Petroclival meningiomas: an update on surgical approaches, decision making, and treatment results

Abstract

<jats:sec> <jats:title>Object</jats:title> <jats:p>Petroclival meningiomas remain a formidable challenge for neurosurgeons because of their location deep within the skull base and proximity to eloquent neurovascular structures. Various skull base approaches have been used in their treatment, and deciding which is the optimal one remains controversial. Attempts at achieving gross- or near-total resections are associated with an increased rate of morbidity and mortality. As adjunctive treatment options such as stereotactic radiosurgery have been developed and become widely available, there has been a trend toward accepting subtotal resections in an effort to minimize neurological morbidity. This paper reviews a recent series of patients with petroclival meningiomas and highlights current management trends and important considerations useful in surgical decision making.</jats:p></jats:sec> <jats:sec> <jats:title>Methods</jats:title> <jats:p>The records of patients with large (&gt; 3 cm) petroclival meningiomas surgically treated by the senior author over the past 5 years were reviewed. The clinical results are presented as examples of the surgical approaches available for approaching these tumors, and treatment options are reviewed.</jats:p></jats:sec> <jats:sec> <jats:title>Results</jats:title> <jats:p>Of 196 meningiomas surgically treated during the study period, 8 lesions in 8 patients met the study criteria. Overall clinical results were excellent, with no death or major morbidity. Intracranial gross- or near-total resection (Simpson Grade 1, 2, or 3) was achieved in 5 patients (67%). New cranial nerve deficits occurred in 3 patients (37%) and were more common in patients in whom a subtotal resection was performed (2 of 3 cases). A variety of surgical approaches were used. Important considerations determining the best approach include the location of the tumor relative to the internal auditory canal, the presence of preoperative hearing loss, and the location of the tumor relative to the tentorium.</jats:p></jats:sec> <jats:sec> <jats:title>Conclusions</jats:title> <jats:p>Achieving gross- or near-total resections of large petroclival meningiomas remains achievable and should be the primary goal of surgical treatment. A retrosigmoid craniotomy remains a workhorse surgical approach for most petroclival tumors of any size. Tumors that are medial to the internal auditory canal and span both middle and posterior cranial fossae are often best treated with a combined transpetrosal approach, which is especially true if there is a preoperative hearing deficit.</jats:p></jats:sec>

ICAR: endoscopic skull‐base surgery

“…The focus of current practice is to achieve as extensive a resection as possible while limiting the development of neurological deficits . This new paradigm applies in particular to lesions demonstrating preoperative radiologic invasion, with compromise of the brainstem and surrounding neurovascular structures or of sizes >4 cm in either plane.…”

Anatomic comparison of anterior petrosectomy versus the expanded endoscopic endonasal approach: interest in petroclival tumors surgery

“…The posterior transpetrosal approaches may be useful for attaining the petroclival region, particularly in case of tumor extension posterior to the IAM. Indeed, the retrolabyrinthine, translabyrinthine and transcochlear approaches provide an increasing petroclival exposure which comes with a longer time of drilling and greater risk of facial palsy [3,21,28,32]. Finally, their corridor endangers the acoustic facial bundle and does not expose the whole petroclival area.…”

Gamma Knife Radiosurgery for Petroclival Meningioma: Long-Term Outcome and Failure Pattern

“…Petroclival meningiomas remain formidable challenges for most neurosurgeons, although remarkable advances have been made during the past decades in the microsurgical techniques that are used for skull base surgery [1,2]. Whenever possible, a complete surgical resection is considered as the mainstay of initial treatment for petroclival meningiomas because the majority of them have a benign nature (World Health Organization [WHO] grade I).…”