Petroclival meningiomas: study on outcomes, complications and recurrence rates

Clinical article

Restricted access

Object

Petroclival meningiomas are notoriously difficult lesions to manage surgically, given the critical neurovascular structures that are intimately associated with the tumors. In this paper, the authors' aim was to review their series of patients with petroclival meningiomas who underwent surgical treatment; emphasis was placed on evaluating modes of presentation, postoperative neurological outcome, complications, and recurrence rates.

Methods

Fifty patients underwent surgical treatment for petroclival meningiomas. The majority of the patients were women (72%). The authors retrospectively reviewed the patients' medical records, imaging studies, and pathology reports to analyze presentation, surgical approach, neurological outcomes, complications, and recurrence rates.

Results

Headache was the most common presentation (58%). The most commonly used approach was the transpetrous approach (in 16 patients), followed by the orbitozygomatic approach (in 13). Gross-total resection was performed in 14 patients (28%), and in the remaining patients there was residual tumor (72%). Eighteen patients with tumor remnants were treated with Gamma Knife surgery. New postoperative cranial neuropathies were noted in 22 patients (44%). The most common cranial nerve (CN) deficit following surgery was CN III dysfunction (in 11 patients) and facial weakness (in 10). In 9 patients, the CN dysfunction was transient (41%), and 7 patients had permanent dysfunction (32%). Eight patients developed hydrocephalus and all required placement of a ventriculoperitoneal shunt. A CSF leak was noted in only 2 patients (4%), and wound dehiscence was noted in 1. The CSF leaks and the wound dehiscence occurred in patients who were undergoing reoperations. Adequate radiographic follow-up (minimum 6 months) was available for 31 patients (62%). The mean follow-up was 22.1 months. In 6 patients, tumor progression or recurrences were noted. The median time to recurrence was 84 months. At the time of discharge from the hospital, 92% of the patients had good outcomes (Glasgow Outcome Scale Scores 4 and 5). Three patients died of causes not directly related to the surgery.

Conclusions

Petroclival meningiomas still pose a formidable challenge to neurosurgeons. In their series, the authors used multiple skull base approaches and careful microneurosurgical technique to achieve a good functional outcome (Glasgow Otcome Scale Score 4 or 5) in 92% of patients, although the extent of gross-total resection was only 28%. The authors' primary surgical goal was to achieve maximal tumor resection while maintaining or improving neurological function. The authors favor the treatment of residual tumor or recurrent tumor with stereotactic radiosurgery.

Abbreviations used in this paper: CN = cranial nerve; CPA = cerebellopontine angle; GOS = Glasgow Outcome Scale; GTR = gross-total resection; GSPN = greater superficial petrosal nerve; SRS = stereotactic radiosurgery; STR = subtotal resection; VP = ventriculoperitoneal.

Article Information

Address correspondence to: Anil Nanda, M.D., Department of Neurosurgery, Louisiana State University Health Sciences Center in Shreveport, 1501 Kings Highway, P.O. Box 33932, Shreveport, Louisiana 71130-33932. email: ananda@lsuhsc.edu.

Please include this information when citing this paper: published online December 24, 2010; DOI: 10.3171/2010.11.JNS10326.

© AANS, except where prohibited by US copyright law.

Headings

Figures

  • View in gallery

    Pie chart showing the numerous surgical approaches used to resect the petroclival meningiomas. The most commonly used approaches were the transpetrosal and orbitozygomatic approaches. The numbers before the commas indicate the number of patients.

  • View in gallery

    The majority of the residual tumors in our series underwent either Gamma Knife surgery (GKS) or follow-up.

  • View in gallery

    The GOS score was used to evaluate neurological outcome following excision. The numbers before the commas indicate the number of patients.

  • View in gallery

    Kaplan-Meier survival analysis showing the overall recurrence-free survival plot. Only 31 patients with follow-up longer than 6 months were included.

  • View in gallery

    A and B: Preoperative CT scans showing gross calcification of the tumor. C–F: Preoperative MR images showing a large petroclival meningioma with obstructive hydrocephalus in a 70-year-old patient with hypertension, diabetes, and dyslipidemia. The patient underwent VP shunt placement only, and the tumor is undergoing follow-up. Over the past 3 years, the tumor has remained stable. Conservative management is a good option for asymptomatic tumors, especially in elderly patients and in those with risk factors for surgery.

  • View in gallery

    Preoperative CT scan (A) and MR images (C and D) showing a large petroclival meningioma causing brainstem compression. B: Computed tomography angiogram showing a large enhancing mass consistent with a meningioma. E and F: Postoperative MR images showing a small remnant.

  • View in gallery

    Left: Preoperative MR image showing a large petroclival meningioma with sphenocavernous extension. Right: Postoperative CT scan showing a small residual tumor.

  • View in gallery

    Axial T2-weighted (A) and T1-weighted (B) MR images obtained after contrast administration, showing a large right-sided petroclival meningioma. There was a small residual tumor that was treated with radiosurgery. Images showing the Gamma Knife surgery plan for the tumor remnant (C).

References

  • 1

    al-Mefty OAyoubi SSmith RR: The petrosal approach: indications, technique, and results. Acta Neurochir Suppl (Wien) 53:1661701991

  • 2

    Al-Mefty OFox JLSmith RR: Petrosal approach for petroclival meningiomas. Neurosurgery 22:5105171988

  • 3

    Bambakidis NCKakarla UKKim LJNakaji PPorter RWDaspit CP: Evolution of surgical approaches in the treatment of petroclival meningiomas: a retrospective review. Neurosurgery 61:5 Suppl 22022112007

  • 4

    Bochenek ZKukwa A: An extended approach through the middle cranial fossa to the internal auditory meatus and the cerebello-pontine angle. Acta Otolaryngol 80:4104141975

  • 5

    Bricolo APTurazzi STalacchi ACristofori L: Microsurgical removal of petroclival meningiomas: a report of 33 patients. Neurosurgery 31:8138281992

  • 6

    Campbell EWhitfield RD: Posterior fossa meningiomas. J Neurosurg 5:1311531948

  • 7

    Castellano FRuggiero G: Meningiomas of the posterior fossa. Acta Radiol Suppl 104:11771953

  • 8

    Cherington MSchneck SA: Clivus meningiomas. Neurology 16:86921966

  • 9

    Couldwell WTFukushima TGiannotta SLWeiss MH: Petroclival meningiomas: surgical experience in 109 cases. J Neurosurg 84:20281996

  • 10

    Culley DJBerger MSShaw DGeyer R: An analysis of factors determining the need for ventriculoperitoneal shunts after posterior fossa tumor surgery in children. Neurosurgery 34:4024081994

  • 11

    Cushing H: Experiences with the cerebellar astrocytomas: a critical review of seventy-six cases. Surg Gynecol Obstet 52:1292041931

  • 12

    Cushing HEisenhardt L: Meningiomas: Their Classification Regional Behaviour Life History and Surgical End Results Springfield ILCharles C Thomas1938

  • 13

    Gnanalingham KKLafuente JThompson DHarkness WHayward R: Surgical procedures for posterior fossa tumors in children: does craniotomy lead to fewer complications than craniectomy?. J Neurosurg 97:8218262002

  • 14

    Goel AMuzumdar D: Conventional posterior fossa approach for surgery on petroclival meningiomas: a report on an experience with 28 cases. Surg Neurol 62:3323402004

  • 15

    Hakuba ANishimura SJang BJ: A combined retroauricular and preauricular transpetrosal-transtentorial approach to clivus meningiomas. Surg Neurol 30:1081161988

  • 16

    Jung HWYoo HPaek SHChoi KS: Long-term outcome and growth rate of subtotally resected petroclival meningiomas: experience with 38 cases. Neurosurgery 46:5675752000

  • 17

    Kawase TShiobara RToya S: Anterior transpetrosal-transtentorial approach for sphenopetroclival meningiomas: surgical method and results in 10 patients. Neurosurgery 28:8698761991

  • 18

    Kawase TToya SShiobara RMine T: Transpetrosal approach for aneurysms of the lower basilar artery. J Neurosurg 63:8578611985

  • 19

    Lefkowitz MAHinton DRWeiss MHGiannotta SLCouldwell WT: Prognostic variables in surgery for skull base meningiomas. Neurosurg Focus 2:4e21997

  • 20

    Little KMFriedman AHSampson JHWanibuchi MFukushima T: Surgical management of petroclival meningiomas: defining resection goals based on risk of neurological morbidity and tumor recurrence rates in 137 patients. Neurosurgery 56:5465592005

  • 21

    Manley GTDillon W: Acute posterior fossa syndrome following lumbar drainage for treatment of suboccipital pseudomeningocele. Report of three cases. J Neurosurg 92:4694742000

  • 22

    Mathiesen TGerlich AKihlström LSvensson MBagger-Sjöbäck D: Effects of using combined transpetrosal surgical approaches to treat petroclival meningiomas. Neurosurgery 60:9829922007

  • 23

    Natarajan SKSekhar LNSchessel DMorita A: Petroclival meningiomas: multimodality treatment and outcomes at long-term follow-up. Neurosurgery 60:9659812007

  • 24

    Nicolato AForoni RPellegrino MFerraresi PAlessandrini FGerosa M: Gamma knife radiosurgery in meningiomas of the posterior fossa. Experience with 62 treated lesions. Minim Invasive Neurosurg 44:2112172001

  • 25

    Nutik SLKorol HW: Cerebrospinal fluid leak after acoustic neuroma surgery. Surg Neurol 43:5535571995

  • 26

    Park CKJung HWKim JEPaek SHKim DG: The selection of the optimal therapeutic strategy for petroclival meningiomas. Surg Neurol 66:1601662006

  • 27

    Ramina RNeto MCFernandes YBSilva EBMattei TAAguiar PH: Surgical removal of small petroclival meningiomas. Acta Neurochir (Wien) 150:4314392008

  • 28

    Rhoton AL JrTedeschi H: Microsurgical anatomy of acoustic neuroma. 2002. Neurosurg Clin N Am 19:145174v2008

  • 29

    Roberti FSekhar LNKalavakonda CWright DC: Posterior fossa meningiomas: surgical experience in 161 cases. Surg Neurol 56:8212001

  • 30

    Roche PHPellet WFuentes SThomassin JMRégis J: Gamma knife radiosurgical management of petroclival meningiomas results and indications. Acta Neurochir (Wien) 145:8838882003

  • 31

    Rowe JGrainger AWalton LSilcocks PRadatz MKemeny A: Risk of malignancy after gamma knife stereotactic radiosurgery. Neurosurgery 60:60662007

  • 32

    Russell JRBucy PC: Meningiomas of the posterior fossa. Surg Gynecol Obstet 96:1831921953

  • 33

    Samii MAmmirati MMahran ABini WSepehrnia A: Surgery of petroclival meningiomas: report of 24 cases. Neurosurgery 24:12171989

  • 34

    Sawamura YAsaoka KTerasaka STada MUchida T: Evaluation of application techniques of fibrin sealant to prevent cerebrospinal fluid leakage: a new device for the application of aerosolized fibrin glue. Neurosurgery 44:3323371999

  • 35

    Schaller BMerlo AGratzl OProbst R: Premeatal and retromeatal cerebellopontine angle meningioma. Two distinct clinical entities. Acta Neurochir (Wien) 141:4654711999

  • 36

    Sekhar LNJannetta PJBurkhart LEJanosky JE: Meningiomas involving the clivus: a six-year experience with 41 patients. Neurosurgery 27:7647811990

  • 37

    Shamisa ABance MNag STator CWong SNorén G: Glioblastoma multiforme occurring in a patient treated with gamma knife surgery. Case report and review of the literature. J Neurosurg 94:8168212001

  • 38

    Shin MUeki KKurita HKirino T: Malignant transformation of a vestibular schwannoma after gamma knife radiosurgery. Lancet 360:3093102002

  • 39

    Spetzler RFDaspit CPPappas CT: The combined supra- and infratentorial approach for lesions of the petrous and clival regions: experience with 46 cases. J Neurosurg 76:5885991992

  • 40

    Steinbok PSinghal AMills JCochrane DDPrice AV: Cerebrospinal fluid (CSF) leak and pseudomeningocele formation after posterior fossa tumor resection in children: a retrospective analysis. Childs Nerv Syst 23:1711752007

  • 41

    Subach BRLunsford LDKondziolka DMaitz AHFlickinger JC: Management of petroclival meningiomas by stereotactic radiosurgery. Neurosurgery 42:4374451998

  • 42

    Tao WZhimin WXianhaou YWeiguo C: Multivariate analysis of recurrence in meningioma. Chinese-German. J Clin Oncol 4:26292005

  • 43

    Than KDBaird CJOlivi A: Polyethylene glycol hydrogel dural sealant may reduce incisional cerebrospinal fluid leak after posterior fossa surgery. Neurosurgery 63:1 Suppl 1ONS182ONS1872008

  • 44

    Van Havenbergh TCarvalho GTatagiba MPlets CSamii M: Natural history of petroclival meningiomas. Neurosurgery 52:55642003

  • 45

    Voss NFVrionis FDHeilman CBRobertson JH: Meningiomas of the cerebellopontine angle. Surg Neurol 53:4394472000

  • 46

    Yingling CDGardi JN: Intraoperative monitoring of facial and cochlear nerves during acoustic neuroma surgery. 1992. Neurosurg Clin N Am 19:289315vii2008

  • 47

    Yu JSYong WHWilson DBlack KL: Glioblastoma induction after radiosurgery for meningioma. Lancet 356:157615772000

TrendMD

Cited By

Metrics

Metrics

All Time Past Year Past 30 Days
Abstract Views 180 180 14
Full Text Views 185 185 7
PDF Downloads 173 173 7
EPUB Downloads 0 0 0

PubMed

Google Scholar