Importance of preserved periosteum around jugular foramen neurinomas for functional outcome of lower cranial nerves: anatomic and clinical studies

Early-onset adverse events after stereotactic radiosurgery for jugular foramen schwannoma: a mid-term follow-up single-center review of 46 cases

Background

Recently, stereotacitc radiosurgery (SRS) has been in the spotlight as an alternative therapeutic option for jugular foramen schwannomas (JFS). While most reported studies focus on the long-term efficacy and safety issues of SRS, none describe the early-onset adverse events (eAEs). We aimed to investigate the incidence, clinical characteristics, and mid-term outcomes of eAEs occurring within six months after SRS for JFS.

Methods

In this retrospective review, patients who underwent at least six months of follow-up were included among all patients with JFS who have performed SRS at our institution between July 2008 and November 2019. And eAEs were defined as a newly developed neurological deficit or aggravation of pre-existing symptoms during the first six months after SRS.

Results

Forty-six patients were included in the analysis. The median follow-up period was 50 months (range 9–136). The overall tumor control rate was 91.3%, and the actuarial 3-, 5-, and 10-year progression-free survival rates were 97.8%, 93.8%, and 76.9%, respectively. Of the 46 patients, 16 had eAEs, and the median time to onset of eAEs was one month (range 1–6 months), and the predominant symptoms were lower cranial nerve dysfunctions. Thirteen of 16 patients showed improved eAE symptoms during the follow-up period, and the median resolution time was six months (range 1–52). In 11 (68.8%) of 16 patients with eAEs, transient expansions were observed with a mean of 3.6 months after the onset of eAEs, and the mean difference between the initial tumor volume and the transient expansion volume was more prominent in the patients with eAEs (3.2 cm³ vs. 1.0 cm³; p = 0.057). In univariate analysis, dumbbell-shaped tumors (OR 10.56; p = 0.004) and initial tumor volume (OR 1.32; p = 0.033) were significantly associated with the occurrence of eAEs.

Conclusions

Although acute adverse events after SRS for JFS are not rare, these acute effects were not permanent and mostly improved with the steroid treatment. Dumbell-shaped and large-volume tumors are significant predictive factors for the occurrence of eAEs. And the transient expansion also seems to be closely related to eAEs. Therefore, clinicians need to be more cautious when treating these patients and closely monitor the occurrence of eAEs.

Management of non-vestibular schwannomas in adult patients: a systematic review and consensus statement on behalf of the EANS skull base section Part III: Lower cranial nerve schwannomas, jugular foramen (CN IX, X, XI) and hypoglossal schwannoma (XII)

BACKGROUND

Non-vestibular schwannomas are relatively rare, with trigeminal and jugular foramen schwannomas being the most common. This is a heterogenous group which requires detailed investigation and careful consideration to management strategy. The optimal management for these tumours remains unclear, and there are several controversies. The aim of this paper is to provide insight into the main principles defining management and surgical strategy, in order to formulate a series of recommendations.

METHODS

A task force was created by the EANS skull base section committee along with its members and other renowned experts in the field to generate recommendations for the surgical management of these tumours on a European perspective. To achieve this, the task force performed an extensive systematic review in this field and had discussions within the group. This article is the third of a three-part series describing non-vestibular schwannomas (IX, X, XI, XII).

RESULTS

A summary of literature evidence was proposed after discussion within the EANS skull base section. The constituted task force dealt with the practice patterns that exist with respect to preoperative radiological investigations, ophthalmological assessments, optimal surgical and radiotherapy strategies and follow-up management.

CONCLUSION

This article represents the consensually derived opinion of the task force with respect to the treatment of non-vestibular schwannomas. For each of these tumours, the management paradigm is shifting towards the compromise between function preservation and progression free survival.

Surgical treatment of dumbbell-shaped jugular foramen schwannomas via two-piece lateral suboccipital approach: Report of 26 patients

BACKGROUND

Dumbbell-shaped jugular foramen schwannomas (JFS) are rare but challenging for the treatment. Surgical resection is believed to be the optimal therapy; however, postoperative dysfunction of the lower cranial nerves (CNs), tumor residual, cerebrospinal fluid (CSF) leakage, and subcutaneous hydrops are common. The current study's objectives were to describe the optimal surgical strategies for the total removal of dumbbell-shaped JFS, the functional preservation of lower CNs, and the prevention of postoperative CSF leakage.

METHODS

26 consecutive patients with dumbbell-shaped JFS were surgically treated between January 2014 and June 2019. All patients were operated on via two-piece lateral suboccipital approach, vascularized muscle flap was used for the repair of the dural defect after an operation. The clinical information and radiological data of these patients were retrospectively reviewed, and the optimal surgical strategies were further evaluated and discussed.

RESULTS

The tumor was completely removed in all 26 patients, one patient developed new CN Ⅶ paralysis, and 2 developed new CN IX and Ⅹ paralysis after an operation, all patients were significantly relieved during follow up. None of them developed subcutaneous hydrops and postoperative CSF leakage. No tumor recurrence was observed during a mean follow up of 38.8 (16-69) months.

CONCLUSIONS

Dumbbell-shaped JFS could be safely and completely removed via the two-piece lateral suboccipital approach. Postoperative CSF leakage could be effectively prevented by careful repair of the dural defect in the jugular foramen (JF) and filling the mastoid cavity with a vascularized muscular flap.

Intratumoral hemorrhage in jugular foramen schwannoma after stereotactic radiosurgery: A case report

Background:

Clinically significant intratumoral hemorrhage is a rare complication of stereotactic radiosurgery (SRS) for benign tumors.

Case Description:

Here, we present the case of a 64-year-old man who underwent SRS for a relatively large dumbbell-shaped left jugular foramen schwannoma (JFS) and thereafter developed intratumoral hemorrhage. On post-SRS day 3, he developed lower cranial nerve palsies with radiographically evident tumor expansion. His neurological conditions had gradually improved thereafter; however, he suddenly developed headache, dizziness, and mild hearing deterioration at 7 months due to intratumoral hemorrhage. We managed the patient conservatively, and eventually, his symptoms improved except for slight ataxia and hearing deterioration. Follow-up images at 4 years from SRS demonstrated significant tumor shrinkage. This is the first report describing intratumoral hemorrhage after SRS for JFS.

Conclusion:

Transient expansion of the tumor and subsequent venous stasis around the tumor may have played a role in the hemorrhage. Intratumoral hemorrhage should be considered as a rare, but potential complication of SRS for JFSs.

Efficacy of the Suboccipital Paracondylar-Lateral Cervical Approach: The Series of 64 Jugular Foramen Tumors Along With Follow-Up Data

Objective

Complete resection of jugular foramen tumors with minimal cranial nerve complications remains challenging even for skilled neurosurgeons. Here, we introduce a modified paracondylar approach, named the suboccipital paracondylar-lateral cervical (SPCLC) approach for this purpose. We also share the follow-up data of our series and discuss the advantages and limitations of this modified paracondylar approach.

Methods

We included 64 patients with jugular foramen tumors who underwent surgery by the same senior neurosurgeon between November 2011 and August 2020. All patients were treated with the SPCLC approach, which aimed for gross total tumor removal in a single-stage operation. The clinical characteristics, including preoperative and postoperative neurological status, the extent of surgical resection, and follow-up data were retrospectively acquired and evaluated.

Results

There were 48 schwannomas, nine meningiomas, three paragangliomas, one hemangiopericytoma, one chordoma, one endolymphatic sac tumor, and one Langerhans’ cell histiocytosis. The median age of our patients was 43 years (range: 21–77 years). Dysphagia, hoarseness, and tongue deviation were observed in 36, 26, and 28 patients, respectively. Thirty-two patients had hearing function impairments, including hearing loss or tinnitus. Gross total resection was achieved in 59 patients (59/64, 92.2%). Gamma Knife treatment was used to manage residual tumors in five patients. Postoperatively, new-onset or aggravative dysphagia and hoarseness occurred in 26 and 18 cases, respectively. Nine patients developed new-onset facial palsy, and one patient developed new-onset hearing loss. There were no cases of intracranial hematoma, re-operation, tracheostomy, or death. At the latest follow-up, hearing loss and tinnitus had improved in 20 cases (20/32, 62.5%), dysphagia alleviated in 20 cases (20/36, 55.6%), and hoarseness improved in 14 cases (14/26, 53.8%). Over a mean follow-up period of 27.8 ± 19.5 months (range: 3–68 months), tumor recurrence was observed in one patient.

Conclusion

The SPCLC approach, modified from the paracondylar approach, and was less invasive, safe, and efficient for certain jugular foramen tumors. Taking advantage of the anatomic understanding, clear operational vision, and appropriate surgical skills, it is possible to achieve gross total tumor removal and the preservation of neurological function.

Surgical Management of Jugular Foramen Schwannomas

Simple Summary

Treatments of jugular foramen schwannomas may be challenging due to critical anatomical relations and the involvement of different aspects of the skull base. Advances in microsurgery have led to improved outcomes over recent decades, whereas in contrast, some advocate stereotactic radiotherapy as an effective therapy, controlling the tumor volume with few complications. In this manuscript, we present the outcomes and adverse events in a contemporary cohort and discuss surgical advantages and disadvantages of different performed classic skull base approaches.

Abstract

Background: Resection of jugular foramen schwannomas (JFSs) with minimal cranial nerve (CN) injury remains difficult. Reoperations in this vital region are associated with severe CN deficits. Methods: We performed a retrospective analysis at a tertiary neurosurgical center of patients who underwent surgery for JFSs between June 2007 and May 2020. We included nine patients (median age 60 years, 77.8% female, 22.2% male). Preoperative symptoms included hearing loss (66.6%), headache (44.4%), hoarseness (33.3%), dysphagia (44.4%), hypoglossal nerve palsy (22.2%), facial nerve palsy (33.3%), extinguished gag reflex (22.2%), and cerebellar dysfunction (44.4%). We observed Type A, B, C, and D tumors in 3, 1, 1, and 4 patients, respectively. A total of 77.8% (7/9) underwent a retrosigmoid approach, and 33.3% (3/9) underwent an extreme lateral infrajugular transcondylar (ELITE) approach. Gross total resection (GTR) was achieved in all cases. The rate of shunt-dependent hydrocephalus was 22.2% (2/9). No further complications requiring surgical intervention occurred during follow-up. The median follow-up time was 16.5 months (range 3–84 months). Conclusions: Considering the satisfying outcome, the GTR of JFSs is feasible in performing well-known skull base approaches. Additional invasive and complicated approaches were not needed. Radiosurgery may be an effective alternative for selected patients.

Fine configuration of the dural fibrous network and the extradural neural axis compartment in the jugular foramen: an epoxy sheet plastination and confocal microscopy study

OBJECTIVE

The extradural neural axis compartment (EDNAC) is an adipovenous zone that is located between the meningeal (ML) and endosteal (EL) layers of the dura mater and has been minimally investigated in the jugular foramen (JF) region. In this study, the authors aimed to explore the fine architecture of the EDNAC within the JF and evaluate whether the EDNAC can be used as a component for JF compartmentalization.

METHODS

A total of 46 cadaveric heads (31 male, 15 female; age range 54-96 years) and 30 dry skulls were examined in this study. Twelve of 46 cadaveric heads were plastinated as a series of transverse (7 sets), coronal (3 sets), and sagittal (2 sets) slices and examined using stereomicroscopy and confocal microscopy. The dural entry points of the JF cranial nerves were recorded in 34 cadaveric skulls. The volumes of the JF, intraforaminal EDNAC, and internal jugular vein (IJV) were quantified.

RESULTS

Based on constant osseous landmarks, the JF was subdivided into preforaminal, intraforaminal, and subforaminal segments. The ML-derived fascial sheath along the anteromedial wall of the IJV demarcated the "venous portion" and the "EDNAC portion" of the bipartite JF. The EDNAC did not surround the intraforaminal IJV and comprised an ML-derived dural fibrous network and an adipose matrix. A fibrovenous curtain subdivided the intraforaminal EDNAC into a small anterior column containing cranial nerve (CN) IX and the anterior condylar venous plexus and a large posterior adipose column containing CNs X and XI. In the intraforaminal segment, the IJV occupied a slightly larger space in the foramen (57%; p < 0.01), whereas in the subforaminal segment it occupied a space of similar size to that of the EDNAC.

CONCLUSIONS

Excluding the IJV, the neurovascular structures in the JF traverse the dural fibrous network that is dominant in the foraminal EDNAC. The results of this study will contribute to anatomical knowledge of the obscure yet crucially important JF region, increase understanding of foraminal tumor growth and spread patterns, and facilitate the planning and execution of surgical interventions.

Long-Term Outcomes of Stereotactic Radiosurgery for Trigeminal, Facial, and Jugular Foramen Schwannoma in Comparison with Vestibular Schwannoma

Stereotactic radiosurgery (SRS) is known to provide excellent tumor control with functional preservation for vestibular schwannomas (VS), but its efficacy in the other major intracranial schwannomas including trigeminal (TS), facial (FS), and jugular foramen schwannomas (JFS) has not been established yet due to their rarity. We retrospectively analyzed data of 514 consecutive patients who had intracranial schwannomas (460 VS, 22 TS, 7 FS, and 25 JFS) and underwent SRS. The 5- and 10-year tumor control rates were 97% and 94% for VS, 100% and 100% for TS, 80% and 80% for FS, and 100% and 80% for JFS. Radiation-induced complications included one hydrocephalus for TS (4.5%), no cases for FS (0%), and one hydrocephalus and one lower palsy for JFS (8.0%). Through matched cohort analysis between patients with VS and each of the non-VS, we found no statistical difference in tumor control and radiation-induced adverse events. SRS seems to provide long-term tumor control with functional preservation for TS, FS and JFS and the efficacies are similar to VS.

Optimal surgical approaches and treatment outcomes in patients with jugular foramen schwannomas: a single institution series of 31 cases and a literature review

Complete resection of jugular foramen schwannomas (JFSs) with minimal cranial nerve complications remains difficult even for skilled neurosurgeons. Between November 2011 and November 2017, 31 consecutive patients diagnosed with JFSs underwent a single-stage operation performed by the same neurosurgeon. We retrospectively analyzed clinical characteristics, surgical approaches, treatment outcomes, and follow-up data for these patients. JFSs were classified according to the Samii classification system. A retrosigmoid approach was used to resect type A tumors, while a suboccipital transjugular process (STJP) approach was used to resect type B tumors. Notably, the present study is the first to report the use of a paracondylar-lateral cervical (PCLC) approach for the treatment of type C and D tumors. Type A-D tumors were observed in seven, four, four, and 16 patients, respectively. Gross-total resection was achieved in 29 patients (93.5%). There were no cases of intracranial hematoma, re-operation, tracheotomy, or death. Adjunctive gamma knife treatment was used to manage residual tumors in two patients. Neurological deficits relieved in half of patients at the last follow-up. By reviewing the studies published on PubMed, the approaches gradually be more conservative, rather than widely expose the skull base. Nonetheless, endoscope and stereotactic radiosurgery plays an important role in the management of JFSs. Both tumor removal and neurological function retention can be obtained by choosing individual treatment.

Optimal treatment of jugular foramen schwannomas: long-term outcome of a multidisciplinary approach for a series of 29 cases in a single institute

BACKGROUND

The goal of treatment for jugular foramen schwannomas (JFSs) is to achieve complete tumor removal with cranial nerve preservation. However, achieving this goal remains a challenge despite the advances in microsurgical techniques. The aim of this study was to determine optimal treatment strategies for JFSs based on a review of a series of 29 surgical cases in our institute.

MATERIALS AND METHODS

Between 1997 and 2013, 29 patients with JFSs underwent surgical treatment by multidisciplinary otoneurosurgical approaches. We retrospectively evaluated various clinical outcomes including the extent of tumor resection, postoperative cranial nerve deficits, and the recurrence rate. Tumor extension was classified using the Kaye and Pellet classification (KPC) system, and the extent of tumor resection was graded as gross total resection (GTR), near total resection (NTR), and subtotal resection (STR). We utilized the House-Brackmann facial nerve grading system (HBFNGS), the average pure-tone audiometry and speech audiometry (PTA/SA) tests, and the American Speech-Language-Hearing Association National Outcome Measurement System (ASHA NOMS) swallowing scale (ASHA level) for assessment of functional outcomes.

RESULTS

The extent of tumor resection was not related to the degree of immediate postoperative cranial nerve deficits. However, the surgical approach was significantly related to postoperative hearing status and immediate postoperative facial function. Also, among the ten patients who were below the level of acceptable facial function immediately postoperatively, nine patients (90%) recovered to acceptable facial function by the last follow-up. Concerning postoperative swallowing status, all 21 patients recovered swallowing function by the last follow-up. Postoperative Gamma Knife stereotactic radiosurgery (GKRS) was performed for three recurrent and seven residual tumors, and recurrence was not observed in the mean 36-month follow-up period.

CONCLUSIONS

A surgical strategy should be tailored to the individual case, and clinicians should consider the possibility of recurrence and further adjuvant treatment.

Microsurgical management of primary jugular foramen meningiomas: a series of 22 cases and review of the literature

This study summarized clinical manifestations, surgical management, histological grading, and long-term outcome of jugular foramen meningiomas (JFMs). Retrospective study was performed in 22 consecutive patients with primary JFMs from January 2004 to October 2010, enrolling 10 men and 12 women with average age of 39.4 (14-57 years). The most common initial symptom is hearing disorder, followed by lower cranial nerve dysfunctions. The tumor was classified into type I (intracranial) in 1, type II (intracranial) in 15, type IV (intracranial-extracranial) in 6, and none type III (extracranial). Surgical approaches mainly included retrosigmoid in 7, far lateral in 10, and juxtacondylar in 5, with some variations. The gross total resection was achieved in 15 cases and subtotal resection in 7. Fourteen patients (63.6 %) developed new or worse neurological deficits immediately after operation, of whom 11 (78.6 %) got alleviation. Postoperatively, keeping airway patency and prevention from aspiration pneumonia is very important. Nasotracheal intubation is much more tolerated than orotracheal intubation for postoperative patient management. WHO grade 2 was found in four cases (18.2 %) and grade 3 in one. During the average time of follow-up in 83.2 months, only one (grade 3) died of tumor regrowth 20 months after surgery and radiosurgery. Five of 17 patients of grade 1 developed tumor regrowth. Radiosurgery provides a good tumor control for tumor regrowth in grade 1, or postoperative grade 2 tumor. In conclusion, JFMs has a favorable long-term overall survival; however, neurological preservation is still challenging, especially low cranial nerves.

A Single-Institution Retrospective Study of Jugular Foramen Schwannoma Management: Radical Resection Versus Subtotal Intracranial Resection Through a Retrosigmoid Suboccipital Approach Followed by Radiosurgery

BACKGROUND

Despite advances in skull base surgery, achieving effective surgical management of jugular foramen schwannomas (JFSs) that avoids postoperative cranial nerve (CN) deficits remains a challenge. Subtotal resection followed by radiosurgery (rather than radical resection) is increasingly being viewed as a better treatment strategy. Here, an institutional database was retrospectively analyzed for outcomes after surgical treatment of JFSs to evaluate the optimal strategy for managing JFSs.

METHODS

Twenty-two patients with JFSs were operated on by either radical resection (n = 13) or conservative resection plus radiosurgery (n = 9). These 2 different groups were compared in terms of early (≤4 weeks after surgery) and late postoperative functional outcome and oncologic control.

RESULTS

No deaths occurred in either group, but there were 3 surgery-related complications in the radical resection group. Postoperative CN deficits and additional procedures related to CN morbidity were generally higher in the radical resection group, but the differences were not statistically significant. The conservative surgery group showed a statistically significant improvement in the level of dysphagia and dysphagia-related functional state in the late postoperative period. There was 1 case of recurrence after radical resection over a mean follow-up period of 73 months. All tumors in the conservative surgery group were controlled over a mean period of 34 months.

CONCLUSIONS

Our results suggest that conservative resection of JFSs via a familiar intracranial approach plus radiosurgery may be an effective surgical alternative for improving functional outcome with adequate oncologic control.