Management of Intracranial Meningiomas Using Keyhole Techniques

Abstract

Background: Keyhole craniotomies are increasingly being used for lesions of the skull base. Here we review our recent experience with these approaches for resection of intracranial meningiomas.Methods: Clinical and operative data were gathered on all patients treated with keyhole approaches by the senior author from January 2012 to June 2013. Thirty-one meningiomas were resected in 27 patients, including 9 supratentorial, 5 anterior fossa, 7 middle fossa, 6 posterior fossa, and 4 complex skull base tumors. Twenty-nine tumors were WHO Grade I, and 2 were Grade II. Results: The mean operative time was 8 hours, 22 minutes (range, 2:55-16:14) for skull-base tumors, and 4 hours, 27 minutes (range, 1:45-7:13) for supratentorial tumors. Simpson Resection grades were as follows: Grade I = 8, II = 8, III = 1, IV = 15, V = 0. The median postoperative hospital stay was 4 days (range, 1-20 days). In the 9 patients presenting with some degree of visual loss, 7 saw improvement or complete resolution. In the 6 patients presenting with cranial nerve palsies, 4 experienced improvement or resolution of the deficit postoperatively. Four patients experienced new neurologic deficits, all of which were improved or resolved at the time of the last follow-up. Technical aspects and surgical nuances of these approaches for management of intracranial meningiomas are discussed. Conclusions: With careful preoperative evaluation, keyhole approaches can be utilized singly or in combination to manage meningiomas in a wide variety of locations with satisfactory results.

International expert consensus statement about methods and indications for keyhole microneurosurgery from International Society on Minimally Invasive Neurosurgery

“…Level III [12,38] Sphenoid wing meningiomas Level III [5,76] Parasellar meningiomas Level III [76] approximately 4 cm above the zygomatic arch is made. A Yshaped temporalis fascia incision is made and retracted to expose the surgical field.…”

Critical Appraisal of Minimally Invasive Keyhole Surgery for Intracranial Meningioma

“…By measuring acute postoperative MRI changes, we also demonstrate that these "retractorless" approaches can be performed with minimal brain impact and manipulation. Except for our recent report on elderly meningioma patients and that by Burks et al, to our knowledge, there are no prior studies with over 40 patients treated with a minimally invasive keyhole paradigm for all intracranial meningiomas 26,33 .…”

Bur Hole–Based Resections of Intrinsic Brain Tumors with Exoscopic Visualization

“…[7][8][9][10][11][12][13][14][15][16][17][18][19] The advantages of this approach are that it may decrease anesthesia and operative time by minimizing skin opening and closure, reduces cortical areas and vessels exposed to inadvertent injury, may facilitate quicker discharges because of less anesthesia and pain, and may also allow for administration of sooner adjuvant therapy because of quicker skin healing times. [7][8][9][10][11][12][13][14][15][16][17][18][19] The disadvantages, however, include limited degree of surgeon maneuverability and flexibility, difficulty in visualization and microscope lighting especially for deeper lesions, and potential lack of vascular control, among others. [7][8][9][10][11][12][13][14][15][16][17][18][19] Previous studies limited to bur hole-based tumor resections are limited.…”

“…[7][8][9][10][11][12][13][14][15][16][17][18][19] The disadvantages, however, include limited degree of surgeon maneuverability and flexibility, difficulty in visualization and microscope lighting especially for deeper lesions, and potential lack of vascular control, among others. [7][8][9][10][11][12][13][14][15][16][17][18][19] Previous studies limited to bur hole-based tumor resections are limited. 8,10,16,17 The majority of studies on tumor resection utilized a keyhole-based approach, where openings are often more than double as compared with a bur hole-based approach.…”