| Petroclival meningioma which is deep in the middle of the skull base is the most frequent tumor arising in the petroclival region. It account for approximately 5% of the intracranial meningiomas. It tends to grow slowly and may produce symptoms only when its volume becomes huge with the involvement of the cranial nerves, and compression of the brainstem and the basilar artery. Petroclival meningioma is the most formidable challenge for most neurosurgeons because of its proximity to critical neural and vascular structures and because of its large size at diagnosis. During the past decades, major advances have been made in microsurgical techniques for skull base surgery. However, there is still a high morbidity and mortality with the overly aggressive surgical goals. Now more and more neurosurgeons have recognized that radical resection seems to be incompatible with good postoperative quality of life in some cases. On the basis of this experience, when we make the therapeutic strategy for a patient, we should make the decision of surgical extent of resection cautiously, choose the surgical approach properly and pay more attention to the clinical application of the radiotherapy.Objective: To investigate the extent of tumor resection,the choice of surgical approach and the clinical application of the radiotherapy.Patients and Methods: We retrospectively reviewed the medical records of patients with a petroclival meningioma treated at our institution between January 2000 and October 2009. Diagnoses were made on the basis of intraoperative findings and/or postoperative pathology. 14 patients were men and 37 patients were women (ratio, 1:2.6). The ages of the patients in this study ranged from 20 to 40 years (mean age, 47.6 yr; median age, 49 yr). The mean courses of disease in this study were 2 years and 50 days, ranged from 5 days to 18 years. The hospital days of the patients ranged from 10 to 50 days (mean, 20.7 days). Signs and symptoms at presentation were, dizziness (n=20, 39.22%), headaches (n=23, 45.10%), tinnitus (n=18, 35.29%), decreased hearing (n=23, 45.10%), facial hypoaesthesia (n=26, 50.98%), facial anesthesia (n=20, 39.22%), facial chorea (n=1, 1.96%), facial paresis (n=7, 13.73%), gait disturbance (n=28, 54.90%), diplopia (n=7, 13.73%), hoarse voice (n=3, 5.88%), hydroposia bucking (n=22, 43.14%), limb weakness (n=10, 19.61%), seizures (n=1, 1.96%). Preoperative performance status of all patients was evaluated using the Karnofsky Performance Scale, and the mean preoperative score was 78.84, ranged from 68 to 90.MRI results were evaluated before surgery for all patients, CT scan was performed in 25 patients, and, in one case, DSA was performed. All the patients were classified according to the tumor size (maximal tumor diameter) as giant (n=21), large (n=25), medium (n=3), or small (n=2). The relationship between the tumor and the brainstem was classified according to Kawase grading scale as gradeâ… (n=31), gradeâ…¡(n=11), gradeâ…¢(n=9). According to Sekhar-Monaci assignment system, there were 4 patients in low risk group, 47 patients in moderate risk group, no patient in high risk group.Microsurgical removal of the tumor was performed in all patients on the state of general anesthesia. Surgical approach was predicated on the tumor size, the location and extension of the tumor, and the preoperative performance status of patients. Subtemporal- transtentorial approach was used in 31 patients, presigmoid approach was used in 3 patients and suboccipital-retrosigmoid approach was used in 17 patients.Results: According to intraoperative inspection and postoperative radiological evaluation, gross total resection (Simpson Grade I or II) was achieved in 40 patients (78.43%), subtotal resection (Grade III) was achieved in 9 patients (17.65%), partial resection was achieved in 2 patients (3.92%). All the patients with incomplete tumor resection underwent radiotherapy sequentially after surgery. Nine patients (17.65%) in this series experienced postoperative facial nerve palsy. The facial nerve palsy disappeared in 3 patients when they were discharged, improved in 4 patients 3 months after surgery. Two patients had persistent facial nerve palsy. Eleven patients (21.57%) presented conscious disturbance which improved 6 months after surgery. Fifteen patients (9.41%) presented limb weakness which improved during the follow-up period. Twenty-two patients (43.14%) experienced postoperative oculomotor nerve palsy which disappeared 3 months after surgery. Six patients (11.76%) presented abducent nerve palsy. In 3 patients the abducent nerve palsy improved during the follow-up period. Intracranial infection happened in 3 patients (5.88%) who were discharged from hospital as cured. In 21 patients the preoperative decreased hearing disappeared after tumor removal. Two patients had persistent decreased hearing. Two patients died after surgery. One 42-year old female patient who had hypertension, diabetes and chronic glomerulonephritis preoperative died after surgery due to pulmonary infection, the other patient died after surgery due to other reasons irrelative to the petroclival meningomas. Outcomes of the survivals were graded according to Samii grading scale: excellent (n=31), good (n=10), poor (n=8). Follow-up period of all the survivals ranged from 6 to 18 months. Tumor did not recur or regrow during the follow-up period.Conclusion:â‘ Total surgical removal is the only treatment that may cure this benign tumor, however, it usually causes serious postoperative complications. The policy of incomplete resection of petroclival meningioma in patients at surgical risk is therefore a reasonable selection. Subtotal resection and partial resection have a significantly better quality of life for patients, especially with postoperative radiotherapy which can control the residual tumor growth and reduce the tumor recurrence effectively.â‘¡There are Several surgical approaches to remove the petroclival meningioma, each approach has its advantages and disadvantages. We can choose surgical approach for each patient individualized, according to the preoperative performance status.â‘¢Radiotherapy can effectively control the tumor growth and improve the clinical symptoms. |
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