Characteristics and surgical strategies for posterior clinoid process meningioma: two case reports and review of the literature

Abstract

Clinical and radiological features or characteristics of posterior clinoid process (PCP) meningiomas have rarely been described because of their extreme scarcity and terminological confusion. Therefore, the strategies in the surgical intervention for PCP meningiomas have not been well established. Moreover, the presence of deep and critical neuroanatomical structures and relatively high morbidity, which can be difficult to predict preoperatively, make their surgical excision more challenging. We report two surgical cases of PCP meningioma and discuss the appropriate assessment of preoperative features and surgical strategies with review of the literature. Our study suggests that PCP meningioma may be characterized by the anterior displacement of internal carotid artery, and infero-laterally shifted posterior communicating arteries, and homonymous hemianopsia, a distinctive clinical feature. One of the key issues in PCP meningioma surgery is preservation of the optic nerve. Unlocking the optic nerve by anterior clinoidectomy and dissection, the falciform ligament is the important step to preserve vision for larger tumors. Complication with the perforators is also hazardous of these challenging surgeries than anterior clinoid meningiomas for their specific neuroanatomical structures and might not be feasible to avoid even with additional techniques and critical monitoring. A combination and multi-staged-surgical approach can be options of tailor-made surgical strategy in cases with tumor adhesion to the perforators.

Staged Resection of Difficult-to-Treat Intracranial Meningiomas: A Systematic Review of the Indications, Surgical Approaches, and Postoperative Outcomes

“…Transient visual acuity declines that lasted 3 months Takase et al 10 Tumor adhesion to perforator arteries 1 no complications; 1 transient motor weakness after minor basal ganglia infarct, transient hemiparesis…”

“…All rights reserved. 8 Extended from left lateral wall of cavernous sinus, left Meckel cave, to the cerebellopontine angle 1st: Lateral suboccipital approach; 2nd: Anterior petrosal approach Leutjens et al 9 Sphenoid wing with orbital and temporobasal extension 1st: Pterional approach; 2nd: Pterional Takase et al 10 Posterior clinoid process Patient one, 1st: Anterior clinoidectomy; 2nd: Fronto-temporal craniotomy with wide splitting of the Sylvain fissure, Patient two, 1st: Right-sided fronto-temporal orbito-zygomatic osteotomy with an extra-dural optic canal opening and an anterior clinoidectomy; 2nd: two-piece Hart et al 11…”

“…This can minimize morbidity and potential mortality, from injury to critical local vasculature while maximizing the extent of resection. 10,22,24 Staged removals were performed with the initial surgery acting as the devascularization procedure, which resulted in generally favorable outcomes. 24,51 Additionally, hypervascular tumors in the lateral ventricle most often require devascularization due to the involvement of feeders from the anterior and/or posterior choroidal arteries.…”

Bone Invasive Meningioma: Recent Advances and Therapeutic Perspectives

“…Taken together, in cases of suspected meningioma with bone invasion, maximal resection of the adjacent bone would be preferable (107). Although, meningioma surgery is sometimes challenging due to anatomical circumstances (e.g., venous sinus involvement, arterial or cranial nerve envelopment, and extensive involvement of the base of the skull), especially in skull base cases (108)(109)(110)(111). To achieve maximal resection of meningiomas, including the adjacent bone, a multidisciplinary surgical strategy combined with preoperative embolization may help (112).…”

Surgical Outcome Following Meningioma Operation: Our Experience from a Tertiary Care Hospital

“…The complete surgical resection while preserving the patient's neurological status is the goal, a Simpson I resection is neither always attainable nor does it guarantee increased Progression free survival 6 , 10 . This holds especially true in view of other available adjuvant therapeutic options such as radiotherapy [11][12][13] , second surgery [14][15][16] , or a watchful wait-and-scan follow-up.…”