Tag: Tentorial meningioma

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Transzygomatic approach with anteriorly limited inferior temporal gyrectomy for large medial tentorial meningiomas

Transzygomatic approach with anteriorly limited inferior temporal gyrectomy for large medial tentorial meningiomas

Acta Neurochir (2015) 157:1747–1756

Tentorial meningiomas near the middle third of the medial tentorial edge with supratentorial extension are usually removed via the subtemporal approach. This approach, however, may not be practical, especially for huge tumors extending to the posterior subtemporal space. This study describes the use of the transzygomatic approach with anteriorly limited inferior temporal gyrectomy (TZ-AITG) to remove these large tumors.

Methods Between 2008 and 2012, five patients with symptomatic tentorial meningiomas (median diameter, 5.2 cm; range, 4.0–5.7 cm) near the middle third of the medial tentorial edge with supratentorial extension underwent TZAITG, consisting of zygomatic osteotomy, low-positioned craniotomy, and resection of the inferior temporal gyrus around 4 cm from the tip.

Results Tumors were completely resected in all patients. Postoperatively, none had a newly developed neurological morbidity, and none died. Of three patients with preoperative hemianopia, two showed improvement and one remained stationary. One patient with preoperative hemiparesis recovered completely. All patients returned to their normal activities during the follow-up period. Surgical morbidities included epidural hematoma and chronic subdural hematoma in one patient each, with both requiring evacuation.

Conclusions TZ-AITG may be a good alternative to the subtemporal approach for large tentorial meningiomas near the middle third of the medial tentorial edge. TZ-AITG provides access to the lesions and visualization of the middle fossa, facilitating early feeder control while minimizing brain retraction, thus reducing potential injury to the vein of Labbé. TZ-AITG is also safe and feasible in minimizing neurological compromise.

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Tentorial meningiomas with special aspect to the tentorial fold: management, surgical technique, and outcome

Acta Neurochir (2010) 152:827–834. DOI 10.1007/s00701-009-0591-z

From a surgical perspective, tentorial fold (TF) meningiomas (TFM) are a unique entity of tumors. They involve the supra- and infratentorial space and often are in close contact to the cavernous sinus, cranial nerves, and the mesencephalon. Complete resection is challenging and can be hazardous. We present our experience with this rare tumor entity and demonstrate the surgical outcome related to a topographical classification.

Methods A retrospective analysis on 21 consecutive patients (female/male ratio 17/4) with meningiomas originating from the TF, who underwent surgery between 1992 and 2005 in our clinic, was performed. The follow-up period ranged from 6 to 93 months. The cases were classified according to tumor extension in three different types: type I, TF meningiomas with compression of the brain stem; type II, with extension into the anterior portion of middle fossa; and type III, a combination of type I and II. Depending on tumor location, surgical approaches consisted of pterional (nine cases), subtemporal (nine cases), or combined subtemporal–pterional craniotomies (three cases). We defined transient and persistent operative complications in relation to Simpson grade and TF classification.

Results Tumor size ranged from 1 to 6 cm in diameter, with a median at 2.5 cm. The presenting symptoms of the patients were anisocoria (six cases), diplopia (six cases), ptosis (five cases), hemianopia (four cases), and ataxia (two cases). Extent of tumor resection was Simpson grade II in 19 patients, grade III in one patient, and grade IV in one patient. There was no operative mortality (first 30 days after surgery). The rate of postoperative transient new neurological deficits was found at 9.5%, the rate of permanent at 33%. The neurological deficits at admission recovered in two patients.

Conclusion In the majority of patients with TF meningiomas, total resection can be achieved through a pterional, subtemporal, or combined approaches but at a substantial toll in terms of permanent morbidity. Radiotherapy after volume reductive surgery in TFM type II and III and decompression of eloquent anatomical structures with low tolerance of radiation should be considered.

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Tentorial meningiomas: operative nuances and perioperative management dilemmas

Acta Neurochir (2009) 151:1037–1051.DOI 10.1007/s00701-009-0421-3

Tentorial meningiomas (TM), comprising approximately 3–6% of all intracranial meningiomas, are complex entities with an intricate relationship to surrounding structures and require multiple surgical approaches. In the present study, the rationale for deciding the approaches for TMs and the perioperative management dilemmas were evaluated.
Methods  Thirty-seven patients (28 primary [supratentorial (2), infratentorial (20) and both (6)] and nine complex [cerebellopontine (CP) angle (5) and petroclival (4)] TM) underwent surgery using the occipital transtentorial, supracerebellar infratentorial, subtemporal transtentorial, bioccipital suboccipital, midline suboccipital, retrosigmoid, and combined pre and retrosigmoid approaches. The extent of excision was categorized according to Simpson’s grade.
Results  Simpson’s grade of excision was I in six, II in 11, III in nine and IV in 11 patients, respectively. Follow-up assessment (2 months to 9 years) in 27 patients (72.9%) showed that 23 patients returned to their previous activity level with either no or minimal symptoms, three returned to previous activity level with major cranial nerve palsy, and one patient required permanent assistance. One patient had recurrence and four others underwent resurgery for residual tumor. Two patients with petroclival lesions died due to aspiration pneumonitis and meningitis, respectively; one with CP angle TM presented in a poor general condition and expired following emergency ventriculoperitoneal shunt and subsequent definite surgery. Pseudomeningocele, cerebrospinal fluid leak, and cranial nerve palsy were the major morbidities.
Conclusions  Classifying TM into medial and lateral, supra and infratentorial groups helps in deciding an appropriate and safe approach. Meticulously preserving venous sinuses is important since the risk of venous infarction cannot be predicted even with radiological good venous collaterization and apparent venous sinus blockade by tumor. Laterally situated tumors carry a better prognosis when compared to the medially situated ones. Leaving a small residual tumor in an effort to preserve important neurovascular structures does not obviate the expectation of a good long-term prognosis with minimal morbidity and low recurrence rates.

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