Palsy of the Contralateral Abducens Nerve after Aneurysm Surgery and Temporal Meningioma in the Presence of Petroclival Meningioma: A Case Report

The sixth abducens nerve is subject to injury after rare complications of intracranial hypotension caused by procedures such as dural punctures and spinal surgeries. The purpose of this case report is to discuss the mechanism of nerve palsy in these situations. Therefore, we describe a case of onset of contralateral sixth cranial nerve palsy after intracranial aneurysm and temporal meningioma surgery. Moreover, in this case there is a singularity due to the presence of the petroclival meningioma that amplified the unfolding of the lesion.

O sexto nervo abducente está sujeito a lesões após raros eventos de hipotensão intracraniana gerada por procedimentos como punções de dura-máter e cirurgias de coluna. O propósito deste relato de caso é discutir o mecanismo da paralisia deste nervo nestas situações. Para isso, descrevemos um caso de aparecimento de paresia do sexto nervo craniano contralateral após cirurgia de aneurisma intracraniano e de meningioma temporal. Além do mais, neste caso há uma singularidade em razão da presença do meningioma petroclival contralateral, que amplificou o desdobramento da lesão.

Meningiomas petroclivales: estrategia quirúrgica endoscópica a propósito de dos casos / Petroclival meningioma: endoscopic approach and case report

A pesar del desarrollo de las técnicas quirúrgicas de base de cráneo, los meningiomas petroclivales constituyen un reto para el neurocirujano debido a su localización y relación con estructuras neurológicas y vasculares críticas. Se reportan 2 pacientes con diagnóstico de meningioma petroclival que recibieron tratamiento por etapas incluyendo derivación ventrículo peritoneal asistida por endoscopia para la hidrocefalia, abordaje endonasal endoscópico (AEE) extendido al ápex petroso, keyhole subtemporal y retromastoideo con remoción de la lesión. La evolución fue satisfactoria. Se concluyó que los abordajes endoscópicos y por etapas constituyen una excelente opción en el tratamiento de los meningiomas petroclivales.

In spite of the development of the skull base surgery techniques, petroclival meningiomas are a challenge for neurosurgeon due to their localization and relationship with neurovascular structures. Those are two patient with diagnostic of petroclival meningioma whom received treatment step by step included ventricle peritoneal shunt with endoscopic guide for hydrocephalus, extended endonasal approach to petrous apex, subtemporal and retrosigmoid keyhole. The endoscopic approach is an excellent option in the treatment of petroclival meningioma.

Meningioma petroclival. abordaje petroso combinado con extensión translaberíntica / Petroclival meningioma. petrosus approach combined with translabyrinthine extension

Objetivo: Presentar un caso de meningioma petroclival con extensión al cavum de Meckel, tratado quirúrgicamente a través de un abordaje petroso combinado con extensión translaberíntica. Introducción: Se define como meningioma petroclival, al que se origina en los dos tercios superiores de la fisura petroclival, y medial al nervio trigémino. Existen numerosos abordajes para estos tumores, y cada caso requiere un análisis individualizado. Descripción del caso: Paciente de 25 años que refiere cefalea de 6 meses de evolución, progresiva e invalidante, e hipoacusia derecha. Al examen físico presenta hipoestesia en territorio trigeminal derecho y desviación velopalatina a derecha. En la imagen de resonancia magnética (IRM) se evidencia voluminosa lesión expansiva petroclival derecha con extensión al cavum de Meckel. La cirugía fue programada en dos tiempos: en el primero se realizó el abordaje y en el segundo la exéresis tumoral total. En el post operatorio evolucionó con una hemiparesia izquierda transitoria y parálisis completa del tercer par derecho en recuperación. Discusión: Existen múltiples modalidades terapéuticas para los meningiomas de base de cráneo. En este caso considerando la ubicación, el tamaño, su extensión clival, al cavum de Meckel y su relación con la arteria basilar, se decidió realizar un abordaje petroso combinado, con extensión translaberíntica debido a la hipoacusia. Conclusiones: Los abordajes de base de cráneo acortan la distancia de trabajo al tumor y mejoran los ángulos de exposición, facilitando su exéresis. Su principal desventaja, que es el tiempo de realización, puede sortearse dividiendo la cirugía en 2 tiempos.

Objective: To present a patient with a right petroclival meningioma with extension into Meckel´s cave, surgically treated by combining a petrosal approach with translabyrinthine extension.Introduction: Petroclival meningiomas are tumors that arise from the upper two thirds of the petroclival fissure, medial to the trigeminal nerve. There are several treatment options, with every case warranting an individualized approach.Case description: Our patient was a 25-year-old male/female with a 6-month history of progressive, disabling headaches and right hearing loss. The physical exam revealed right trigeminal hypoesthesia and rightward deviation of the soft palate. Magnetic resonance imaging detected a huge right petroclival tumor with extension into Meckel´s cave. Two-stage surgery was planned, the first procedure to create an approach, and the second to attempt total tumor resection, which was achieved. Postoperatively, the patient had transient left hemiparesis and a complete third nerve palsy that recovered partially. Discussion: Many different surgical approaches exist for treating petroclival meningiomas. In this case, considering the tumor’s location and volume, its clival and Meckel´s cave extension and basilar artery involvement, we elected to combine a petrosal approach with translabyrinthine extension, due to the patient’s previous hearing loss. Conclusion: Skull-base approaches shorten the working distance to the tumor, improving the angle of approach and rendering total resection possible. One of the procedure’s main disadvantages is the time required; but this can be overcome by performing the procedure in two stages.

Surgical Removal of Large Petroclival Meningiomas: the Transpetrosal Approach

For surgery involving complex lesions of the petroclival region, the transpetrosal approach-which may be anterior or posterioris known to have distinct advantages over traditional approaches. Six patients with large petroclival meningiomas(over 4.5cm), underwent surgery. In three cases, where the lesion extended only into the posterior fossa, the posterior transpetrosal approach was used, and in the other three, where it extended into the Meckels cave or cavernous sinus, surgery involved a combined anterior-posterior transpetrosal approach. In three cases with serviceable hearing, the retrolabyrinthine technique was employed, the remaining three, without serviceable hearing, were subjected to the translabyrinthine technique. Total removal was achieved in three cases(50%), and no patient died. Immediate postoperative neurological dysfunction appeared in all cases; almost all involved new cranial nerve deficit. As time passed, this dysfunction became less serious, though in four cases, it was permanent; there was mild to moderate hemiparesis in two cases and facial nerve paralysis in two. The surgical outcome was good in four cases, fair in one and poor in one. The authors suggest that the selection of surgical approach to petroclival meningiomas should be based upon the size and location of the tumor, the extent of dural attachment and the status of the patient's hearing. For a high-risk group, with brain stem invasion, arterial and cranial nerve encasement and cavernous sinus invasion, subtotal resection of the tumor is recommended.