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Surgical Management of
Petroclival Meningiomas
Schmidek chapter 40
Khaled M. Aziz Sebastien,Froelich,Sanjay Bhatia,
Alexander K. Yu,Albino Bricolo,Todd Hillman,Raymond F. Sekula Jr.
Outline
• Natural history
• Recurrence rate
• Clinical picture
• Neurologic evaluation
• Anesthetic consideration
• Intraoperative Neurophysiologic monitoring
• Goal of surgical management
• Surgical approach
• Radiosurgery
Natural history
• The position of cranial nerves VII and VIII is the critical
landmark to differentiate petroclival meningiomas from
cerebellopontine angle meningiomas
• Petroclival meningiomas originate anterior to the IAC
and displace cranial nerves VII and VIII posteriorly.
• Cerebellopontine angle meningiomas originate posterior
to the IAC and displace cranial nerves VII and VIII
anteriorly
• Slow growing skull base meningioma
Recurrence rate
• Depend on location, cavernous sinus involvement, brain
stem infiltration, grade of resection, and histopathologic
result
Simpson After 5 Yrs
(%)
After 15 Yrs
(%)
After 25 Yrs
(%)
Grade 1 3.5 7-10 13-16
Grade 2 4 11-15 15-20
Grade 3 25 37-43 39-76
Grade 4-5 36-45 63-100 -
Recurrence rate
Clinical Picture
• Involvement of cranial nerves
– V, VIII, VI, VII, IX, and X
• Cerebellar compression
– Gait ataxia
• Brain stem compression
– Motor and sensory deficit
• Increased intracranial pressure
– Dementia
– Duu to secondary to hydrocephalus
Neurologic evaluation
• CT for transpetrosal approach
– Anatomy of the inner ear
– Height of jugular bulb
– Pneumatization of mastoid bone
• MRI
– T1 : delinate tumor,its relationship to other structure
– T2 : arachnoid cleavage plane,brain stem edema and infiltration
– Flow void : location of major vertebrobasilar vessel
• MRV
– Torcula, transverse sinus, sigmoid sinus
– Vein of Labbe(posterior temporal venous drainage)
Neuroradiologic evaluation
• Cerebral angiography
– Tumor blood supply
• meningohypophysial trunk of the internal carotid artery
• the posterior branch of the middle meningeal artery
• the meningeal branch of the vertebral artery
• the clivus artery from the carotid siphon
• the petrosal branches of the meningeal arteries
• the ascending pharyngeal branches of the external carotid
artery
– Mass effect on vertebrobasilar systems
Anesthetic consideration
• Brain relaxation
• Monitor nerve and tract : Muscle relatant is not use
• Remifentanil or sufentanil infusion for analgesia
• Sevoflurane or propofol for hypnosis
Intraoperative
Neurophysiologic monitoring
• Somatosensory evoked potentials (SSEPs)
– Record peripheral nerve afferent
• Motor evoked potentials (MEPs)
– Recording electromyogram activity in muscle
• Brain stem auditory evoked potentials (BSAEPs)
– Cortical response to auditory stimuli
• EMG
Goal of surgical management
• Goal of surgery is complete resection of the tumor
without causing additional deficits to the patient
• Tumor with brain stem compression
– decompression with either total or subtotal excision
• Tumor with neurovascular invasion
– Excision of tumor that leaves the part infiltrating the
neurovascular structure
Goal of surgical management
Surgical approachs
• Clivus and petroclival zone
• Anterior petrosal approach
• Posterior petrosal approach
• Lateral Suboccipital Approach
Clivus and petroclival zone
Clivus and petroclival zone
• Zone I (upper zone)
• dorsum sellae to the upper border of the IAC
• retrosellar region, region medial to the trigeminal
impression down to the IAC
• exposed via the Kawase approach (anterior petrosal
approach)
• Zygomatic osteotomy can be added
• If tumor involve only retrosellar region of zone I : trans-
sylvian transcavernous approach
Clivus and petroclival zone
• Zone II (middle zone)
• IAC to the upper border of the jugular tubercle
• exposure provided via the posterior petrosal approach
• tumor involve Zone I and II : combined petrosal
approach
• Zone III (lower zone)
• jugular tubercle to the lower edge of the clivus
• Exposed via lateral suboccipital–transcondylar
approaches
Clivus and petroclival zone
• Petroclival angle
• angle between the petrous
bone and the clivus at the
level of IAC
• Central clival depression
• relationship between
intermeatal
plane(superior) and
jugular tubercle(inferior)
• The less obtuse the
petroclival angle, the more
difficult the exposure of
the central clival
depression
Anterior petrosal approach
Anterior petrosal approach
• allows exposure
– the middle fossa floor
– the petrous bone apex,
– zone I of the petroclival region
• subtemporal or frontotemporal craniotomy and anterior
petrosectomy
• lumbar drain
Anterior petrosal approach
• Position
– Supine position and rotate 90
– Ipsilateral shoulder is elevated
– Head tilt 15 degrees downward
– Patient’s upper back is elevated 25-30 degrees
• Skin incision
– initiated posterior to the midpoint of the mastoid
process extends superiorly and anteriorly
– traversing the superior temporal line and ending at the
middle of the zygomatic arch for a subtemporal
anterior petrosal approach
Anterior petrosal approach
• Subtemporal approach
– Myocutaneous flap reflex inferiorly
– Rectangular craniotomy along the squamosal suture
– Zygomatic osteotomy
– Drilled floor of middle fossa
– Key : preserve dura and remain extradura
• Frontotemporal craniotomy approach
– Skin flap extend anteriorly
– Mycutaneous flap reflex anteroinferiorly
– Sphenoid wing complete drill
Anterior petrosal approach
• The dura is elevated from the middle fossa floor, and
petrous bone via a posterior to anterior approach;
elevation starts at the arcuate eminence and proceeds
anteriorly
• The middle meningeal artery is controlled with bipolar
cautery and sectioned, the foramen spinosum is packed
with bone wax
• Greater superficial petrosal nerve(GSPN) is identified
and keep intact : dissection follows the GSPN from
posterior to anterior until it courses under the third
division of the trigeminal nerve (V3)
• Glasscock’s triangle
– Laterally : foramen spinosum to the facial hiatus
– Medially : GSPN
– Base : V3
• Kawase’s triangle
– Laterally : GSPN
– Medially : petrous ridge
– Base : Arcuate eminence
Anterior petrosal approach
• Anteriorly, the mandibular division (V2) is identified at the
foramen rotundum
• Dissection continues medially to the petrous ridge
indenting the superior petrosal sinus
• Separation of the dura propia continues until the
connective tissues sheath over V2,V3 and the Gaserian
ganglion is visible(Meckel’s cave)
Anterior petrosal approach
• Kawase’s quadrilateral is drilled under microscope at
petrous ridge to identify the IAC
– The arcuate eminence forms a 120-degree angle to
the GSPN (or the internal carotid artery), and the IAC
bisects this angle
– Follow the geniculate ganglion to the labyrinthine
segment of the facial nerve(high incidence of facial
nerve injury)
• Drilling of the IAC continues to the bone crest dividing
the facial nerve and the superior vestibular nerve (Bill’s
bar)
Anterior petrosal approach
• The bone overlying the cochlea is drilled until the
cochlea appears as a blue line
• After identify of the dura covering the IAC posterior
• the Kawase’s quadrilateral is drilled to the
– GSPN (preserved) laterally
– the petrous segment of the internal carotid artery anterolaterally
– V3 anteriorly
– the superior petrosal sinus medially
– the posterior fossa dura and inferior petrosal sinus inferiorly
Anterior petrosal approach
• The inferior temporal lobe dura is open above and
parallel to the superior petrosal sinus. The dura is
reflected inferiorly
• The superior petrosal sinus is secured with titanium
hemoclips and is split
• The tentorium is cut medially toward the tentorial incisura
posterior to the dural entry of the trochlear nerve
• The posterior fossa dura is further split inferiorly
Anterior petrosal approach
• After completion of surgical resection
• Watertight dural closure is demanding
• The IAC bony opening is plugged with a small piece of
fat or muscle
• The dura is approximated utilizing a synthetic dural graft
and is sprayed with fibrin glue. If there is a big filling
defect, it can be judiciously obliterated with pieces of fat
graft to prevent postoperative fluid collection and
cerebrospinal fluid (CSF) leak
Anterior petrosal approach
• Closure
• Bone flaps are connected and fixed with titanium plates
and secures
• Bony defects are filled with bone cement for cosmetic
reconstruction and prevention of CSF leak
• We prefer to keep the lumbar drain in place for 48 hours
after obtaining an immediate postoperative CT scan
Posterior petrosal approach
Posterior petrosal approach
• Temporal craniotomy + presigmoid craniectomy + a
small lateral retrosigmoid craniectomy
• Depending on the preoperative hearing
– retrolabyrinthine or translabyrinthine bony temporal bone drilling
is added
• Sectioning of the superior petrosal sinus and tentorium,
and a relaxing incision in the dura above the lateral
transverse sinus
– frees the sigmoid sinus and allows mobilization of the sigmoid
sinus posteriorly to expand the presigmoid space : crucial step
Posterior petrosal approach
• Position
– Same in anterior petrosal approach
– Lateral oblique position
• Skin Incision
– three fingerbreadths circumferentially around the
edge of the ear pinna
Posterior petrosal approach
• The transverse sinus and the transverse–sigmoid
junction are dissected from the overlying bone
• Retrolabyrinthine mastoidectomy
• Landmark
– Spine of Henle : Antrum
– After drilling the bone over the sinodural angle, the
sigmoid sinus, superior petrosal sinus, and posterior
semicircular canal are exposed
– Floor of Antrum : Cortical bone of the lateral
semicircular canal
Posterior petrosal approach
• Landmark
– Follow lateral semicircular canal : posterior
semicircular canal
– Follow posterior semicircular canal : superior
semicircular canal
• The air cells of the mastoid tip are removed to expose
the digastric ridge : landmark for the stylomastoid
foramen and the beginning of the fallopian canal
Posterior petrosal approach
• Dura openings
– Below temporal lobe : parallel to the superior petrosal
sinus
– Posterior fossa dura in presigmoid space :
longitudinally between superior petrosal sinus and the
jugular bulb
– Gentle traction on temporal lobe and cerebellum :
superior petrosal sinus is sectioned and clipped
– Incision dura along transverse sinus
– The tentorium is sectioned into the incisura at a point
posterior to entrance of the trochlear nerve
Posterior petrosal approach
Posterior petrosal approach
• Closure
– Pericranium or a synthetic dural graft for close
– Open mastoid air cell : wax
– The antrum : muscle
– The mastoidectomy : abdominal fat graft and sprayed
with fibrin glue
– Bone flaps : titanium plates
Posterior petrosal approach
• Closure
– Bony defect : bone cement
– Temporalis m. is closed
– Keep lumbar drain for 48 hrs
– Immediate post-op CT scan
Lateral suboccipital approach
Lateral Suboccipital Approach
• For
– petroclival meningiomas involving zones I, II, and III
• Exposure
– posterior surface of the petrous bone
– the anterolateral brain stem
– craniocervical junction.
Lateral Suboccipital Approach
• The lateral oblique position
• Key hole : inferomedial to asterion to avoid injury to
transverse sigmoid junction
• Mastoid bone is drilled to expose medial edge of the
sigmoid sinus and the inferior edge of sinus
• For tumor extend to zone III : C1 laminectomy and
drilling of the posteromedial third of the occipital
condyle and lateral mass of C1
Lateral Suboccipital Approach
• V3 segment of vertebral artery : groove of the C1
lamina
• Dural incision : C1, extends superiorly through the
foramen magnum, and extends superolaterally to
the top of craniotomy edge
• Closure
– dura is closed watertight
– pericranial graft or a synthetic graft
– suture line is sprayed with fibrin glue
Radiosurgery
• < 3 cm in diameter
• adjuvant treatment to prevent tumor regrowth and
recurrence after maximal safe surgical resection
Outcome
• Increase post operative morbidity
• Preoperative neurologic deficits (diminished
Karnofsky Performance Scale score
• tumor size of 2.5 cm or more
• multiple cranial fossae involvement and cavernous
sinus infiltration
• absence of arachnoid cleavage plane
Outcome
• brain stem compression and invasion, brain stem
edema
• adhesions to and encasement of vascular structures
• high vascularity and direct tumor blood supply from
the basilar artery
• firm tumor consistency affecting the extent of tumor
resection

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Sch.40 surgical management of petroclival meningioma

  • 1. Surgical Management of Petroclival Meningiomas Schmidek chapter 40 Khaled M. Aziz Sebastien,Froelich,Sanjay Bhatia, Alexander K. Yu,Albino Bricolo,Todd Hillman,Raymond F. Sekula Jr.
  • 2. Outline • Natural history • Recurrence rate • Clinical picture • Neurologic evaluation • Anesthetic consideration • Intraoperative Neurophysiologic monitoring • Goal of surgical management • Surgical approach • Radiosurgery
  • 3. Natural history • The position of cranial nerves VII and VIII is the critical landmark to differentiate petroclival meningiomas from cerebellopontine angle meningiomas • Petroclival meningiomas originate anterior to the IAC and displace cranial nerves VII and VIII posteriorly. • Cerebellopontine angle meningiomas originate posterior to the IAC and displace cranial nerves VII and VIII anteriorly • Slow growing skull base meningioma
  • 4. Recurrence rate • Depend on location, cavernous sinus involvement, brain stem infiltration, grade of resection, and histopathologic result Simpson After 5 Yrs (%) After 15 Yrs (%) After 25 Yrs (%) Grade 1 3.5 7-10 13-16 Grade 2 4 11-15 15-20 Grade 3 25 37-43 39-76 Grade 4-5 36-45 63-100 -
  • 6. Clinical Picture • Involvement of cranial nerves – V, VIII, VI, VII, IX, and X • Cerebellar compression – Gait ataxia • Brain stem compression – Motor and sensory deficit • Increased intracranial pressure – Dementia – Duu to secondary to hydrocephalus
  • 7. Neurologic evaluation • CT for transpetrosal approach – Anatomy of the inner ear – Height of jugular bulb – Pneumatization of mastoid bone • MRI – T1 : delinate tumor,its relationship to other structure – T2 : arachnoid cleavage plane,brain stem edema and infiltration – Flow void : location of major vertebrobasilar vessel • MRV – Torcula, transverse sinus, sigmoid sinus – Vein of Labbe(posterior temporal venous drainage)
  • 8. Neuroradiologic evaluation • Cerebral angiography – Tumor blood supply • meningohypophysial trunk of the internal carotid artery • the posterior branch of the middle meningeal artery • the meningeal branch of the vertebral artery • the clivus artery from the carotid siphon • the petrosal branches of the meningeal arteries • the ascending pharyngeal branches of the external carotid artery – Mass effect on vertebrobasilar systems
  • 9. Anesthetic consideration • Brain relaxation • Monitor nerve and tract : Muscle relatant is not use • Remifentanil or sufentanil infusion for analgesia • Sevoflurane or propofol for hypnosis
  • 10. Intraoperative Neurophysiologic monitoring • Somatosensory evoked potentials (SSEPs) – Record peripheral nerve afferent • Motor evoked potentials (MEPs) – Recording electromyogram activity in muscle • Brain stem auditory evoked potentials (BSAEPs) – Cortical response to auditory stimuli • EMG
  • 11. Goal of surgical management • Goal of surgery is complete resection of the tumor without causing additional deficits to the patient • Tumor with brain stem compression – decompression with either total or subtotal excision • Tumor with neurovascular invasion – Excision of tumor that leaves the part infiltrating the neurovascular structure
  • 12. Goal of surgical management
  • 13. Surgical approachs • Clivus and petroclival zone • Anterior petrosal approach • Posterior petrosal approach • Lateral Suboccipital Approach
  • 15. Clivus and petroclival zone • Zone I (upper zone) • dorsum sellae to the upper border of the IAC • retrosellar region, region medial to the trigeminal impression down to the IAC • exposed via the Kawase approach (anterior petrosal approach) • Zygomatic osteotomy can be added • If tumor involve only retrosellar region of zone I : trans- sylvian transcavernous approach
  • 16. Clivus and petroclival zone • Zone II (middle zone) • IAC to the upper border of the jugular tubercle • exposure provided via the posterior petrosal approach • tumor involve Zone I and II : combined petrosal approach • Zone III (lower zone) • jugular tubercle to the lower edge of the clivus • Exposed via lateral suboccipital–transcondylar approaches
  • 17. Clivus and petroclival zone • Petroclival angle • angle between the petrous bone and the clivus at the level of IAC • Central clival depression • relationship between intermeatal plane(superior) and jugular tubercle(inferior) • The less obtuse the petroclival angle, the more difficult the exposure of the central clival depression
  • 19. Anterior petrosal approach • allows exposure – the middle fossa floor – the petrous bone apex, – zone I of the petroclival region • subtemporal or frontotemporal craniotomy and anterior petrosectomy • lumbar drain
  • 20. Anterior petrosal approach • Position – Supine position and rotate 90 – Ipsilateral shoulder is elevated – Head tilt 15 degrees downward – Patient’s upper back is elevated 25-30 degrees • Skin incision – initiated posterior to the midpoint of the mastoid process extends superiorly and anteriorly – traversing the superior temporal line and ending at the middle of the zygomatic arch for a subtemporal anterior petrosal approach
  • 21. Anterior petrosal approach • Subtemporal approach – Myocutaneous flap reflex inferiorly – Rectangular craniotomy along the squamosal suture – Zygomatic osteotomy – Drilled floor of middle fossa – Key : preserve dura and remain extradura • Frontotemporal craniotomy approach – Skin flap extend anteriorly – Mycutaneous flap reflex anteroinferiorly – Sphenoid wing complete drill
  • 22. Anterior petrosal approach • The dura is elevated from the middle fossa floor, and petrous bone via a posterior to anterior approach; elevation starts at the arcuate eminence and proceeds anteriorly • The middle meningeal artery is controlled with bipolar cautery and sectioned, the foramen spinosum is packed with bone wax • Greater superficial petrosal nerve(GSPN) is identified and keep intact : dissection follows the GSPN from posterior to anterior until it courses under the third division of the trigeminal nerve (V3)
  • 23. • Glasscock’s triangle – Laterally : foramen spinosum to the facial hiatus – Medially : GSPN – Base : V3 • Kawase’s triangle – Laterally : GSPN – Medially : petrous ridge – Base : Arcuate eminence
  • 24. Anterior petrosal approach • Anteriorly, the mandibular division (V2) is identified at the foramen rotundum • Dissection continues medially to the petrous ridge indenting the superior petrosal sinus • Separation of the dura propia continues until the connective tissues sheath over V2,V3 and the Gaserian ganglion is visible(Meckel’s cave)
  • 25. Anterior petrosal approach • Kawase’s quadrilateral is drilled under microscope at petrous ridge to identify the IAC – The arcuate eminence forms a 120-degree angle to the GSPN (or the internal carotid artery), and the IAC bisects this angle – Follow the geniculate ganglion to the labyrinthine segment of the facial nerve(high incidence of facial nerve injury) • Drilling of the IAC continues to the bone crest dividing the facial nerve and the superior vestibular nerve (Bill’s bar)
  • 26. Anterior petrosal approach • The bone overlying the cochlea is drilled until the cochlea appears as a blue line • After identify of the dura covering the IAC posterior • the Kawase’s quadrilateral is drilled to the – GSPN (preserved) laterally – the petrous segment of the internal carotid artery anterolaterally – V3 anteriorly – the superior petrosal sinus medially – the posterior fossa dura and inferior petrosal sinus inferiorly
  • 27. Anterior petrosal approach • The inferior temporal lobe dura is open above and parallel to the superior petrosal sinus. The dura is reflected inferiorly • The superior petrosal sinus is secured with titanium hemoclips and is split • The tentorium is cut medially toward the tentorial incisura posterior to the dural entry of the trochlear nerve • The posterior fossa dura is further split inferiorly
  • 28.
  • 29. Anterior petrosal approach • After completion of surgical resection • Watertight dural closure is demanding • The IAC bony opening is plugged with a small piece of fat or muscle • The dura is approximated utilizing a synthetic dural graft and is sprayed with fibrin glue. If there is a big filling defect, it can be judiciously obliterated with pieces of fat graft to prevent postoperative fluid collection and cerebrospinal fluid (CSF) leak
  • 30. Anterior petrosal approach • Closure • Bone flaps are connected and fixed with titanium plates and secures • Bony defects are filled with bone cement for cosmetic reconstruction and prevention of CSF leak • We prefer to keep the lumbar drain in place for 48 hours after obtaining an immediate postoperative CT scan
  • 32. Posterior petrosal approach • Temporal craniotomy + presigmoid craniectomy + a small lateral retrosigmoid craniectomy • Depending on the preoperative hearing – retrolabyrinthine or translabyrinthine bony temporal bone drilling is added • Sectioning of the superior petrosal sinus and tentorium, and a relaxing incision in the dura above the lateral transverse sinus – frees the sigmoid sinus and allows mobilization of the sigmoid sinus posteriorly to expand the presigmoid space : crucial step
  • 33. Posterior petrosal approach • Position – Same in anterior petrosal approach – Lateral oblique position • Skin Incision – three fingerbreadths circumferentially around the edge of the ear pinna
  • 34. Posterior petrosal approach • The transverse sinus and the transverse–sigmoid junction are dissected from the overlying bone • Retrolabyrinthine mastoidectomy • Landmark – Spine of Henle : Antrum – After drilling the bone over the sinodural angle, the sigmoid sinus, superior petrosal sinus, and posterior semicircular canal are exposed – Floor of Antrum : Cortical bone of the lateral semicircular canal
  • 35. Posterior petrosal approach • Landmark – Follow lateral semicircular canal : posterior semicircular canal – Follow posterior semicircular canal : superior semicircular canal • The air cells of the mastoid tip are removed to expose the digastric ridge : landmark for the stylomastoid foramen and the beginning of the fallopian canal
  • 36. Posterior petrosal approach • Dura openings – Below temporal lobe : parallel to the superior petrosal sinus – Posterior fossa dura in presigmoid space : longitudinally between superior petrosal sinus and the jugular bulb – Gentle traction on temporal lobe and cerebellum : superior petrosal sinus is sectioned and clipped – Incision dura along transverse sinus – The tentorium is sectioned into the incisura at a point posterior to entrance of the trochlear nerve
  • 38. Posterior petrosal approach • Closure – Pericranium or a synthetic dural graft for close – Open mastoid air cell : wax – The antrum : muscle – The mastoidectomy : abdominal fat graft and sprayed with fibrin glue – Bone flaps : titanium plates
  • 39. Posterior petrosal approach • Closure – Bony defect : bone cement – Temporalis m. is closed – Keep lumbar drain for 48 hrs – Immediate post-op CT scan
  • 41. Lateral Suboccipital Approach • For – petroclival meningiomas involving zones I, II, and III • Exposure – posterior surface of the petrous bone – the anterolateral brain stem – craniocervical junction.
  • 42. Lateral Suboccipital Approach • The lateral oblique position • Key hole : inferomedial to asterion to avoid injury to transverse sigmoid junction • Mastoid bone is drilled to expose medial edge of the sigmoid sinus and the inferior edge of sinus • For tumor extend to zone III : C1 laminectomy and drilling of the posteromedial third of the occipital condyle and lateral mass of C1
  • 43. Lateral Suboccipital Approach • V3 segment of vertebral artery : groove of the C1 lamina • Dural incision : C1, extends superiorly through the foramen magnum, and extends superolaterally to the top of craniotomy edge • Closure – dura is closed watertight – pericranial graft or a synthetic graft – suture line is sprayed with fibrin glue
  • 44. Radiosurgery • < 3 cm in diameter • adjuvant treatment to prevent tumor regrowth and recurrence after maximal safe surgical resection
  • 45. Outcome • Increase post operative morbidity • Preoperative neurologic deficits (diminished Karnofsky Performance Scale score • tumor size of 2.5 cm or more • multiple cranial fossae involvement and cavernous sinus infiltration • absence of arachnoid cleavage plane
  • 46. Outcome • brain stem compression and invasion, brain stem edema • adhesions to and encasement of vascular structures • high vascularity and direct tumor blood supply from the basilar artery • firm tumor consistency affecting the extent of tumor resection

Editor's Notes

  1. Hatch area คือ central clival depression
  2. trans-sylvian transcavernous approach : which involves mobilization of the oculomotor nerve and drilling of the posterior clinoid process and the dorsum sellae