Management of Recurrent Trigeminal Neuralgia Associated with Petroclival Meningioma

Surgical Strategy for Petroclival Meningioma-Related Trigeminal Neuralgia: The Role of Porus Trigeminus Opening

OBJECTIVE

Petroclival meningiomas invade Meckel's cave through the porus trigeminus, leading to secondary trigeminal neuralgia. Microsurgery and stereotactic radiosurgery (SRS) are the typical treatment options. This study investigated symptom control, outcomes, and surgical strategies for PC meningioma-induced TN.

METHODS

We retrospectively analyzed 28 TN patients with PC meningiomas who underwent microsurgical nerve decompression between January 2021 and February 2023. In all patients undergoing a transpetrosal approach, the porus trigeminus was opened to enable the removal of the entire tumor within Meckel's cave. Clinical outcomes were assessed using the Barrow Neurologic Institute (BNI) pain intensity scale. Risk factors for poor TN outcomes and poor facial numbness were analyzed.

RESULTS

Among 28 patients, 21 (75%) underwent the transpetrosal approach, 5 (17.9%) underwent the retrosigmoid approach, and 2 (7.1%) underwent the Dolenc approach. Following microsurgery, 23 patients (82.1%) experienced TN relief without further medication (BNI I or II). TN recurrence occurred in 2 patients (7.1%), and 3 patients (10.7%) did not achieve TN relief. Cavernous sinus invasion was significantly correlated with poor TN outcomes (P = 0.047). A history of previous SRS (P = 0.011) and upper clivus type tumor (P = 0.018) were significantly associated with poor facial numbness.

CONCLUSIONS

Microsurgical nerve decompression is effective in improving BNI scores in patients with TN associated with PC meningiomas. Considering the results of our study, the opening of the porus trigeminus can be considered as a suggested procedure in the treatment of PC meningiomas, especially in cases accompanied by TN.

The role of stereotactic radiosurgery in the management of petroclival meningioma: a systematic review

PURPOSE

Petroclival meningioma (PM) is a challenging neuro oncology case and stereotactic radiosurgery (SRS) is proposed as one treatment option. This systematic review aimed to examine the role of SRS in treating PM cases.

METHODS

 We constructed a systematic review using the PRISMA guidelines using peer-reviewed English literature until 16 February 2022 from EuroPMC and PubMed. We used the terms petroclival meningioma, clival meningioma, apex petrous meningioma, spheno petroclival meningioma, stereotactic radiosurgery, radiosurgery, CyberKnife, Gamma Knife, linear accelerator, LINAC, and radiotherapy.

RESULTS

 10 out of 266 studies were chosen for this systematic review, two of which are case reports. The study comprised 719 patients, 73.7% of whom were female (n = 530) and had a median age of 56.99 years (18-90 years). At the time of diagnosis, the median tumor volume was 6.07 cm³ (0.13-64.9 cm³). The tumors were frequently located near the petroclival junction (83.6%, n = 598). Following SRS, the median follow-up was 64.52 months (3-252 months). 46.5% of 719 PMs exhibited a decrease in tumor size. 46% and 7.5% showed no change and increase in tumor volume, respectively. At the last radiographic follow-up (7-21.2 years), tumor control with a median of 98.8% (85-100%). Complications occurred in 6% of patients, with hydrocephalus (2.2%) as the prevalent complication. The use of SRS as a primary treatment for petroclival cases was not associated with increased complication rate RR 0.62 (95% CI [0.11, 3.59], p = 0.59) but statistically correlated with clinical failure clinical failure RR 0.56 (95% CI [0.32, 0.98], p = 0.04).

CONCLUSIONS

 We found a low number of complications following SRS intervention and has been effectively controlling tumor progression.

Drilling off the Petrosal Apex and Opening the Upper Wall of Meckel's Cave Are the Key Elements of Good Outcomes in the Treatment of Trigeminal Neuralgia Secondary to Petrous Apex Meningioma

Objective

The surgical management of trigeminal neuralgia (TN) caused by petrous apex meningioma (PAM) is still a challenge because of the lesion’s deep location and the surrounding complex structures. The authors describe the intradural anterior transpetrosal approach (ATPA) and its effect on the treatment of TN secondary to PAM.

Methods

A retrospective analysis of 15 patients with TN secondary to PAM who underwent surgery via the intradural ATPA was conducted. The key techniques, which included drilling off the petrosal apex (PA) and opening the upper wall of Meckel’s cave (MC), are described in detail.

Results

Total removal of the tumor and complete pain relief (Barrow Neurological Institute I) were achieved in all 15 patients without significant morbidity. Five patients developed new facial numbness postoperatively, which disappeared within three months after surgery. The postoperative magnetic resonance imaging showed temporal lobe swelling in three patients, but no clinical symptoms. One patient had cerebrospinal fluid leakage and was managed with bed rest and temporary lumbar drainage. One patient had an intracranial infection and was treated with antibiotics. By the last follow up, no patients had pain relapse or/and tumor recurrence. It is worth noting that the vascular compression at the root of the trigeminal nerve was found in one patient during the operation.

Conclusion

Our experience suggests that drilling off the PA and opening the upper wall of the MC are key elements for a good outcome of the treatment of TN secondary to PAM. The intradural ATPA has the advantages for both tumor resection and pain relief.

Petroclival meningiomas: update of current treatment and consensus by the EANS skull base section

BACKGROUND

The optimal management of petroclival meningiomas (PCMs) continues to be debated along with several controversies that persist.

METHODS

A task force was created by the EANS skull base section along with its members and other renowned experts in the field to generate recommendations for the management of these tumors. To achieve this, the task force reviewed in detail the literature in this field and had formal discussions within the group.

RESULTS

The constituted task force dealt with the existing definitions and classifications, pre-operative radiological investigations, management of small and asymptomatic PCMs, radiosurgery, optimal surgical strategies, multimodal treatment, decision-making, and patient's counselling.

CONCLUSION

This article represents the consensually derived opinion of the task force with respect to the management of PCMs.

Petroclival Meningioma Leading to Trigeminal Neuralgia: A Kawase Approach Application

BACKGROUND

Trigeminal neuralgia is defined by paroxysmal pain on the trigeminal nerve territory. The petroclival meningioma presents with trigeminal neuralgia in less than 5% of the cases. We report a case of a petroclival meningioma that encased the fifth nerve and was resected through a Kawase approach.

CLINICAL PRESENTATION

A 67-year-old female patient presented paroxysmal shock pain in malar and ocular region with progressive worsening, evolving with daily crises despite the use of carbamazepine. On neurologic examination the patient was oriented, with no strength or coordination impairments. Cranial nerves exam showed left V1, V2, and V3 thermal and pain hypoesthesia, without allodynia. Normal strength in masticatory muscles was observed. Magnetic resonance imaging revealed a petroclival lesion with hypersign on T2 and contrast enhancement, suggestive of a meningioma. The tumor encased the trigeminal nerve at the entrance of the Meckel's cave. A temporal craniotomy with middle fossa peeling and anterior petrosectomy (Kawase approach) was performed and a Simpson II resection was achieved. The patient evolved with transient sixth nerve palsy, recovering completely after 3 months. During a follow-up of 5 years there was no evidence of tumor recurrence and the patient is free from pain without medication.

CONCLUSIONS

The Kawase approach is an interesting access for petroclival tumor resection.

Aggressive Progression of a WHO Grade I Meningioma of the Posterior Clinoid Process: An Illustration of the Risks Associated With Observation of Skull Base Meningiomas

Benign, small, and asymptomatic World Health Organization grade I meningiomas are usually managed expectantly with surveillance imaging with the assumption that they are predictably slowing growing. In this paper, we report the case of an incidentally discovered small, right-sided posterior clinoid meningioma in a 53-year-old female. The tumor was managed conservatively but an annual surveillance magnetic resonance imaging demonstrated that the meningioma had an unexpected significant growth impinging on the brainstem, requiring surgical resection and radiosurgery for residual tumor. Despite histopathological confirmation of a grade I meningioma, the tumor recurred significantly and incurred substantial neurological deficits, requiring further surgery and radiotherapy. This report illustrates the potential pitfall for expectant management of small meningiomas in anatomically precarious locations and draws attention to the need for detailed informed discussions with patients regarding the management of these tumors.

Microsurgical resection of petroclival meningiomas treated with stereotactic radiosurgery to address persistent post-treatment trigeminal pain

BACKGROUND

Petroclival meningiomas (PCM) are challenging tumors to manage. Observation, Stereotactic radiosurgery (SRS) and surgical resection have typically been offered as treatment options. A percentage of patients with PCMs present with trigeminal pain. We present four patients with small PCMs presenting with Trigeminal neuralgia (TN) that were treated with radiosurgery and continued to have debilitating trigeminal pain afterwards. All of them underwent microsurgical resection (MR) of their tumor to manage their trigeminal pain.

OBJECTIVE

Trigeminal Neuralgia in the setting of PCM is rare. Oftentimes in these subset of patients TN pain persists after radiation and medical therapy. We explore the possibility of addressing intractable TN pain with microsurgical resection.

METHODS

Patients with petroclival meningiomas presenting with trigeminal pain and having persistent pain after treatment with radiosurgery were included in our review. Those patients were treated with microsurgical resection of their tumor to help control their persistent pain. The patients' demographics, clinical, and radiological data were reviewed. The primary aim of the review was to assess the patients' Barrow Neurological Institute (BNI) trigeminal neuralgia scores following microsurgical resection.

RESULTS

Four female patients were identified. The tumors were locally controlled after SRS, however all four patients continued to have debilitating trigeminal pain despite medical management. All patients had complete resolution of their TN pain in the immediate postoperative period, with a BNI score of I on their last follow up.

CONCLUSION

Microsurgical resection is an appropriate option for patient's petroclival meningiomas with persistent facial pain after treatment with SRS.

Radiosurgery vs. microsurgery for newly diagnosed, small petroclival meningiomas with trigeminal neuralgia

Trigeminal neuralgia (TN) is an excruciating pain that can occur with petroclival meningiomas (PCMs). Gamma knife radiosurgery (GKRS) is an appealing option for small PCMs, but the role of microsurgery (MS) compared to GKRS is not well defined for small PCMs with regard to TN relief. From January 2009 to September 2019, 70 consecutive patients were treated by GKRS or MS for newly diagnosed, small (< 3.5 cm) PCMs with TN. GKRS or MS were performed for 35 patients each. The surgical outcome and TN control according to Barrow Neurological Institute (BNI) score were retrospectively analyzed and compared between GKRS and MS. The predominant origin of PCMs was upper clival (49%) with trigeminal nerve compression at the medial dorsal root entry zone. Tumor control rates were equally 94% with GKRS or MS for a mean tumor size and volume of 2.3 cm and 5.3 cm³, respectively. The preoperative BNI scores were mostly II (40%) and IV (37%) with GKRS and MS, respectively. TN relief without medications (BNI scores I and II) was achieved in 13 of 35 patients (37%) with GKRS and 32 of 35 patients (91%) with MS during a mean follow-up of 50.5 months. The most common complications after GKRS and MS were dysesthesia (23%) and diplopia (9%), respectively. MS could be more effective than GKRS in providing prompt, medication-free pain relief from TN for small PCMs. The risks of MS have to be considered carefully in experienced hands, especially for small PCMs.