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Two step approach for surgical removal of petroclival meningiomas with large supratentorial extension

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Abstract

The treatment of petroclival meningiomas is still a matter of controversy in literature. In the last decades, many approaches have been introduced. Our strategy for the treatment of such tumors having large supratentorial extension with encasement of the internal carotid artery or compression of optic and oculomotor nerves has evolved in the attempt to improve the outcome. Currently, we favor a surgical technique consisting of two steps. As first step, we perform a retrosigmoid suprameatal approach in order to resect the posterior part of the tumor and obtain brainstem decompression. In the second step, carried out after patient’s recovery from the first surgery, we remove the supratentorial portion of the lesion using a frontotemporal craniotomy to achieve the decompression of the optic nerve, oculomotor nerve, and carotid artery. The retrosigmoid suprameatal approach allows for adequate brainstem decompression: the tumor itself creates a surgical channel increasing the accessibility to the lower and upper petroclival surface. Moreover, this route allows for early visualization of cranial nerves in the posterior fossa and safe tumor removal under direct visual control, reducing the risk of postoperative deficits. Via the simple and safe frontotemporal craniotomy, the supratentorial part of the lesion can be removed thus avoiding the need of invasive approaches. We propose a two-stage surgery for treatment of petroclival meningiomas combining two simple routes such as retrosigmoid suprameatal and frontotemporal craniotomy. This approach reflects our philosophy to use simple and less invasive approaches in order to preserve neurological function and a good quality of life of the patient.

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Authors and Affiliations

  1. Department of Neurosurgery, International Neuroscience Institute, Rudolf-Pichlmayer-Straße. 4, 30625, Hannover, Germany

    Madjid Samii, Venelin Gerganov, Mario Giordano & Amir Samii

Authors
  1. Madjid Samii
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  2. Venelin Gerganov
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  3. Mario Giordano
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  4. Amir Samii
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Correspondence to Mario Giordano.

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Comments

Michael W. McDermott, San Francisco, USA

The article by Dr. Samii et al. is important in that it offers a surgical option for petroclival meningiomas other than a petrosal approach. The surgery for these tumors is one of the most frustrating and difficult in neurosurgery. The operation via a retrolabyrinthine petrosectomy with a temporal craniotomy and tentorial incision takes many hours and retraction on the inferior temporal lobe is almost universally not tolerated without some contusion or hemorrhagic infarction. With the first-stage retrosigmoid suprameatal approach (illustrated well in the video), there is no temporal lobe retraction. This first stage is also a shorter operation than the combined petrosal approach. Selecting another day for stage 2 makes sense, allowing the patient, and surgeon(s) time to recover before the supratentorial approach. This is a standard intradural pterional approach as opposed to a middle fossa extradural approach. As one experience grows with these tumors, it becomes all too clear that many times we do our patients a disservice by selecting an aggressive surgical approach. The two-stage option discussed herein is a reasonable alternative.

Sunil Manjila, Nicholas C. Bambakidis, Cleveland, USA

This is an interesting technical note, demonstrating the use of simple, well-known, and lesser invasive surgical approaches—using standard retrosigmoid suprameatal approach combined with a frontotemporal approach. The authors talk about the complexity of the lesion with respect to the encasement of ICA and compression of optic and oculomotor nerves by the formidable tumor. Cavernous sinus invasion and brainstem pial invasion are two important risk factors to be considered while setting goals for resection. It is not evident that the resection is safer or more complete with use of this less invasive combination approach. We do feel that the frontotemporal approach provides a lesser exposure to anatomy in the region compared to an orbitozygomatic approach (OZ). We have been recently using combined OZ standard retrosigmoid approaches for these lesions, and we have not experienced a significant morbidity (CSF leak, maxillary sinus injury, etc.) with OZ approaches. Subtemporal approaches have fallen out of favor due to risk of injury to vein of Labbe. In general however, we still favor the use of transpetrous approaches in lesions which span both the middle and posterior cranial fossas and which are located medial to the internal auditory canal, particularly if they are located in the nondominant hemisphere and are associated with preoperative hearing loss or facial nerve impairment.

Volker Seifert, Frankfurt am Main, Germany

This is a timely technical note on the staged removal of large petroclival meningiomas, based on the extensive experiences of the senior author Professor Madjid Samii. The last 10–15 years have seen a gradual shift from the application of extensive skull-base approaches like the combined petrosal approach to more simple approaches like the retrosigmoid approach for surgery of petroclival meningiomas. In agreement with the conceptual thinking of Samii’s group, I have personally changed my surgical philosophy over the last 10 years using now almost exclusively the retrosigmoid approach for petroclival meningiomas, leaving intentionally tumor remnants in those supratentorial compartments and the cavernous sinus which cannot be safely reached from the infratentorial route despite suprameatal drilling. (1) When the combined petrosal approaches are to be avoided because of inherent possibilities of approach-related complications (CSF fistula, temporal lobe contusion, sigmoid sinus thrombosis), the staged removal is a logical way to attack large petroclival meningiomas. However, only a small percentage of patients with large infra- and supratentorial tumor extension ultimately require a second surgery after successful removal of the infratentorial part of the meningioma. In very large petroclival meningiomas, clinical symptoms are almost always due to the brain stem compression by the infratentorial tumor extension. If this is relieved by retrosigmoid tumor removal, the supratentorial tumor part can, e.g., be observed or, if possible, treated by radiosurgery. However, in very large supratentorial tumor remnants, causing additional clinical symptoms surgical tumor resection must of course be accomplished after the patient has recovered from the first surgery. So in summary, the concept of staged removal in large petroclival meningiomas is both patient and surgeon friendly and should be incorporated into our evolving concepts of the treatment of these still extremely difficult tumors. A follow-up publication of this group should detail the clinical results of this staged concept compared to the traditional concept of one-stage tumor removal via the petrosal approach.

Reference

1. V. Seifert. Clinical management of petroclival meningiomas and the eternal quest for preservation of quality of life. Personal experiences over a period of 20 years. ACTA NEUROCHIRURGICA,152: 1099–1116, 2010

Electronic supplementary material

Below is the link to the electronic supplementary material.

In this video, we show the first step (retrosigmoid suprameatal approach) and the second step (frontotemporal approach) for surgical removal of petroclival meningiomas with large supratentorial extension (MP4 7,624 kb).

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Samii, M., Gerganov, V., Giordano, M. et al. Two step approach for surgical removal of petroclival meningiomas with large supratentorial extension. Neurosurg Rev 34, 173–179 (2011). https://doi.org/10.1007/s10143-010-0299-9

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