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Importance of appropriate surgical approach selection for radical resection of cerebellopontine angle epidermoid cysts with preservation of cranial nerve functions: our experience of 54 cases

  • Original Article - Tumor - Other
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Abstract

Background

Although many reports state that only the lateral suboccipital retrosigmoid approach (LSO) should be used for removal of cerebellopontine angle (CPA) epidermoid cysts, it is preferable to use various surgical approaches as appropriate for each patient, for radical resection with an optimal operative field under direct visualization, and for the preservation of cranial nerve (CN) functions. In the present study, we hence focused on the importance of surgical approach selection for removal of CPA epidermoid cysts and analyzed the results of CPA epidermoid cysts after surgery in our series.

Methods

Fifty-four patients who underwent surgery for CPA epidermoid cysts were retrospectively analyzed, regarding their surgical approaches, removal rates, preservation rates of CN function 1 year after surgery, and recurrence. Surgical approaches were selected for patients according to the size and extension of the tumor.

Results

Surgical approaches consisted of LSO (20 cases), anterior transpetrosal approach (ATP; 3 cases), combined transpetrosal approach (27 cases), and ATP + LSO (4 cases). Mean tumor content removal and capsule removal rates were 97.4% and 78.3%, respectively. Preservation rates of facial nerve function and useful hearing were 94.4% and 90.7%, respectively. The mean postoperative follow-up time was 62.8 months, and there were two cases of recurrence requiring reoperation about 10 years after surgery.

Conclusions

For CPA epidermoid cyst surgeries, selection of the appropriate surgical approach for each patient and radical resection with an optimal operative field under direct visualization enable tumor removal without the need for reoperation for a long time, with preservation of CN functions.

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Abbreviations

AAO-HNS:

American Academy of Otolaryngology–Head and Neck Surgery

ABR:

Auditory brainstem response

ATP:

Anterior transpetrosal approach

CN:

Cranial nerve

CPA:

Cerebellopontine angle

CTP:

Combined transpetrosal approach

GTR:

Gross total removal

H-B:

House–Brackmann

LSO:

Lateral suboccipital retrosigmoid approach

SS:

Sigmoid sinus

ST:

Subtemporal approach

STR:

Subtotal removal

References

  1. Aboud E, Abolfotoh M, Pravdenkova S, Gokoglu A, Gokden M, Al-Mefty O (2015) Giant intracranial epidermoids: is total removal feasible? J Neurosurg 122:743–756

    Article  PubMed  Google Scholar 

  2. Akar Z, Tanriover N, Tuzgen S, Kafadar AM, Kuday C (2003) Surgical treatment of intracranial epidermoid tumors. Neurol Med Chir (Tokyo) 43(6):275–281

    Article  Google Scholar 

  3. Altschuler E, Jungreis C, Sekhar LN, Jannetta P, Sheptak P (1990) Operative treatment of intracranial epidermoid cysts and cholesterol granulomas: report of 21 cases. Neurosurg 26(4):606–614

    Article  CAS  Google Scholar 

  4. Alvord ECJ (1977) Growth rates of epidermoid tumors. Ann Neurol 2(5):367–370

    Article  PubMed  Google Scholar 

  5. Baumann CH, Bucy PC (1956) Paratrigeminal epidermoid tumors. J Neurosurg 13:455–468

    Article  CAS  PubMed  Google Scholar 

  6. Berger MS, Wilson CB (1985) Epidermoid cysts of the posterior fossa. J Neurosurg 62(2):214–219

    Article  CAS  PubMed  Google Scholar 

  7. Chandler WF, Farhat SM, Pauli FJ (1975) Intrathalamic epidermoid tumor. J Neurosurg 43(5):614–617

  8. Chowdhury F, Haque M, Sarker M (2013) Intracranial epidermoid tumor; microneurosurgical management: an experience of 23 cases. Surg 8(1):21–28

    Google Scholar 

  9. Czernicki T, Kunert P, Nowak A, Wojciechowski J, Marchel A (2016) Epidermoid cysts of the cerebellopontine angle: clinical features and treatment outcomes. Neurol Neurochir Pol 50(2):75–82

    Article  PubMed  Google Scholar 

  10. Darrouzet V, Franco-Vidal V, Hilton M, Nguyen DQ, Lacher-Fougere S, Guerin J, Bebear JP (2004) Surgery of cerebellopontine angle epidermoid cysts: role of the widened retrolabyrinthine approach combined with endoscopy. Otolaryngol Head Neck Surg 131(1):120–125

    Article  PubMed  Google Scholar 

  11. DeSouza CE, DeSouza R, Da Costa S, Sperling N, Yoon TH, Abdelhamid MM, Sharma RR, Goel A (1989) Cerebellopontine angle epidermoid cysts: a report on 30 cases. J Neurol Neurosurg Psychiatry 52(8):986–990

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  12. Farhoud A, Khedr W, Aboul-Enein H (2018) Surgical resection of cerebellopontine epidermoid cysts: limitations and outcome. J Neurol Surg Part B Skull Base 79(2):167–172

    Article  Google Scholar 

  13. Goel A, Muzumdar D, Desai K (2006) Anterior tentorium-based epidermoid tumours: results of radical surgical treatment in 96 cases. Br J Neurosurg 20(3):139–145

    Article  CAS  PubMed  Google Scholar 

  14. Gopalakrishnan CV, Ansari KA, Nair S, Menon G (2014) Long term outcome in surgically treated posterior fossa epidermoids. Clin Neurol Neurosurg 117:93–99

    Article  PubMed  Google Scholar 

  15. Grahnke K, Burkett D, Li D, Szujewski C, Leonetti JP, Anderson DE (2018) Cranial nerve preservation following surgical treatment for epidermoid cysts of the posterior and middle fossae. J Neurol Surg Part B Skull Base 79(5):445–450

    Article  Google Scholar 

  16. Guidetti B, Gagliardi FM (1977) Epidermoid and dermoid cysts. Clinical evaluation and late surgical results. J Neurosurg 47(1):12–18

    Article  CAS  PubMed  Google Scholar 

  17. Guo Z, Ouyang H, Cheng Z (2011) Surgical treatment of parapontine epidermoid cysts presenting with trigeminal neuralgia. J Clin Neurosci 18(3):344–346

    Article  PubMed  Google Scholar 

  18. Hasegawa M, Inamasu J, Yoshida K, Nagahisa S, Nouri M, Adachi K, Hirose Y, Fujisawa H (2016) Cerebellopontine angle epidermoid cysts: clinical presentations and surgical outcome. Neurosurg Rev 39(2):259–267

    Article  PubMed  Google Scholar 

  19. Hu Z, Guan F, Kang T, Huang H, Dai B, Zhu G, Mao B, Kang Z (2016) Whole course neuroendoscopic resection of cerebellopontine angle epidermoid cysts. J Neurol Surg Part A Cent Eur Neurosurg 77:381–388

    Google Scholar 

  20. Kato K, Ujiie H, Higa T, Hayashi M, Kubo O, Okada Y, Hori T (2010) Clinical presentation of intracranial epidermoids: a surgical series of 20 initial and four recurred cases. Surg 5(1):32–40

    Google Scholar 

  21. Kobata H, Kondo A, Iwasaki K (2002) Cerebellopontine angle epidermoids presenting with cranial nerve hyperactive dysfunction: pathogenesis and long-term surgical results in 30 patients. Neurosurg 50(2):276–286

    Google Scholar 

  22. Lunardi P, Missori P, Innocenzi G, Gagliardi FM, Fortuna A (1990) Long-term results of surgical treatment of cerebello-pontine angle epidermoids. Acta Neurochir 103:105–108

    Article  CAS  PubMed  Google Scholar 

  23. Lynch JC, Aversa A, Pereira C, Nogueira J, Gonçalves M, Lopes H (2014) Surgical strategy for intracranial dermoid and epidermoid tumors: an experience with 33 patients. Surg Neurol Int. https://doi.org/10.4103/2152-7806.145764

  24. Mallucci CL, Ward V, Carney AS, O’Donoghue GM, Robertson I (1999) Clinical features and outcomes in patients with non-acoustic cerebellopontine angle tumours. J Neurol Neurosurg Psychiatry 66(6):768–771

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  25. Matsushima K, Kohno M, Nakajima N, Ichimasu N (2019) Combined transpetrosal approach with preservation of superior petrosal vein drainage for a cerebellopontine angle epidermoid cyst extending into Meckel’s Cave: 3-dimensional operative video. Oper Neurosurg 16(6):E172–E173

    Article  Google Scholar 

  26. Meng L, Yuguang L, Feng L, Wandong S, Shugan Z, Chengyuan W (2005) Cerebellopontine angle epidermoids presenting with trigeminal neuralgia. J Clin Neurosci 12(7):784–786

    Article  PubMed  Google Scholar 

  27. Mohanty A, Venkatrama SK, Rao BR, Chandramouli BA, Jayakumar PN, Das BS (1997) Experience with cerebellopontine angle epidermoids. Neurosurg 40(1):24–30

    CAS  Google Scholar 

  28. Nagasawa D, Yew A, Safaee M, Fong B, Gopen Q, Parsa AT, Yang I (2011) Clinical characteristics and diagnostic imaging of epidermoid tumors. J Clin Neurosci 18(9):1158–1162

    Article  PubMed  Google Scholar 

  29. Obrador S, Lopez-Zafra JJ (1969) Clinical features of the epidermoids of the basal cisterns of the brain. J Neurol Neurosurg Psychiatry 32(5):450–454

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  30. Peng Y, Yu L, Li Y, Fan J, Qiu M, Qi S (2014) Pure endoscopic removal of epidermoid tumors of the cerebellopontine angle. Childs Nerv Syst 30(7):1261–1267

    Article  PubMed  Google Scholar 

  31. Rubin G, Scienza R, Pasqualin A, Rosta L, Da Pian R (1989) Craniocerebral epidermoids and dermoids. Acta Neurochir 97:1–16

    Article  CAS  PubMed  Google Scholar 

  32. Sabin HI, Bordi LT, Symon L (1987) Epidermoid cysts and cholesterol granulomas centered on the posterior fossa: twenty years of diagnosis and management. Neurosurg 21(6):798–805

    Article  CAS  Google Scholar 

  33. Safavi-Abbasi S, Di Rocco F, Bambakidis N, Talley MC, Gharabaghi A, Luedemann W, Samii M, Samii A (2008) Has management of epidermoid tumors of the cerebellopontine angel improved? A surgical synopsis of the past and present. Skull Base 18(2):85–98

    Article  PubMed  PubMed Central  Google Scholar 

  34. Samii M, Tatagiba M, Piquer J, Carvalho GA (1996) Surgical treatment of epidermoid cysts of the cerebellopontine angle. J Neurosurg 84(1):14–19

    Article  CAS  PubMed  Google Scholar 

  35. Schiefer TK, Link MJ (2008) Epidermoids of the cerebellopontine angle: a 20-year experience. Surg Neurol 70(6):584–590

    Article  PubMed  Google Scholar 

  36. Schroeder HWS, Oertel J, Gaab MR (2004) Endoscope-assisted microsurgical resection of epidermoid tumors of the cerebellopontine angle. J Neurosurg 101(2):227–232

    Article  PubMed  Google Scholar 

  37. Shear BM, Jin L, Zhang Y, David WB, Fomchenko EI, Erson-Omay EZ, Huttner A, Fulbright RK, Moliterno J (2019) Extent of resection of epidermoid tumors and risk of recurrence: case report and meta-analysis. J Neurosurg 1–11. https://doi.org/10.3171/2019.4.JNS19598

  38. Singh I, Rohilla S, Kumar P, Krishana D (2018) Combined microsurgical and endoscopic technique for removal of extensive intracranial epidermoids. Surg Neurol Int. https://doi.org/10.4103/sni.sni

  39. Talacchi A, Sala F, Alessandrini F, Turazzi S, Bricolo A (1998) Assessment and surgical management of posterior fossa epidermoid tumors: Report of 28 cases. Neurosurg 42(2):242–252

    Article  CAS  Google Scholar 

  40. Tancredi A, Fiume D, Gazzeri G, Knosp E, Isamat F (2003) Epidermoid cysts of the fourth ventricle: very long follow up in 9 cases and review of the literature. Acta Neurochir 145(10):905–911

    Article  CAS  PubMed  Google Scholar 

  41. Tuchman A, Platt A, Winer J, Pham M, Giannotta S, Zada G (2014) Endoscopic-assisted resection of intracranial epidermoid tumors. World Neurosurg 82(3):450–454

    Article  PubMed  Google Scholar 

  42. Vinchon M, Pertuzon B, Lejeune J-P, Assaker R, Pruvo J-P, Christiaens J-L (1995) Intradural epidermoid cysts of the cerebellopontine angle: diagnosis and surgery. Neurosurg 36(1):52–57

    Article  CAS  Google Scholar 

  43. Yamakawa K, Shitara N, Genka S, Manaka S, Takakura K (1989) Clinical course and surgical prognosis of 33 cases of intracranial epidermoid tumors. Neurosurg 24(4):568–573

    Article  CAS  Google Scholar 

  44. Yasargil M, Abernathey C, Sarioglu A (1989) Microneurosurgical treatment of intracranial dermoid and epidermoid tumors. Neurosurg 24(4):561–567

    Article  CAS  Google Scholar 

  45. Yawn RJ, Patel NS, Driscoll CL, Link MJ, Haynes DS, Wanna GB, Thompson RC, Carlson ML (2016) Primary epidermoid tumors of the cerebellopontine angle: a review of 47 cases. Otol Neurotol 37:951–955

    Article  PubMed  Google Scholar 

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Funding

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Author information

Authors and Affiliations

  1. Department of Neurosurgery, Tokyo Medical University, Tokyo, Japan

    Hiroki Sakamoto, Michihiro Kohno, Ken Matsushima, Norio Ichimasu & Nobuyuki Nakajima

  2. Department of Neurosurgery, Tokyo Metropolitan Police Hospital, Tokyo, Japan

    Masanori Yoshino

Authors
  1. Hiroki Sakamoto
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  2. Michihiro Kohno
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  3. Ken Matsushima
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  4. Norio Ichimasu
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  5. Nobuyuki Nakajima
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Contributions

The authors are indebted to Helena Akiko Popiel, Department of International Medical Communications of Tokyo Medical University, for her review of the English manuscript. Also, we thank Mrs. Asa Otonari for her assistance in preparing this manuscript.

Corresponding author

Correspondence to Michihiro Kohno.

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Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee (Tokyo Medical University and Tokyo Metropolitan Police Hospital) and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

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For this type of study, formal consent is not required.

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The authors declare that they have no conflict of interest and no personal or institutional financial interest regarding any of the drugs, materials, or devices described in this article.

Additional information

Comments:

In this series of 54 epidermoid cysts of the cerebellopontine area (CPA) and surrounding compartments, the authors achieved good results tailoring the surgical approaches into retrosigmoid, anterior petrosal and transpetrosal approaches to remove the CPA epidermoid cysts. In fact, epidermoid cysts do not respect the subarachnoidal compartments and may invade distant areas. The classical retrosigmoid approach may be insufficient to address to all these compartments in giant epidermoid cysts due to limited angle of view provided by this approach. In order to achieve maximal resection of the lesion and protect the cranial nerves one must sometimes include additional approaches such as those described in this paper. However, transpetrosal approaches are more demanding and involve higher risks of CSF leak and hearing loss. These disadvantaged must be taken into consideration when choosing the approaches. The additional use of endoscopes with different angulations (30°, 45°, 70°) may incredibly enhance the possibilities of the retrosigmoid approach, so that far lesions located "around the corner" can be addressed as well. Finding a good balance between radically removing the beging cyst while increasing potential risks to cranial nerves and vessels, or risking recurrence that might be very difficult to treat with use of less invasive approaches, is the real challenge in these cases and demands large experience in dealing with these lesions.

Marcos Tatagiba

Tübingen, Germany

Comment

There are several issues of discussion in the surgical treatment of epidermoid cysts in the cerebellopontine angle, including surgical indication, selection of appropriate approach, decision-making of how radically the capsule should be removed considering function preservation before and during the surgery, evaluation of residual capsule during and after the operation, analysis of long-term follow-up results relating to the surgical radicality and growth rate of recurrence, and timing of reoperation for recurrent tumor, etc. In this paper, the authors intended to perform radical capsule resection via a wide exposure by selecting approaches like suboccipital approach, anterior transpetrosal approach and combined transpetrosal approach, which was tailored to the individual case. The retrospective review in 54 patients showed excellent surgical outcomes as compared to those in the literature. Nevertheless, there still exists the same issues of discussion as described above. In the surgery of epidermoid cysts, unlike meningiomas, coagulation of feeding arteries at the deeper part of the petro-clival area is not required, and there is a risk of complication due to the overexposure of the skull base. Careful consideration should be given when using an invasive transpetrosal approach for a highly benign disease like this. Further studies are needed on the combined use of suboccipital and endoscopic surgery. Surgery for epidermoid cysts, which requires long-term follow-up after surgery, often needs further resolution.

Kenji Ohata

Osaka, Japan

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Sakamoto, H., Kohno, M., Matsushima, K. et al. Importance of appropriate surgical approach selection for radical resection of cerebellopontine angle epidermoid cysts with preservation of cranial nerve functions: our experience of 54 cases . Acta Neurochir 163, 2465–2474 (2021). https://doi.org/10.1007/s00701-021-04840-0

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