Two step approach for surgical removal of petroclival meningiomas with large supratentorial extension

Samii, M.; Gerganov, Venelin; Giordano, Mario; Samii, Amir

doi:10.1007/s10143-010-0299-9

Cited by 36 publications

(30 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%

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%

True petroclival meningiomas: results of surgical management

Almefty

Dunn

Pravdenkova³

et al. 2014

JNS

130

121

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“…39 The transzygomatic approach has also been used with the retrosigmoid approach in the treatment of petroclival meningiomas because of their complementarity. 4,47 It does provide an option in conjunction with staged orbitozygomatic and retrosigmoid approaches for treatment of paracentral petroclival meningiomas with large supratentorial extension into the parasellar region, cavernous sinus, or middle fossa. 4,32 However, the staged orbitozygomatic and retrosigmoid approach requires separate procedures, incisions, and general anesthetic inductions and has not been found, in our recent experience, to be beneficial.…”

Section: Surgical Approachesmentioning

confidence: 99%

“…4,47 With larger tumors, combined transpetrosal approaches remain an important tool, as others have pointed out. 11,33,39,51,52 It must be remembered that many factors that prevent GTR are independent of the particular surgical approach chosen or even of the surgical skill or experience of the treatment team.…”

Section: Treatment Planningmentioning

confidence: 99%

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

Karampelas

Megerian³

et al. 2013

FOC

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Object 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. Methods The records of patients with large (> 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. Results 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. Conclusions 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.

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“…Due to the deep location of these lesions and their proximity to eloquent neurovascular structures, resection of PCM was associated with a high level of morbidity and mortality in the past [4,6,7,9,17,26,41]. Advances in microsurgery and introduction of refined skull base techniques have considerably improved clinical outcome to where mortality is rare and severe morbidity unlikely [15,22,23,27,29,32]. Nowadays, with the advent of radiosurgery, a shift of treatment paradigm has been recommended by many authors, advocating subtotal removal of PCM and subsequent irradiation of tumor remnants in order to minimize surgical morbidity and improve quality of life [13,14,21,30].…”

Section: Introductionmentioning

confidence: 98%