1
|
Bono BC, Faedo F, Riva M, Pessina F. Microsurgical resection of a large petroclival meningioma through an extended retrosigmoid approach: how I do it. Acta Neurochir (Wien) 2024; 166:178. [PMID: 38625597 DOI: 10.1007/s00701-024-06073-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2024] [Accepted: 04/04/2024] [Indexed: 04/17/2024]
Abstract
BACKGROUND Petroclival meningiomas are challenging tumors. Several skull base approaches have been proposed in the last decades, with variable rates of postoperative morbidity and extent of resection. METHODS We herein reported the step-by-step microsurgical resection of a large petroclival meningioma through an extended retrosigmoid approach. Detailed surgical technique has been accompanied by a 2D operative video. CONCLUSION The extended retrosigmoid approach allowed for a safe gross total resection of the tumor, as confirmed by the postoperative MRI. The patient did not experience any new postoperative deficit, despite a transient diplopia, and was discharged on postoperative day 7.
Collapse
Affiliation(s)
- Beatrice C Bono
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, 20090, Milan, Italy.
- Department of Neurosurgery, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, 20089, Milan, Italy.
| | - Francesca Faedo
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, 20090, Milan, Italy
- Department of Neurosurgery, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, 20089, Milan, Italy
| | - Marco Riva
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, 20090, Milan, Italy
- Department of Neurosurgery, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, 20089, Milan, Italy
| | - Federico Pessina
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, 20090, Milan, Italy
- Department of Neurosurgery, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, 20089, Milan, Italy
| |
Collapse
|
2
|
程 进, 王 其, 李 陈, 荣 军, 李 廷, 李 敏, 白 瑞. [Microanatomical Investigation of the Subtemporal Transtentorial Approach]. SICHUAN DA XUE XUE BAO. YI XUE BAN = JOURNAL OF SICHUAN UNIVERSITY. MEDICAL SCIENCE EDITION 2024; 55:290-296. [PMID: 38645855 PMCID: PMC11026899 DOI: 10.12182/20240360506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Indexed: 04/23/2024]
Abstract
Objective To study the microanatomic structure of the subtemporal transtentorial approach to the lateral side of the brainstem, and to provide anatomical information that will assist clinicians to perform surgeries on the lateral, circumferential, and petroclival regions of the brainstem. Methods Anatomical investigations were conducted on 8 cadaveric head specimens (16 sides) using the infratemporal transtentorial approach. The heads were tilted to one side, with the zygomatic arch at its highest point. Then, a horseshoe incision was made above the auricle. The incision extended from the midpoint of the zygomatic arch to one third of the mesolateral length of the transverse sinus, with the flap turned towards the temporal part. After removing the bone, the arachnoid and the soft meninges were carefully stripped under the microscope. The exposure range of the surgical approach was observed and the positional relationships of relevant nerves and blood vessels in the approach were clarified. Important structures were photographed and the relevant parameters were measured. Results The upper edge of the zygomatic arch root could be used to accurately locate the base of the middle cranial fossa. The average distances of the star point to the apex of mastoid, the star point to the superior ridge of external auditory canal, the anterior angle of parietomastoid suture to the superior ridge of external auditory canal, and the anterior angle of parietomastoid suture to the star point of the 10 adult skull specimens were 47.23 mm, 45.27 mm, 26.16 mm, and 23.08 mm, respectively. The subtemporal approach could fully expose the area from as high as the posterior clinoid process to as low as the petrous ridge and the arcuate protuberance after cutting through the cerebellar tentorium. The approach makes it possible to handle lesions on the ventral or lateral sides of the middle clivus, the cistern ambiens, the midbrain, midbrain, and pons. In addition, the approach can significantly expand the exposure area of the upper part of the tentorium cerebelli through cheekbone excision and expand the exposure range of the lower part of the tentorium cerebelli through rock bone grinding technology. The total length of the trochlear nerve, distance of the trochlear nerve to the tentorial edge of cerebellum, length of its shape in the tentorial mezzanine, and its lower part of entering into the tentorium cerebelli to the petrosal ridge were (16.95±4.74) mm, (1.27±0.73) mm, (5.72±1.37) mm, and (4.51±0.39) mm, respectively. The cerebellar tentorium could be safely opened through the posterior clinoid process or arcuate protrusion for localization. The oculomotor nerve could serve as an anatomical landmark to locate the posterior cerebral artery and superior cerebellar artery. Conclusion Through microanatomic investigation, the exposure range and intraoperative difficulties of the infratemporal transtentorial approach can be clarified, which facilitates clinicians to accurately and safely plan surgical methods and reduce surgical complications.
Collapse
Affiliation(s)
- 进超 程
- 宣城市中心医院 神经外科 (宣城 242000)Department of Neurosurgery, Xuancheng Central Hospital, Xuancheng 242000, China
- 南京医科大学鼓楼临床医学院 (南京 210000)Gulou School of Clinical Medicine, Nanjing Medical University, Nanjing 210000, China
| | - 其福 王
- 宣城市中心医院 神经外科 (宣城 242000)Department of Neurosurgery, Xuancheng Central Hospital, Xuancheng 242000, China
- 南京医科大学鼓楼临床医学院 (南京 210000)Gulou School of Clinical Medicine, Nanjing Medical University, Nanjing 210000, China
| | - 陈 李
- 宣城市中心医院 神经外科 (宣城 242000)Department of Neurosurgery, Xuancheng Central Hospital, Xuancheng 242000, China
| | - 军 荣
- 宣城市中心医院 神经外科 (宣城 242000)Department of Neurosurgery, Xuancheng Central Hospital, Xuancheng 242000, China
- 南京医科大学鼓楼临床医学院 (南京 210000)Gulou School of Clinical Medicine, Nanjing Medical University, Nanjing 210000, China
| | - 廷政 李
- 宣城市中心医院 神经外科 (宣城 242000)Department of Neurosurgery, Xuancheng Central Hospital, Xuancheng 242000, China
- 南京医科大学鼓楼临床医学院 (南京 210000)Gulou School of Clinical Medicine, Nanjing Medical University, Nanjing 210000, China
| | - 敏 李
- 宣城市中心医院 神经外科 (宣城 242000)Department of Neurosurgery, Xuancheng Central Hospital, Xuancheng 242000, China
| | - 瑞军 白
- 宣城市中心医院 神经外科 (宣城 242000)Department of Neurosurgery, Xuancheng Central Hospital, Xuancheng 242000, China
| |
Collapse
|
3
|
Simon M, Gousias K. Grading meningioma resections: the Simpson classification and beyond. Acta Neurochir (Wien) 2024; 166:28. [PMID: 38261164 PMCID: PMC10806026 DOI: 10.1007/s00701-024-05910-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Accepted: 11/06/2023] [Indexed: 01/24/2024]
Abstract
Technological (and also methodological) advances in neurosurgery and neuroimaging have prompted a reappraisal of Simpson's grading of the extent of meningioma resections. To the authors, the published evidence supports the tenets of this classification. Meningioma is an often surgically curable dura-based disease. An extent of meningioma resection classification needs to account for a clinically meaningful variation of the risk of recurrence depending on the aggressiveness of the management of the (dural) tumor origin.Nevertheless, the 1957 Simpson classification undoubtedly suffers from many limitations. Important issues include substantial problems with the applicability of the grading paradigm in different locations. Most notably, tumor location and growth pattern often determine the eventual extent of resection, i.e., the Simpson grading does not reflect what is surgically achievable. Another very significant problem is the inherent subjectivity of relying on individual intraoperative assessments. Neuroimaging advances such as the use of somatostatin receptor PET scanning may help to overcome this central problem. Tumor malignancy and biology in general certainly influence the role of the extent of resection but may not need to be incorporated in an actual extent of resection grading scheme as long as one does not aim at developing a prognostic score. Finally, all attempts at grading meningioma resections use tumor recurrence as the endpoint. However, especially in view of radiosurgery/radiotherapy options, the clinical significance of recurrent tumor growth varies greatly between cases.In summary, while the extent of resection certainly matters in meningioma surgery, grading resections remains controversial. Given the everyday clinical relevance of this issue, a multicenter prospective register or study effort is probably warranted (including a prominent focus on advanced neuroimaging).
Collapse
Affiliation(s)
- Matthias Simon
- Department of Neurosurgery, Evangelisches Klinikum Bethel, Universitätsklinikum OWL, Bielefeld, Germany.
| | - Konstantinos Gousias
- Department of Neurosurgery, St. Marien Academic Hospital Luenen, University of Muenster, Luenen, Germany
- Medical School, University of Nicosia, Nicosia, Cyprus
- Department of Neurosurgery, Athens Medical Center, Athens, Greece
| |
Collapse
|
4
|
De Jesus O. Complications After Open Skull Base Surgery for Brain Tumors: A 26-Year Experience. Cureus 2023; 15:e50312. [PMID: 38205474 PMCID: PMC10776455 DOI: 10.7759/cureus.50312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/11/2023] [Indexed: 01/12/2024] Open
Abstract
INTRODUCTION Open skull base surgery carries the risk of significant complications. It is important to inform patients and family members clearly of the details of these complications. This study aimed to present the numerous complications encountered with open skull base surgery for brain tumors. This report analyzed the complications experienced by patients treated with open skull base surgery by a single skull base surgeon at a single tertiary center over 26 years. METHODS A retrospective study was performed using the University of Puerto Rico Neurosurgery database to identify patients who were managed using open skull base procedures from 1995 to 2020. The neurosurgical database for each patient had been prospectively recorded. Patients with skull base tumors under the author's care during the study period were included in the investigation. Exclusions include patients with non-tumoral conditions and non-skull base tumors and those operated using a microscopic transsphenoidal route. Patients who experienced an intraoperative or postoperative complication within 30 days of the surgery were further analyzed. RESULTS In the cohort, 141 patients with brain tumors underwent open skull base surgery. The cohort had a median age of 48 (range 3-79). It consisted of 101 (71.6%) females and 40 (28.4%) males, with a female-to-male ratio of 2.5:1. The approach most frequently used was an orbitofrontal craniotomy (with or without zygomatic osteotomy) in 79 patients (56%). A petrosal approach was utilized in 26 patients (18%). Forty-six patients (33%) developed an intraoperative or postoperative complication. Twenty-four percent of the complications occurred in the 30-day postoperative period. Five patients had more than one complication. The median age of the patients who experienced a complication was 44.5 (range 22-79), with a female-to-male ratio similar to the entire cohort. Cranial nerve injury was the most frequent complication. Worsening or loss of vision in the affected eye occurred in 5.7% of the patients. A cerebrospinal fluid leak occurred in 2% of the patients. Six patients died, two of them after a massive myocardial infarction. CONCLUSIONS The results of this study showed that approximately one-third of the patients undergoing open skull base surgery can develop a complication. The most frequent complication was injury to a cranial nerve. A large number of complications occurred intraoperatively. The majority of the complications in patients with tumors in the posterior fossa were associated with injury to a cranial nerve. At the middle fossa, damage to the optic nerves is a noteworthy complication. Complications at the anterior fossa involved worsening of vision or myocardial infarction. Less aggressive surgery near the cavernous sinus and the petroclival region may reduce complications. Understanding the complications can help counsel patients and family members.
Collapse
Affiliation(s)
- Orlando De Jesus
- Neurosurgery, University of Puerto Rico, Medical Sciences Campus, San Juan, PRI
| |
Collapse
|
5
|
Giammattei L, Starnoni D, Peters D, George M, Messerer M, Daniel RT. Combined petrosal approach: a systematic review and meta-analysis of surgical complications. Neurosurg Rev 2023; 46:172. [PMID: 37439884 PMCID: PMC10344984 DOI: 10.1007/s10143-023-02072-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Revised: 05/31/2023] [Accepted: 06/20/2023] [Indexed: 07/14/2023]
Abstract
Transpetrosal approaches are known to be associated with a significant risk of complications, including CSF leak, facial palsy, hearing impairment, venous injury, and/or temporal lobe injury. We aimed to evaluate the morbidity of the standard combined petrosal approach (CPA), defined as a combination of the posterior (retrolabyrinthine) and the anterior petrosal approach. We performed a systematic review and meta-analysis of articles reporting on clinical series of patients operated on for petroclival meningiomas through CPA. Studies that used the terminology "combined petrosal approach" without matching the aforementioned definition were excluded as well as clinical series that included less than 5 patients. A total of 8 studies were included involving 160 patients. The pooled complication rates were 3% (95% CI, 0.5-5.6) for CSF leak, 8.6% (95% CI, 4.1-13.2%) for facial palsy, 8.2% (95% CI, 3.9-12.6%) for hearing impairment, 2.8% (95% CI, 0.9-6.5%) for venous complications, and finally 4.8% (95%, 1.2-8.4%) for temporal lobe injury. Contrary to the general belief, CPA is associated with an acceptable rate of complications, especially when compared to alternative approaches to the petroclival area. In view of the major advantages like shorter trajectory, multiple angles of surgical attack, and early tumor devascularization, CPA remains an important tool in the armamentarium of the skull base surgeon.
Collapse
Affiliation(s)
- L Giammattei
- Department of Neurosurgery, Lausanne University Hospital, Lausanne, Switzerland.
| | - D Starnoni
- Department of Neurosurgery, Lausanne University Hospital, Lausanne, Switzerland
- Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland
| | - D Peters
- Department of Neurosurgery, Lausanne University Hospital, Lausanne, Switzerland
- Carolina Neurosurgery & Spine Associates, Charlotte, NC, USA
| | - M George
- Department of Otorhinolaryngology and Head and Neck Surgery, Lausanne University Hospital, Lausanne, Switzerland
| | - M Messerer
- Department of Neurosurgery, Lausanne University Hospital, Lausanne, Switzerland
- Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland
| | - R T Daniel
- Department of Neurosurgery, Lausanne University Hospital, Lausanne, Switzerland
- Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland
| |
Collapse
|