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Transzygomatic approach with anteriorly limited inferior temporal gyrectomy for large medial tentorial meningiomas

  • Technical Note - Neurosurgical Techniques
  • Published:
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Abstract

Background

Tentorial meningiomas near the middle third of the medial tentorial edge with supratentorial extension are usually removed via the subtemporal approach. This approach, however, may not be practical, especially for huge tumors extending to the posterior subtemporal space. This study describes the use of the transzygomatic approach with anteriorly limited inferior temporal gyrectomy (TZ-AITG) to remove these large tumors.

Methods

Between 2008 and 2012, five patients with symptomatic tentorial meningiomas (median diameter, 5.2 cm; range, 4.0–5.7 cm) near the middle third of the medial tentorial edge with supratentorial extension underwent TZ-AITG, consisting of zygomatic osteotomy, low-positioned craniotomy, and resection of the inferior temporal gyrus around 4 cm from the tip.

Results

Tumors were completely resected in all patients. Postoperatively, none had a newly developed neurological morbidity, and none died. Of three patients with preoperative hemianopia, two showed improvement and one remained stationary. One patient with preoperative hemiparesis recovered completely. All patients returned to their normal activities during the follow-up period. Surgical morbidities included epidural hematoma and chronic subdural hematoma in one patient each, with both requiring evacuation.

Conclusions

TZ-AITG may be a good alternative to the subtemporal approach for large tentorial meningiomas near the middle third of the medial tentorial edge. TZ-AITG provides access to the lesions and visualization of the middle fossa, facilitating early feeder control while minimizing brain retraction, thus reducing potential injury to the vein of Labbé. TZ-AITG is also safe and feasible in minimizing neurological compromise.

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Acknowledgments

The authors express our special thanks to Dr. Kim (Sang Joon Kim M.D., Ph.D., Professor, Department of Radiology, University of Ulsan College of Medicine, ASAN Medical Center, Seoul, Korea) who helped in the preparation of the illustration showing relationship between the optic radiation and the relevant language fasciculi by providing the diffusion fiber tracking images of them.

Conflict of interest

All authors certify that they have no affiliations with or involvement in any organization or entity with any financial interest (such as honoraria; educational grants; participation in speakers’ bureaus; membership, employment, consultancies, stock ownership, or other equity interest; and expert testimony or patent-licensing arrangements), or non-financial interest (such as personal or professional relationships, affiliations, knowledge, or beliefs) in the subject matter or materials discussed in this manuscript.

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Authors and Affiliations

  1. Department of Neurological Surgery, ASAN Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 138-736, Korea

    Eun Jung Lee, Young Hyun Cho, Seok Ho Hong, Jeong Hoon Kim & Chang Jin Kim

  2. Department of Neurosurgery, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea

    Eun Suk Park

Authors
  1. Eun Jung Lee
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  2. Eun Suk Park
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  3. Young Hyun Cho
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  4. Seok Ho Hong
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Correspondence to Chang Jin Kim.

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Comments

The authors describe a subtemporal transzygomatic trans-inferior temporal gyrus approach for resection of medial tentorial meningiomas. Their rational for this approach dealing with larger tumors is acceptable and their complication rate reasonable.

Although this is a small series and the approach has been described before, it is a good addition to technical note series and reminds us of the possibility of decreasing brain retraction by removal of the infero-anterior and sometimes middle-inferior part of the temporal lobe. Although I would definitely urge for not resecting the normal brain for an extra-axial lesion, the antero-inferior temporal lobe as described here could be an exception to the routine strategy of cisternal microsurgery in very selected cases.

Amir Dehdashti

NY, USA

Doctor Jung Lee and colleagues describe their technique for removal of large medial tentorial meningiomas through a transzygomatic approach with partial inferior temporal gyrectomy. They operated on five patients during a 6-year period (2008–2012). The paper is well written, with good illustrations as well as clear neurophysiological and anatomical explanations. However, although the authors present excellent results following resection of four large tentorial meningiomas and a hemangiopericytoma in these five patients, I have a great concern regarding the need of a partial temporal lobectomy, which is a part of the approach for removal of completely extra-axial tumors. In their review of alternative approaches to the medial tentorial region, the authors missed somehow a supracerebellar transtentorial approach [1–3], which also enables removal of the medial tentorial meningioma without temporal lobe injury. There is also another possibility. At least for the meningiomas presented in Figs. 4 and 5, I would operate using a subtemporal presigmoid transtentorial approach with partial superior mastoidectomy. As the authors state, “the tentorium has an upward slope as it goes from the petrous bone towards its apex, and the superior pole of the tumor becomes higher from the temporal base as it goes in a posterior and medial direction.” Similar to zygomatic osteotomy, superior mastoidectomy provides a higher angle of view, diminishing the need for temporal lobe retraction and avoiding altogether the need for partial temporal lobectomy. In addition, removal of the superior part of the mastoid, adjacent to the temporal dura mater, without labyrinth violation, enables sectioning the tentorium anterior to the point at which the vein of Labbé merges into the tentorium. This provides excellent access to the tumor origin with minimal temporal lobe retraction, similar to the approach used for the removal of petroclival meningiomas with a high-riding supratentorial component. Another advantage of this approach is that tentorial section facilitates early meningioma devascularization and detachment.

Serge Spektor

Jerusalem, Israel

References

(1) Ansari SF, Young RL, Bohnstedt BN, Cohen-Gadol AA (2014) The extended supracerebellar transtentorial approach for resection of medial tentorial meningiomas. Surg Neurol Int 5:35

(2) Ture U, Harput MV, Kaya AH, Baimedi P, Firat Z, Ture H, Bingol CA (2012) The paramedian supracerebellar-transtentorial approach to the entire length of the mediobasal temporal region: an anatomical and clinical study. Laboratory investigation. J Neurosurg 116:773–791

(3) Uchiyama N, Hasegawa M, Kita D, Yamashita J (2001) Paramedian supracerebellar transtentorial approach for a medial tentorial meningioma with supratentorial extension: technical case report. Neurosurgery 49:1470–1473; discussion 1473–1474

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Lee, E.J., Park, E.S., Cho, Y.H. et al. Transzygomatic approach with anteriorly limited inferior temporal gyrectomy for large medial tentorial meningiomas. Acta Neurochir 157, 1747–1756 (2015). https://doi.org/10.1007/s00701-015-2551-0

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  • DOI: https://doi.org/10.1007/s00701-015-2551-0

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