Surgical and Functional Outcome after Resection of 64 Petroclival Meningiomas

Abstract

Objective: The management of petroclival meningiomas (PCMs) remains notoriously difficult due to their close association with neurovascular structures and their complex anatomy, hence the surgical paradigm change from radical to functional resection in the past. With this study, we aimed to analyze surgical and functional outcomes of a modern consecutive series of patients with PCMs. Methods: We reviewed patient charts and imaging data of 64 consecutive patients from 2006 to 2018 with a PCM resected at our institution and compared surgical and functional outcomes between subgroups stratified by surgical approach. Results: Females comprised 67.2% of patients (n = 43), with a mean age of 55 years (median 56; range 21–84). Follow-up data were available for 68.8% and reached a mean of 42.3 months (range 1–129) with a median of 28.5 months. The mean tumor diameter was 37.3 mm (standard deviation (SD) 15.4; median 37.0). Infiltration of the cavernous sinus was observed in 34 cases (53.1%), and the lesions affected the brain stem in 28 cases (43.8%). Preoperative cranial nerve palsy was observed in 73.4% of cases; trigeminal neuropathy (42.2%), hearing loss (32.8%), and impairment of vision (18.8%) were the most common. A retrosigmoid approach was employed in 47 cases (78.1%), pterional in 10 (15.6%), combined petrosal in 2 (3.1%), and transnasal and subtemporal in 1 (1.6%). Fifteen cases (23.4%) were resected in a two-staged fashion. Gross total resection (GTR) was attempted in 30 (46.9%) cases without cavernous sinus infiltration and was achieved in 21 (70.0%) of these cases. Surgical complications occurred in 13 cases (20.3%), most commonly meningitis (n = 4; 6.3%). Postoperatively, 56 patients (87.5%) developed new cranial nerve palsy, of which 36 (63.6%) had improved or resolved on last follow up. Achieving GTR was not significantly associated with higher rates of surgical complications (chi-square; p = 0.288) or postoperative cranial nerve palsy (chi-square; p = 0.842). Of all cases, 20 (31.3%) underwent postoperative radiation. Tumor progression was observed in 10 patients (15.9%) after a mean 102 months (median 124). Conclusions: Surgical resection remains the mainstay of treatment for PCMs, with perioperative cranial neuropathies exhibiting favorable recovery rates. Most essentially, the preselection of patients with hallmarks of brain stem affection and cavernous sinus infiltration should dictate whether to strive for a functionally oriented strategy in favor of radical resection.

Postoperative Complications and Neurological Deficits After Petroclival Region Meningioma Resection: A Case Series

“…4,17 The rates of postoperative CN deficits in the literature range from 23% to 76%. 6,8,9,11-13,18 In 2 recent meta-analyses, the rate of extremity weakness was 10.3%–14%, slightly lower than the 15.3% observed in the present cohort. 4,17 Lack of consensus regarding the definition of petroclival meningiomas means that meta-analyses may include a more heterogeneous population of tumors than those in our study.…”

“…Despite similar rates of preoperative CN deficits and tumor volume, the rate of GTR/ NTR in this study was 15.4%, notably lower than the previously reported rates of 28%-79%. [8][9][10][11][12][13] This may reflect an institutional bias toward accepting a subtotal resection (STR) as a tradeoff for neurological preservation and using adjuvant radiation therapy, an approach others have advocated. 2 Most tumors in our series were sphenocavernopetroclival with significant extension into the cavernous sinus, a common obstacle in achieving a GTR along with adhesion to the brainstem or encasement of nearby vasculature.…”

Giant Meningiomas Invading the Cavernous Sinus: The “Inevitable Ones”

“…They observed more than 80% of transient CN deficits with around 25% of definite morbidity of such nerves. 39 In the present series, the abducens nerve was the most common preoperative CN deficit, followed by the trigeminal and facial nerves. In the postoperative period, three cases (25%) presented new six nerve palsy and one case with new trigeminal disturbances.…”

“…They observed more than 80 % of transient cranial nerves deficits with around 25% of definite morbidity of such nerves. 38 In the present series, the abducens nerve was the most common preoperative cranial nerve deficit, followed by the trigeminal and facial nerves.…”

Pterional Craniotomy With Anterior Clinoidectomy for the Resection of a Sphenoid Ridge Meningioma: A Case Report and Two-Dimensional Operative Video

“…Sphenoid ridge meningiomas are characterized by deep location, complex structures, and narrow surgical space, leading to a high risk of damaging nerves, blood vessels, and brainstem as well as possibly causing postoperative paralysis, so that completely removing it could be challenging [ 8 , 14 ]. When the tumor is hard and adherent to normal structures, leaving a piece of it intentionally can preserve the patient's postoperative neurological functions [ 15 ]. The pterional approach with anterior clinoidectomy for this patient was chosen as it provides great convenience not for the lesion removal in the carotid-oculomotor triangle (COT) but the treatment of the tumor base.…”