Surgical management of petroclival meningiomas: Factors affecting early post-operative outcome

Surgical resection of petroclival meningiomas of the cerebellopontine angle and/or diaphragma sellae extension via an extended intradural anterior transpetrous approach

OBJECTIVE

This study aimed to describe the extended intradural anterior transpetrous approach (ATPA) and its usefulness for the surgical resection of petroclival meningiomas (PCMs) of the cerebellopontine angle (CPA) and/or diaphragma sellae (DS) extension.

METHODS

Between January 2017 and December 2019, a total of 22 patients with PCMs extending to the CPA/or DS underwent surgery via extended intradural ATPA by the senior author (Xr.X.). We retrospectively analysed the clinical data, radiological findings, surgical treatment, complications, and outcomes of patients and discussed the operative technique.

RESULTS

In 22 patients, the tumours were gross totally removed (Simpson I and II) in 18 patients (81.8%), subtotally (Simpson III) in 3 patients (13.6%), and partially (Simpson IV) in 1 patient (4.5%). One patient died 48 days after the operation, and no recurrence was found in 21 patients during a median follow-up of 26 months. Postoperative complications included in abducens nerve palsy in 12 patients with recovery in 10 patients, facial numbness in 4 patients with recovery in 3 patients, and hemiplegia and oculomotor nerve palsy in 1 patient each with recovery in all patients. The postoperative MRI showed temporal lobe oedema but no clinical symptoms in 3 patients.

CONCLUSION

Extended intradural ATPA is an alternative approach for PCMs of the CPA and/or DS extension. The single approach can expose both the sellar region and the posterolateral area of the IAC, which is advantageous for extended intradural ATPA.

POLR2A Mutation is a Poor Prognostic Marker of Cerebellopontine Angle Meningioma

BACKGROUND AND OBJECTIVES

Recent molecular analyses have shown that the driver genetic mutations of meningiomas were associated with the anatomic location. Among these, POLR2A mutation is common among lesions in the skull base, mainly in the cerebellopontine angle (CPA). The objective of this study was to investigate the efficacy of POLR2A mutation as a prognostic marker for CPA meningiomas.

METHODS

We retrospectively analyzed the clinical data of 70 patients who had World Health Organization grade I CPA meningiomas. Somatic DNA was analyzed by Sanger sequencing and microsatellite array to examine for NF2 , AKT1 , KLF4 , SMO , and POLR2A mutations and 22q loss. Genetic and clinical parameters were analyzed to identify the factors related with tumor recurrence.

RESULTS

We detected clearly the clinical features of the CPA cases with POLR2A mutation. Compared with cases without POLR2A mutation, cases with POLR2A mutation had more meningothelial type ( P = 6.9 × 10 -4 ), and higher rate of recurrence ( P = .04). We found that the poor prognostic factors associated with the recurrence of CPA meningiomas were POLR2A mutation ( P = .03, hazard ratio [HR] 9.38, 95% CI 1.26-70.0) and subtotal resection (STR) ( P = 5.1 × 10 -4 , HR 63.1, 95% CI 6.09-655.0). In addition, in the group that underwent STR, POLR2A mutation was a poor prognostic factor associated with tumor recurrence ( P = .03, HR 11.1, 95% CI 1.19-103.7).

CONCLUSION

POLR2A mutation and STR were the poor prognostic markers associated with the recurrence of CPA meningioma. For CPA meningioma cases that underwent STR, only POLR2A mutation was a poor prognostic factor. Detecting POLR2A mutation may be a cost-effective, easy, and useful marker for prognostication.

The Evolution of Anterior Transpetrosal Approach for the Treatment of Petroclival Meningiomas: A Single-Center 128-Case Experience

BACKGROUND

The profound understanding of anterior transpetrosal approach (ATPA) is increasingly used to treat petroclival meningiomas (PCMs). We introduce the evolution of ATPA and the outcomes of PCMs treatment.

METHODS

Between January 2013 and December 2019, 128 patients with PCMs underwent surgery. According to tumor extension, we classified the 128 patients into 5 types (I-V), introduced key technologies of ATPA into different types for the first time, and achieved a supreme surgical technology. Clinical data, radiological findings, surgical treatments, complications, and patient outcomes were retrospectively analyzed.

RESULTS

A total of 22 (17.2%), 44 (34.4%), 25 (19.5%), 29 (22.7%), and 8 (6.3%) patients had type I, II, III, IV, and V disease, respectively. Tumors were gross totally removed (Simpson I and II) in 100 patients (78.1%), subtotally removed (Simpson III) in 20 patients (15.6%), and partially removed (Simpson IV) in 8 patients (6.3%). The progression or recurrence rates were 5% (5/100) for gross totally removed, 22.3% (6/20) for subtotally removed, and 62.5% (5/8; 1 died) for partially removed. According to the Karnofsky Performance Scale and Glasgow Outcome Scale, 108 patients had good recovery (84.4%, 108/128) and 115 were independent (89.8%, 115/128) at the end of follow-up.

CONCLUSIONS

Because some key technologies were used in ATPA, the application of ATPA was extended, and greater tumor resection and nerve function protection could be achieved in the treatment of PCMs.

Surgical and Functional Outcome after Resection of 64 Petroclival Meningiomas

Objective: The management of petroclival meningiomas (PCMs) remains notoriously difficult due to their close association with neurovascular structures and their complex anatomy, hence the surgical paradigm change from radical to functional resection in the past. With this study, we aimed to analyze surgical and functional outcomes of a modern consecutive series of patients with PCMs. Methods: We reviewed patient charts and imaging data of 64 consecutive patients from 2006 to 2018 with a PCM resected at our institution and compared surgical and functional outcomes between subgroups stratified by surgical approach. Results: Females comprised 67.2% of patients (n = 43), with a mean age of 55 years (median 56; range 21-84). Follow-up data were available for 68.8% and reached a mean of 42.3 months (range 1-129) with a median of 28.5 months. The mean tumor diameter was 37.3 mm (standard deviation (SD) 15.4; median 37.0). Infiltration of the cavernous sinus was observed in 34 cases (53.1%), and the lesions affected the brain stem in 28 cases (43.8%). Preoperative cranial nerve palsy was observed in 73.4% of cases; trigeminal neuropathy (42.2%), hearing loss (32.8%), and impairment of vision (18.8%) were the most common. A retrosigmoid approach was employed in 47 cases (78.1%), pterional in 10 (15.6%), combined petrosal in 2 (3.1%), and transnasal and subtemporal in 1 (1.6%). Fifteen cases (23.4%) were resected in a two-staged fashion. Gross total resection (GTR) was attempted in 30 (46.9%) cases without cavernous sinus infiltration and was achieved in 21 (70.0%) of these cases. Surgical complications occurred in 13 cases (20.3%), most commonly meningitis (n = 4; 6.3%). Postoperatively, 56 patients (87.5%) developed new cranial nerve palsy, of which 36 (63.6%) had improved or resolved on last follow up. Achieving GTR was not significantly associated with higher rates of surgical complications (chi-square; p = 0.288) or postoperative cranial nerve palsy (chi-square; p = 0.842). Of all cases, 20 (31.3%) underwent postoperative radiation. Tumor progression was observed in 10 patients (15.9%) after a mean 102 months (median 124). Conclusions: Surgical resection remains the mainstay of treatment for PCMs, with perioperative cranial neuropathies exhibiting favorable recovery rates. Most essentially, the preselection of patients with hallmarks of brain stem affection and cavernous sinus infiltration should dictate whether to strive for a functionally oriented strategy in favor of radical resection.

Midline Skull Base Meningiomas: Transcranial and Endonasal Perspectives

Simple Summary

Skull base meningiomas have always represented a challenge for neurosurgeons. Despite their histological nature, they may be associated with unfavorable outcomes due to their deep-seated location and the surrounding neurovascular structures. Over time, several corridors have been proposed, each one carrying its own pros and cons. During the last decades, the endoscopic endonasal route has been asserted among the classic routes for a growing number of midline and paramedian lesions. Therefore, the aim of our paper is to present a comprehensive review of the indications and techniques for the management of skull base meningiomas, emphasizing the ambivalent and complementary role of the low and high routes.

Abstract

Skull base meningiomas have always represented a challenge for neurosurgeons. Despite their histological nature, they may be associated with unfavorable outcomes due to their deep-seated location and the surrounding neurovascular structures. The state of the art of skull base meningiomas accounts for both transcranial, or high, and endonasal, or low, routes. A comprehensive review of the pertinent literature was performed to address the surgical strategies and outcomes of skull base meningioma patients treated through a transcranial approach, an endoscopic endonasal approach (EEA), or both. Three databases (PubMed, Ovid Medline, and Ovid Embase) have been searched. The review of the literature provided 328 papers reporting the surgical, oncological, and clinical results of different approaches for the treatment of skull base meningiomas. The most suitable surgical corridors for olfactory groove, tuberculum sellae, clival and petroclival and cavernous sinus meningiomas have been analyzed. The EEA was proven to be associated with a lower extent of resection rates and better clinical outcomes compared with transcranial corridors, offering the possibility of achieving the so-called maximal safe resection.

Mortality and morbidity in surgically treated patients with petroclival meningiomas: a systematic review and meta-analysis of case series

BACKGROUND

Reports on petroclival meningioma (PCM) surgical mortality and morbidity often deviate from established standards; as such, a comprehensive summary is lacking.

METHODS

Eligibility/sources. Peer-reviewed case series of at least 10 PCM patients identified from PubMed, Web of Science, Ovid, or Google Scholar. Outcomes. Primary: mortality, tumor recurrence, any cranial nerve deficit (CND); other: individual CNDs, other complications. Data synthesis. Random-effects meta-analysis/meta-regression [effects: surgical approach (supratentorial, S; infratentorial, I; combined, (C), average age and follow-up, sample size, and percent of patients with gross-total resection (GTR)] of logit-transformed proportions.

RESULTS

Data. 73 case-series/3553 patients. Mortality. Adjusted predicted mortalities of 2.4%, 2.5%, and 1.2% (50-month follow-up) for the S, I, and C approaches, respectively, with the upper limits of the 95% credibility intervals at 3.3%, 3.7%, and 3.6%, respectively. Recurrence. Adjusted predicted recurrences of 5.5%, 11.1%, and 12.0% (50-month follow-up and 57% GTR) for the S, I, and C approaches, respectively; recurrence was positively associated with follow-up period and negatively associated with having received GTR. At all covariates at median values but at GTR 90% predictions: 3.1% (95%CI 3.1-9.8), 6.3% (3.8-10.4), and 6.9% (3.4-13.2) with the S, I, and C; prediction credibility intervals 1-4% and 22.4%. Any CND. Adjusted predicted probabilities of 37.2%, 23.4%, and 29.5% (at median covariate values) for the S, I, and C approaches, respectively; prediction credibility intervals ranged from <10% to 78%. Other outcomes. The most common individual CNDs were nVII (14.4%), nV (11.5%), and nIII (10.2%); other common complications included motor deficit (10.8%), infection (9.8%), and CSF leak (7.5%).

CONCLUSION

This is the first systematic review on PCM surgical mortality, recurrence, and morbidity. Outcomes differ between surgical approaches and reporting quality varies greatly.

Surgical Treatment and Clinical Outcomes of Petroclival Meningiomas: A Single-Center Experience of 107 Patients

Objective

This study aimed to establish optimal surgical strategies via reviewing the clinical outcomes of various surgical approaches for the pertroclival meningiomas (PCMs).

Methods

This retrospective study enrolled 107 patients with PCMs at the authors’ institution from year 2010 to 2020. Patient demographics, the clinical characteristics, various operative approaches, major morbidity, post-operative cranial nerve deficits and tumor progression or recurrence were analyzed.

Results

The subtemporal transtentorial approach (STA), the Kawase approach (KA), the retrosigmoid approach (RSA) and the anterior sigmoid approach (ASA), namely the posterior petrosal approach (PPA) were adopted for 17 cases, 22 cases, 31 cases and 34 cases respectively. Total or subtotal resection was achieved in 96 cases (89.7%). The incidence of new-onset and aggravated cranial nerve dysfunction were 13.1% (14/107) and 10.4% (15/144), respectively. Furthermore, 14 cases suffered from intracranial infection, 9 cases had cerebrospinal fluid leakage, and 3 cases sustained intracranial hematoma (1 case underwent second operation). The mean preoperative and postoperative Karnofsky Performance Status (KPS) score was 80 (range 60-100) and 78.6 (range 0-100), but this was not statistically significant (P>0.05). After a mean follow-up of 5.1 years (range 0.3- 10.6 years), tumor progression or recurrence was confirmed in 23 cases. Two cases died from postoperative complications.

Conclusions

For the treatment of PCMs, it is still a challenge to achieve total resection. With elaborate surgical plans and advanced microsurgical skills, most patients with PCMs can be rendered tumor resection with satisfactory extent and functional preservation, despite transient neurological deterioration during early postoperative periods.

Petroclival Meningiomas: A Simple System That Could Help in Selecting the Approach

BACKGROUND

Petroclival meningiomas (PCM) represent a neurosurgical challenge due to their strategic location close to the brainstem.

OBJECTIVE

To assess the applicability of a retrosigmoid approach (RSA) by analyzing the degree of displacement of the middle cerebellar peduncle (MCP) elicited by PCM.

METHODS

Patients with PCM were prospectively included and divided into those whose imaging studies showed that the posterior end of the MCP was displaced by the tumor and were eligible for and underwent RSA (group A) and those who were not eligible for RSA and who underwent surgery via a posterior transpetrosal approach (group B). We compared tumor behavior, clinical characteristic of patients and surgical results.

RESULTS

Twenty patients with PCM were enrolled and allocated to group A (n = 15) or group B (n = 5). The clinical manifestations were more severe in group B; tumors in this group were larger and gross total removal was achieved in only 1 patient (20%). In comparison, in 12 cases on group A, tumors could be totally removed (80%) and all of these patients could recover their quality of life after surgery.

CONCLUSION

To our knowledge, this study is the first to consider displacement of the MCP when establishing a suitable surgical approach for PCM. Our results suggest that the RSA becomes increasingly suitable when peduncle displacement is greater. By using this method, it was also possible to identify two types of tumors: petroclivals (group A) and clivopetrosals (group B), that show some specific clinical and surgical differences.

Does general comorbidity impact the postoperative outcomes after surgery for large and giant petroclival meningiomas?

We assessed the role of the general condition of the patient in addition to usual anatomical reasoning to improve the prediction of personalized surgical risk for patients harboring a large and giant petroclival meningiomas. Single-center, retrospective observational study including adult patients surgically treated for a large and giant petroclival meningioma between January 2002 and October 2019 in a French tertiary neurosurgical skull-base center by one Neurosurgeon. Inclusion criteria were as follows: (1) histopathologically proven meningioma; (2) larger than 3 cm in diameter; (3) located within the upper two-thirds of the clivus, the inferior petrosal sinus, or the petrous apex around the trigeminal incisura, medial to the trigeminal nerve. Clinical and radiological characteristics were gathered preoperatively including ASA score, the modified frailty index, and the Charlson comorbidity index. Post-operative severe neurological and non-neurological complications were collected. A total of 102 patients harboring a large and giant petroclival meningioma were included. The rate of postoperative death was 3.0% related to a congestive heart failure (n = 1), a surgical site hematoma (n = 1), and an ischemic stroke (n = 1). A severe neurological impairment was found in 12.8% and a severe non-neurological morbidity was found in 4.0%. The overall rate of severe morbidity and mortality was 15.7% after large and giant petroclival meningioma surgery. The presence of brainstem peri-tumoral edema (adjusted OR, 4.83 [95% CI 1.84-7.52], p = 0.028) was independently associated with a history of postoperative severe neurological morbidity. Male gender (adjusted OR, 7.42 [95% CI 1.05-49.77], p = 0.044), major cardiovascular morbidity (adjusted OR, 9.5 [95% CI 1.05-86.72], p = 0.045), and an ASA score ≥ 2 (adjusted OR, 11.09 [95% CI 1.46-92.98], p = 0.038) were independently associated with a history of postoperative severe non-neurological morbidity. A modified frailty index ≥ 1 (adjusted OR, 3.13 [95% CI 1.07-9.93], p = 0.047) and a low neurosurgical experience (adjusted OR, 5.38 [95% CI 1.38-20.97], p = 0.007) were independently associated with a history of postoperative overall morbidity and mortality. Pre-operative cranial nerve deficits (adjusted OR, 4.77 [95% CI 1.02-23.31], p = 0.024) and gross total resection (adjusted OR, 10.72 [95% CI 1.72-66.90], p = 0.022) were independently associated with postoperative new cranial nerve deficits. This study suggests to add scores assessing the patient general condition in daily practice to improve the selection of patients eligible for surgery. Collaborative international multicenter studies will be necessary to confirm these results and allow their implementation in clinical routine.

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 meningiomas: long-term outcomes of multimodal treatments and management strategies based on 30 years of experience at a single institution

OBJECTIVE

A thorough investigation of the long-term outcomes and chronological changes of multimodal treatments for petroclival meningiomas is required to establish optimal management strategies. The authors retrospectively reviewed the long-term clinical outcomes of patients with petroclival meningioma according to various treatments, including various surgical approaches, and they suggest treatment strategies based on 30 years of experience at a single institution.

METHODS

Ninety-two patients with petroclival meningiomas were treated surgically at the authors' institution from 1986 to 2015. Patient demographics, overall survival, local tumor control rates, and functional outcomes according to multimodal treatments, as well as chronological change in management strategies, were evaluated. The mean clinical and radiological follow-up periods were 121 months (range 1-368 months) and 105 months (range 1-348 months), respectively.

RESULTS

A posterior transpetrosal approach was most frequently selected and was followed in 44 patients (48%); a simple retrosigmoid approach, undertaken in 30 patients, was the second most common. The initial extent of resection and following adjuvant treatment modality were classified into 3 subgroups: gross-total resection (GTR) only in 13 patients; non-GTR treatment followed by adjuvant radiosurgery or radiation therapy (non-GTR+RS/RT) in 56 patients; and non-GTR without adjuvant treatment (non-GTR only) in 23 patients. The overall progression-free survival rate was 85.8% at 5 years and 81.2% at 10 years. Progression or recurrence rates according to each subgroup were 7.7%, 12.5%, and 30.4%, respectively.

CONCLUSIONS

The authors' preferred multimodal treatment strategy, that of planned incomplete resection and subsequent adjuvant radiosurgery, is a feasible option for the management of patients with large petroclival meningiomas, considering both local tumor control and postoperative quality of life.

Surgical outcomes of anterior cerebellopontine angle meningiomas using the anterior transpetrosal approach compared with the lateral suboccipital approach

BACKGROUND

Anterior transpetrosal approach (ATPA) and lateral suboccipital approach (LSO) are the major surgical approaches for cerebellopontine angle (CPA) meningiomas. Particularly, anterior CPA meningiomas are challenging lesions to be treated surgically. To date, only a few studies have directly compared the outcomes of both approaches focusing on the anterior CPA meningiomas.

METHODS

For the comparative analysis, anterior CPA meningiomas that were eligible for both APTA and LSO were collected in our hospital from April 2005 to March 2017. Anterior CPA meningiomas targeted for this study were defined as follows: (1) without cavernous sinus, clivus, and middle cranial fossa extension, (2) the posterior edge is 1 cm behind the posterior wall of the internal auditory canal, and (3) the inferior edge is above the jugular tuberculum. Based on these criteria, the operative outcomes of 17 patients and 13 patients who were operated via ATPA and LSO were evaluated.

RESULTS

The complication rate of the LSO group was significantly higher than that of the ATPA group (30.7% vs. 0%, p = 0.033). The removal rate did not differ between the ATPA and LSO groups (97.35% vs. 99.23%, p = 0.12). The operative time was significantly shorter in the LSO group than in the ATPA group (304.3 min vs. 405.8 min, p = 0.036).

CONCLUSIONS

Although the LSO is more widely used for CPA meningiomas, ATPA is also considered for these anterior CPA meningiomas.