Critical Appraisal of Minimally Invasive Keyhole Surgery for Intracranial Meningioma

Purpose Minimally invasive meningioma removal through transcranial and endoscopic endonasal keyhole routes remain controversial. Herein we detail results of keyhole meningioma removal defined as use of a minimally invasive “retractorless” approach for which a traditional larger approach is often used instead. Methods Retrospective analysis from 2008-2021 of consecutive patients undergoing keyhole meningioma removal through one of six approaches: extent of resection, complications, endoscopy use, MRI FLAIR/T2 changes. Surgical goal was maximal safe removal including conservative(subtotal) removal for some invasive locations. Results Of 329 patients, keyhole approaches were utilized in 193(59%) patients (mean age 59±13; 30(15.5%) prior surgery) who underwent 213 operations; 205(96%) were skull base location. Approaches included: endoscopic endonasal(n=74,35%), supraorbital(n=73,34%), retromastoid(n=38,18%), mini-pterional(n=20,9%), suboccipital(n=4,2%), and contralateral transfalcine(n=4,2%). Primary outcomes: Gross total/near total(>90%) resection: 125(59%); (5% for petroclival, cavernous sinus/Meckel’s cave, spheno-cavernous locations vs 77% other locations). Complications included: permanent neurological worsening12(6%); CSF leak 2(1%); meningitis 2(1%); no patients sustained DVT, PE, MI, or 30-day mortality. Median LOS was 3 days with 94% discharged home and 96% with favorable 90-day KPS. Secondary outcomes: Small persistent FLAIR/T2 changes: 11(5.2%) patients. Endoscopy use: 87/139(63%) of craniotomies, facilitating additional tumor removal in 55%. Tumor progression was observed in 26(13%) patients(mean follow-up 42±36 months). Conclusion This analysis suggests keyhole meningioma removal can be associated with reasonable resection rates, low complication rates, short hospitalizations and high 90-day performance scores. Subtotal removal may be appropriate for invasive/adherent meningiomas to avoid complications. With careful patient selection and requisite experience, these approaches may be considered alternatives to traditional approaches.

Treatment strategy for multisegmental cervicomedullary ependymoma: illustrative case

BACKGROUND Сervicomedullary ependymoma (CME) is a rare tumor of the central nervous system. The CME treatment strategy is insufficiently represented in the literature and is a complex task for neurosurgeons. OBSERVATIONS The authors describe an infrequent case of a large multisegmental CME that extended from the medulla oblongata to the cervical spinal cord at the level of the sixth cervical vertebra in a 21-year-old female. Neurological disorders presented with headache, dysphagia, hypophonia, and weakness in the limbs. Subtotal removal of the tumor was performed according to intraoperative neurophysiological monitoring (IONM) results. A wait-and-see approach with patient follow-up was chosen. LESSONS Total tumor removal of the CME is the most important favorable prognostic factor. Subtotal resection can be considered if the borders of the tumor are unclear and the result of IONM is unfavorable. The role of postoperative radiation therapy in the case of subtotal removal of the tumor remains controversial.

Retrolabyrinthine transsigmoid approach to complex parabrainstem tumors in the posterior fossa

OBJECTIVE The surgical management of large and complex tumors of the posterior fossa poses a formidable challenge in neurosurgery. The standard retrosigmoid craniotomy approach has been performed at most neurosurgical centers; however, the retrosigmoid approach may not provide enough working space without significant retraction of the cerebellum. The transsigmoid approach provides wider and shallower surgical fields; however, there have been few clinical and no cadaveric studies on its usefulness. In the present study, the authors describe the transsigmoid approach in clinical cases and cadaveric specimens. METHODS For the clinical study, the authors retrospectively reviewed the medical records and operative charts of patients who had been surgically treated for parabrainstem tumors using the transsigmoid approach between 1997 and 2019. They analyzed patient demographic and clinical data, as well as surgical and clinical outcomes. In the cadaveric study, they compared the surgical views obtained in different approaches (retrosigmoid, presigmoid, retrolabyrinthine, and transsigmoid) and measured the sigmoid sinus width at the level of the endolymphatic sac and the distance between the anterior edge of the sigmoid sinus and the endolymphatic sac on 35 sides in 19 cadaveric specimens. RESULTS A total of 21 patients (6 males and 15 females) with a mean age of 42.2 (range 15–67) years were included in the clinical study. Eleven patients had meningioma, 7 had vestibular schwannoma, 2 had hemangioblastoma, and 1 had epidermoid cyst. Gross-total, near-total, and subtotal removal were achieved in 7 (33.3%), 3 (14.3%), and 11 (52.4%) patients, respectively. In the cadaveric study, 19 cadaveric specimens were used. The sigmoid sinus was cut in the middle, and the incision was extended from the retrosigmoid to the presigmoid dura. The dura was then retracted upward and downward like opening a door. The results indicated that this technique can widen the operative field anteriorly by approximately 2 cm as compared to the retrosigmoid approach and provides a better view anterior to the brainstem. CONCLUSIONS The transsigmoid approach is useful for complex parabrainstem tumors in the posterior fossa because it provides a wider and shallower operative view with less retraction of the cerebellum. This enables safer tumor removal with less damage to important structures in the posterior fossa, resulting in better operative and clinical outcomes.

Surgical management of tentorial meningiomas: case series

Background There are several surgical strategies involved in the treatment of patients with tentorial meningioma, and choosing the most appropriate one is not straight forward. Our study aims to illustrate our experience in the management of tentorial meningiomata at our center. Results This study included 32 patients with tentorial meningiomas, operated upon, with assessment of the extent of resection and the Glasgow outcome score (GOS). The mean age at the time of surgery for the studied group was 48.4 years ranging from 20 to 70 years. Total removal was considered as Simpson grade I or II and was achieved in 26 cases (81.25%). Subtotal removal was considered as Simpson grade III or IV and was achieved in 6 cases (18.75%). The final Glasgow outcome score (GOS) for all cases was GOS 1 in 4 cases (12.5%), GOS 4 in 9 cases (28.2%), and GOS 5 in 19 cases (59.3%). Conclusion Tentorial meningiomas can be very challenging during surgery due to their proximity to vital structures. Subtotal resection should be considered when total removal can be hazardous to the patient or result in severe morbidity.

Application of Endoport-Assisted Neuroendoscopic Techniques in Lateral Ventricular Tumor Surgery

PurposeThe aim of this study was to review the experience of Endoport-assisted neuroendoscopic surgery for lateral ventricular tumors resection, investigate the therapeutic efficiency and discuss the key points. MethodsWe retrospectively reviewed the clinical data of 16 patients suffering from lateral ventricular tumors. All the patients received Endoport-assisted neuroendoscopic surgery from January 2018 to June 2020 in the department of neurosurgery, Nanjing Drum Tower Hospital, the Affiliated Hospital of Nanjing University Medical School. ResultsAll the patients received standardized treatment according to the preoperative image data and the postoperative pathology of the tumors. Endoport-assisted Neuroendoscopic surgery achieved complete removal of lateral ventricular tumors in 14 cases (87.5%) and subtotal removal in 2 cases (12.5%, glioma). The perioperative complications were analyzed, 1 acute epidural hematoma occurred during surgery, 1 hemiplegia and 2 obstructive hydrocephalus occurred after surgery. All the complications were managed timely. During the long-time follow up, the patient with glioblastoma died 16 months after surgery, the other patients are still alive with Glasgow outcome scales not less than 4.ConclusionEndoport-assisted neuroendoscopic surgery is suitable for the resection of lateral ventricular tumors. This procedure is simple, effective, minimally invasive, and associated with fast postoperative recovery.

A STUDY OF CLINICAL PRESENTATION AND MANAGEMENT OF PITUITARY TUMORS

The study includes 25 cases of pituitary adenomas. Most common age group by pituitary tumors falls between 41-50 years of age. Male: Female incidence of these tumors is 1: 2.12. Most common clinical symptoms in our series are visual disturbances followed by headache. Optic nerve involvement is other common clinical nding presenting in form of decreased vision or loss of vision, eld defect or fundus changes. Commonest eld defect is bitemporal hemianopia. MRI is the diagnostic investigation of choice in pituitary tumors to dene extent, invasion and relationship to major vessels and nerves. Approximately half (44%) of the patients exhibited normal preoperative pituitary function in form of baseline hormone prole. Increased GH level (32%) followed by hyperprolactinemia (20%) are the most common endocrinologic abnormalities. Total/near total removal was done in 21 patients (84%) and subtotal removal done in 4 patients (16%). Adjuvant therapies were given in 5 patients. Two patients were given radiotherapy and 3 were given pharmacotherapy. Post operative complications were CSF leak, diabetes insipidus and meningitis. 20 patients (80%) had improvement in their symptoms including relief from headache, improvement in vision and endocrinal dysfunction. Post operatively visual functions improved in 13 patients (52%) and it remained stationary in 11 (44%) patients. Only one patient (4%) complained of worsening of his visual function and it was improved in follow up period

Retropharyngeal chordoma extending to the spinal cord, mimicking a neurogenic tumor: a case report and literature review

Chordomas are rare, locally aggressive bone malignancies with poor prognoses. However, those with minimal or no bone involvement are more easily resectable because of their well-delineated margins and thus have better prognoses. Such extraosseous chordomas of the spine are localized both intradurally and extradurally. Only a few case reports have focused on extraosseous, extradural spinal chordomas. Radiologically, this type of chordoma has a dumbbell shape; however, dumbbell-shaped spinal tumors are traditionally thought to be neurogenic tumors (i.e., schwannomas or neurofibromas). We herein report a unique case involving a woman with a dumbbell-shaped extraosseous chordoma protruding predominantly into the retropharyngeal space. A 44-year-old woman presented for evaluation of a left submandibular mass. A T2-hyperintense, gadolinium-enhancing mass was found in her cervical spinal canal, protruding through the C2/3 neural foramen into the retropharyngeal space with minimal vertebral involvement. The initial diagnosis was a neurogenic tumor, most likely a schwannoma. After subtotal removal, the pathologic diagnosis was a chordoma. Because chordomas and schwannomas have significantly different prognoses, caution is warranted when a dumbbell-shaped tumor is identified in the spine with minimal or no vertebral deterioration on radiology. This report also provides the first thorough review of extraosseous dumbbell-shaped intraspinal–extraspinal chordomas.

Foramen magnum meningiomas: a systematic review and meta-analysis

Foramen magnum meningiomas (FMMs) account for 1.8–3.2% of all meningiomas. With this systematic review and meta-analysis, our goal is to detail epidemiology, clinical features, surgical aspects, and outcomes of this rare pathology. Using PRISMA 2015 guidelines, we reviewed case series, mixed series, or retrospective observational cohorts with description of surgical technique, patient and lesion characteristics, and pre- and postoperative clinical status. A meta-analysis was performed to search for correlations between meningioma characteristics and rate of gross total resection (GTR). We considered 33 retrospective studies or case series, including 1053 patients, mostly females (53.8%), with a mean age of 52 years. The mean follow-up was of 51 months (range 0–258 months). 65.6% of meningiomas were anterior, and the mean diameter was of 29 mm, treated with different surgical approaches. Postoperatively, 17.2% suffered complications (both surgery- and non-surgery-related) and 2.5% had a recurrence. The Karnofsky performance score improved in average after surgical treatment (75 vs. 81, p < 0.001). Our meta-analysis shows significant rates of GTR in cohorts with a majority of posterior and laterally located FMM (p = 0.025) and with a mean tumor less than 25 mm (p < 0.05). FMM is a rare and challenging pathology whose treatment should be multidisciplinary, focusing on quality of life. Surgery still remains the gold standard and aim at maximal resection with neurological function preservation. Adjuvant therapies are needed in case of subtotal removal, non-grade I lesions, or recurrence. Specific risk factors for recurrence, other than Simpson grading, need further research.

Acute onset of paraplegia due to melanocytic cervicodorsal lesion

Background: Melanocytomas are rare pigmented tumors of the central nervous system (CNS). They are more frequent in females in their fifties and are typically benign, but locally aggressive lesions that very are rarely found in the spine. They can occur in all the age groups. Case Description: A 62-year-old male presented with acute paraplegia a attributed to a C7-T1 intradural extramedullary melanocytoma. Urgent surgery, consisting of subtotal removal of the lesion, resulted in subtotal recovery of motor function with full resolution of his sensory deficit. Histologically, the lesion proved to be a melanocytoma. Conclusion: Rarely, patients with intradural extramedullary melanocytomas of the spine may present with acute paralytic deficits warranting emergent surgical intervention.