Large and giant medial sphenoid wing meningiomas involving vascular structures: clinical features and management experience in 53 patients.

BACKGROUND: Large and giant medial sphenoid wing meningiomas that are located deeply in the skull base where they are closely bounded by cavernous sinus, optic nerve, and internal carotid artery make the gross resection hard to achieve. Also, this kind of meningiomas is often accompanied by a series of severe complications. Therefore, it was regarded as a formidable challenge to even the most experienced neurosurgeons. This study aimed to investigate the clinical features and management experience of patients with large and giant medial sphenoid wing meningiomas. METHODS: In this study, 53 patients (33 female and 20 male, mean age of 47.5 years) with large and giant medial sphenoid wing meningiomas were treated surgically between April 2004 to March 2012, with their clinical features analyzed, management experience collected, and treatment results investigated retrospectively. RESULTS: In this study, gross total resection (Simpson I and II) was applied in 44 patients (83%). Fifty-three patients had accepted the routine computed tomography scan and magnetic resonance imaging scan as postoperative neuroradiological evaluation. Their performance showed surgical complications of vascular lesions and helped us evaluate patients' conditions, respectively. Meanwhile, the drugs resisting cerebral angiospasm, such as Nimodipine, were infused in every postoperative patient through vein as routine. As a result, 11 patients (21%) were found to have secondary injury of cranial nerves II, III, and IV, and nine patients got recovered during the long-term observing follow-up period. Temporary surgical complications of vascular lesions occurred after surgery, such as cerebral angiospasm, ischemia, and edema; 24 patients (45%) appeared to have infarction and dyskinesia of limbs. Overall, visual ability was improved in 41 patients (77%). No patient died during the process. CONCLUSIONS: Microsurgical treatment may be the most effective method for the large and giant medial sphenoid wing meningiomas. The surgical strategy should focus on survival and postoperative living quality.

Subtemporal transtentorial petrosalapex approach for giant petroclival meningiomas: analyzation and evaluation of the clinical application.

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.

Subtemporal transpetrosal apex approach: study on its use in large and giant petroclival meningiomas.

BACKGROUND: The subtemporal transtentoral approach has been reported for nearly two decades; however it was not well used due to some limitations in dealing with large and giant petroclival meningiomas. The clinical outcome and merit of the modified subtemporal transpetrosal apex approach in large and giant petroclival meningiomas, as well as the choices, the improvements and the therapy strategies of the microsurgical approach in such patients were evaluated in this study. METHODS: Totally 25 cases of large and giant petroclival meningiomas undergone the modified subtemporal transpetrosal apex approach between April 2004 and January 2010 were enrolled in this study. The choice and improvement of the approach, the basis of anatomy and related research, the effect of accessory equipment, the exposure of tumor and the changes of neurofunction pre- and post-operation were all reviewed retrospectively. The operation outcomes and complications in this approach were also compared with those in the transpetrous presigmoid approach done in 14 cases in the same period. RESULTS: All 25 cases underwent the modified subtemporal transpetrosal apex approach under electrophysiologic monitoring of cranial nerves and brain stem function. Trochlear nerve was partly wrapped in 14 cases, totally wrapped but can be explored in the initial segment of the cerebellum tentorium in 8 cases, totally wrapped and could not be seen until tumor was partly removed in 3 cases. The cerebellum tentorium was cut along the temporal bone from the anterior part of the apex to the mastoid part of superior petrous sinus in 6 cases, from the posterior part of the apex to the mastoid part of superior petrous sinus in 19 cases. Gross tumor resection was accomplished in 17 (68%) patients, subtotal resection in 7 (28%) patients, and partial resection in 1 (4%) patient. The most common postoperative complication was new neurological deficits or aggravations of preexisting deficit (64%). Follow-up ranged from 3 to 69 months. Compared with the transpetrous presigmoid approach done in 14 cases in the same period, the modified subtemporal transpetrosal apex approach showed obvious advantages such as simplicity in manipulating, microinvasiveness, less time-consuming, less complication, higher rate of tumor resection though the rates of gross tumor resection might be of no significant difference. CONCLUSIONS: Modified subtemporal transpetrosal apex approach has obvious advantages compared with the transpetrous presigmoid approach. Some complications need to be solved by practice and modification of the approach as well as the accumulation of the experiences.

[Microanatomic and three-dimensional reconstruction study of lateral wall and related structures of optic canal].

OBJECTIVE: To investigate the key microanatomic and radiological structures of optic canal comprehensively so as to provide anatomic parameters and procedural flows for the decompression of optic canal. METHODS: Gross observations and microscopic measurements were applied on 10 (20 sides) formalin-treated cadaveric specimens and 15 (30 sides) adult skulls. Using multislice helical CT (computed tomography)-aided three-dimensional reconstruction in combination with direct anatomic measurement, the investigators dissected, photographed, measured and analyzed the shape of optic canal and analyze its anatomic relationship with the adjoining structures. RESULTS: Optic canal was formed by the superior, inferior, medial and external walls and distal proximal opening. The lateral wall of optic canal was formed by anterior clinoid process with a length of (9.87 ± 1.34) mm, a width of (11.66 ± 2.35) mm, a base thickness of (5.35 ± 1.07) mm and a middle thickness of (4.50 ± 1.06) mm. Optic strut separating the optic canal from the superior orbital fissure was located inferiorly. And the distance between the apex of anterior clinoid process and the middle of ICA (internal carotid artery) groove was (4.25 ± 2.30) mm. The CSF (cerebrospinal fluid) leakage and secondary injury of optic nerve and injury of ICA, ophthalmic artery might occur during the surgical procedures due to the variation of anterior clinoid process. The microanatomic figures and radiological measurements had a mean difference very close to each other at (0.08 - 0.48) mm. No statistical difference was found (P > 0.05). CONCLUSION: Optic nerve, ophthalmic artery and ICA may be exposed by a high-speed drilling of the lateral wall of optic canal. The drilling dissection of lateral wall plays a vital role during a successful optic canal decompression. Radiological measurement and three-dimensional reconstruction of skull base may be of great clinical significance in lesion visualization. And it helps to make a better choice of surgical approaches. The measurements provide valuable references for surgeons and researchers.

[Microsurgery treatment with aneurysm on the top of basilar artery].

OBJECTIVE: To explore the efficacy and method of microsurgery for aneurysm on the top of basilar artery. METHODS: The investigators analyzed retrospectively the clinical data of 8 microsurgical patients with aneurysm on the top of basilar artery from May 2007 to September 2010. There were 5 males and 3 females with an average age of 52.6 years old. Six of 8 cases underwent clipping of aneurysm while other 2 patients received superficial temporal artery-radial artery-posterior cerebral artery bypass grafting surgery and clipping of aneurysm. RESULTS: On the basis of GOS (Glasgow outcome score), the postoperative recovery was excellent in 7 patients. And 1 patient suffered insufficiency of oculomotor nerve similarly as preoperatively. CONCLUSION: The surgical procedures for aneurysm of basilar artery are so complicated as to lead to many complications. A wise choice of operative approaches may yield a better outcome.

[Outcomes of early surgery combined with anti-vasospasm agents treat ruptured cranial aneurysms: an analysis of 127 cases].

OBJECTIVE: Retrospective study on 127 cases of early microsurgery combined with antivasospasm agents for treatment of subarachnoid hemorrhage after the rupture of intracranial aneurysm. To evaluate the microsurgery for early-stage (3 days) of ruptured aneurysm. METHODS: 127 cases of subarachnoid hemorrhage after the rupture of intracranial aneurysm were diagnosed by MRI and CTA. Patients underwent early microsurgical clipping of intracranial aneurysm followed by antivasospasm agents treatment were retrospectively analyzed for their clinical manifestation, characteristics of imaging presentation, the curative effects and experiences of different operative approaches, surgical methods and techniques, pharmaceutical treatment and other integrated management. RESULTS: In all 127 cases, organized blood clot accompanied with subarachnoid hemorrhage and cerebral vasospasm surrounding the ruptured aneurysm was found in the course of surgical probing, among which 21 aneurysms ruptured during the operation; according to the GOS, 109 cases were cured or free of symptom, 23 cases got a transient hemiparalysis or aggravation of hemiparalysis, among which 18 cases were free of symptom, 9 were slight disability, 6 were severe disability, 3 cases die when discharged. CONCLUSIONS: Early operation could prevent second-time rupture effectively, lower the death rate, and at the same time lower the occurrence of cerebral vasospasm and the succeeding damage caused. Cerebral vasospasm is still the serious complication of subarachnoid hemorrhage of ruptured aneurysm and inappropriate management would cause critical consequences. Antivasospasm agents used postoperative could help preventing cerebral vasospasm and maintaining function.