Outcomes of Extended Middle Fossa Approach for Petroclival Tumors in the Elderly

Abstract

Objective The aims of the study are (1) to evaluate the extended middle fossa approach (eMCF) for resection of tumors in the petroclivus and anterior cerebellopontine angle (CPA) and (2) to compare surgical outcomes between elderly (≥65 years) and nonelderly patients.

Design Retrospective cohort.

Setting Tertiary referral center.

Participants Adults with petroclival, anterior CPA, or posterior fossa lesions who underwent an eMCF approach from 2012 to 2021 were included in the study.

Main Outcome Measure Demographics, symptoms, cranial nerve (CN) function, and postoperative outcomes.

Results Twenty-nine patients (mean age of 55 years, 59% females) were identified. Eleven (38%) were ≥65 years (65–79 years). The most common pathology was meningioma (n = 13, 45%), followed by vestibular schwannoma (n = 4, 14%) and squamous cell carcinoma (n = 3, 10%). Nineteen tumors (65.5%) were located in the petroclivus, 7 (24%) involved the cavernous sinus, and 10 (34%) were located in the posterior fossa. The mean tumor maximal diameter was 3.4 cm (range: 1.3–7.9 cm). Gross total tumor resection was accomplished in 15 (52%) patients. Most patients (n = 23, 79%) did not develop new CN deficits postoperatively. Of the 13 patients who had complete pre- and postoperative audiometric data, 69% (n = 9) maintained their hearing. Comparing the elderly versus nonelderly patients, there were no significant differences in the development of new CN palsies (p = 0.14), length of stay (p = 0.91), or incidence of postoperative complications (p = 0.30).

Conclusions The eMCF approach provides exposure to the petroclival region, anterior CPA cistern, and posterior fossa for a variety of pathologies. It has a favorable safety profile in the elderly (≥65 years) population with low morbidity.

Keywords

extended middle fossa - Kawase - petroclival - vestibular schwannoma - meningioma - elderly

Previous Presentation

The abstract was presented at the North American Skull Base Association Annual Meeting, Phoenix, AZ, 2022.

Publikationsverlauf

Eingereicht: 12. Juli 2023

Angenommen: 25. November 2023

Accepted Manuscript online:
29. November 2023

Artikel online veröffentlicht:
22. Dezember 2023

• References

• 1 Nassif PS, Hankinson HL, Horn KL. The middle fossa transpetrous approach: experience with 13 cases. Skull Base Surg 1997; 7 (01) 5-14
• 2 Rennert RC, Budohoski KP, Gurgel RK, Couldwell WT. Extended middle fossa approach for resection of a petroclival meningioma and vestibular schwannoma. Neurosurg Focus Video 2022; 6 (02) V5
• 3 Danner C, Cueva RA. Extended middle fossa approach to the petroclival junction and anterior cerebellopontine angle. Otol Neurotol 2004; 25 (05) 762-768
• 4 Ciappetta P. Subtemporal approach. In: Cappabianca P, Iaconetta G, Califano L, eds. Cranial, Craniofacial and Skull Base Surgery. Milan: Springer; 2010: 107-135
• 5 Tomio R, Horiguchi T, Borghei-Razavi H, Tamura R, Yoshida K, Kawase T. Anterior transpetrosal approach: experiences in 274 cases over 33 years. Technical variations, operated patients, and approach-related complications. J Neurosurg 2021; 136 (02) 413-421
• 6 Charabi S, Thomsen J, Mantoni M. et al. Acoustic neuroma (vestibular schwannoma): growth and surgical and nonsurgical consequences of the wait-and-see policy. Otolaryngol Head Neck Surg 1995; 113 (01) 5-14
• 7 Yu YL, Lee MS, Juan CJ, Hueng DY. Calculating the tumor volume of acoustic neuromas: comparison of ABC/2 formula with planimetry method. Clin Neurol Neurosurg 2013; 115 (08) 1371-1374
• 8 Committee on Hearing and Equilibrium. Committee on Hearing and Equilibrium guidelines for the evaluation of hearing preservation in acoustic neuroma (vestibular schwannoma). American Academy of Otolaryngology-Head and Neck Surgery Foundation, INC. Otolaryngol Head Neck Surg 1995; 113 (03) 179-180
• 9 Driscoll CL, Jackler RK, Pitts LH, Banthia V. Extradural temporal lobe retraction in the middle fossa approach to the internal auditory canal: biomechanical analysis. Am J Otol 1999; 20 (03) 373-380
• 10 Gelb AW, Craen RA, Rao GS. et al. Does hyperventilation improve operating condition during supratentorial craniotomy? A multicenter randomized crossover trial. Anesth Analg 2008; 106 (02) 585-594
• 11 Abdulhamid AS, Ghaddaf AA, Bokhari AF. et al. Equiosmolar hypertonic saline and mannitol for brain relaxation in patients undergoing supratentorial tumor surgery: a systematic review and meta-analysis. Surg Neurol Int 2022; 13: 120
• 12 Pollay M, Fullenwider C, Roberts PA, Stevens FA. Effect of mannitol and furosemide on blood-brain osmotic gradient and intracranial pressure. J Neurosurg 1983; 59 (06) 945-950
• 13 Lorenzo AV, Hornig G, Zavala LM, Boss V, Welch K. Furosemide lowers intracranial pressure by inhibiting CSF production. Z Kinderchir 1986; 41 (Suppl 1): 10-12
• 14 DeMonte F, Gidley PW. Hearing preservation surgery for vestibular schwannoma: experience with the middle fossa approach. Neurosurg Focus 2012; 33 (03) E10
• 15 Kutz Jr JW, Scoresby T, Isaacson B. et al. Hearing preservation using the middle fossa approach for the treatment of vestibular schwannoma. Neurosurgery 2012; 70 (02) 334-340 , discussion 340–341
• 16 Sacko O, Sesay M, Roux FE. et al. Intracranial meningioma surgery in the ninth decade of life. Neurosurgery 2007; 61 (05) 950-954 , discussion 955
• 17 Cornu P, Chatellier G, Dagreou F. et al. Intracranial meningiomas in elderly patients. Postoperative morbidity and mortality. Factors predictive of outcome. Acta Neurochir (Wien) 1990; 102 (3–4): 98-102
• 18 Black P, Kathiresan S, Chung W. Meningioma surgery in the elderly: a case-control study assessing morbidity and mortality. Acta Neurochir (Wien) 1998; 140 (10) 1013-1016 , discussion 1016–1017
• 19 Bambakidis NC, Kakarla UK, Kim LJ. et al. Evolution of surgical approaches in the treatment of petroclival meningiomas: a retrospective review. Neurosurgery 2007; 61 (5, Suppl 2): 202-209 , discussion 209–211
• 20 Gosal JS, Behari S, Joseph J. et al. Surgical excision of large-to-giant petroclival meningiomas focusing on the middle fossa approaches: the lessons learnt. Neurol India 2018; 66 (05) 1434-1446
• 21 Natarajan SK, Sekhar LN, Schessel D, Morita A. Petroclival meningiomas: multimodality treatment and outcomes at long-term follow-up. Neurosurgery 2007; 60 (06) 965-979 , discussion 979–981
• 22 Tao J, Wang Y, Qiu B, Ou S, Wang Y, Wu P. Selection of surgical approaches based on semi-quantifying the skull-base invasion by petroclival meningiomas: a review of 66 cases. Acta Neurochir (Wien) 2014; 156 (06) 1085-1097
• 23 Kawase T, Shiobara R, Toya S. Anterior transpetrosal-transtentorial approach for sphenopetroclival meningiomas: surgical method and results in 10 patients. Neurosurgery 1991; 28 (06) 869-875 , discussion 875–876
• 24 Manzoor NF, Nassiri AM, Sherry AD. et al. Predictors of recurrence after sub-total or near-total resection of vestibular schwannoma: importance of tumor volume and ventral extension. Otol Neurotol 2022; 43 (05) 594-602
• 25 Strickland BA, Ravina K, Rennert RC. et al. intentional subtotal resection of vestibular schwannoma: a reexamination. J Neurol Surg B Skull Base 2020; 81 (02) 136-141
• 26 Radwan H, Elserry T, Eisenberg MB, Knisely JPS, Ghaly MM, Schulder M. Subtotal resection followed by adjuvant radiosurgery for large vestibular schwannomas: outcomes with regard to the timing and regimen of irradiation. Acta Neurochir Suppl (Wien) 2021; 128: 1-5