Leczenie operacyjne oponiaków tylnej ściany piramidy kości skroniowej

Background and purpose The aim of the study is to present our experience in the surgical treatment of posterior petrous meningiomas in regard to clinical presentation, surgical anatomy, complications and long-term functional postoperative results. Material and methods A series of 48 consecutive patients operated on for posterior petrous meningiomas at the authors’ institution between 2002 and 2011 is reported. The main symptom on first admission was hypoacusis, impairment of the fifth cranial nerve and cerebellar ataxia. The tumour was found to be attached to the premeatal dura in 46%, the inframeatal dura in 29% and the postmeatal dura in 25% of cases. Tumour resection was categorized as grade I in 16 patients, grade II in 29 patients, grade III in 1 patient and grade IV in 2 patients, according to the Simpson classification system. The petrosal approach and retrosigmoid approach were suitable for posterior petrous meningiomas. Results Postoperative facial nerve dysfunction appeared in 8 and further deteriorated in 2 patients. Hearing function deteriorated after surgery in 8 and improved in 2 cases. Perioperative death occurred in two patients. Tumour recurrence was observed in two patients, and both underwent a second operation and postoperative stereotactic radiotherapy. Conclusions Surgical treatment of posterior petrous meningiomas has become increasingly safe but these tumours still remain a surgical challenge because of the relatively high incidence of permanent complications associated with their removal. The site of displacement of the cranial nerves depending on the dural origin of the tumour has the most influence on the related difficulties in its removal.Wstęp i cel pracy Celem pracy jest przedstawienie własnych doświadczeń w leczeniu operacyjnym oponiaków tylnej ściany piramidy kości skroniowej z uwzględnieniem objawów klinicznych choroby, anatomii chirurgicznej, powikłań pooperacyjnych i odległej oceny stanu neurologicznego. Materiał i metody Materiał kliniczny obejmuje kolejnych 48 chorych leczonych operacyjnie w naszym ośrodku w latach 2002–2011 z rozpoznaniem oponiaka tylnej ściany piramidy kości skroniowej. W badanej grupie były 44 kobiety i 4 mężczyzn, a średnia wieku pacjentów wyniosła 55 lat. Najczęstszymi objawami stwierdzanymi przy przyjęciu pacjenta były niedosłuch, zaburzenia funkcji nerwu trójdzielnego i ataksja móżdżkowa. Przyczep guza zlokalizowany był do przodu, poniżej i do tyłu od otworu słuchowego wewnętrznego odpowiednio u 46%, 29% i 25% pacjentów. Guz usunięto całkowicie w 45 przypadkach (Simpson I i II), a subtotalnie u 3 pacjentów (Simpson III i IV). Guzy usuwano drogą dostępu podpotylicznego zasutkowego i dostępu przezskalistego. Wyniki Po operacji u 8 pacjentów wystąpiło porażenie nerwu twarzowego, a u 2 chorych nasilił się niedowład uprzednio istniejący. U 8 pacjentów zaobserwowano pogorszenie słuchu po operacji, a u 2 chorych nastąpiła poprawa w tym zakresie. Dwóch pacjentów po operacji zmarło. W 2 przypadkach stwierdzono w dalszej obserwacji wznowę guza. Obu pacjentów operowano ponownie i poddano stereotaktycznej radioterapii. Wnioski Oponiaki tylnej ściany piramidy kości skroniowej mogą być leczone operacyjnie z dobrym wynikiem, niemniej jednak istnieje ryzyko zgonu i wystąpienia istotnych deficytów z zakresu nerwów czaszkowych. Najistotniejsze znaczenie dla oceny ryzyka leczenia ma lokalizacja przyczepu oponowego na podstawie czaszki, decydująca o kierunku przemieszczenia nerwów czaszkowych

Surgery for sporadic vestibular schwannoma. Part II. Complications (not related to facial and auditory nerves)

Introduction The aim of this study was to analyze the frequency and consequences of postoperative complications (PC) after surgery for sporadic vestibular schwannoma and to find factors that increase the risk of PC occurrence. Materials and methods The study included 220 consecutive patients (134 women, 86 men; age ranged from 18 to 74) operated on with the retrosigmoid (217) or translabyrinthine (3) approach. Complicated postoperative period was defined as an occurrence of at least one of: cerebrospinal fluid (CSF) leakage, hematoma in the tumor bed, intracerebellar hematoma, cerebellar swelling, brainstem stroke, hydrocephalus (HCP), healing problems, meningitis and cranial nerves (excluding VII–VIII) palsies or cerebellar symptoms. Correlation studies and multivariate regression analysis were performed. Results PC occurred in 55 patients (25%). PC included lower cranial nerve (LCN) palsy (8.2%), cerebellar symptoms (7.3%), CSF leakage (5.9%), HCP (5%), CNVI palsy (3.1%), meningitis (1.8%), cerebellar swelling (1.4%), CNV dysfunction (0.9%), intracerebellar hematoma (0.5%) and lethal brainstem stroke (0.5%). In long term follow-up, LCN deficit was present in 2 patients (0.9%), cerebellar syndrome in 4(1.8%) and facial hypoesthesia in 2(0.9%). One patient (0.5%) developed bilateral blindness, secondary to preoperative optic nerve atrophy. As a result of PC, 10 patients (4.5%) required 11 additional surgical procedures. In statistical analysis, PC were independently related to preoperative cerebellar syndrome (p=0.002) and tumor size (>30mm vs.<30mm, p<0.05). The risk of PC diminished significantly with the increased number of performed procedures from 40% at the beginning to 16.4% in the last 55 cases. Conclusions Tumor size, cerebellar syndrome at presentation and experience of the team were the three most important risk factors for PC occurrence. Permanent deficit secondary to PC remained in only 4% of the patients

Surgical treatment of parasagittal and falcine meningiomas invading the superior sagittal sinus

Objective We present our experience with surgery of parasagittal and falcine meningiomas invading the superior sagittal sinus with special consideration of the surgical complications and the incidence of tumour recurrence. Materials and methods The analysis included 37 patients with parasagittal and falcine meningiomas invading the superior sagittal sinus. In 13 cases, the sinus was ligated and resected with tumour. In 14 cases, the sinus was entered with the goal of tumour resection and the sinus was reconstructed, while in 10 patients the sinus was not entered and the remaining residual tumour was observed for growth. Results Out of 13 patients after radical resection of the tumour and invaded part of sinus, 9 revealed haemodynamic complications: venous infarction (4), significant brain oedema (3) and hypoperfusion syndrome (2). 2 out of 14 patients after resection of the tumour from the lumen of the superior sagittal sinus with subsequent sinus repair developed venous infarction after surgery. Among 27 patients after radical tumour excision the remote follow-up revealed recurrence in 2 patients. There were no significant haemodynamic complications in none of 10 cases, in which the residual tumour was left after surgery in the superior sagittal sinus. In this group, 3 cases were subjected to early post-operative radiotherapy and local recurrence was observed in 4 patients. Conclusions The aggressive surgical treatment of meningiomas infiltrating the superior sagittal sinus is associated with a high surgical risk. The incidence of recurrence of these tumours increases significantly in the case of non-radical excision of the tumour

Surgical treatment of jugular foramen schwannomas

Objective We present our experience with surgery of jugular foramen schwannomas with special consideration of clinical presentation, surgical technique, complications, and outcomes. Methods This retrospective study includes ten patients with jugular foramen schwannomas treated by the senior author between January 2007 and December 2012. Three patients had undergone partial tumour resection elsewhere. The initial symptom for which they sought medical help was hearing loss, dysphagia, hoarseness, and shoulder weakness. Preoperative glossopharyngeal and vagal nerve deficits were the most common signs. In our series, tumour extension was classified according to Kaye-Pellet grading system. In two cases the tumours were classified into type A and 8 patients presented with type D tumours. A retromastoid suboccipital craniotomy was performed for type A tumours and modifications of cranio-cervical approach were suitable for type D. Results No death occurred in this series. Four patients deteriorated after surgery: in two patients preoperative cranial nerve deficits deteriorated after surgery while new cranial nerve palsy occurred in 2 other patients. In four patients, the cranial nerve dysfunction had improved at the last follow-up examination. In all other patients, the cranial nerve dysfunction remained the same. One patient experienced tumour recurrence over a follow-up period of 40 months. This patient underwent a successful second surgery without further evidence of tumour growth. Conclusions Jugular foramen schwannomas can be radically managed with the use of skull base surgery techniques. However, the surgical treatment of jugular foramen schwannomas carries a significant risk of the lower CN deficits

Surgical treatment of jugular foramen meningiomas

Object We present our experience with surgery of jugular foramen meningiomas with special consideration of clinical presentation, surgical technique, complications, and outcomes. Methods This retrospective study includes three patients with jugular foramen meningiomas treated by the senior author between January 2005 and December 2010. The initial symptom for which they sought medical help was decreased hearing. In all of the patients there had been no other neurological symptoms before surgery. The transcondylar approach with sigmoid sinus ligation at jugular bulb was suitable in each case. Results No death occurred in this series. All of the patients deteriorated after surgery mainly due to the new lower cranial nerves palsy occurred. The lower cranial nerve dysfunction had improved considerably at the last follow-up examination but no patient fully recovered. Two of three patients with preoperatively impaired yet functional hearing deteriorated after surgery with no subsequent cranial nerve VIII function improvement. In one case postoperative stereotactic radiosurgery was performed due to non-radical tumour resection (Simpson Grade IV) and tumour remnant proved stable in the 4-year follow-up. None of the patients have shown signs of tumour recurrence in the mean follow-up period of 56 months. Conclusions Jugular foramen meningiomas represent one of the rarest subgroups of meningiomas and their surgical treatment is associated with significant risk of permanent cranial nerve deficits

Surgery for sporadic vestibular schwannoma. Part I: General outcome and risk of tumor recurrence

Background Vestibular schwannomas are slow growing, benign tumors. There are three possible management options: surgery, radiation treatment or active surveillance. The aim of this study was to assess the general outcome and risk of tumor recurrence. Materials and methods The study included 220 consecutive patients (134 women, 86 men; the age ranged from 18 to 74) operated with the retrosigmoid transmeatal approach. The largest extrameatal diameter of the tumor ranged from 8 to 72mm (mean 30mm). According to the Samii grading scale, the tumors were classified as follows: T2–12 (6%), T3–51 (23%) and T4–157 (71%). Gross total resection was performed in 217 patients and neartotal in 3. Results Two hundred and eighteen (99.1%) patients were discharged home in a satisfactory neurological condition (GR or MD in GOS). One (0.5%) patient died due to brainstem infarction. One (0.5%) patient had unchanged severe cerebellar syndrome in comparison to the preoperative period (SD in GOS). In long-term follow-up, one patient went blind within a few months after surgery. Including the results of further neurosurgical procedures for CSF leak, shunt implantation, tumor regrowth and facial nerve reanimation, 98.6% of the patients were fully independent but with different neurological deficits. Tumor recurrence was observed in 5 (2.3%) patients during the follow-up period (mean term: 6.4 years). The average time to recurrence diagnosis was 8.8 years. All those patients were operated on again without any adjuvant therapy and there was no further re-growth at mean follow-up of 5.2 years. Conclusions Complete removal of VS is usually curative and poses very low risks of severe disability (if audio-facial sequels are not included), mortality and long-term recurrence. For recurrent tumors, carefully tailored revision surgery without irradiation offers a high efficacy with low risk of complications

Clinical course and management of intracranial meningiomas in neurofibromatosis type 2 patients

Objective The aim of this study is to evaluate our surgical experience with intracranial meningiomas in NF2 patients and provide knowledge of the natural history of these lesions. Methods We included in the natural growth study patients with the diagnosis of NF2 who harbored intracranial meningiomas and were observed for at least 1 year. Tumors that were resected before achieving long-term follow-up were excluded from this analysis. Results We found 118 intracranial meningiomas in 34 patients in our series. 8 meningiomas in 7 patients were symptomatic. It was found that with an increase in tumor volume, brain edema and with the tumor location at the skull base, meningiomas are more likely to be symptomatic. Univariate analysis revealed that tumor growth was associated with a younger age at the onset of NF2-related symptoms, greater initial tumor volume, brain edema and with the presence of intracranial non-vestibular schwannoma. Multivariate analysis showed that the probability of tumor growth is associated with prolonged follow-up time. De novo meningiomas exhibited a significantly higher growth rate than other meningiomas. These tumors were more frequent in patients with intracranial non-vestibular schwannoma and with increasing length of meningioma observation. Conclusion Meningiomas occur in about half NF2 patients. Many of them exhibit slow growth and long remain asymptomatic, however, those associated with early onset of NF2 symptoms and other features of the disease severity should be monitored in case of clinical and radiological progression that may require surgical treatment

Falcotentorial and velum interpositum meningiomas: Two distinct entities of the pineal region

Objective Among pineal region lesions meningiomas are extremely rare and include falcotentorial and velum interpositum meningiomas. It is very difficult to discriminate between these two lesions and description of the clinical presentation and the surgical technique in approaching these tumors is limited. We respectively analyzed a series of patients harboring pineal region meningiomas with regard to clinical features, neuroimaging studies, and results of surgical treatment. Methods Clinical data of 5 women and 1 man with pineal region meningiomas treated between January 1993 and December 2012 were retrospectively reviewed. All patients were assessed preoperatively with MRI and cerebral angiography. The only surgical approach we used was occipital transtentorial route. Results There were four falcotentorial and two velum interpositum meningiomas. The main presenting symptom was headache, dizziness and gait disturbance. The angiogram revealed that these tumors were fed by tentorial artery, posterior choroidal arteries, and branches of the posterior cerebral artery and in four cases additional evidence of occlusion of the galenic venous system was seen. Two patients had total resection (Simpson Grade I and Grade II) and in four patients small remnants of tumor were left (Simpson Grade III). No death occurred in this series. The most common complication after surgery was homonymous hemianopsia which fully recovered in all patients in the follow-up. Conclusion The falcotentorial and velum interpositum meningiomas can be safely managed with the use of occipital transtentorial approach. Homonymous hemianopsia is the most common although always transient complication of surgery