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Surgical excision of large-to-giant petroclival meningiomas focusing on the middle fossa approaches: The lessons learnt
- Source :
- Neurology India. 66:1434
- Publication Year :
- 2018
- Publisher :
- Medknow, 2018.
-
Abstract
- 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). 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.
- Subjects :
- Adult
Male
medicine.medical_specialty
medicine.medical_treatment
Osteotomy
Skull Base Neoplasms
Neurosurgical Procedures
03 medical and health sciences
0302 clinical medicine
Clivus
Internal auditory meatus
medicine
Humans
Trigeminal Nerve
Petroclival Meningioma
Craniotomy
Cranial Fossa, Middle
Cistern
business.industry
Glasgow Outcome Scale
Middle Aged
medicine.anatomical_structure
Neurology
030220 oncology & carcinogenesis
Cavernous sinus
Female
Neurology (clinical)
Radiology
Meningioma
business
030217 neurology & neurosurgery
Subjects
Details
- ISSN :
- 00283886
- Volume :
- 66
- Database :
- OpenAIRE
- Journal :
- Neurology India
- Accession number :
- edsair.doi.dedup.....43115e931006172bbc92ff5d15b11ef3