Neurosurg Focus 61(3):E6, 2026
Surgery for a jugular foramen meningioma requires balancing access to several anatomical compartments against the vulnerability of the lower cranial nerves and venous outflow. An apparently satisfactory resection may still carry a substantial functional cost if swallowing or voice deteriorates. Matsushima and colleagues describe a perioperative strategy linking compartment-based exposure, selective embolization, vagus nerve monitoring and structured swallowing assessment. Their series illustrates how deliberate residual tumor can form part of a function-preserving operation, while emphasizing that avoidance of severe disability does not mean absence of postoperative symptoms.
Objective
To describe a function-prioritized surgical workflow for jugular foramen meningiomas and evaluate recovery of oral intake, swallowing and voice outcomes, extent of resection and subsequent treatment for tumor progression.
Methods
This retrospective single-center study included 26 consecutive primary resections performed between 2014 and 2025. Mean age was 45.1 years, with a range of 16–77 years; the cohort therefore was not exclusively adult. Previous surgery for the same lesion was excluded, although one patient previously treated with stereotactic radiosurgery was retained.
Twenty tumors involved the intradural and intrajugular compartments (IJ), and six also extended extracranially (IJE). Imaging assessed tumor extension, vascularity and sigmoid–jugular venous patency. Embolization was performed selectively in 16 patients, and continuous vagus nerve monitoring was implemented in 16. Outcomes included extubation timing, time to oral intake and swallowing and voice status at one year, together with resection extent and salvage treatment during follow-up.
Main results
The principal approaches were suprajugular in 13 patients, retrosigmoid in nine and transjugular transsigmoid in four. All four transjugular cases had extracranial extension and ipsilateral sigmoid–jugular occlusion, illustrating the anatomical selection underlying approach choice.
Gross-total resection was achieved in seven patients, near-total resection in ten, subtotal resection in eight and partial resection in one. Eighteen operations were classified as Simpson grade IV. Residual disease associated with subtotal or partial resection predominantly occupied the intrajugular or extracranial compartments rather than representing persistent intradural tumor bulk. All six IJE tumors underwent subtotal or partial resection.
All patients were extubated immediately after surgery. Twenty resumed oral intake within seven days, five between days eight and fourteen, and one after fourteen days. At one year, swallowing remained worse than baseline in 14 patients (54%) and voice in 12 (46%). Almost all worsening was mild; one patient had moderate impairment of both functions. No patient required tracheostomy, gastrostomy, long-term tube-feeding dependence or phonosurgical intervention. One surgical site infection required bone flap removal, and one CSF leak was managed with lumbar drainage.
All six patients with IJE tumors reported persistent worsening of swallowing and voice, compared with 40% and 30%, respectively, in the IJ group. Median time to oral intake was eight versus two days. These differences should be interpreted in the context of larger tumors, more baseline dysfunction and different operative exposures in the IJE subgroup.
Among monitored patients, lower preservation of vagus response amplitude was associated with worse swallowing at one year in an exploratory analysis. The most symptomatic patient experienced an abrupt decline to zero. During a median follow-up of 55.6 months, three patients underwent salvage radiosurgery for progression. No patient received routine planned adjuvant radiosurgery after limited resection.
Interpretation – operative relevance
The operative corridor was chosen to expose the involved compartments while accounting for venous function. A retrosigmoid approach served predominantly intradural lesions. When additional intrajugular access was necessary, an intradural suprajugular extension allowed drilling of the jugular foramen roof while preserving the sigmoid–jugular venous system. This distinction is useful when intraforaminal exposure is required but functioning venous drainage should be maintained.
For selected extensive IJE tumors with an occluded ipsilateral venous system, the transjugular transsigmoid approach combined posterior mastoidectomy with high cervical exposure. The reported technique included ligation and division of the exposed sigmoid–jugular system to obtain access to the intrajugular and extracranial disease. This describes a strategy used in four anatomically selected cases; it is not evidence that venous sacrifice is generally safe or that an imaging finding of occlusion alone establishes expendability.
Continuous vagus monitoring complemented intermittent nerve mapping. The authors used repetitive direct stimulation at 1 Hz and compared the final evoked amplitude with baseline. Their practical response to declining or unstable signals was to reassess traction, coagulation and dissection planes, accepting residual tumor when further dissection threatened function. The study does not validate a universal amplitude threshold for stopping resection or prove that monitoring independently improves outcomes.
The location of residual tumor is as important as the overall resection category. Deliberately retaining adherent intrajugular, extracranial or paracarotid disease may preserve function after substantial intradural clearance. Reporting both compartmental residual and resection extent is therefore more informative than interpreting Simpson grade IV as a uniform measure of operative inadequacy.
Functional preservation also extended beyond tumor removal. Intraoperative findings and monitoring changes were communicated to anesthesia, while laryngoscopic and swallowing assessment guided oral intake and diet progression. Immediate extubation in this series should be understood within that individualized multidisciplinary workflow, not as a mandatory postoperative target.
Limitations
This is a small retrospective series without a comparator. Approach, embolization and monitoring were selected according to anatomy and clinical judgment, so their individual effects cannot be separated. The extracranial-extension subgroup comprised only six patients and had shorter follow-up, limiting conclusions about durable tumor control. Swallowing and voice were assessed with clinical severity categories rather than comprehensive patient-reported instruments. The age range includes an adolescent, and aggregate outcomes cannot be treated as exclusively adult results. The association between monitoring amplitude and swallowing is exploratory rather than a validated predictive rule.
Clinical takeaway
Use compartmental extension and functional venous anatomy to plan exposure, and let the lower cranial nerve interface define the safe boundary of resection. Monitoring can inform reassessment during dissection, while deliberate residual disease requires a documented surveillance and salvage strategy. The central achievement in this series was avoidance of severe dependency, not elimination of swallowing and voice morbidity—a distinction that belongs in both surgical planning and patient counseling.