Résumé
Objective To summary the microsurgical strategies and techniques of petroclival meningiomas by trans-subtemporal combined with suboccipital retrosigrnoid keyhole approaches to raise the removal rate and improve the prognosis.Methods The clinical data of consecutive 26 patients with petroclival meningiomas,admitted to our hospital from January 2011 to December 2015 and accepted microsurgical treatment,were reviewed retrospectively;7 of them were guided by neuronavigation,8 were performed under neuroelectrophysiological monitoring,and 11 were guided by neuronavigation combined intraoperative MRI or neuroelectrophysiological monitoring.The operative methods and techniques,tumor resection rate and Kamofsky performance scale (KPS) scores before and after operation were analyzed.Results Of all patients who underwent surgical treatment by trans-subtemporal combined with suboccipital retrosigmoid keyhole approaches,gross total tumor resection (Simpson Ⅰ-Ⅱ) was achieved in 23 patients (88.5％),subtotal (Simpson Ⅲ-Ⅳ) in 3 patients (1 1.5％).Six patients (23.1％) had cranial nerve deficit postoperatively.No mortality which related with operation was noted.Patients were followed up for 3-35 months,23 patients had KPS scores ≥70,and 3 patients had KPS ＜70;no tumor recurrence or progression was noted.Conclusion The trans-subtemporal combined with suboccipital retrosigmoid keyhole approaches are safe,effective and minimally invasive for resection of petroclival meningiomas;mastering the operation strategies and intraoperative skills is conducive to improve the efficacy of surgery.
Résumé
Objective:With the development of modern skull base minimally invasive technology mature and neural radio surgery techniques,it is necessary to re-examine the therapeutic strategy for the treat-ment of petroclival meningiomas.To sum up the operative experience and methods in microsurgical resec-tion of petroclival meningiomas by the combining trans-subtemporal and suboccipital retrosigmoid keyhole approach.To explore the minimally invasive operation approach of petroclival meningiomas,to raise the removal degree and to improve the postoperative result using this approach.Methods:The clinical data of the consecutive 21 patients with the petroclival meningiomas were reviewed retrospectively.The meth-od,degree of tumor resection,techniques of the combining keyhole approach,Karnofsky performance score (KPS)before and after operation were also analyzed.The neuronavigation guided operation was performed in 9 cases,and 12 cases were operated in the neuroelectrophysiological monitoring.Results:Total excision of the tumor resection (Simpson,Ⅰ -Ⅱlevels)was conducted in 18 cases (85.7%,18 /21),and 3 patients underwent close resection (Simpson Ⅲ level,14.3%,3 /21).Postoperative three-dimensional CT showed good lock bone flap restoration;Postoperative pathology confirmed meningioma. Postoperative cranial nerve dysfunction or new original nerve dysfunction were aggravated in 5 cases (23.8%),including transient trochlear nerve (3 cases),abducent nerve (1 case),and the motor branch of trigeminal nerve paralysis (1 case).Abducent nerve paralysis (1 case)appeared,with hearing impairment.After the 3-month follow-up,11 cases had the same KPS aspreoperation,7 cases improved,and 3 cases not improved.The KPS score was 77.14 ±23.12 on average,and there was no statistically significant difference compared with that before operation (P >0.05 ).The postoperative follow-up for half a year showed fluent speaking and writing in 19 cases (KPS 70 or higher),and general recovery in 2 cases (KPS <70).The postoperative follow-up for 3 -29 months showed no tumor recur-rence or progress.Conclusion:The combining trans-subtemporal and suboccipital retrosigmoid keyhole approach is simple,safe,and minimally invasive,and an ideal operation approach of petroclival menin-gioma.To master the operation skills and the intraoperative matters needing attention in the operation,is favorable to improve the resection rate and curative effect.
Résumé
Objective To study the endoscopic anatomical characteristics of the upper petroclival and suprasellar region via subtemproal keyhole approach and to explore the clinical feasibility of this approach to these regions.Methods The operation of subtemporal keyhole approach was performed bilaterally in ten adult cadaver heads fixed with formalin and injected with colored emulsion.The anatomical structures in the upper petroclival region under the endoscope and microscope were recorded.Results Without removal of the zygomatic arch,most of structures in upper petroclival region and suprasellar region were observed under endoscope,including bilateral side anatomical structures; and most perforating branch arteries could be clearly displayed.The natural intracephalic spaces,including posterior communicating artery (PcoA)-oculomotor nerve,posterior communicating artery-anterior choroidal artery (AchA) were important spaces.The stripping of petrous apex and posterior clinoid process could be performed to obtain the ideal surgical exposure.The endoscopic structures in upper petroclival region and suprasellar region may be localized by combination of different markers; the bony structure,such as orifice of internal auditory canal,could be applied as markers.Conclusion The endoscope-assisted neurosurgery through subtemporal keyhole approach is very helpful in exposing the lesions of the upper petroclival and suprasellar region,which minimizes the trauma and is useful in practice.
Résumé
Background To investigate the feasibility of a novel anterior subtemporal transepidural-anterior transpetrous keyhole approach assisted by neuronavigation in attempt to apply the keyhole conception to imitate a new keyhole approach and to observe microanatomical structures, which can be regard as the base of this approach for clinical use. Methods The new keyhole approach was imitated by using ten adult cadaveric heads fixed in 10% formalin and perfused intracranial vessels with colored silicone. Under operative microscope, the anatomic structures were observed and important structures were measured after the maximal anterior petrous bone removal and the cavernous sinus exposure. Results The approach could provide a full visualization for the lateral structures and the internal contents of the cavernous sinus. The upper and middle clivus, the cerebellopintine angle, basilar artery and anterior inferior cerebellar artery were exposed after the maximal anterior petrous bone removal. Conclusions It is feasible to perform the anterior subtemporal transepidural-anterior transpetrous keyhole approach on operation of lesions involved in the cavernous sinus or/and the upper and middle clival regions.