Gamma Knife surgery in the treatment paradigm for foramen magnum meningiomas

Clinical article

Restricted access

Object

Microsurgical management of foramen magnum meningiomas (FMMs) can be associated with significant morbidity and mortality. Stereotactic radiosurgery may be an efficient and safe alternative treatment modality for such tumors. The object of this study was to increase the documented experience with Gamma Knife surgery (GKS) for FMMs and to delineate its role in an overall management paradigm.

Methods

The authors report on their experience with 24 patients harboring FMMs managed with GKS. Twelve patients had primary symptomatic tumors, 5 had asymptomatic but enlarging primary tumors, and 7 had recurrent or residual tumors after a prior surgery.

Results

Follow-up clinical and imaging data were available in 21 patients at a median follow-up of 47 months (range 3–128 months). Ten patients had measurable tumor regression, which was defined as an overall volume reduction > 25%. Eleven patients had no further tumor growth. Two patients died as a result of advanced comorbidities before follow-up imaging. One patient was living 8 years after GKS but had no clinical evaluation. Ten of 17 symptomatic patients with at least 6 months of follow-up had symptom improvement, and 7 remained clinically stable. Smaller tumors were more likely to regress. No patient suffered an adverse radiation effect after radiosurgery.

Conclusions

Gamma Knife surgery was a safe management strategy for small, minimally symptomatic, or growing FMMs as well as for residual tumors following conservative microsurgical removal.

Abbreviations used in this paper:FMM = foramen magnum meningioma; GKS = Gamma Knife surgery.

Article Information

Address correspondence to: Georgios Zenonos, M.D., Department of Neurological Surgery, 200 Lothrop Street, Suite B400, UPMC Presbyterian Hospital, Pittsburgh, Pennsylvania 15213. email: zenonosg@upmc.edu.

Please include this information when citing this paper: published online September 14, 2012; DOI: 10.3171/2012.8.JNS111554.

© AANS, except where prohibited by US copyright law.

Headings

Figures

  • View in gallery

    Axial and sagittal MR images with contrast showing a left FMM. Images without (A, 1–6) and with (B, 1–6) the radiosurgical dose plan are shown. This tumor received a margin dose of 11.5 Gy and a maximum dose of 23 Gy.

  • View in gallery

    Bar graph demonstrating radiographic tumor progression and symptom progression in patients with at least 6 months of follow-up imaging data in relation to the initial tumor size. Tumor regression was defined as > 25% reduction in tumor volume. The average follow-up interval was similar in the 3 groups (< 3 cm3 group: 52 months, 3–6 cm3 group: 45 months, > 6 cm3 group: 47 months). Asymptomatic lesions were not included in the symptom progression analysis. Dark gray bars represent tumor regression; light gray bars, improved symptoms.

  • View in gallery

    Proposed management algorithm for FMMs.

References

  • 1

    Akalan NSeçkin HKiliç COzgen T: Benign extramedullary tumors in the foramen magnum region. Clin Neurol Neurosurg 96:2842891994

  • 2

    Arnautović KIAl-Mefty OHusain M: Ventral foramen magnum meninigiomas. J Neurosurg 92:1 Suppl71802000

  • 3

    Babu RPSekhar LNWright DC: Extreme lateral transcondylar approach: technical improvements and lessons learned. J Neurosurg 81:49591994

  • 4

    Bassiouni HNtoukas VAsgari SSandalcioglu EIStolke DSeifert V: Foramen magnum meningiomas: clinical outcome after microsurgical resection via a posterolateral suboccipital retrocondylar approach. Neurosurgery 59:117711872006

  • 5

    Bertalanffy HGilsbach JMMayfrank LKlein HMKawase TSeeger W: Microsurgical management of ventral and ventrolateral foramen magnum meningiomas. Acta Neurochir Suppl 65:82851996

  • 6

    Borba LAde Oliveira JGGiudicissi-Filho MColli BO: Surgical management of foramen magnum meningiomas. Neurosurg Rev 32:49602009

  • 7

    Boulton MRCusimano MD: Foramen magnum meningiomas: concepts, classifications, and nuances. Neurosurg Focus 14:6e102003

  • 8

    Bruneau MGeorge B: Foramen magnum meningiomas: detailed surgical approaches and technical aspects at Lariboisière Hospital and review of the literature. Neurosurg Rev 31:19332008

  • 9

    Cheshier SHHanft SJAdler JRChang SD: CyberKnife radiosurgery for lesions of the foramen magnum. Technol Cancer Res Treat 6:3293362007

  • 10

    Crockard HASen CN: The transoral approach for the management of intradural lesions at the craniovertebral junction: review of 7 cases. Neurosurgery 28:88981991

  • 11

    George BMeningiomas of the foramen magnum. Schmidek HH: Meningiomas and Their Surgical Management PhiladelphiaSaunders1991. 459470

  • 12

    George BDematons CCophignon J: Lateral approach to the anterior portion of the foramen magnum. Application to surgical removal of 14 benign tumors: technical note. Surg Neurol 29:4844901988

  • 13

    George BLot GBoissonnet H: Meningioma of the foramen magnum: a series of 40 cases. Surg Neurol 47:3713791997

  • 14

    Guidetti BSpallone A: Benign extramedullary tumors of the foramen magnum. Surg Neurol 13:9171980

  • 15

    Kandenwein JARichter HPAntoniadis G: Foramen magnum meningiomas—experience with the posterior suboccipital approach. Br J Neurosurg 23:33392009

  • 16

    Kano TKawase THoriguchi TYoshida K: Meningiomas of the ventral foramen magnum and lower clivus: factors influencing surgical morbidity, the extent of tumour resection, and tumour recurrence. Acta Neurochir (Wien) 152:79862010

  • 17

    Kratimenos GPCrockard HA: The far lateral approach for ventrally placed foramen magnum and upper cervical spine tumours. Br J Neurosurg 7:1291401993

  • 18

    Margalit NSLesser JBSinger MSen C: Lateral approach to anterolateral tumors at the foramen magnum: factors determining surgical procedure. Neurosurgery 56:2 Suppl3243362005

  • 19

    Marin Sanabria EAEhara KTamaki N: Surgical experience with skull base approaches for foramen magnum meningioma. Neurol Med Chir (Tokyo) 42:4724802002

  • 20

    Menezes AH: Surgical approaches: postoperative care and complications “posterolateral-far lateral transcondylar approach to the ventral foramen magnum and upper cervical spinal canal. Childs Nerv Syst 24:120312072008

  • 21

    Meyer FBEbersold MJReese DF: Benign tumors of the foramen magnum. J Neurosurg 61:1361421984

  • 22

    Miller ECrockard HA: Transoral transclival removal of anteriorly placed meningiomas at the foramen magnum. Neurosurgery 20:9669681987

  • 23

    Muthukumar NKondziolka DLunsford LDFlickinger JC: Stereotactic radiosurgery for anterior foramen magnum meningiomas. Surg Neurol 51:2682731999

  • 24

    Nanda AVincent DAVannemreddy PSBaskaya MKChanda A: Far-lateral approach to intradural lesions of the foramen magnum without resection of the occipital condyle. J Neurosurg 96:3023092002

  • 25

    Pamir MNKilic TOzduman KTure U: Experience of a single institution treating foramen magnum meningiomas. J Clin Neurosci 11:8638672004

  • 26

    Parlato CTessitore ESchonauer CMoraci A: Management of benign craniovertebral junction tumors. Acta Neurochir (Wien) 145:31362003

  • 27

    Pirotte BDavid PNoterman JBrotchi J: Lower clivus and foramen magnum anterolateral meningiomas: surgical strategy. Neurol Res 20:5775841998

  • 28

    Pirotte BJBrotchi JDeWitte O: Management of anterolateral foramen magnum meningiomas: surgical vs conservative decision making. Neurosurgery 67:3 Suppl Operativeons58ons702010

  • 29

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

  • 30

    Salas ESekhar LNZiyal IMCaputy AJWright DC: Variations of the extreme-lateral craniocervical approach: anatomical study and clinical analysis of 69 patients. J Neurosurg 90:2 Suppl2062191999

  • 31

    Samii MKlekamp JCarvalho G: Surgical results for meningiomas of the craniocervical junction. Neurosurgery 39:108610951996

  • 32

    Sen CNSekhar LN: An extreme lateral approach to intradural lesions of the cervical spine and foramen magnum. Neurosurgery 27:1972041990

  • 33

    Starke RMNguyen JHReames DLRainey JSheehan JP: Gamma knife radiosurgery of meningiomas involving the foramen magnum. J Craniovertebr Junction Spine 1:23282010

  • 34

    United Nations: World Population Prospects the 2010 Revision New YorkDepartment of Economic and Social Affairs, Population Division(http://esa.un.org/wpp/Sorting-Tables/tab-sorting_mortality.htm) [Accessed August 16 2012]

  • 35

    Wu ZHao SZhang JZhang LJia GTang J: Foramen magnum meningiomas: experiences in 114 patients at a single institute over 15 years. Surg Neurol 72:3763822009

  • 36

    Yaşargil MGCurcic MMeningiomas of basal posterior cranial fossa. Krayenbuhl H: Advances and Technical Standards in Neurosurgery ViennaSpringer-Verlag7:11151980

  • 37

    Yasuoka SOkazaki HDaube JRMacCarty CS: Foramen magnum tumors. Analysis of 57 cases of benign extramedullary tumors. J Neurosurg 49:8288381978

TrendMD

Metrics

Metrics

All Time Past Year Past 30 Days
Abstract Views 432 432 83
Full Text Views 169 169 0
PDF Downloads 51 51 0
EPUB Downloads 0 0 0

PubMed

Google Scholar