File 15: CLIVUS AND PETROCLIVAL MENIGIOMAS
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| FIG. 17.25. Clivus
and petroclinal meningioma. This 60-year-old woman had undergone
a limited subtotal removal of this tumor 12 years previously.
No radiation therapy was given. Her only symptom, a mild sixth
nerve paresis, and the size of the tumor on the scan have remained
unchanged for 12 years. (A-D) CT scans after contrast,
showing extension into the cavernous sinus and middle fossa.
G. OJEMANN, M.D.
© Congress of Neurological Surgeons
Honored Guest Presentation
Originally Published Clinical Neurosurgery, Volume 40, Chapter
17, Pages 321-383, 1992
Used with permission of the Congress of Neurological Surgeons.
HTML Editor: Stephen
B. Tatter, M.D., Ph.D.
The information and reference materials contained herein are intended
solely to provide background information. They were written for an
audience of physicians. They are in no way intended to constitute
medical advise. For medical advise a physician must, of course, be
CLIVUS AND PETROCLIVAL MENIGIOMAS
(Meningioma Management, File 15)
These tumors arise from the clivus
or petroclival junction medial to the trigeminal nerve. They may
grow out along the petrous pyramid or into the cavernous sinus and
middle fossa. Large tumors displace or encase the basilar artery
or its branches.
| FIG. 17.26. Clivus
meningioma. This 52-year-old woman presented with progressive
hemiparesis and fifth cranial nerve symptoms. Extensive removal
was followed by a full recovery of the hemiparesis. (A-D)
CT scans after contrast, showing brainstem compression and
extension into the @ddle fossa, cavernous sinus, and apex of
The MRI scan gives a great deal of
information about the tumor but angiography with both vertebral
and carotid studies is usually needed to clarify the location of
major arterial branches and the blood supply to the tumor.
The decision regarding the best treatment
may be difficult because the patients may have large tumors with
minimal symptoms (Fig. 17.25), the natural history is unknown, there
is risk of significant morbidity associated with the surgery, and
the long-ten-n results of the newer radiation therapy modalities
are not known.
Surgery is indicated in patients with
worsening symptoms of brainstem dysfunction (Fig. 17.26) and in
younger patients with cranial nerve deficits. Patients with mild
symptoms may be observed. Radiation therapy is used if an adequate
decompression cannot be accomplished or there is regrowth after
radical subtotal removal.
Several different approaches or a
combination of approaches have been used with these tumors and they
have been summarized in several publications (2, 6, 26, 27, 30,
43, 59, 60, 64). In general the approach selected depends on the
configuration of the tumor and the direction of the growth. Mayberg
and Symon (43) concluded that the combined subtemporal-posterior
fossa approach gave the best results, as did Guthrie et al. (26).
Various modifications of this approach have been described by Samii
et al. (60) and Hakuba et al. (27). Al-Mefty and co-workers (2,
6) have described in detail a petrosal approach for these tumors.
Total removal is difficult because
of the location of the tumor anterior to the brainstem, the involvement
of cranial nerves, and the encasement of the vertebral-basilar arteries
and their branches.
The key considerations in the operation
- Careful planning of the approach.
- Opening of the tentorium.
- Intemal decompression of the tumor,
taking great care to look for cranial nerves and arteries that
may be engulfed by the tumor.
- Dissection of tumor capsule, alternating
between the supratentorial and infratentorial exposures.
Results of the treatment of tumors
in this location have not been as good as for meningiomas in general.
Mayberg and Symon (43) found that 60% of patients were worse in
the immediate postoperative period and only a small percentage were
improved. About 70% eventually returned to independent existence,
although many of those patients had a cranial nerve deficit. Total
removal was possible in only nine of 35, but no evidence of recurrence
was noted after
9 years. With microsurgical techniques
a higher percentage of total removals has been reported (6, 27, 30,
60, 62). Samii et al. (60) reported that 83% of the patients had independent
existence but nearly half had new postoperative complications, mainly
Cranial nerve deflcits. There was no postoperative mortality. Total
tumor removal was done in 71%. For the 52 patients reported by Javid
and Sehkar (30) the functional results were not recorded but operative
mortality was 4% and 30-40% of the patients had significant postoperative
problems. Al-Mefty and Smith (6) reported total removal in 15 of 18
patients, with no postoperative mortality and apparently fairly good
|TABLE 17.14 Clivus
aT, total removal
RST, radical subtotal removal
ST, subtotal removal
bGood, free of major
and able to return to previous activity level
Fair, independent but not able
to return to full activity
because of new neurological deficit or significant
preoperative deficit that did not fully recover
In this series there were 10 patients,
seven women and three men, ranging in age from 38 to 69 years (Table
17.14). All but one had a large tumor. One patient had a radical
subtotal removal and nine a subtotal removal. Three required a ventriculoperitoneal
shunt. In five patients the tumor not only involved the clivus and
adjacent petrous bone but also had grown into the cavernous sinus
and middle fossa. The involvement in the cavemous sinus and encasement
of the basilar artery, its branches, and the lower cranial nerve
prevented a more extensive removal.
Five patients had a good result that
has continued for 2-14 years. They have not been given radiation
therapy. Three patients had a fair result; two were worse after
operation and one did not improve from a preoperative disability
and also subsequently had a complication from radiation therapy
given when the tumor started to regrow. No further growth has been
seen in these patients. Two patients had a poor result, one because
of recurrence in spite of multiple surgeries and radiation therapy
and one with a postoperative hemiparesis.
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