with the anatomy of the petrous bone, and so suboccipital and pterional routes are usually preferred. Some authors have encouraged using traditional neurosurgical approaches to these tumors. In this manuscript we review tumor location and approaches used for resection of these challenging tumors.

Analysis of Approaches in the Microsurgical Treatment of 102 Cases of Petroclival Meningioma in a Single Center

Objectives: We identified the optimal approaches for treating the diverse tumor subtypes of petroclival meningioma (PM) by analyzing the clinical benefits of various surgical approaches adopted for each subtype.Methods: Tumors in 102 PM patients from a single center who underwent surgical treatment were classified as upper clivus (UC), cavernous sinus (CS), tentorium (TE), or petrous apex (PA) types based on the attachment site of the tumor base and the displacement of the trigeminal nerve. The therapeutic effects of different surgical approaches among the subtypes were evaluated according to the patient outcomes.Results: The subtemporal (33.33%), retrosigmoid (16.67%), and Kawase approaches (50%) were used for the UC type. Simpson I/II resection was achieved in 46.66% of patients with the Kawase approach. Significant differences were found between the other two approaches (P = 0.044) and in the follow-up Karnofsky performance scale (KPS) scores (P = 0.008). The subtemporal (60%) and Kawase approaches (40%) were used for the CS type; neither approach achieved Simpson I/II resection. The retrosigmoid (25.81%) and Kawase approaches (74.19%) were used for the TE type. The Simpson I/II resection rates of the two approaches were 55.55 and 86.95%, respectively, and a significant difference was observed between them (P = 0.039). The retrosigmoid (43.75%) and Kawase approaches (56.25%) were used for the PA type. The Simpson I/II resection rates of the two approaches were 31.25 and 50%, respectively. The resection degrees of the two approaches and the KPS scores at follow-up were significantly different (P = 0.034).Conclusion: The individual microsurgical approaches adopted for the various PM tumor subtypes can provide maximal safe resection and good KPS scores. The Kawase approach is more suitable for PM, especially for UC- and PA-type PM tumors.

Does General Comorbidity Impact the Postoperative Outcomes After Surgery for Large and Giant Petroclival Meningiomas?

ObjectiveWe assessed the role of the general condition of the patient in addition to usual anatomical reasoning to improve the prediction of personalized surgical risk for patients harbouring a large and giant petroclival meningiomas.MethodsSingle-center, retrospective observational study including adult patients surgically treated for a large and giant petroclival meningioma between January 2002 and October 2019 in a French tertiary neurosurgical skull-base center by one Neurosurgeon. Inclusion criteria were: 1) histopathologically proven meningioma; 2) larger than 3cm in diameter; 2) located within the upper two-thirds of the clivus, the inferior petrosal sinus, or the petrous apex around the trigeminal incisura, medial to the trigeminal nerve. Clinical and radiological characteristics were gathered preoperatively including ASA score, the modified Frailty Index and the Charlson Comorbidity Index. Post-operative severe neurological and non-neurological complications were collected.ResultsA total of 102 patients harbouring a large and giant petroclival meningioma were included. The rate of postoperative death was 3.0% related to a congestive heart failure (n=1), a surgical site hematoma (n=1), and an ischemic stroke (n=1). A severe neurological impairment was found in 12.8% and a severe non-neurological morbidity was found in 4.0%. The overall rate of severe morbidity and mortality was 15.7% after large and giant petroclival meningioma surgery. The presence of brainstem peri-tumoral edema (adjusted OR, 4.83 [95% CI 1.84–7.52], p=0.028) was independently associated with a history of postoperative severe neurological morbidity. Male gender (adjusted OR, 7.42 [95% CI 1.05–49.77], p=0.044), major cardiovascular morbidity (adjusted OR, 9.5 [95% CI 1.05–86.72], p=0.045), and an ASA score ≥ 2 (adjusted OR, 11.09 [95% CI 1.46–92.98], p=0.038) were independently associated with a history of postoperative severe non-neurological morbidity. A modified Frailty index ≥ 1 (adjusted OR, 3.13 [95% CI 1.07–9.93], p=0.047), and a low neurosurgical experience (adjusted OR, 5.38 [95% CI 1.38–20.97], p=0.007) were independently associated with a history of postoperative overall morbidity and mortality.ConclusionsThis study suggests to add scores assessing the patient general condition in daily practice to improve the selection of patients eligible for surgery. Collaborative international multicenter studies will be necessary to confirm these results and allow their implementation in clinical routine.