Meningiomas of the skull base : treatment nuances in contemporary neurosurgery

A comprehensive overview of the contemporary management of skull base meningiomas Meningiomas, the second most frequent of intracranial tumors, are characterized by a protean range of possible locations and appearances, due to their origin from the extensive and intricately formed meninges. As such, a wide variety of differential diagnoses is typical, and the therapies chosen are necessarily highly variable. The introductory chapters of this book cover the pathology of these tumors, the evolution of special surgical methods, instrumentation, intraoperative monitoring, and the role of radiosurgery. Ten surgical chapters cover the individual regions of occurrence, including the sphenoid wing, olfactory groove, cerebellopontine angle, etc., all of which require a specialized approach and therapeutic strategy. Key Features : Discussion of pathology and therapy organized by anatomic location of the lesions with the goal of providing best patient outcomes New WHO meningioma classification system based on most recent research in growth patterns, gene sequencing, and molecular patterns of development Important updates on the newest developments in treatment modalities for meningioma, including the lesser invasive radiotherapy and radiosurgery for the smaller lesions and to avoid the necessity of performing radical surgery Meningiomas of the Skull Base: Treatment Nuances in Contemporary Neurosurgery is an essential reference guide for neurosurgeons and neurologists (in training and in practice) and will also be welcomed by skull base surgeons and otolaryngologists. This book includes complimentary access to a digital copy on (https://medone.thieme.com) https://medone.thieme.com. Meningiomas of the Skull Base: Treatment Nuances in Contemporary Neurosurgery Title Page Copyright Dedication Contents Foreword Preface Contributors Abbreviations 1 Introduction 1.1 Essential "Arrows" in the Technical Quiver: Fragments of Personal Memoirs 1.2 Imaging (1973) 1.2.1 The Operating Microscope (1955) 1.2.2 Modern Endoscopy (1974) 1.2.3 Imaging Directed Stereotaxy and Navigation (1977) 1.2.4 Bipolar Forceps (1955) 1.2.5 Ultrasonic Aspirator (1978) 1.2.6 Microanatomy (1973) 2 The Evolution of Surgery–the Soul of Neurosurgery 2.1 Introduction: Early History 2.2 Nomenclature 2.3 Stages of Surgery for Meningiomas 2.4 Initial Surgical Progress 2.5 Extracranial Approaches to Skull Base Lesions 2.6 Microneurosurgery 2.7 Refined Skull Base Approaches and Anatomical Studies 2.8 Allied Advances in Meningioma Management 2.9 Modern Surgical Management References 3 Inside the Pathology 3.1 Skull Base: Elements of Anatomy and Embryology 3.2 Surgical Resectability 3.3 Meningiomas 3.3.1 Definition and Epidemiology 3.3.2 Histopathology 3.3.3 Immunohistochemistry 3.3.4 Molecular Features 3.3.5 Prognostic Factors 3.4 Solitary Fibrous Tumor/Hemangiopericytoma 3.5 Meningiomas of the Skull Base 3.5.1 Skull Base Meningiomas in Pediatric Age 3.6 Future Perspectives References 4 Exogenous Factors Affecting Meningiomas 4.1 Introduction 4.2 Ionizing Radiation 4.3 Exogenous Hormones 4.3.1 Link between Cyproterone Acetate and Meningiomas 4.4 Radiofrequency Electromagnetic Fields 4.5 Metabolic Syndrome and Obesity 4.6 Occupational Exposures 4.7 Smoking 4.8 Immunity 4.9 Trauma 4.10 Conclusion References 5 Instrumentation (Micro, Endo, IGS, MRI Application) 5.1 Introduction 5.2 The Role of the Microscopy in Skull Base Surgery 5.2.1 Positioning 5.2.2 Operating Microscope 5.2.3 Microsurgical Instruments and Techniques 5.3 Endoscopy 5.3.1 Introduction 5.3.2 The Endoscope 5.3.3 Pure Endoscopic Approaches 5.3.4 Endoscope-Assisted Microneurosurgery 5.4 Image-Guided Surgery 5.5 Reconstruction Materials 5.5.1 Duraplasty and Hemostasis References 6 Intraoperative Neurophysiologic Monitoring during Surgery 6.1 Introduction 6.2 Intraoperative Neurophysiologic Monitoring Techniques 6.2.1 Mapping Techniques to Identify Cranial Motor Nerves 6.2.2 Monitoring Techniques 6.2.3 Anesthetic Considerations 6.3 Clinical Application in Skull Base Surgery 6.3.1 IONM for Sellar and Cavernous Sinus Surgery 6.3.2 IONM for Cerebellopontine Angle Surgery 6.3.3 IONM for Jugular Foramen–Clival and Foramen Magnum Surgery 6.4 IONM Changes and Surgical Strategy 6.5 Conclusions References 7 Role of Stereotactic Radiosurgery 7.1 Introduction 7.2 Radiobiology of Skull Base Meningiomas 7.3 Outcomes of Stereotactic Radiosurgery for Skull Base Meningiomas 7.3.1 Radiological Response 7.3.2 Cranial Neuropathy 7.3.3 Brainstem Toxicity 7.3.4 Other Complications 7.4 Management of Skull Base Meningiomas and Indications for Stereotactic Radiosurgery 7.4.1 General Indications 7.4.2 Specific Tumor Locations 7.4.3 Primary, Residual, and Recurrent Disease 7.4.4 Atypical and Anaplastic Meningiomas 7.4.5 Case Example 7.5 Conclusions References 8 Sphenoid Wing Meningiomas 8.1 General Considerations and Definition 8.2 Lateral or Pterional Sphenoid Wing Meningiomas 8.2.1 General Aspects and Clinical Presentation 8.2.2 Evaluation 8.2.3 Indications for Procedure 8.2.4 Surgical Approach 8.3 Medial Sphenoid Wing Meningioma 8.3.1 General Aspects and Clinical Presentation 8.3.2 Evaluation 8.3.3 Indications for Procedure 8.3.4 Surgical Procedure 8.4 Final Considerations References 9 Clival Meningiomas 9.1 Preoperative Definition of Lesion Features 9.1.1 Definition 9.1.2 Anatomical Considerations 9.2 Surgical Indications 9.3 Surgical Techniques 9.3.1 Preoperative Assessment 9.3.2 Approach Selection 9.4 Complications 9.4.1 Vascular 9.4.2 Cranial Nerve 9.4.3 Brainstem 9.4.4 CSF Leak 9.4.5 Cholesteatoma 9.5 Early and Long-term Postoperative Management References 10 Petroclival Meningiomas 10.1 Introduction 10.2 Anatomical Considerations 10.3 Clinical Presentation 10.4 Preoperative Evaluation 10.5 Surgical Indications 10.6 Surgical Techniques 10.6.1 Retrosigmoid Approach 10.6.2 Transpetrosal Approaches 10.6.3 Anterior Petrosal Approach 10.6.4 Posterior Petrosal Approach 10.7 Complications 10.8 Early and Long-term Postoperative Management 10.9 Conclusion References 11 Olfactory Groove Meningiomas 11.1 Introduction 11.2 Preoperative Definition of the Lesion Features 11.2.1 Anatomical Consideration 11.2.2 Clinical Presentation and Workup 11.3 Surgical Indications 11.3.1 Planning the Surgical Strategy 11.3.2 Preoperative Embolization 11.4 Surgical Techniques 11.4.1 Subfrontal Approach with Unilateral or Bilateral Frontal Craniotomy 11.4.2 Transbasal Approach 11.4.3 Pterional Approach 11.4.4 Frontolateral Approach 11.4.5 Supraorbital Keyhole Approach 11.4.6 Endoscopic Endonasal Approach 11.4.7 Algorithm for Surgical Management of Olfactory Groove Meningiomas (Endoscopic Endonasal Approaches vs. Craniotomy vs. Two-stages Strategy) 11.5 Illustrative Cases 11.5.1 Case 1 11.5.2 Case 2 11.5.3 Case 3 11.6 Complications 11.7 Early and Long-term Follow-up 11.7.1 Functional Outcomes 11.7.2 Recurrence References 12 Middle Fossa Floor Meningiomas 12.1 Introduction 12.2 Preoperative Definition of Lesion Features 12.2.1 Surgical Anatomy of the Middle Cranial Fossa 12.2.2 Middle Cranial Fossa Floor Meningiomas 12.3 Preoperative Management 12.4 Surgical Indications 12.5 Surgical Approaches 12.5.1 Pterional Approach 12.5.2 Fronto-temporo-(orbito)-zygomatic Approach 12.5.3 Temporal Approach 12.5.4 Operative Techniques 12.6 Complications 12.6.1 How to Avoid Complications? 12.7 Long-term Outcome 12.8 Conclusion 12.9 Acknowledgment References 13 Cerebellopontine Angle Meningiomas 13.1 Introduction 13.2 Clinical Presentation and Preoperative Evaluation 13.3 Neuroradiological Evaluation 13.4 Patient Evaluation and Decision-making 13.5 Preoperative Surgical Planning and Complication Avoidance 13.6 Surgical Approaches 13.6.1 Anterior Petroesectomy Approach 13.7 Posterior and Combined Petrosal Approaches 13.7.1 Retrolabyrinthine Approach 13.7.2 Translabyrinthine Approach 13.7.3 Combined Petrosal Approach 13.7.4 Closure of Posterior and Combined Petrosal Approaches 13.8 Retrosigmoid Approach for the Treatment of Cerebellopontine Angle Meningiomas 13.9 Postoperative Complications Avoidance 13.10 Radiosurgery for Cerebellopontine Angle Meningiomas 13.11 Conclusion References 14 Foramen Magnum Meningioma 14.1 Introduction 14.2 History 14.3 Surgical Anatomy 14.3.1 Occipital Condyle 14.3.2 Vertebral Artery 14.4 Epidemiology, Clinical Presentation, and Imaging 14.5 Classification of Foramen Magnum Meningioma 14.6 Operative Approaches 14.6.1 Posterior Suboccipital Approach 14.6.2 Far Lateral Approach 14.6.3 Extreme Lateral Approach 14.7 Controversies in Surgical Approaches 14.7.1 Need for Condyle Resection 14.7.2 Need for C1 Laminectomy 14.7.3 Need of Vertebral Artery Mobilization 14.8 Choosing the Right Approach 14.9 Complications 14.10 Outcome 14.11 Role of Radiosurgery 14.12 Personal Experience 14.13 Conclusion References 15 Tuberculum Sellae/Planum Meningiomas 15.1 Introduction 15.2 Preoperative Definition of Lesion Features 15.3 Surgical Indications 15.3.1 Indications for the Endoscopic Endonasal Approach 15.3.2 Indications for the Supraorbital Approach 15.4 Surgical Techniques 15.4.1 Endoscopic Endonasal Approach 15.4.2 Supraorbital Eyebrow Approach 15.5 Complications 15.6 Surgical Results 15.6.1 Endoscopic Endonasal Surgery 15.6.2 Supraorbital Surgery 15.7 Early- and Long-term Postoperative Management 15.8 Conclusion References 16 Cavernous Sinus Meningiomas 16.1 Introduction 16.2 Anatomy 16.3 Development 16.4 Symptoms 16.5 Diagnosis 16.6 Treatment 16.7 Surgical Approaches 16.7.1 Preoperative Preparation 16.7.2 Positioning and Incision 16.7.3 Fronto-Orbitozygomatic Osteotomy 16.7.4 Drilling of the Sphenoid Ridge 16.7.5 Identification and Dissection of the Meningoorbital Band 16.7.6 Anterior Clinoidectomy 16.7.7 Unroofing the Optic Nerve 16.7.8 Extradural Exposure of the Cavernous Sinus 16.7.9 Cavernous Sinus Exploration 16.8 Surgery and Radiosurgery 16.9 Acknowledgments References 17 Reconstruction of the Skull Base 17.1 Introduction 17.2 Reconstruction Techniques and Materials 17.2.1 Free Autografts 17.2.2 Nonautologous Materials 17.2.3 Vascularized Flaps 17.3 Current Reconstruction Techniques 17.3.1 Transcranial Approaches 17.3.2 Endoscopic Endonasal Approaches 17.4 Discussion and Conclusions References 18 Management of Recurrent Skull Base Meningiomas 18.1 Introduction 18.2 Recurrence 18.2.1 Presentation 18.2.2 Extent of Resection 18.2.3 Location 18.2.4 Histopathology 18.2.5 Radiation-induced Meningiomas 18.2.6 Adjuvant Therapy of De Novo Meningiomas 18.2.7 Multiple Recurrences 18.3 Management 18.3.1 Surveillance 18.3.2 Surgical Resection 18.3.3 Radiation 18.3.4 Chemotherapy 18.4 Conclusion References 19 Natural History and Adjunctive Modalities of Treatment 19.1 Introduction 19.2 Natural History 19.2.1 WHO Grade I 19.2.2 WHO Grade II 19.2.3 WHO Grade III 19.3 Adjunct Treatment Modalities 19.3.1 Radiation 19.3.2 Brachytherapy 19.3.3 Medical Therapies 19.4 Conclusion References 20 Complications in the Management of Skull Base Meningioma 20.1 Overview 20.2 Preoperative Factors for Prediction of Complications 20.2.1 Clinicoradiological Factors 20.2.2 Multidisciplinary Approach 20.2.3 Surgeon Factors 20.2.4 Patient Factors 20.3 Perioperative, Operative Complications and Prevention 20.3.1 Anesthesia Considerations 20.3.2 Operative Complications 20.4 Postoperative Complications and Prevention 20.5 Approach-related Problems 20.5.1 Transcranial Approaches (Table 20.1, Table 20.2, and Table 20.3) 20.5.2 Transnasal Endoscopic Skull Base Approaches (Table 20.4) 20.6 Location-related Complications 20.6.1 Olfactory Groove 20.6.2 Planum and Tuberculum Sellae 20.6.3 Cavernous Sinus/Parasellar 20.6.4 Sphenoid Wing Meningioma 20.6.5 Middle Cranial Fossa Meningioma 20.6.6 Petroclival Meningioma 20.6.7 Petrous-tentorial 20.6.8 Foramen Magnum Meningioma 20.7 Conclusion 20.8 Acknowledgment References Index

Meningiomas, the second most frequent of intracranial tumors, are characterized by a protean range of possible locations and appearances, due to their origin from the extensive and intricately formed meninges. As such, a wide variety of differential diagnoses is typical, and the therapies chosen are necessarily highly variable.

The introductory chapters of this book cover the pathology of these tumors, the evolution of special surgical methods, instrumentation, intraoperative monitoring, and the role of radiosurgery. Ten surgical chapters cover the individual regions of occurrence, including the sphenoid wing, olfactory groove, cerebellopontine angle, etc., all of which require a specialized approach and therapeutic strategy.

Key Features:

• Discussion of pathology and therapy organized by anatomic location of the lesions with the goal of providing best patient outcomes
• New WHO meningioma classification system based on most recent research in growth patterns, gene sequencing, and molecular patterns of development
• Important updates on the newest developments in treatment modalities for meningioma, including the lesser invasive radiotherapy and radiosurgery for the smaller lesions and to avoid the necessity of performing radical surgery

Meningiomas of the Skull Base: Treatment Nuances in Contemporary Neurosurgery is an essential reference guide for neurosurgeons and neurologists (in training and in practice) and will also be welcomed by skull base surgeons and otolaryngologists.