True petroclival meningiomas: results of surgical management

Abstract

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.

Retrosigmoid-transtentorial approach for petroclival meningiomas: operative technique and clinical outcome

“…Of the three subtype of PCMs mentioned above, those with the clivus type achieved GTR at the rate of 92.9 % (26 cases in 28 patients); 61.5 % (8 cases in 13 patients) of those with the petroclival type achieved GTR; on the other hand, 52.2 % (12 cases in 23 patients) of the petroclivosphenoidal type achieved and GTR (Table 3). And encouragingly the rate of GTR of our group was not lower or even higher than other approaches [10,[24][25][26]. We found that most of the patients recovered significantly and satisfactorily.…”

Estudio Descriptivo: Tratamiento Quirúrgico de los Meningiomas. Hospital “Santa Inés” Cuenca – Ecuador, 2011-2017

“…Una muestra de 271 pacientes, luego del análisis multivariado encontraron que no existen diferencias significativas en cuanto a la recurrencia según localización [17], en estas localizaciones los meningiomas envuelven estructuras neurovasculares relevantes, lo que ratifica que es mejor preservar la función, que lograr resecciones completas con discapacidades permanentes [20]. Estos estudios contrastan con los obtenidos por Al-Mefty que logra resecciones Simpson de los pacientes con lesiones petroclivales [21], lo que reafirma la importancia de la experiencia quirúrgica.…”

“…Si bien la limitación de este estudio y práctica es el tamaño de la muestra, se lograron estándares internacionales en cuanto a los grados de resección y se aplicaron las técnicas microscópicas descritas para lograr el mayor beneficio [17,[20][21].…”

Surgical management of medium and large petroclival meningiomas: benchmark and limits

“…Permanent surgical morbidity remained in 20 % of patients during the average long-term follow-up of almost 10 years, but significantly more patients lived independently after than before surgery (61 vs 46 %). One-fourth of patients were lost to longterm follow-up, so that the numbers regarding long-term outcome must be appreciated with sound judgment.These key data focusing on medium and large petroclival meningioma are important, although difficult to compare with the smaller unselected series [1,3,[7][8][9]12]. Petroclival meningiomas smaller than 2 cm carry a much smaller surgical risk than large tumours, and in unselected series the small tumours dilute information regarding the problematic larger tumours.…”

“…These key data focusing on medium and large petroclival meningioma are important, although difficult to compare with the smaller unselected series [1,3,[7][8][9]12]. Petroclival meningiomas smaller than 2 cm carry a much smaller surgical risk than large tumours, and in unselected series the small tumours dilute information regarding the problematic larger tumours.…”