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Hiroki Morisako, Takeo Goto and Kenji Ohata

OBJECT

Petroclival meningiomas are among the most challenging intracranial tumors to treat surgically. Many skull base approaches have been described to improve resection and decrease patient morbidity. The authors undertook this study to evaluate the results of their treatment of petroclival meningiomas using objective measurements of tumor volume and a new impairment scoring system to assess neurological symptoms that severely affect the patient's quality of life, such as impairment of swallowing and speaking, motor function, and consciousness and communication.

METHODS

Between January 1990 and December 2009, the authors used a combined transpetrosal approach to treat 60 patients with benign (WHO Grade I) petroclival meningiomas. In this retrospective study, all 60 cases were analyzed in detail with regard to tumor volume, extent of resection (EOR), long-term tumor control, neurological outcome, and the patient condition. In addition, patients were divided into 2 groups according to the period during which the surgery was performed: the early group, from 1990 to 1999, and the late group, from 2000 to 2009. A new scoring system, the petroclival meningioma impairment scale (PCMIS), was created for quantitative assessment of 8 categories of neurological functions, with scores assigned in each category according to the level of disability and its impact on the patient. The PCMIS was used preoperatively, at 3 months after surgery, and at the time of the last follow-up examination, and the results for the 2 groups were compared.

RESULTS

There were 24 cases in the early group (1990–1999), and the mean duration of follow-up was 149.3 months. The mean EOR was 96.1%, and good long-term tumor control was obtained in 22 patients (91.7%). One of patients died because of a postoperative complication in the perioperative period. The PCMIS improved in 3 patients (12.5%), remained stable in 1 (4.2%), and worsened in 20 (83.3%). There were 36 cases in the late group (2000–2009), and the mean duration of follow-up was 77.9 months. The mean EOR was 92.7%, and good long-term tumor control was obtained in 34 patients (94.4%). The PCMIS score improved in 23 patients (63.9%), remained stable in 5 (13.9%), and worsened in 8 (22.2%).

CONCLUSIONS

The combined transpetrosal approach has provided satisfactory functional improvements and excellent tumor control for patients with petroclival meningiomas. The PCMIS provides a specific tool for quantitative assessment of the patient's state.

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Hiroki Morisako, Takeo Goto, Hiroyuki Goto, Christian Aisse Bohoun, Samantha Tamrakar and Kenji Ohata

OBJECTIVE

Craniopharyngiomas remain a particularly formidable challenge in the neurosurgical field. Because these lesions involve the hypothalamus and ophthalmological systems, their resection is associated with either higher rates of mortality and recurrence or a lower rate of radical resection. The authors report the outcomes of aggressive surgeries based on an anatomical subclassification of craniopharyngiomas.

METHODS

Clinical and ophthalmological examinations, imaging studies, endocrinological studies, neuropsychological function, and surgical complications in all patients who had undergone microsurgical resection for craniopharyngioma at Osaka City University hospital between January 2000 and December 2014 were retrospectively reviewed through the medical records. Radical resections were planned in all of the patients. To help choose the correct surgical approach, craniopharyngiomas were classified based on tumor origin. The 4 possible groups included the intrasellar type, prechiasmatic type, retrochiasmatic type, and intra–third ventricle type. A multistage surgery was planned in some cases.

RESULTS

Seventy-two cases of craniopharyngioma were resected. Thirty-two patients (44.4%) had undergone previous surgical procedures at other institutions. Thirty-five cases (48.6%) were classified as retrochiasmatic, 19 (26.4%) as prechiasmatic, 12 (16.7%) as intra–third ventricle, and 6 (8.3%) as intrasellar. In 26 cases (36.1%), multistage surgery was required to complete the radical resection. Overall, 41 cases involved an orbitozygomatic approach; 21, a transpetrosal approach; 21, an interhemispheric approach; and 14, a transsphenoidal approach. In 3 cases, other approaches were applied. Gross-total resection was achieved in 43 patients (59.7%), near-total resection in 28 (38.9%), and partial resection in only 1 patient (1.4%). The mean follow-up period after resection was 4.7 years. Tumor recurrence or regrowth occurred in 15 (20.8%) of the 72 patients, with 14 of the 15 cases successfully controlled after additional resections and stereotactic radiosurgery. However, 1 patient died of uncontrollable tumor progression, and 2 patients died of unrelated diseases during the follow-up. Overall, disease in 69 (95.8%) of 72 patients was well controlled at the last follow-up.

CONCLUSIONS

Aggressive tumor resection is the authors' treatment policy for craniopharyngioma. Using an anatomical subclassification of craniopharyngioma to choose the most appropriate surgical approach is helpful in achieving that goal of aggressive resection.

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Noritsugu Kunihiro, Takeo Goto, Kenichi Ishibashi and Kenji Ohata

Object

Retrochiasmatic craniopharyngiomas are surgically challenging tumors. Retrochiasmatic craniopharyngiomas with complicated conditions such as large diameter, major calcification, or significant extension to the third ventricle or posterior fossa present surgical challenges; moreover, recurrent retrochiasmatic craniopharyngiomas are particularly formidable challenges. Although the transpetrosal approach to retrochiasmatic craniopharyngiomas published by Hakuba in 1985 can provide unique advantageous exposure of the retrochiasmatic area to allow safe neurovascular dissection and facilitate radical tumor removal, the procedure is viewed as complicated and time consuming and has a high risk of damaging hearing functions. The authors have modified Hakuba's technique to minimize petrosectomy and reduce surgical complications and have applied this modified approach to retrochiasmatic craniopharyngiomas with complicated conditions. In this study, the authors describe their technique and surgical outcomes to elucidate the role of this modified transpetrosal approach for retrochiasmatic craniopharyngiomas with complicated conditions. This is the first study to report surgical outcomes of the transpetrosal approach for retrochiasmatic craniopharyngiomas.

Methods

Between 1999 and 2011, the minimum anterior and posterior combined (MAPC) transpetrosal approach, which is a modification of Hakuba's transpetrosal approach, was applied in 16 cases of retrochiasmatic craniopharyngiomas with complicated conditions. Eight cases were recurrent tumors, 4 had previously received radiotherapy, 11 had a large diameter, 10 had large calcification, 15 had superior extension of the tumor into the third ventricle, and 10 had a posterior extension of the tumor that compressed the midbrain and pons. In all 16 patients, more than 2 of these complicated conditions were present. The follow-up duration ranged from 0.8 to 12.5 years (mean 5.3 years). Surgical outcomes assessed were the extent of resection, surgical complications, visual function, endocrinological status, and neuropsychological function. Five-year and 10-year recurrence-free survival rates were also calculated.

Results

Gross-total or near-total resection was achieved in 15 cases (93.8%). Facial nerve function was completely maintained in all 16 patients. Serviceable hearing was preserved in 15 cases (93.8%). Visual function improved in 13 out of 14 cases (92.9%) that had visual disturbance before surgery. None of the patients experienced deterioration of their visual function. Twelve cases had endocrinological deficit and received hormonal replacement before surgery. New endocrinological deficit occurred in 2 cases (12.5%). Neuropsychological function was maintained in 14 cases (87.5%) and improved in 1 case (6.3%). One case that had received previous conventional radiotherapy treatment showed a gradual decline in neuropsychological function. The 5-year and 10-year recurrence-free survival rates were both 86.5%.

Conclusions

The authors obtained good results by using the MAPC transpetrosal approach for the removal of retrochiasmatic craniopharyngiomas with complicated conditions. The MAPC transpetrosal approach should be considered as a therapeutic option for selected cases of retrochiasmatic craniopharyngiomas with complicated conditions.

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Hiroki Morisako, Takeo Goto, Hiroki Ohata, Sachin Ranganatha Goudihalli, Keisuke Shirosaka and Kenji Ohata

OBJECTIVE

Meningiomas arising from the cavernous sinus (CS) continue to be a significant technical challenge, and resection continues to carry a relatively higher risk of neurological morbidity in patients with these lesions because of the tumor’s proximity to neurovascular structures. The authors report the surgical outcomes of 9 patients with primary CS meningiomas (CSMs) that were surgically treated using a minimal anterior and posterior combined (MAPC) transpetrosal approach, and they emphasize the usefulness of the approach.

METHODS

This retrospective study included 9 patients who underwent surgery for CSM treatment between 2015 and 2016 via the MAPC transpetrosal approach. Two patients were men and 7 were women, with a mean age of 58.5 years (39–72 years). Five patients (55.5%) had undergone previous treatment. The surgical technique consisted of a temporo-occipito-suboccipital craniotomy and exposure of the posterolateral part of the CS via the presigmoidal MAPC approach. After opening Meckel’s cave and identifying the 3rd–5th cranial nerves in the prepontine cistern, Parkinson’s triangle and supratrochlear triangles were opened. Finally, the tumor occupying the posterolateral part of the CS was removed.

RESULTS

All lesions were safely and maximally removed, with preservation of external ocular movements and preoperative Karnofsky Performance Scale scores. The mean extent of resection was 77.0% (range 58.7%–95.4%). Six patients underwent adjuvant therapy in the form of stereotactic radiosurgery (SRS) or stereotactic radiotherapy (SRT) during the follow-up period; none of these patients experienced recurrence.

CONCLUSION

The authors conclude that the MAPC transpetrosal approach could be superior to other approaches for CSMs, as it provides direct visual access to the posterolateral portion of the CS. In their experience, this approach is an alternative and better option for safe maximal resection of CSMs.

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Tsutomu Ichinose, Takeo Goto, Kenichi Ishibashi, Toshihiro Takami and Kenji Ohata

Object

Because resection followed by timely stereotactic radiosurgery (SRS) is becoming a standard strategy for skull base meningiomas, the role of initial surgical tumor reduction in this combined treatment should be clarified.

Methods

This study examined 161 patients with benign skull base meningiomas surgically treated at Osaka City University between January 1985 and December 2005. The mean follow-up period was 95.3 months. Patients were categorized into 3 groups based on the operative period and into 4 groups based on tumor location. Maximal resection was performed as first therapy throughout all periods. In the early period (1985–1994), in the absence of SRS, total excision of the tumor was intentionally performed for surgical cure of the disease. In the mid and late periods (1995–2000 and 2001–2005), small parts of the tumor invading critical neurovascular structures were left untouched to obtain good functional results. Residual tumors with high proliferation potential (Ki 67 index > 4%) or with progressive tendencies were treated with SRS. The extent of initial tumor resection, recurrence rate, Karnofsky Performance Scale score, and complication rate were investigated in each group.

Results

The mean tumor equivalent diameter of residual tumors was 3.67 mm in the no-recurrence group and 11.7 mm in the recurrence group. The mean tumor resection rate (TRR) was 98.5% in the no-recurrence group and 90.1% in the recurrence group. A significant relationship was seen between postoperative tumor size, TRR, and recurrence rate (p < 0.001), but the recurrence rate showed no significant relationship with any other factors such as operative period (p = 0.48), tumor location (p = 0.76), or preoperative tumor size (p = 0.067). The mean TRR was maintained throughout all operative periods, but the complication rate was lowest and postoperative Karnofsky Performance Scale score was best in the late period (p < 0.001 each). Late-period results were as follows: mean TRR, 97.9%; mortality rate, 0%; and severe morbidity rate, 0%. Stereotactic radiosurgery procedures were added in 27 cases (16.8%) across all periods. Throughout all follow-up periods, 158 tumors were satisfactorily controlled by maximal possible excision alone or in combination with adequate SRS.

Conclusions

The combination of maximal possible resection and additional SRS improves functional outcomes in patients with skull base meningioma. A TRR greater than 97% in volume can be achieved with satisfactory functional preservation and will lead to excellent tumor control in combined treatment of skull base meningioma.

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Hiroki Morisako, Takeo Goto, Christian A. Bohoun, Hironori Arima, Tsutomu Ichinose and Kenji Ohata

Surgical resection of pontine cavernous malformation remains a particularly formidable challenge. We report the surgical outcome of eight cases with pontine cavernous malformations operated using the anterior transpetrosal approach. All cases presented with neurological deficits caused by hemorrhage before surgery. Gross-total removal was achieved in all cases without any postoperative complication such as worsening of facial nerve palsy, ocular movement disorder, or hemiplegia. A small incision of the pons with multidirectional dissection is the most important factor for minimizing postoperative neurological deficits, so resection of a pontine cavernous malformation via this approach can be an alternative better option.

The video can be found here: https://youtu.be/2Q2CUhBbo28.

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André Beer-Furlan, Ali O. Jamshidi, Ricardo L. Carrau and Daniel M. Prevedello

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Alhusain Nagm, Toshihiro Ogiwara, Takeo Goto, Kazuhiro Hongo and Kenji Ohata

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Takashi Nagata, Takeo Goto, Tsutomu Ichinose, Yutaka Mitsuhashi, Naohiro Tsuyuguchi and Kenji Ohata

Fusiform dilation of the internal carotid artery (FDICA) after radical resection of a suprasellar craniopharyngioma has been reported. To the authors' knowledge, however, fatal conditions associated with FDICA have not been reported and pathological findings have not been obtained. The authors performed biopsy sampling of the wall of an FDICA for histopathological evaluation and found hyperplastic adventitia. This pathological result strongly supports conclusions from previous reports that FDICA has a low risk of rupture.

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Irwan Barlian Immadoel Haq, Rahadian Indarto Susilo, Takeo Goto and Kenji Ohata

The petrosal approach has been applied for the treatment of many lesions in the posterior fossa, but the location and preservation of the superior petrosal veins (SPVs) during this approach are usually not particularly considered. The authors developed a technique of dural incision with special consideration of the location of the SPVto preserve venous flow during the petrosal approach. The authors describe technical details on how to cut the dura mater and superior petrosal sinus, with special attention to the location of SPV, so that the normal flow of the SPV to the lateral sinus can be preserved. Between July 2007 and March 2014, this technique was used in 45 patients, and no major complications were reported. The SPVs should be considered critical structures in the petrosal approach. Preoperative evaluation of the SPV anatomy should be performed in patients undergoing such surgical treatment, and the dural opening must be performed with special attention to the SPVto avoid intraoperative injury and postoperative complications.