Petro-Clival Tumours: Role and Indications of Transoral and Transsphenoidal Approaches Followed by Hypofractionated Stereotactic Radiotherapy

Abstract

Background: Petro-clival, clival and spheno-petro-clival tumours are still a neurosurgical challenge. Usually, the classical skull base transpetrous approaches are employed, although they are burdened by an important rate of morbidity, and a very low rate of radical removal is reported. Objectives: We present our indications and results with minimally invasive transnasal and transoral approaches. Patients and Methods:We present 14 patients affected by petro-clival, clival and spheno-petro-clival meningiomas/chordomas with prevalent extension ventrally to the brainstem; cranial nerves V to XII and vertebra-basilar arterial complex resulted posterior and laterally displaced. Preoperative clinical symptoms were represented by aspecific headache in 6 patients, mild and moderate contralateral hemiparesis in 3 and 2 patients respectively, mild and moderate tetraparesis in 2 and 1 patients respectively and cranial nerves deficit in 11 ones. Preoperative planning considered three objectives: to avoid operative and post-operative mortality/morbidity, to achieve satisfactory tumour removal and to avoid tumour regrowth. Anterior approach (transoral in 6 and transsphenoidal in 8 other) was selected for these patients according to postero-lateral approaches complexity due to the anteriormedial position of the tumour in respect of cranial nerves and vascular arteries. Results: In no patient radical removal was performed because gross total/subtotal removal had been programmed preoperatively on the basis of tumours extension. Concerning the 4 clival chordomas, gross total in two patients and subtotal removal in the two other ones was performed. Gross total removal was accomplished in the clival meningioma, while subtotal removal was achieved in 5 petro-clival and in 2 spheno-petro-clival meningiomas; partial removal was performed in one spheno-petro-clival and one petroclival meningioma. No mortality and no neurologic deficits were registered after surgery. Preoperative neurologic deficit improved in the majority of patients. Conclusions: Anterior transoral and transsphenoidal approaches are indicated for clival and spheno-petro-clival region tumours located ventrally to the brainstem and medially to acoustic meatus, to perform a prevalently median tumour debulking; these approaches allowed an extremely low rate of new neurological deficit and a rapid resumption of vital activities, obviously in relation with preoperative clinical status in our patients.