The middle fossa transpetrous approach for petroclival meningiomas

Seventeen patients with petroclival meningioma were operated on through a middle fossa transpetrous approach. This approach exposes the anterior cerebellopontine angle through a middle fossa craniotomy with removal of the petrous apex medial to the cochlea and petrous carotid artery. This approach may be enlarged by transection of the superior petrosal sinus and tentorium. The surgical technique and application of the middle fossa transpetrous approach for petroclival meningiomas is presented.     

单侧额下入路显微切除大型及巨大型嗅沟脑膜瘤

目的 总结经单侧额下入路显微手术切除大型及巨大型嗅沟脑膜瘤的体会.方法 大型及巨大型嗅沟脑膜瘤患者31例,所有患者均经单侧额下入路开颅,显微手术切除病变.结果 Simpson Ⅰ级切除21例,Ⅱ级切除8例,Ⅲ级切除2例.结论 单侧额下入路显微手术能够用于切除大型及巨大型嗅沟脑膜瘤,与双侧额下入路比较,创伤小,恢复快,术后并发症少,符合微侵袭的理念.     

枕下乙状窦后-内听道上入路切除岩斜区脑膜瘤

目的介绍应用枕下乙状窦后-内听道上入路显微手术切除岩斜区脑膜瘤的显微手术技术。方法回顾性分析采用枕下乙状窦后-内听道上入路显微手术治疗的8例岩斜区脑膜瘤的临床资料,并对手术方法进行分析。结果肿瘤全切除6例,次全切除2例。术后新增脑神经损害2例,无手术死亡病例。结论枕下乙状窦后-内听道上入路是切除主体位于后颅窝、同时累及中颅窝的岩斜区脑膜瘤的安全有效的改良入路,娴熟的显微神经外科技术,熟练掌握入路的显微解剖可获得满意的手术疗效,有利于提高肿瘤切除率和疗效。     

Surgical removal of small petroclival meningiomas

Summary Treatment of large petroclival meningiomas causing brain stem compression is surgical removal followed by radiotherapy or radiosurgery if the lesion was partially resected. The management of small petroclival meningiomas is, however, controversial. Clinical observation, radiosurgery and surgical removal are the options of treatment. The natural history of these tumours is not well known. Published series of patients treated with radiosurgery are not comparable with surgical series because the latter also includes large size tumours. In this paper we present a series of 18 patients with small petroclival meningiomas (diameter ≤ 2.8 cm) treated with radical surgical removal. Total resection (Simpson’s Grade 1) [43] was possible with minimal morbidity and no mortality. Background. We present a series of small petroclival meningiomas (SPM) treated by radical surgical removal and compare the outcome with other management modalities proposed for these lesions. Methods. Eighteen patients with SPM were surgically treated at our department of neurological surgery. The tumours were classified as small when they had a diameter < 3.0 cm. Headaches (n = 12), diplopia (n = 8), facial hypoaesthesia (n = 3) and tinnitus (n = 6) were the most frequent symptoms at presentation. The approaches used were retrosigmoid (n = 14), fronto-orbito-zygomatic (n = 3) and presigmoid (n = 1). The post-operative follow-up ranged from 1 to 110 months (mean 41.8 months). Findings. Radical tumour resection (Simpson’s Grades 1 and 2) was achieved in all patients. There was no major morbidity or mortality related to the surgical procedure. Transient abducent nerve palsy was the only post-operative complication. The pre-operative cranial nerves deficits improved after surgery. Only one patient had persistent diplopia postoperatively. Conclusion. Radical surgical removal of SPM is possible with minimal morbidity and may cure the patient. The effectiveness and outcome of surgery for small petroclival meningiomas should be compared with series treated by radiosurgery. Correspondence: Ricardo Ramina, R. Goncalves Dias 713, 80240340 Curitiba, Brazil.     

前入路肝切除术

由于临床和解剖学研究的不断进步和手术器械的更新,肝脏外科手术技术取得了较大的发展.近年来,前入路肝切除技术以其相较于传统肝切除术的诸多优点,日益受到肝脏外科医师的重视.     

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

The treatment of petroclival meningiomas is still a matter of controversy in literature. In the last decades, many approaches have been introduced. Our strategy for the treatment of such tumors having large supratentorial extension with encasement of the internal carotid artery or compression of optic and oculomotor nerves has evolved in the attempt to improve the outcome. Currently, we favor a surgical technique consisting of two steps. As first step, we perform a retrosigmoid suprameatal approach in order to resect the posterior part of the tumor and obtain brainstem decompression. In the second step, carried out after patient’s recovery from the first surgery, we remove the supratentorial portion of the lesion using a frontotemporal craniotomy to achieve the decompression of the optic nerve, oculomotor nerve, and carotid artery. The retrosigmoid suprameatal approach allows for adequate brainstem decompression: the tumor itself creates a surgical channel increasing the accessibility to the lower and upper petroclival surface. Moreover, this route allows for early visualization of cranial nerves in the posterior fossa and safe tumor removal under direct visual control, reducing the risk of postoperative deficits. Via the simple and safe frontotemporal craniotomy, the supratentorial part of the lesion can be removed thus avoiding the need of invasive approaches. We propose a two-stage surgery for treatment of petroclival meningiomas combining two simple routes such as retrosigmoid suprameatal and frontotemporal craniotomy. This approach reflects our philosophy to use simple and less invasive approaches in order to preserve neurological function and a good quality of life of the patient.     

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

Neurosurgical Review - The treatment of petroclival meningiomas is still a matter of controversy in literature. In the last decades, many approaches have been introduced. Our strategy for the...     

Surgical resection and reconstruction for a giant cell tumor of the anterior rib

Giant cell tumors (GCTs) are rare neoplasms, most commonly arising in the metaphysis/epiphysis of long bones. They consist of multinucleated giant cells with surrounding spindle-shaped mononuclear stromal cells. GCTs rarely appear in the ribs. We report a case of a GCT originating from the anterior arc of the fourth rib in a 31-year-old man who presented with a progressively growing thoracic mass in the left anterior chest wall. Thoracotomy involving en bloc resection of the chest wall and tumor and a reconstruction of the chest wall were performed.     

Four subtypes of petroclival meningiomas: differences in symptoms and operative findings using the anterior transpetrosal approach

Summary   Background. Petroclival meningiomas are vaguely defined as tumours arising from the antero-medial zone to the internal auditory meatus. This report subclassifies petroclival meningiomas based on their origin determined by using radiological and intra-operative findings. Method. Ninety-one patients with petroclival meningioma underwent surgery via the anterior transpetrosal approach. The Meckel’s cave was routinely opened. Tumour origin was classified into four subtypes according to the main attachment and trigeminal nerve deviation into, upper clivus (UC), cavernous sinus (CS), tentorium (TE), and petrous apex (PA). Their characteristic clinical symptoms and anatomical features were investigated. Findings. The characteristic symptom was ataxia in the UC type (37.5%), abducens nerve palsy in the CS type (64.3%) and trigeminal neuropathy, mainly neuralgia in the PA type (80.0%) with a higher statistical difference from other subtypes. The rate of tumour invasion into Meckel’s cave reached 70.3% in average, with the lowest rate in the PA type (25.0%). The rate of middle fossa extension was the highest in the TE type (59.5%). The middle fossa approach was considered to be ideal for UC and TE types because of easier access to the Meckel’s cave. Radical dissection without complications was difficult in the CS type. Both the anterior transpetrosal approach and the lateral suboccipital approach could be indicated in the PA type due to the rare invasion of Meckel’s cave and middle fossa, and frequent extension into the internal auditory meatus. Conclusions. This classification is useful to predict the relation between the tumour and the cranial nerves based on symptoms and images. The anterior transpetrosal approach could be used for all four subtypes and with an absolute indication in the UC and TE types showing middle fossa extension. Correspondence: Takeshi Kawase, M.D., Ph.D., Department of Neurosurgery, Keio University School of Medicine, 35 Shinano-machi, Shinjukuku, Tokyo 160-8582, Japan.     

Surgical treatment of a giant coronary artery aneurysm: a modified approach

A common surgery for giant coronary artery aneurysms includes aneurysmal ligation and coronary artery bypass grafting. We report a patient with such an aneurysm involving the left main trunk in whom the aneurysmal characteristics precluded this approach. Surgical strategy was modified and the aneurysmal sac was dissected open to define the coronary vasculature before ligating the aneurysm and completing the bypass operation.     

Surgical management of ventrally located spinal meningiomas via posterior approach

Background

Spinal meningioma is a relatively common tumor among intradural extramedullary spinal tumors. When the locus of the meningioma is located on the ventral side, tumor removal, dura mater resection, and reconstruction via a posterior approach safety become technically difficult.

Methods

Twelve patients, who received surgical treatment for ventral spinal meningioma via a posterior approach, were included. There were three male and nine female patients, with an average age of 66.3 years (47–88 years). The average observation period was 55.4 months (22–132 months). In these cases, we analyzed the spinal level of tumor position, histopathological type (subtype), the grade of tumor resection (Simpson grade), pre- and post-operative walking state (Nurick grade), perioperative neurological complications, and the recurrence.

Results

Spinal meningioma occurred in the cervical spinal cord in three cases, with a further nine cases in the thoracic spinal cord. Histopathologically, all 12 tumors were assessed as grade I on the WHO classification system (eight cases of meningothelial type and four cases of psammomatous type). The level of tumor resection was Simpson grade I resection for two cases and Simpson grade II resection for the remaining ten cases. The average of Nurick grade improved from 3.3 preoperatively to 1.3 postoperatively. In all cases, we identified no neurological complications. One incident of tumor recurrence was identified 11 years after an operation involving a Simpson grade II resection

Conclusion

Posterior approaches provide adequate exposure to safely remove ventrally located meningioma. Posterior exposures with lateral bone resection, dentate ligament division, provide also adequate exposure for safe removal.

     

Middle fossa transpetrosal-transtentorial approaches for petroclival meningiomas selective pyramid resection and radicality

Summary Fourty-two patients with petroclival meningioma were operated upon by the middle fossa transpetrosal-transtentorial approaches since 1977. Half of those showed tumour extension into the middle fossa and one-third in the cavernous sinus. Seventeen (40%) had a large tumour of 40 mm in diameter or larger, and 8 of those had a broad attachment from the clivus to petrous pyramid of the temporal bone. The site of pyramid resection was selected from three types, depending on the tumour location and the patients' pre-operative hearing. There was no surgical mortality. Significant risk of lower cranial nerves palsy was minimal and useful hearing was preserved in 18 out of 21 patients. The follow-up, an average of 4 and a half years, showed tumours were completely eradicated in 32 patients (76%) and there was regrowfh in 3 (7%). Thirty-four patients (81%) were independent, 3 disabled and only one died of rapid tumour regrowth. The most influential factor on surgical results was the extent to which the tumour had invaded the brain stem. The presence or absence of arterial encasement and of peritumoural oedema on MRI were important in the selection for radical surgery.     

Surgical management and outcomes of petroclival meningiomas: a single-center case series of 259 patients

Background

Surgical management of petroclival meningiomas is challenging. Various and inconsistent outcome and prognostic factors of the lesions have been evaluated previously. In the present study, the surgical outcome, philosophy, and experience of petroclival meningiomas are detailed based on a large patient series.

Methods

A series of 259 patients with petroclival meningiomas (70 males and 189 females) were surgically treated. Clinical charts and radiographs were reviewed. Follow-up results were evaluated.

Results

The preoperative Karnofsky Performance Scale (KPS) score was 74.2?±?10.5. The mean tumor size was 4.3?±?1.0 cm. The gross total resection (GTR) rate was 52.5 %. During a mean follow-up period of 55.3 months, recurrence/progression (R/P) occurred in 11 patients. The recent KPS score was 78.4?±?22.7, it improved in 139 (57.2 %) patients and stabilized in 53 (21.8 %) patients, and 201 (82.7 %) patients lived independently. The risk factors affecting the KPS score included (but were not limited to) age?≥?60, preoperative KPS?≤?60, and brainstem edema. The adverse factors contributing to R/P-free survival included (but were not limited to) non-total resection and the absence of the subarachnoid space. The R/P-free survival rate was 94.5 % at 5 years and 91.2 % at 9 years. The overall survival rate was 94.7 % at 5 years and 94.7 % at 9 years.

Conclusions

Favorable outcomes from petroclival meningiomas could be achieved by microsurgery. Neurological function and quality of life were prioritized, and GTR was attempted. Risk factors should be considered in surgical schemes, and tumor recurrence should be aggressively monitored and treated.     

大型前床突脑膜瘤的外科治疗经验

目的探讨前床突区手术临床应用解剖,提高前床突区肿瘤的治疗效果。方法回顾性总结1998-2004年收治的采用前外侧硬脑膜外入路手术的前床突脑膜瘤12例,其中视力减退者10例,头痛者11例。采用眶上翼点联合入路,肿瘤累及海绵窦者采用额颞眶颧联合入路。磨除前床突。硬脑膜外阻断肿瘤基底部血供。硬脑膜下切除肿瘤。结果本组患者全切除8例,次全切除3例,部分切除1例。全组无手术死亡。术前视力明显减退的10例患者,术后6例明显好转,2例改善,1例无变化,1例较术前恶化,其中术后视力无改变和视力恶化的2例均为术前有明显视神经萎缩的患者。结论前床突脑膜瘤采用前外侧硬脑膜外入路,磨除前床突,有利于肿瘤基底部的血供阻断以及前床突下肿瘤与颈内动脉的分离。眶上翼点联合入路可明显减小手术对脑组织的牵拉,有利于大型肿瘤上极的显露。     

幕上下经岩骨乙状窦前入路切除巨大岩斜部肿瘤

目的 探讨幕上下经岩骨乙状窦前入路切除岩斜部肿瘤手术的技巧及并发症。方法 取颞枕游离骨瓣,分别于迷路前后将乳突及岩骨根部大部切除,但保留骨性半规管、耳蜗及鼓室的完整性;结扎并切断岩上窦,自乙状窦前方抵达岩斜部。结果 ４１例肿瘤包括脑膜瘤２０例,表皮样囊肿２０例,神经鞘瘤１例。手术全切肿瘤３４例,近全切除６例,大部切除１例。术后一过性失语１０例,脑水肿６例。脑干梗塞２例,第Ⅲ、Ⅵ、Ⅶ及后组颅神经损伤     

体表巨大血管瘤的手术切除与整复治疗

目的 通过４５例巨型血管瘤的手术治疗,阐明血管瘤选用手术切除是一种带有根治性的有效治疗方法。方法 ①术前放射数字减影（ＤＳＡ）检查,可明确诊断了,了解病变范围,有利于手术设计等。②术中具体操作宜采用“假包膜剥率法”。③应用整复手术进行创面修复。结果 ４５例手术,一期治愈２７例,二例治愈１３例,治愈率达８９％。术后随访时间最长已达８年,无复发,疗效好。结论 术前ＤＳＡ检查结果是制定手术方案的重要依据     

Surgical strategies for giant medial sphenoid wing meningiomas: a new scoring system for predicting extent of resection

Background  Surgical management of giant medial sphenoid meningiomas (≥5 cm in maximum dimension) is extremely challenging due to their intimate relationship with vital neural structures like the optic nerve, cranial nerves of the cavernous sinus and the cavernous internal carotid artery. Their surgical management is presented incorporating a radiological scoring system that predicts the grade of tumour excision. Materials and methods  20 patients of giant medial sphenoidal wing meningioma (maximum tumour dimension range: 5.2 to 9.5 cm; mean maximum dimension = 6.12 ± 1.06 cm) with mainly visual and extraocular movement deficits, and raised intracranial pressure, underwent surgery. A preoperative radiological scoring system (range 1–12) was proposed considering tumour volume (using Kawamoto’s method); extension into the surrounding surgical corridors; extent of cavernous sinus invasion (based on the tumour relationship to the cavernous internal carotid artery); associated hyperostosis and/or >50% calcification; and, associated brain oedema. Both the conventional frontotemporal craniotomy (n = 13) and its extension to orbitozygomatic osteotomy (n = 7) were utilized. The cavernous sinus was explored in 4 patients and the hyperostotic sphenoid ridge drilled in five patients. Findings  Total excision was achieved in nine patients; small tumour remnants within the cavernous sinus, interpeduncular fossa or suprasellar cistern were left in eight patients; and less than 10% of tumour was left in three patients. A patient with a completely calcified meningioma died due to myocardial infarction. When the preoperative radiological score was ≥7, there was considerable difficulty in achieving total tumour excision. A mean follow of 17.58 ± 15.05 months revealed improvement in visual acuity/field defects in three, stabilisation in 11, and deterioration of ipsilateral visual acuity in five patients. Symptoms of raised pressure, cognitive dysfunction, aphasia and proptosis showed improvement. Conclusion  A relatively conservative approach to these extensive lesions resulted in good outcome in a majority of our patients. Both the standard as well as skull base approaches may be utilized for successful removal of giant medial sphenoidal wing meningiomas. A preoperative radiological score of ≥7 predicts a greater degree of difficulty in achieving complete surgical extirpation.