Petroclival Meningiomas: Predictive Parameters for Transpetrosal Approaches

Aziz, Khaled; Sanan, Abhay; Loveren, Harry R. van; Tew, John M.; Keller, Jeffrey T.; Pensak, Myles L.

doi:10.1097/00006123-200007000-00030

Cited by 66 publications

(81 citation statements)

References 27 publications

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“…5,8,19,21,26,27,38,41 Recently, however, some authors have endorsed more conservative surgical approaches coupled with radiotherapy, with the twin goals of brainstem decompression and avoidance of cranial neuropathies. 1,14,21,32,34 One of the arguments for this approach is that subtotal removal decreases the likelihood of cranial nerve dysfunction and thus improves quality of life. In our series, however, the extent of resection did not correlate with cranial nerve impairment postoperatively; cranial nerve dysfunction was higher in patients treated with subtotal resection, although this may also reflect a greater difficulty in these particular cases.…”

Section: Recurrence and Progression-free Survivalmentioning

confidence: 99%

“…With the advent of radiosurgery, many have recommended subtotal removal and subsequent radiosurgery to avoid operative morbidity 1,7,21,28,33,34,42 One of the arguments for this approach is that subtotal removal decreases the likelihood of cranial nerve dysfunction and thus improves quality of life, and that pairing this approach with postoperative radiation may form the basis of safer tumor control. Cranial nerve dysfunction may still occur with a more cautious surgical approach and is often temporary after total or partial removal.…”

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confidence: 99%

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True petroclival meningiomas: results of surgical management

Almefty

Dunn

Pravdenkova³

et al. 2014

JNS

130

121

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Object The relentless natural progression of petroclival meningiomas mandates their treatment. The management of these tumors, however, is challenging. Among the issues debated are goals of treatment, outcomes, and quality of life, appropriate extent of surgical removal, the role of skull base approaches, and the efficacy of combined decompressive surgery and radiosurgery. The authors report on the outcome in a series of patients treated with the goal of total removal. Methods The authors conducted a retrospective analysis of 64 cases of petroclival meningiomas operated on by the senior author (O.A.) from 1988 to 2012, strictly defined as those originating medial to the fifth cranial nerve on the upper two-thirds of the clivus. The patients' average age was 49 years; the average tumor size (maximum diameter) was 35.48 ± 10.09 mm (with 59 tumors > 20 mm), and cavernous sinus extension was present in 39 patients. The mean duration of follow-up was 71.57 months (range 4–276 months). Results In 42 patients, the operative reports allowed the grading of resection. Grade I resection (tumor, dura, and bone) was achieved in 17 patients (40.4%); there was no recurrence in this group (p = 0.0045). Grade II (tumor, dura) was achieved in 15 patients (36%). There was a statistically significant difference in the rate of recurrence with respect to resection grade (Grades I and II vs other grades, p = 0.0052). In all patients, tumor removal was classified based on postoperative contrast-enhanced MRI, and gross-total resection (GTR) was considered to be achieved if there was no enhancement present; on this basis, GTR was achieved in 41 (64%) of 64 patients, with a significantly lower recurrence rate in these patients than in the group with residual enhancement (p = 0.00348). One patient died from pulmonary embolism after discharge. The mean Karnofsky Performance Status (KPS) score was 85.31 preoperatively (median 90) and improved on follow-up to 88, with 30 patients (47%) having an improved KPS score on follow-up. Three patients suffered a permanent deficit that significantly affected their KPS. Cerebrospinal fluid leak occurred in 8 patients (12.5%), with 2 of them requiring exploration. Eighty-nine percent of the patients had cranial nerve deficits on presentation; of the 54 patients with more than 2 months of follow-up, 21 (32.8%) had persisting cranial nerve deficits. The overall odds of permanent cranial nerve deficit of treated petroclival meningioma was 6.2%. There was no difference with respect to immediate postoperative cranial nerve deficit in patients who had GTR compared with those who had subtotal resection. Conclusions Total removal (Grade I or II resection) of petroclival meningiomas is achievable in 76.4% of cases and is facilitated by the use of skull base approaches, with good outcome and functional status. In cases in which circumstances prevent total removal, residual tumors can be followed until progression is evident, at which point further intervention can be planned.

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Section: Recurrence and Progression-free Survivalmentioning

confidence: 99%

mentioning

confidence: 99%

True petroclival meningiomas: results of surgical management

Almefty

Dunn

Pravdenkova³

et al. 2014

JNS

130

121

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“…Radiosurgery is a useful adjuvant therapy in these cases 1,2 . In the future CT and MRI units targeted for interactive virtual image-guided surgery and not solely for diagnostic purposes should be used during the pre-operative phase.…”

Section: Discussionmentioning

confidence: 99%

“…The clival length and the percentage of clival exposure through each approach were obtained by dipping the end of the dissector in dye. We used the clival subdivision into Zones I,II, and III, as suggested by Aziz et al 1 ( Fig. 6).…”

Section: ; 19mentioning

confidence: 99%

The partial labyrinthectomy petrous apicectomy approach to petroclival meningiomas. A quantitative anatomic comparison with other approaches to the same region

et al. 2008

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SummaryThe partial labyrinthectomy petrous apicectomy (PLPA) approach is a transpetrous route that provides the advantages of the labyrinthine removal but with hearing preservation. Using seven temporal bone tissue blocks and three formaldehyde-fixed cadaveric heads we have made a morphometric and comparative study on this approach that summarizes the invasiveness, the optimal surgical exposure, the anatomic complexity of the skull base approaches and, on the other hand, the spirit of preservation that is the constant aim of modern neurosurgery. The morphometric analysis is designed to make the bony phase of the PLPA approach safer and to define the relationship between petrous landmarks. The comparative study is made between the PLPA and other neurosurgical routes enhancing the potentiality of the PLPA approach that permits a wider angle of incidence towards the brainstem than with the retrosigmoid routes.KEY WORDS: Meningioma. Partial labyrinthectomy. Petroclival. Petrosal approach. Rretrosigmoid approach.La laberintectomia parcial con apicectomía petrosa como acceso a los meningiomas petroclivales. Una comparación anatómico -quantitativa con otras vías de abordaje a la misma zona Resumen La laberintectomía parcial con apicectomía petrosa (PLPA) es una vía de abordaje que proporciona las ventajas de la extirpación parcial del laberinto preservando la audición. Trabajando sobre 7 piezas anatómicas de hueso temporal y 3 cabezas de cadáver fijadas con formaldehido, hemos realizado un estudio morfométrico y comparativo de este abordaje interesándonos los aspectos de la invasividad del abordaje, óptima exposición quirúrgica obtenida, complejidad anatómica de la entrada a la base craneal, y por otra parte, la actitud conservadora de la moderna neurocirugía. El análisis morfométrico tiene como objetivo hacer la fase ósea de la PLPA más segura al definir la relación entre los puntos de referencia petrosos. El estudio comparativo entre la PLPA y otros abordajes neuroquirúrgicos exalta la posibilidades de la PLPA ya que proporciona un ángulo de incidencia hacia el tronco cerebral máºs amplio que el que proporcionan las vías retrosigmoideas.

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“…Usually, the classical skull base transpetrous approaches (middle fossa anterior petrosal, posterior petrosal, combined petrosal approaches and complete petrosectomy) (1,(4)(5)(6) are employed although they are burdened by an important rate of morbidity and a very low rate of radical removal is reported (3,(7)(8)(9)(10)(11)(12)(13)(14). Because tumour growth is slow and neurovascular structures present a various degree of adjustment, diagnosis is usually performed when tumour is large, and this fact implies the need to perform surgery as first therapeutic step; the problem is that if surgical removal is too extended, rate of postoperative deficit is too high, and on the contrary if surgical removal is too little, control of postoperative tumor remnant is problematic also with radiotherapy.…”

Section: Introductionmentioning

confidence: 99%

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

Fraioli

Giovinazzo

Umana

et al. 2016

J Minim Invasive Surg Sci

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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.

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Petroclival Meningiomas: Predictive Parameters for Transpetrosal Approaches

Cited by 66 publications

References 27 publications

True petroclival meningiomas: results of surgical management

True petroclival meningiomas: results of surgical management

The partial labyrinthectomy petrous apicectomy approach to petroclival meningiomas. A quantitative anatomic comparison with other approaches to the same region

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

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