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Surgical management of ventral and ventrolateral foramen magnum meningiomas: report on a 64-case series and review of the literature

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Abstract

Foramen magnum meningioma poses a challenge for neurosurgeons. Prognosis has generally improved with diagnostic and surgical advances over the past two decades; however, it may ultimately depend more on the surgeon's ability to tailor the approach and interpret intraoperative risks in single cases. The series comprised 64 patients operated on for ventral and ventrolateral foramen magnum meningioma. All patients underwent preoperative magnetic resonance imaging and received surgery via the dorsolateral route, rendering the series homogeneous in neuroradiological workup and surgical treatment. Particular to this series was that the majority of patients were of advanced age (n = 29; age, >65 years), had serious functional impairment (n = 30, Karnofski score <70), and large tumors (mean diameter, 3.5 cm). Total tumor removal was achieved in 52 (81 %) patients; operative mortality was nil. Early outcome varied depending on difficulties encountered at surgery (cranial nerve position and type of involvement in particular) and type of preoperative dysfunction. Long-tract signs and cerebellar deficits improved in 74 and 77 % of cases, respectively, but only 27 % of cranial nerve deficits did so. Surgical complications most often involved the cranial nerves: cranial nerve impairment, especially of the 9th through the 12th cranial nerves, due to stretching or encasement was noted in 44 cases. At final outcome assessment, two thirds of the cranial nerve deficits cleared, and all but two patients returned to a normal productive life. One patient was reoperated on during the follow-up period. Foramen magnum meningiomas behave like clival or spinal tumors depending on their prevalent extension. A dorsolateral approach tailored to tumor position and extension and meticulous surgical technique allow for definitive control of surgical complications. Scrupulous postoperative care may prevent dysphagia, a major persistent complication of surgery. Long-term observation of indolent tumor behavior at follow-up suggests that incomplete resection may be a viable surgical treatment option.

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Authors and Affiliations

  1. Section of Neurosurgery, Department of Neuroscience, University of Verona, Verona, Italy

    Andrea Talacchi & Albino Bricolo

  2. Institute of Neurosurgery, University Hospital, Verona, Italy

    Antonio Biroli, Christian Soda & Barbara Masotto

  3. Section of Neurosurgery, Department of Neuroscience, University Hospital, P. Stefani 1, 37126, Verona, Italy

    Andrea Talacchi

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  1. Andrea Talacchi
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  5. Albino Bricolo
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Correspondence to Andrea Talacchi.

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Comments

Michaël Bruneau, Jacques Brotchi, Brussels, Belgium

This article reflects the wide experience of the authors about the surgical treatment of anterior and lateral foramen magnum meningiomas. In this large series based on 64 cases, total removal was achieved in 81 %, while in the remaining cases, a remnant was judiciously left in place due to adherences to perforators, to the vertebral artery, or to the brainstem. The authors noted, as experienced by others, difficulties generated by encasement of important neurovascular structures, excessive bleeding, hard tumor consistency, and aggressive tumor behavior inducing dural invasion and the absence of the arachnoidal plane. Their results were excellent with, respectively, 74, 77, and 27 % of improvement of preoperative long tracts, cerebellar and cranial nerve deficits. The authors noted 21 new cranial deficits postoperatively and pointed out the importance of swallowing disturbances. We agree that these must be systematically checked postoperatively as soon as possible in order to prevent aspiration. In all cases, their approach consisted in a far-lateral approach. This approach is associated with the lowest morbidity rate and allows an adequate exposure of these tumors. In our experience, the drilling of the medial aspect of the foramen magnum lateral wall must only be performed in selected cases and, when required, can always be very limited. It is extremely important to be able to anticipate the position of the lower cranial nerves. In lateral tumors, their position depends on the relation of the meningioma with the vertebral artery. Tumors growing below the vertebral artery (which is the most common situation) displace the lower cranial nerves upwards and posteriorly. Unfortunately, while growing above the vertebral artery, the lower cranial nerves can be displaced in any direction.

William T. Couldwell, Salt Lake City, USA

The authors have presented their surgical results of a series of 64 patients treated at their institution over a 20-year period. They had many older patients (>65 years, n = 29). They provide an honest appraisal of the complications associated with removal of these tumors, especially the lower cranial nerve palsies.

This is a great contribution to the literature and will represent the best example of contemporary microsurgical results for the treatment of meningiomas in this location. It provides a thorough review of other series in the recent literature and also sets the standard for which to compare outcomes of evolving anterior transfacial and endoscopic techniques.

Helmut Bertalanffy, Hannover, Germany

I wish to congratulate the authors and particularly the senior author (AB) for the nice presentation of their patient series and their good results in this special group of skull base meningiomas. The authors' expertise is also reflected in the remarkable number of patients treated at a single institution.

Some neurosurgeons consider the surgical removal of foramen magnum meningiomas an easy task, as has occasionally been mentioned during oral presentations. The authors of this study have nicely shown that this may be an inadequate generalization and underestimation of the problems that can occur in treating a foramen magnum meningioma. Surgery can be quite challenging, for instance when they firmly adhere to the brainstem or in cases in which the tumor extends into the extradural space. Indeed, each type of tumor may require a tailored surgical technique. However, I am not in favor of distinguishing so many variations of exposure such as transfacetal, retrocondylar, partial transcondylar, complete transcondylar, extreme-lateral transjugular, and transtubercular that evolved in the recent literature. In analogy to different ways of exposing a medial sphenoid wing meningioma by various degrees of resecting the sphenoid wing, the amount of bony resection at the level of the lateral foramen magnum depends upon the local anatomy and the exact location and extent of the tumor. For an adequate exposure of a foramen magnum meningioma, I recommend exposing the vertebral artery up to the dural entrance that is hidden by the surrounding venous plexus. Initially, this venous plexus has to be dealt with properly either by injecting fibrin glue or by resecting the plexus and achieving good hemostasis with gentle packing of hemostatic sponges or Surgicel. Thus, the exact course of the horizontal portion of the vertebral artery becomes clearly visible: it is lateral to medial within the sulcus of the atlantal arch, but medial to lateral prior to piercing the dura mater. In a meningioma that completely encases the proximal intradural vertebral artery; I always open the dural ring around the artery to completely mobilize the vessel. This nicely exposes the tumor portions located ventral to the artery that may otherwise not be easily accessible. Mobilizing the artery by opening the dural ring is also required in the cases of intra- and extradural extension of a foramen magnum meningioma. In such case, the medial portions of the occipital condyle and of the lateral atlantal mass have to be drilled away lateral to the dural entrance of the vertebral artery [1].

We are grateful not only for the detailed description of the authors' technique but also for their nice overview of the pertinent literature on this subject.

References

1. H Bertalanffy, O Bozinov, O Sürücü, U Sure, L Benes, C Kappus, N Krayenbühl (2010) Dorsolateral approach to the craniocervical junction. In: P. Cappabianca et al. (eds.), Cranial, craniofacial and skull base surgery. Springer, Italy pp. 175–196

Engelbert Knosp, Vienna, Austria

Foramen magnum meningiomas are a rare and challenging pathology in neurosurgery. Although we achieved significant technological improvements during the time, the requirements in this specific pathology remained unchanged over the decades : namely detailed anatomical knowledge, an accurate approach and an excellent surgical technique.

In this publication, Dr Bricolo et al. presented a very large series of ventrally located foramen magnum meningiomas, which were collected over the period of 20 years and were treated in the same fashion over the years: semisitting position and using the dorsolateral approach. The authors focused on anatomical and surgical details of this confined area of the foramen magnum, lower clivus and upmost spinal canal. They addressed many specific problems arising in surgical treatment of these lesions and they provide the readers sound suggestions to avoid complications. Although it was rare in the senior authors hand, the suggestion to stop resection in case of hard and calcified tumors or encasement of perforators or loss of arachnoid plane at the brainstem is very helpful.

A topic still remained for discussion is, in which extent one has to resect the posterior part of the condyle and the necessity to remove arch of C1 or whether it is always necessary to dissect (and displace) the vertebral artery. As seen in the manuscript, the authors prefer an extensive extradural resection to reach the anterior rim of the foramen magnum.

In this publication the reader can appreciate a life long dedication to neurosurgery, furthermore his surgical philosophy in treating difficult pathologies like eg foramen magnum meningiomas. The results showed here are excellent and rich in details, well analysed and a must to read for every surgeon dealing with meningiomas of the foramen magnum.

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Talacchi, A., Biroli, A., Soda, C. et al. Surgical management of ventral and ventrolateral foramen magnum meningiomas: report on a 64-case series and review of the literature. Neurosurg Rev 35, 359–368 (2012). https://doi.org/10.1007/s10143-012-0381-6

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