Neoplasm
Posterior fossa meningiomas: surgical experience in 161 cases

https://doi.org/10.1016/S0090-3019(01)00479-7Get rights and content

Abstract

BACKGROUND

We report the clinical, radiological, and surgical findings of patients with posterior fossa meningiomas surgically treated at our institution over the last 6 years.

METHODS

We reviewed 161 consecutive cases of posterior fossa meningiomas operated on between April 1993 and April 1999 at The George Washington University Medical Center.

RESULTS

There were 128 female and 33 male patients (mean age 47 years, range of 10–81 years). Meningiomas were classified as petroclival (110 cases), foramen magnum (21 cases), cerebellar hemispheric, lateral tentorial (14 cases), cerebellopontine angle (9 cases), and jugular foramen (7 cases). Mean tumor equivalent diameter (TED) = (D1×D2×DE)1/3 was 3.1 cm (range of 0.53–8.95). Head pain (50% of cases) and disturbance of gait (44%) were the most common presenting symptoms, and cranial neuropathies the most common neurological signs on admission. Mean preoperative performance status (Karnofsky scale) was 80.2 (range 40–100). Surgical approaches to these tumors included partial labyrinthectomy petrous apicectomy, fronto-temporal/fronto-temporal orbitozygomatic osteotomy, retrosigmoidal, extreme lateral, transpetrosal, and combined. In 38 cases a staged procedure was performed. Gross-total resection was achieved in 57% of patients, and subtotal/partial in 43%. Surgical mortality was 2.5% and complications were encountered in 41% of patients. Postoperative CSF leak occurred in 22 cases (13.6%). The mean follow-up was 19 months, ranging from 0.2 to 63.6, and the mean performance status of patients with a follow-up of at least 12 months was 77 (range of 40–100). Recurrence or progression of disease was found in 13.7% of cases (follow-up 2 years or more).

CONCLUSION

Our experience suggests that although posterior fossa meningiomas represent a continuing challenge for contemporary neurosurgeons, such tumors may be completely or subtotally removed with low rate of mortality and acceptable morbidity, allowing most of these patients to achieve a good outcome in a long-term follow-up.

Section snippets

Methods and material

A total of 161 consecutive patients with PFM were operated on by the senior authors (L.N.S. and D.C.W.) at The George Washington University Medical Center, Washington D.C. over a period of 6 years, from April 1993 to April 1999. The retrospective analysis of these cases forms the subject of this report. All clinical, neuroradiological, surgical, and follow-up data for these patients were retrieved from our computerized database.

Patient population and clinical preoperative features

Thirty-three patients (20.5%) were male and 128 patients (79.5%) were female (ratio of 1:3.8). The ages of the patients in this study ranged from 10 to 81 years (mean = 47 years); their presenting symptoms and signs on admission are summarized in Table 1. Six patients were affected by neurofibromatosis type II, three patients had multiple brain meningiomas and one patient had a contralateral vestibular schwannoma. Head pain (50% of the patients) and disturbance of gait (44% of the patients)

Results

In this series the degree of operative tumor excision has been evaluated in terms of gross total, subtotal, and partial resection, as previously proposed [49]. This evaluation was primarily made based on postoperative MRI images but also supported by the surgeon’s impression at surgery (in patients with gross total excision). Gross total resection was obtained when residual tumor was not found on the MR images, and the surgeon also felt the resection was complete. If more than 90% of the tumor

Surgical complications

In this series there were no intraoperative deaths. Death occurred in four patients and the peri-operative mortality rate was 2.5%. Among them one patient was from group IV, one from group III and two from group V. One patient who had seizures and status epilepticus died while still hospitalized. Two patients died 2 months after surgery and one after 4, and their deaths were related to the progression of postoperative morbidity. In the postoperative period, one of these patients developed

Follow-up

All surviving patients were monitored by timed controls; the average follow-up was 19 months with a range of 0.2 to 63.6 months. Performance status was measured according to the Karnofsky scale and the mean score, over a 12-month follow-up, was 77 with a range between 40 and 100 (Table 3).

Radiographic evidence of recurrent meningioma (in patients with prior gross total resection, and follow-up of at least 2 years) was well documented in seven cases (14.2%). Among 35 patients with residual tumor

Classification scheme

Cushing and Eisenhardt, in 1938, proposed the first classification of PFMs [10]. Castellano and Ruggiero [6] subdivided these tumors into five groups: cerebellar convexity, tentorium, posterior petrous, clivus, and foramen magnum meningiomas. However, in the last 2 decades meningiomas arising from the clivus, medial tentorium, petrous apex, and CPA have been labeled with different nomenclature by several authors 7, 9, 29, 30, 36, 57, 62. In our series, we grouped these slow-growing neoplasms

Conclusion

Despite significant advances in microsurgery and the removal of tumors using skull base techniques, PFM still represents a formidable surgical challenge for contemporary neurosurgeons. In agreement with previously published reviews, postoperative impairment of cranial nerves heavily influences the morbidity after surgery. Despite this, in our series most patients had a good long-term clinical outcome. As for supratentorial meningiomas and other benign lesions, the ideal goal of surgery remains

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