Surgical excision of large-to-giant petroclival meningiomas focusing on the middle fossa approaches: The lessons learnt

• Published in: Neurology India Vol. 66; no. 5; pp. 1434 - 1446
• Main Authors: Gosal, Jaskaran, Behari, Sanjay, Joseph, Jeena, Jaiswal, Awadhesh, Sardhara, Jayesh, Iqbal, Mohammad, Mehrotra, Anant, Srivastava, Arun
• Format: Journal Article
• Language: English
• Published: India Wolters Kluwer India Pvt. Ltd 01.09.2018; Medknow Publications and Media Pvt. Ltd; Medknow Publications & Media Pvt. Ltd
• Subjects: Adult; Brain cancer; Care and treatment; Cranial Fossa, Middle - pathology; Cranial Fossa, Middle - surgery; Craniotomy - methods; Development and progression; Excision (Surgery); Female; Humans; Male; Medical imaging; Meningioma; Meningioma - pathology; Meningioma - surgery; Middle Aged; Morbidity; Neurological disorders; Neurosurgical Procedures - methods; NMR; Nuclear magnetic resonance; Ostomy; Patients; Postoperative period; Quality of life; Sinuses; Skull Base Neoplasms - pathology; Skull Base Neoplasms - surgery; Surgery; Surgical outcomes; Trigeminal Nerve - pathology; Trigeminal Nerve - surgery; Tumors; subtemporal approach; surgery utilizing the middle fossa approach often minimizes neurological deficits. An aggressive surgical resection utilizing multiple corridors; petroclival meningiomas; and lower cranial nerve palsy leading to aspiration pneumonitis; Anterior petrosectomy; as well as leaving a thin capsule of tumor adherent to the brain stem in the presence of lack of an arachnoidal plane; often brings about lasting neurological benefit. The bane of postoperative management are extraocular movement deficits; corneal ulceration due to simultaneous ipsilateral Vth and VIIth nerve paresis; trans-sylvian approach Key Message: In large-to-giant petroclival menigiomas; giant; and occasionally a staged surgery; outcome; surgery; trans-sylvian approach
• ISSN: 0028-3886; 1998-4022
• DOI: 10.4103/0028-3886.241354

Introduction: Petroclival meningiomas are based on or arising from the petro-clival junction in upper two-thirds of clivus, medial to the fifth cranial nerve. This study focuses on the surgical experience in resecting large-giant tumors >3.5 in size predominantly utilizing middle fossa approaches. Material and Methods: 33 patients with a large or a giant petroclival meningioma (size >3.5 cm) were included. Clinical features, preoperative radiological details, operative findings, and postoperative clinical course at the follow-up visit were reviewed. Group A tumors (n = 17,51.5%) were sized 3.5cm-5cm, and Group B (n = 16,48.48%) tumors were of size >5 cm. Extent of resection was described as 'gross total' (no residual tumor), 'near total' (<10% residual tumor) and 'subtotal resection' (>10% residual tumor). Glasgow outcome scale (GOS) quantitatively scored postoperative neurological outcome (mean follow up: 35.77months; range 1-106 months). Results: 25 (75.8%) patients had tumour extension into both supratentorial and infratentorial compartments. Extension into Meckel's cave (n = 25,75.8%), cavernous sinus (n = 17,48.4%], sphenoid sinus (n = 12,38.7%] and suprasellar area [12,38.7%] was often seen. In 31 (93.9%) patients, the tumor crossed the midline in the premedullary, prepontine, and interpeduncular cisterns. In 20 (60.6%) patients, the tumour extended below and posterior to the internal auditory meatus (IAM), while in 13 (39.4%) patients, the tumor was located above and anterior to the IAM. Kawase's approach was the most commonly used approach in 16 (48.48%) patients and resulted in maximum tumor resection. Other approaches included half-and-half (trans-Sylvian with subtemporal) [n = 6, 18.18%]; frontotemporal craniotomy with orbitozygomatic osteotomy [n = 1, 3%] and retromastoid suboccipital craniectomy (RMSO) [n = 7, 21.21%]. In 2 (6.06%) patients, staged anterior petrosectomy with RMSO; and, in 1, staged presigmoid with half-and-half approach was used. Gross total excision was achieved in 12 (36.36%), near-total excision in 15 (45.45%) and subtotal excision in 6 (18.18%) patients. 20 (60.6%) patients had a good functional outcome; 6 patients succumbed due to meningitis, pneumonitis, perforator injury or a large tumor recurrence. Conclusions: Half-and-half approach was used in tumors with middle and posterior cranial fossae components often extending to the suprasellar region. Kawase's anterior petrosectomy was utilized in resecting tumors with predominant posterior fossa component (along with a small middle fossa component) that was crossing the midline anterior to the brain stem, and mainly situated superomedial to the IAM. Tumors confined to the posterior fossa, that extended laterally and below the IAM were resected utilizing the RMSO approach. Occasionally, a combination of these approaches was used. Middle fossa approaches help in significantly avoiding morbidity by an early devascularisation and decompression of the tumor. In tumors lacking a plane of cleavage, a thin rim of capsule of tumor may be left to avoid brain stem signs.