Surgical treatment of jugular foramen meningiomas

ObjectWe present our experience with surgery of jugular foramen meningiomas with special consideration of clinical presentation, surgical technique, complications, and outcomes.MethodsThis retrospective study includes three patients with jugular foramen meningiomas treated by the senior author between January 2005 and December 2010. The initial symptom for which they sought medical help was decreased hearing. In all of the patients there had been no other neurological symptoms before surgery. The transcondylar approach with sigmoid sinus ligation at jugular bulb was suitable in each case.ResultsNo death occurred in this series. All of the patients deteriorated after surgery mainly due to the new lower cranial nerves palsy occurred. The lower cranial nerve dysfunction had improved considerably at the last follow-up examination but no patient fully recovered. Two of three patients with preoperatively impaired yet functional hearing deteriorated after surgery with no subsequent cranial nerve VIII function improvement. In one case postoperative stereotactic radiosurgery was performed due to non-radical tumour resection (Simpson Grade IV) and tumour remnant proved stable in the 4-year follow-up. None of the patients have shown signs of tumour recurrence in the mean follow-up period of 56 months.ConclusionsJugular foramen meningiomas represent one of the rarest subgroups of meningiomas and their surgical treatment is associated with significant risk of permanent cranial nerve deficits.     

Medial sphenoid ridge meningiomas: early and long-term results of surgical removal using the fronto-temporo-orbito-zygomatic approach

Background and purposeThe fronto-temporo-orbito-zygomatic approach (FTOZA) is an alternative to the pterional approach in surgical resection of meningiomas of the medial part of the lesser wing of the sphenoid bone. The purpose of this study is to present our results of treatment of these meningiomas using the FTOZA.Material and methodsThirty patients (19 women, 11 men) with a central skull base tumour were included in the study. The neurological status of the patients was assessed before and after surgery as well as at the conclusion of treatment. The approximate volume of the operated tumour, its relation to large blood vessels, cranial nerves and brainstem, as well as consistency and vascularisation were assessed.ResultsThe symptom duration ranged from 1 to 36 months (median: 6 months). Impaired visual acuity was the predominant symptom in 27.5% of patients. Less frequent symptoms included paresis/paralysis of the third cranial nerve, headache, psychoorganic syndrome and epilepsy. Approximate volume of the tumours ranged from 5 to 212 mL (median: 63 mL). Total or subtotal resection was achieved in 77% of patients. The postoperative performance status improved in 16.5%, did not change in 52.8% and deteriorated in 26.4% of patients. One (3.3%) patient died after the surgery.ConclusionsThe FTOZA is a useful technique for removal of tumours expanding superiorly to the middle cranial fossa base without significant compression of the brain. Ability to remove tumours through the described approach decreases as the degree of infiltration of the clivus increases.     

Surgical treatment of intraventricular ependymomas and subependymomas

Background and purposeThe aim of the study was to present our experience in the surgical treatment of intraventricular ependymomas and subependymomas with special consideration to the evaluation of the surgical outcome and risk of tumour recurrence.Material and methodsWe report a series of 36 consecutive patients treated surgically for intraventricular ependymoma or subependymoma in the years 1992–2008. There were 26 lateral ventricle and 10 fourth ventricle tumours. Complete resection was achieved in 19 patients while the remaining 17 patients underwent either subtotal or partial resection. Histopathological evaluation revealed ependymoma, subependymoma and anaplastic ependymoma in 20, 11 and 5 cases, respectivelyResultsEight patients died after surgery due to postoperative brain injury. Five patients were severely disabled postoperatively: one patient developed hemiparesis, three patients presented adynamic syndrome, and one patient developed severe cerebellar ataxia subsequent to vermis injury. All patients with posterior fossa tumours presented with lower cranial nerve deficit. Seventeen patients received radiotherapy postoperatively. There were five recurrent tumours during follow-up; three patients underwent subsequent reoperation. Importantly, five patients with supratentorial tumours and a history of incomplete resection with postoperative radiotherapy had no tumour recurrence in over 10 years’ follow-up.ConclusionsIntraventricular ependymomas and subependymomas still remain a surgical challenge due to a relatively high incidence of incomplete tumour resections and/or permanent neurological complications associated with their removal. Still, even incomplete tumour removal with subsequent radiotherapy facilitates long-term progression-free survival in some cases.     

Meningiomas of the anterior portion of the craniovertebral junction: immediate and late outcome following surgical removal using a partial transcondylar approach

Background and purposeThe partial transcondylar approach (PTA) is an alternative to the suboccipital approach in the surgical treatment of meningiomas of the anterior portion of the craniovertebral junction (APCVJ). The purpose of this study is to present our results of treatment of these meningiomas using PTA.Material and methodsFourteen patients (11 women, 3 men) with meningioma of the APCVJ were included in the study. Neurological status of the patients was assessed before and after surgery as well as at the conclusion of the treatment. The approximate volume of the operated tumour, its relation to large blood vessels, cranial nerves and brainstem, along with its consistency and vascularisation were assessed.ResultsThe symptom duration ranged from 1 to 36 months (median: 11 months). In 79% of patients, motor deficits of the extremities were predominant symptoms. Less frequent symptoms included headache, cervical pain and sensory deficits of cervical nerves C2 to C5. Approximate volume of the tumours ranged from 2.5 mL to 22.1 mL (mean: 11.7 mL). Gross total or subtotal resection was achieved in 86% of patients. The postoperative performance status improved in 57%, did not change in 36% and deteriorated in 7% of the patients.ConclusionsThe PTA is a useful technique for removal of meningiomas expanding intradurally of the APCVJ without significant compression of the medulla. The results of treatment were good in most patients.     

Surgical treatment of jugular foramen schwannomas

ObjectiveWe present our experience with surgery of jugular foramen schwannomas with special consideration of clinical presentation, surgical technique, complications, and outcomes.MethodsThis retrospective study includes ten patients with jugular foramen schwannomas treated by the senior author between January 2007 and December 2012. Three patients had undergone partial tumour resection elsewhere. The initial symptom for which they sought medical help was hearing loss, dysphagia, hoarseness, and shoulder weakness. Preoperative glossopharyngeal and vagal nerve deficits were the most common signs. In our series, tumour extension was classified according to Kaye-Pellet grading system. In two cases the tumours were classified into type A and 8 patients presented with type D tumours. A retromastoid suboccipital craniotomy was performed for type A tumours and modifications of cranio-cervical approach were suitable for type D.ResultsNo death occurred in this series. Four patients deteriorated after surgery: in two patients preoperative cranial nerve deficits deteriorated after surgery while new cranial nerve palsy occurred in 2 other patients. In four patients, the cranial nerve dysfunction had improved at the last follow-up examination. In all other patients, the cranial nerve dysfunction remained the same. One patient experienced tumour recurrence over a follow-up period of 40 months. This patient underwent a successful second surgery without further evidence of tumour growth.ConclusionsJugular foramen schwannomas can be radically managed with the use of skull base surgery techniques. However, the surgical treatment of jugular foramen schwannomas carries a significant risk of the lower CN deficits.     

Meningiomas of the upper and middle part of the clivus and surrounding structures: early and long-term outcome

Background and purposeMeningiomas of the upper and middle parts of the clivus and surrounding structures are removed using petrosal approaches: anterior, posterior, combined and complete. The purpose of this study is to show the results of treatment of these meningiomas and to present our interpretation of the treatment strategy.Material and methodsTwenty-six patients (17 women, 9 men) were included in the study. The neurological status of the patients was assessed before and after surgery as well as at the conclusion of the treatment. The following measurements and data were collected and recorded: approximate volume of the treated lesion, its relation to large blood vessels, cranial nerves and the brainstem, as well as tumour consistency and vascularisation.ResultsSymptoms duration ranged from 1 to 60 months (median: 16 months). In 57.7% of patients, imbalance was the predominant sign. Less frequent symptoms were: headaches, dysacusis and hemiparesis. Approximate volumes of the tumours ranged from 4 to 65 mL (mean: 32 mL). Total or subtotal resection was achieved in 73.1% of patients. The patients’ performance improved postoperatively in 34.5%, remained unchanged in 46.2% and deteriorated in 11.5% of patients. Two (7.8%) patients died after the surgery.ConclusionsThe use of petrosal approaches in the surgical treatment of meningiomas of the upper and middle parts of the clivus and the surrounding structures facilitates good or at least satisfactory neurological outcome with a high proportion of complete resections and relatively low mortality.     

Petrous meningiomas: a review of seventeen cases

Seventeen patients with petrous meningiomas managed at St. Michael's Hospital, during the years 1973-1987, were retrospectively reviewed. There were 15 females and 2 males; their ages ranged from 42 to 68 years (mean age: 53 years). The clinical presentation most commonly included headache and eighth cranial nerve dysfunction; the average duration of symptoms was 6 years (3 month-27 years). Computed tomography was performed in 15 cases. The mean tumour size was 2.5 centimeters (0.5-4 cm). The most common site of tumour origin was at or medial to the porus acousticus. Meningioma was suspected preoperatively in 10 of the 15 patients who had preoperative CT scans. Complete excision was obtained in 12 cases. There were no operative deaths after initial resections. Postoperative morbidity included worsening of pre-existing hearing loss in six patients, transient facial nerve palsies in six, permanent facial nerve palsies in four and new facial or corneal hypesthesia in three. Two patients developed cerebrospinal fluid fistulae. Tumour recurrence occurred into two patients in whom a complete resection was anticipated. Also, in two patients with incompletely resected tumours second operations were required. Fourteen patients are alive, 13 of whom care for themselves independently. The average follow-up was 5 years (6 months-9 years). It seems appropriate to recommend initial radical surgical excision of these benign tumours, where possible, in order to prevent tumour recurrence.     

Giant olfactory groove meningiomas: Advantages of the bilateral fronto-orbitonasal approach

Olfactory groove meningiomas are usually considered surgically curable, but the operation becomes complex when the tumour reaches massive size and involves vital suprasellar structures, extends into the ethmoid sinuses or extensively involves the bony floor of the anterior fossa. The traditional bifrontal approach provides only limited exposure in these situations, and a bilateral fronto-orbitonasal approach may be more effective. We reviewed our experience in five patients with resections of massive olfactory groove meningiomas to assess the advantages and risks of these two approaches. All patients were women (mean age, 45 years; range, 28–59) presenting with symptoms and signs related to increased intracranial pressure, cranial nerve impairment or brain compression. Computed tomography, magnetic resonance imaging and cerebral angiography were used for diagnosis and operative planning. The approach was bifrontal in two patients and bifronto-orbitonasal in three. Total surgical removal (Simpson grade I, three patients; Simpson grade II, one patient) was achieved in four patients (80%) and subtotal tumour removal (Simpson grade III) was performed in one (20%). One patient had two staged operations. No morbidity or mortality occurred in this series. No clinical or radiologic evidence of recurrence developed in the four patients whose tumour was resected totally. The bilateral fronto-orbitonasal approach resulted in safe and successful total removal of giant olfactory groove meningiomas, achieving long-term prevention of recurrence. We highly recommend this approach.     

Petrous apex meningiomas: an alternative surgical approach

The literature describes a variety of surgical approaches to deal with meningiomas that involve the apex of the petrous bone and lie predominantly in the posterior fossa, e.g. the transpetrosal (translabyrinthine and transcochlear), the combined supra- and infratentorial, the subtemporal with or without pyramid resection, the suboccipital and the orbitozygomatic approaches. This study presents an alternative surgical approach, namely a modification of the occipital craniotomy with or without tentorial division. This approach was used for the removal of three petrous bone apex meningiomas which were medium to large in size and located predominantly in the posterior fossa with extension into the middle fossa. Complete tumour excision was achieved with no morbidity and no mortality.     

Acoustic neuromas: management of 204 cases

This paper reviews the author's personal experience with the management of 204 patients with the clinical diagnosis of acoustic neuroma. Craniotomy was performed in 181 of these cases, all of whom were proven to have acoustic neuromas. The remaining 23 cases with the clinical diagnosis of acoustic neuroma did not have tumour surgery, mainly because of advanced age or concurrent disease, although some required shunts for hydrocephalus. The management of acoustic neuromas including the selection of surgical approach depends upon the patient's age and general health, the size and growth direction of the tumour, previous surgical attempts at removal, and the presence of hydrocephalus, a contralateral tumour, and serviceable hearing. Twenty-nine other cases with the clinical diagnosis of acoustic neuroma underwent craniotomy: 20 had petrous or tentorial meningiomas encroaching on the porus acousticus or growing in the internal auditory canal, six had neuromas of the seventh cranial nerve and three had arachnoiditis occluding the internal auditory canal.     

Intraoral surgical approach to tumors destroying the axis. Report of three cases]

Primary and metastatic tumours of the axis vertebra are difficult surgical problems. The authors report 3 patients with axis tumours who underwent surgery in 1993 and 1994. Clinical symptoms and signs included pain in three, myelopathy in two, vertebrobasilar circulatory insufficiency and cranial nerve lesions in two patients. Tumours have been resected through transoral and posterior pharyngeal wall approach. The purpose of surgery was decompression of nervous and vascular structures, and histological verification of the tumour. Tumour pathology was diverse and included: multiple myeloma, chordoma and metastatic tumour from stomach. There were no postoperative complications and improvement of neurological conditions was observed.     

巨大斜坡脑膜瘤的显微外科治疗

目的 总结斜坡脑膜瘤的放射学特点、手术入路和治疗效果,以提高斜坡脑膜瘤的全切除率,降低残死率,改善手术效果。方法 回顾性分析一组３４例斜坡脑膜瘤,采用６种手术入路显微外科治疗,包括（１）眶颧－颞极入路９例;（２）额颞－经海绵窦入路２例;（３）经岩骨－天幕入路１３例;（４）乳突后枕下入路６例;（５）远外侧枕下入路３例;（６）经口咽－斜坡入路１例。结果 术后恢复良好者２９例（８５％）,肿瘤全切除率５６     

Fluorescence-guided resection of primary and recurrent malignant gliomas with 5-aminolevulinic acid. Preliminary results

Background and purposeExtent of resection plays a key role in the treatment of malignant gliomas (MGs). Patients with complete glioma removal, followed by chemoradiation, obtain the longest overall and progression-free survival. Fluorescence-guided resection of MGs enables intraoperative visualization of glioma tissue and increases control of the resection. The authors present preliminary results of 5-aminolevulinic acid (5-ALA) application during the resection of primary and recurrent MGs.Material and methodsSix patients with either a suspected malignant glioma based on magnetic resonance imaging (MRI) or with recurrent glioblastoma multiforme were enrolled in the study. The extent of resection was calculated according to the postoperative MRI performed within 72 hours. Preoperative and early postoperative neurological status and Karnofsky Performance Scale (KPS) were compared.ResultsFluorescence of tumour tissue was observed in 5/6 patients (five with the histopathological diagnosis of glioblastoma multiforme and one with neurotoxoplasmosis and AIDS). Complete tumour resection was achieved in 5 patients. Postoperative KPS and neurological status deteriorated in 2 cases. Radiotherapy and chemotherapy did not interfere with the sensitivity of the fluorescence guided tumour visualization.ConclusionsFluorescence-guided resection of primary and recurrent MGs with 5-ALA improves control of the tumour resection. It enables the cytoreduction to be maximized but experience in neuro-oncological surgery is required to avoid serious, postoperative neurological deficits.     

扩大中颅底硬膜外入路经岩骨窗切除哑铃型三叉神经鞘瘤

目的 探讨扩大中颅底硬膜外入路经岩骨窗切除哑铃型三叉神经鞘瘤的治疗效果.方法 我科2007 - 2010年应用扩大中颅底硬膜外入路经岩骨窗切除哑铃型三叉神经鞘瘤21例.术前CT及MRI评估位于中、后颅窝肿瘤大小及岩骨侵蚀程度,分为三种类型:Mp型12例,MP型7例及mP型2例.结果 肿瘤全切19例,次全切2例,无手术死亡,术后出现新的暂时性脑神经麻痹4例,1例脑脊液漏,经腰大池引流脑脊液治愈.随访18例,时间6个月-3年(平均22.4个月),2例次全切除肿瘤复发,均位于后颅窝,经乙状窦后入路再次手术治愈.结论 扩大中颅底硬膜外入路经岩骨窗切除哑铃型三叉神经鞘瘤是一种有效的治疗方法,尤其对于肿瘤明显侵蚀破坏岩骨者.然而,如果后颅窝肿瘤部分过大时,该入路显露不足,难以全切肿瘤.     

Meningiomas del surco olfatorio: Revisión de una serie de 27 casos

ObjetiveTo describe our experience with olfactory groove meningiomas, analysing their clinical and radiological form of presentation and their surgical treatment.MethodsThe clinical records of 27 patients diagnosed of olfactory groove meningioma, extracted from the series of meningiomas operated on in our department since 1973, were retrospectively reviewed. Demographical data, the clinical presentation and duration of the symptoms before diagnosis were collected. Several radiological characteristics were also reviewed such as the tumour size, associated brain edema, type of contrast enhancement, presence of endostosis and invasion of the cranial base. The surgical resection grade, the histological type and the presence of recurrences in the follow-up were also analysed.ResultsThe average age at presentation was 59 years. Average duration of symptoms prior to diagnosis was 39 months. The most frequent symptom at presentation was higher function impairment (52%), The average máximum tumoral diameter was 6,2 cm. 61 % of the patients presented moderate or severe brain edema, which was quite frequently bilateral (74%). Radiological endostosis was present in 37% of the cases, but there were no signs of bone invasion in any case. The approach used was the basal frontal, uni or bilateral. In all cases the grade of resection was Simpson II. The majority of the cases presented a typical histology. Over 80% of the cases presented a good recovery at discharge. None of the patients presented with a tumoral recurrence after an average radiological follow-up of 74 months.ConclusionThe olfactory groove is an infrequent location for intracranial meningiomas, accounting for only 4,5% of all meningiomas in our experience. These tumours reach a big size due to the delay in diagnosis. Drilling of the cranial base does not seem necessary for preventing tumoral recurrence.     

Radiation-induced tumours of meninges. Report on eight cases and review of the literature

Background and purposeDespite their rarity, post-radiation meningeal tumours seem to be a growing problem due to the increasing application of radiation therapy. The aim of the study was to ascertain the specific features of these tumours.Material and methodsAmong 433 intracranial meningeal tumours treated from 2000 to 2008, eight cases (2%) have been presumed to be associated with high-dose therapeutic radiation for previous neoplasm of the head (7) or neck (1). On average, tumours were diagnosed 24 years after irradiation. All patients had a solitary meningeal tumour, but two of them also developed other neoplasms in the irradiated area.ResultsAll tumours were microsurgically removed. The postoperative course was uncomplicated in two cases only. In the remaining 6 (75%), complications included liquorrhoea (2), brain oedema (1), venous thrombosis (1), bleeding into the tumour bed (1) and focal deficit due to manipulation (3). Most tumours (5) were WHO grade I meningiomas. These benign meningiomas exhibited some peculiar histological features, including focal increase of cellularity, focal enhancement of proliferation index, pleomorphism of nuclei, occasional mitotic figures and, in one case, evidence of brain invasion. One meningioma was assigned to WHO grade II, one to WHO grade III and one appeared to be meningeal fibrosarcoma. The event-free survival and overall survival rate at 4.4 years of follow-up were 63% and 75%, respectively.ConclusionsRadiation-induced tumours of the meninges show certain characteristic histopathological features, which may promote invasiveness of the tumour and higher risk of malignancy.     

岩斜坡脑膜瘤的显微外科治疗

目的通过总结本病的放射学特点、手术入路和治疗效果,以探讨岩斜坡脑膜瘤的手术策略和如何改善手术效果。方法回顾性分析21例岩斜坡脑膜瘤,采用3种手术入路显微外科治疗,包括(1)经岩骨-天幕入路3例;(2)乳突后枕下入路15例;(3)远外侧枕下入路3例。结果术后恢复良好者19例(90.5%),经术后CT或MR证实肿瘤全切除者13例(62%),无手术死亡。术后新增颅神经损害10例(47%),其中永久性损害3例(14%)。肿瘤巨大、肿瘤血管化或纤维化、脑干与肿瘤之间的蛛网膜界面消失、基底动脉供血等因素增加手术困难,影响术后效果。结论采用合适的手术入路和精良的显微外科技术可以提高岩斜坡脑膜瘤的全切除率,降低残死率。但保证病人术后生存质量是最重要的手术目的,当肿瘤巨大或蛛网膜界面消失时,全切除肿瘤会十分困难,应考虑次全切除肿瘤,术后用γ-刀处理残余肿瘤。     

经扩大乙状窦后人路手术切除大型岩斜区脑膜瘤

目的 探讨扩大乙状窦后入路在显微手术切除大型岩斜区脑膜瘤巾的应用.方法 采用扩大乙状窦后入路的手术方式,显微切除人刑岩斜区脑膜瘤6例,肿瘤最大直径3.4～6.7 cm,平均4.5 cm,术中切除枕骨和乳突.完全显露横安和乙状窦,通过悬吊硬脑膜将它们分别向上方和前方牵开,有效地减少了两个粗大的静脉窦对小脑幕下方和岩骨背面的遮挡,手术视野明显增大,能够充分暴露小脑幕和岩骨背面.结果 本组肿瘤全切除3例,次全切除2例.大部切除1例,无手术死亡,神经功能较术前改善3例,与术前相同3例,2例出现新增脑神经损害,未发生脑脊液漏和切口感染.术后随访6-58个月.所有病例MRI复查未见肿瘤复发或增大.结论 扩大乙状窦后入路具有增加暴露范围、扩大手术视角、早期阻断肿瘤血液供应、避免过度牵拉小脑、改善深部结构的显露、有利于保护脑神经和重要血管等优点.     

颈静脉孔区肿瘤的显微外科治疗

目的探讨颈静脉孔区肿瘤的显微手术治疗方法及效果。方法36例颈静脉孔区肿瘤患者行显微外科手术切除,观察切除程度、死亡率、术前术后的颅神经功能和主要并发症。结果全切29例,次全切4例,部分切除3例。术后死亡1例,脑脊液漏1例,出现新的神经功能损害7例。术后1个月KPS分级超过80分28例,术后6个月超过80分32例;术后面神经功能Ⅰ～Ⅱ级(H-B分级)31例;术前有残余听力,术后听力保存者11例;全切后复发3例。结论选择合适的入路进行显微外科手术,可以全切肿瘤并较好的保护或恢复颅神经功能,特别是体积较大和颅神经受损明显的肿瘤,手术切除是首选。     

Dostęp skalisty przedni – analiza techniki operacyjnej na podstawie symulacji na zwłokach

The aim of the study was to present consecutive stages of the anterior petrosal approach (APA).Eight simulations of APA were performed on non-fixed human cadavers without any known pathologies of the head and neck. The consecutive stages of the procedure were documented with photographs and schemes.The starting point for APA is a temporal craniotomy and extradural exposition of the base of the middle cranial fossa. Mobilisation of the trigeminal nerve allows for removal of the apex of the petrous bone. Approach to the upper part of the clivus is achieved by elevation of the temporal lobe and section of the tentorium and superior petrosal sinus with surrounding dura.Anterior petrosal approach is a reproducible technique, which provides surgical penetration of the upper clivus and related regions. This approach is particularly useful in the treatment of tumors of the mentioned above anatomical areas.