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Lateral suboccipital retrosigmoid approach with tentorial incision for petroclival meningiomas: technical note.

ABSTRACT: Introduction The resection of petroclival meningiomas presents great neurosurgical challenges. Although multiple surgical approaches have been developed, the retrosigmoid route tends to be used to address tumors that are predominantly located in the posterior fossa. Our modification of the lateral suboccipital retrosigmoid approach with the placement of a tentorial incision yields good visualization of the supratentorial part of the tumor around the midbrain. Methods We treated four patients, one with primary and three with recurrent petroclival meningioma, by our modified approach. After lateral suboccipital craniotomy, the infratentorial part of the tumor was removed after detaching it from the tentorial surface. The cerebellar tentorium was then carefully incised from the supracerebellar angle, taking care not to damage the superior cerebellar artery and trochlear nerve. Results The operative field surrounding the midbrain was widened by this procedure, and safe dissection of the tumor from the brainstem and other neurovascular structures was performed with direct observation of the interface. Conclusions Our approach is a useful modification of the retrosigmoid approach to petroclival meningiomas. It facilitates the safe resection of the supratentorial part of the tumor in the ambient cistern behind the tentorium.

SUBMITTER: Yamahata H

PROVIDER: S-EPMC4108484 | biostudies-other | 2014 Aug

REPOSITORIES: biostudies-other

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Project description:With the advent of microsurgery and surgical techniques, along with the improvement in neuroimaging techniques and the microanatomy in cadaver study, improvement in terms of surgical morbidity and mortality has been remarkable; however, controversy still exists regarding the optimal surgical strategies for giant petroclival meningiomas (GPMs). We report a study of clinical and radiological features as well as the surgical findings and outcomes for patients with GPM treated at our institution over the past 6 years. During a 6-year period (April 2004 to March 2010), 16 patients with GPM underwent surgery by subtemporal transtentorial petrosal apex approach during which electrophysiological monitoring of cranial nerves and brainstem function were reviewed. There were nine females and seven males with a mean age of 56.9 years (range from 32 to 78 years). The most frequent clinical manifestations were headache (93.7%) and dizziness (93.7%). Regions and directions of tumor extension include clivus, parasellar, and cavernous sinus, as well as compression of brainstem, and so on. The trochlear nerve was totally wrapped in nine cases (56.2%). The postoperative Karnofsky Performance Scale (KPS) score was 76.3 ± 13.1. Mean maximum diameter of the tumors on magnetic resonance imaging was 5.23 cm (range, 4.5 to 6.2 cm). Subtemporal transtentorial petrosalapex approach was performed in all 16 cases. Gross total resection was achieved in 14 cases (87.5%) and subtotal resection in 2 cases (12.5%) with no resultant mortality. Follow-up data were available for all 16 patients, with a mean follow-up period of 28.8 months (range from 4 to 69 months), of which 11 (68.75%) lived a normal life (KPS, 80-100). Our suggestion is that GPM could be completely resected by subtemporal transtentorial petrosalapex approach. The surgical strategy of GPM should be focused on survival and postoperative quality of life. Microneurosurgical technique plays a key role in tumor resection and preservation of nerve function. Intraoperative electrophysiological monitoring also contributes dramatically to the preservation of the nerve function. Complete resection of the tumor should be attempted at the first operation. Any remnant is treated by radiosurgery.

Project description:Background The standard incision for far-lateral suboccipital approaches has been the classic "reverse hockey stick." Although that incision provides ample exposure, concern has been raised that excessive muscle dissection and skin elevation might lead to accumulation of cerebrospinal fluid (CSF) under the flap with increased risk of CSF leak. We hypothesize that the C-shaped incision can minimize the amount of muscle dissection and provide optimal exposure and surgical outcomes. Objective To describe the anatomical dissection for the C-shaped incision and clinical application of the C-shaped incision for the far-lateral approach. Methods A retrospective analysis of all the patients operated on at our center using this approach for the treatment of aneurysm of the posterior inferior cerebellar artery (PICA) from 2005 to 2011. Results of clinical and operative outcome are evaluated. Surgical techniques are described in detail. Cadaveric dissections using the C-shaped incision were performed to assess the exposure of the far-lateral suboccipital area. Results Eleven consecutive patients who had undergone this procedure were selected. All patients underwent clipping of PICA aneurysms. Nine patients (82%) presented with ruptured aneurysms and subarachnoid hemorrhage. All of them underwent suboccipital craniectomy and C1 laminectomy. The dura mater was closed in a watertight fashion in 10 patients (91%). No CSF leak or pseudomeningocele were reported. In nine SAH patients, two (22%) had postoperative dysphagia and required long-term percutaneous endoscopic gastrostomy tube placement. One patient (11%) had chronic respiratory failure and required a tracheostomy. Three patients (33%) developed hydrocephalus and required a ventriculoperitoneal shunt. Conclusions The C-shaped incision is a valid alternative to the classic reverse hockey-stick incision to gain exposure for far-lateral craniotomies. Knowing the anatomy and dissection techniques can provide an easy and safe route to address anterior lateral cranial-cervical lesions. Our results suggest the C-shaped incision is reliable in preventing CSF leak and the formation of pseudomeningocele.

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Lateral suboccipital retrosigmoid approach with tentorial incision for petroclival meningiomas: technical note.

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