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Microsurgical management of primary jugular foramen meningiomas: a series of 22 cases and review of the literature

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Abstract

This study summarized clinical manifestations, surgical management, histological grading, and long-term outcome of jugular foramen meningiomas (JFMs). Retrospective study was performed in 22 consecutive patients with primary JFMs from January 2004 to October 2010, enrolling 10 men and 12 women with average age of 39.4 (14–57 years). The most common initial symptom is hearing disorder, followed by lower cranial nerve dysfunctions. The tumor was classified into type I (intracranial) in 1, type II (intracranial) in 15, type IV (intracranial-extracranial) in 6, and none type III (extracranial). Surgical approaches mainly included retrosigmoid in 7, far lateral in 10, and juxtacondylar in 5, with some variations. The gross total resection was achieved in 15 cases and subtotal resection in 7. Fourteen patients (63.6 %) developed new or worse neurological deficits immediately after operation, of whom 11 (78.6 %) got alleviation. Postoperatively, keeping airway patency and prevention from aspiration pneumonia is very important. Nasotracheal intubation is much more tolerated than orotracheal intubation for postoperative patient management. WHO grade 2 was found in four cases (18.2 %) and grade 3 in one. During the average time of follow-up in 83.2 months, only one (grade 3) died of tumor regrowth 20 months after surgery and radiosurgery. Five of 17 patients of grade 1 developed tumor regrowth. Radiosurgery provides a good tumor control for tumor regrowth in grade 1, or postoperative grade 2 tumor. In conclusion, JFMs has a favorable long-term overall survival; however, neurological preservation is still challenging, especially low cranial nerves.

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Acknowledgments

It is grateful to Dr. Neermala Dassrath for her editing for excellence.

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Authors and Affiliations

  1. Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China

    Jie Tang, Liwei Zhang, Junting Zhang, Zhen Wu, Xinru Xiao, Dabiao Zhou, Guijun Jia & Wang Jia

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  1. Jie Tang
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Correspondence to Liwei Zhang.

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Declaration

This study was funded by Program of Interventional Diagnostic and Therapeutic System using Multi-modality Images for Skull Base and Brain Stem Tumors, Beijing Municipal Science and Technology Commission (Z151100003915079), China, and Beijing Municipal Bureau of Health ( 2012D 00303 40000 25).

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Comments

Florian Roser, Abu Dhabi, UAE

The authors report their institutional experience with jugular foramen meningiomas over the last decade. They follow a very reasonable approach aiming for less invasive approaches and maintaining a high quality of life through subtotal resection in cases of severe adhesions, followed by radiotherapy/radiosurgery. It is very important for the readership to participate in the authors change in strategy with the more challenging cases they subsequently face. They do not perform facial nerve re-routing anymore, they do not advocate radical resection as in the beginning, and they tailor the approach according to the main extension of the tumour in regards to the foramen itself. Although it can be discussed whether nasotracheal intubation can replace tracheotomy entirely, as most of the lower cranial nerve deficits will take up to 12 weeks to improve, the evolution of post-operative management is also very important to follow.

I would even go a step forward and critically discuss the indication in treating jugular foramen meningiomas surgically. We all agree that major intracranial extension into the posterior fossa warrants surgery, but purely extra-cranial tumours or dumbbell-shaped with minor intracranial extension, could be observed or treated by radiosurgery upfront. This would mean that type II and III in their classification should only be treated surgically if there is growth observed or clinical symptoms arise. This philosophy accounts as well for patients in whom the jugular foramen meningioma has been incidentally detected (as in their patient no. 12/17). We need a very good justification for resection in incidental benign lesions as well, even in very experienced hands.

Overall this article again reminds us on the challenges in jugular foramen surgery and the individual decisions we have to take for the optimal outcome of our patients.

Takeshi Mikami, Sapporo, Japan

Jugular foramen meningioma is very rare, and its surgical management is complex and difficult. Radical removal of benign jugular foramen meningioma is the treatment of choice as it can be curative. This case series included five cases in which grade 2 or grade 3 meningioma recurred though the initial surgical results had been excellent.

This paper provides readers with examples of careful postoperative management after tumor excision by an experienced surgeon. The authors achieved a high removal rate with low morbidity and mortality. Larger lesions could be radically excised in one basic surgical corridor by adding a variational multidisciplinary skull base approach. Especially in type III and type IV cases, a lateral skull base approach is indispensable for obtaining wide tumor access. In this series, there was no cerebrospinal fluid leakage; in general, however, it is essential to take steps to prevent postoperative cerebrospinal fluid leakage. Although the authors did not perform any additional procedures in this series, we think that the drilled portion of mastoid air cell should be reconstructed with fat or vascularized myofascial flaps without any artificial material (wax, artificial dura etc.) when mastoidectomy is performed. Lumbar drainage is also performed routinely in our institute. As for postoperative complications, lower cranial nerve deficit is the most dangerous possible complication. Therefore, prophylactic tracheostomy is reasonable to avoid aspiration pneumonitis.

At the time of grade 2 or grade 3 meningioma recurrence, radiation therapy is not always effective. In this series, however, there is only one such case, whereas the others showed good tumor control. For aggressive skull base meningiomas, extensive removal with vascular reconstruction is one possible treatment option [1].

References

1. Wanibuchi M, Akiyama Y, Mikami T, Iihoshi S, Miyata K, Horita Y, Sugino T, Komatsu K, Suzuki K, Yamashita K, Mikuni N (2015) Radical removal of recurrent malignant meningeal tumors of the cavernous sinus in combination with high-flow bypass. World Neurosurg 83 (4):424–430.

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Tang, J., Zhang, L., Zhang, J. et al. Microsurgical management of primary jugular foramen meningiomas: a series of 22 cases and review of the literature. Neurosurg Rev 39, 671–683 (2016). https://doi.org/10.1007/s10143-016-0730-y

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