Meningioma of the Clivus

Contributor:

Dr. Joseph Buwembo

Consultants:

Dr. Fred Gentili
Dr. Mike Tymianski
Dr. Michael Schwartz
Dr. Chris Ekong
Dr. Anthony Kaufmann
Dr. Michael West

Case 15

Age: 66

Sex: Female

History: - Progressive ataxia x 2 y
- Droopy left eyelid x 6 mo
- Left facial numbness x 2 mo
- Diplopia on distant vision x 2 mo
- Headaches and intermitent dysphagia x 2 months

Examination:

- Alert. GCS 15

- Left 3rd, 4th, 5th, and 6th palsies

- No long tract signs

Impression: Meningioma

Now what?

- Watch?

- Surgery?

- Radiosurgery?

- Surgery, then radiosurgery?

February 6, 2004 - Dr. Chris Ekong, Neurosurgeon, Regina

Dear Fred, Mike, Mike, and Anthony,

1. Do you agree that this is a meningioma?

2. What do you suggest we do with it?

Thanks,

Chris

NB: Your response will be posted with or without minor editing in this atlas for CME purposes.

February 7, 2004 - Dr. Fred Gentili, Neurosurgeon,Toronto

Dear Chris,

Yes, I think it is a meningioma. Very remote possibility of a trigeminal schwannoma.

In view of the progressive symptomatology, treatment is required. I would favour surgical resection with the understanding that one will not be able to get a total removal and follow up with some form of focused radiation. I think it is too large for primary radiotherapy. In terms of operative approach, I would favour a trans-petrosal approach. The aim of the surgery should be decompression of brain-stem and neurovascular structures. The patient has to be aware that there are risks to the procedure and that one cannot guarantee return of CN function.

Thanks for giving me the opportunity to review this interesting and challenging case.

Fred

February 7, 2004 - Dr. Mike Tymianski, Neurosurgeon,Toronto

Hi Chris:

Re: What it is:

Agree that meningioma is high on the differential, especially given the involvement of the cavernous sinus and the dural tails. However, in this area of the skull base, one cannot exclude a low grade chondrosarcoma, nor an eccentric chordoma as possibilites. I have had these in my practice that looked very similar to this case.

Re: What to do:

I think that your hands are tied at this stage, as the patient appears to be quite progressively symptomatic, the tumor is large, and there is brainstem compression. I do not think that watchful observation is in the patient's best interest.

I would recommend surgery. There are a number of possible ways to deal with this.

1. One could propose to deal with the whole tumor at a single operation. This would require a combined supra-and infra-tentorial exposure. One would have the choice of going entirely retrosigmoid, but I prefer to do a partial labyrinthectomy (with hearing preservation), and obtaining a pre-sigmoid exposure as well. Wouldn't mind seeing an MRV of the patient - to heck for a patent torcula. If it is patent- it is straightforward to sacrifice the sigmoid sinus, cut the tent, and lift the temporal lobe up while retracting the cerebellum back. This gives an extensive exposure of the entire area, and makes this tumor amenable to radical resection.

2. One can assume that many (or all) of the symptoms in this 66 year old person are related to the posterior fossa component, and that her long tracts will soon be at risk. To deal with this primarily, you can decide to do a more conservative, posterior fossa only exposure. It is possible to deal with the tumor mass through a lateral suboccipital approach, achieve a thorough decompression, and a tissue diagnosis. I still prefer to obtain a pre-sigmoid exposure as well, though I might not cut the sigmoid sinus. We have not had morbidity related to this additional exposure, and I believe that it improves your angle of approach for the most medial aspect of the tumor. In previous cases, after the patient has had a good recovery period, I have sometimes taken out the middle fossa component of the lesion at a later operation (through a pterional approach).

I would not focus on the cavernous sinus involvement at this time, though some of her symptoms (diplopia etc...) may well be related. Depending on the degree of surgical resection, pathological diagnosis and clinical recovery, one can make additional plans to control the residual tumor.

Best,

Mike T

February 8, 2004 - Dr. Mike Schwartz, Neurosurgeon,Toronto

Dear Chris,

I agree that there is a differential diagnosis, as Mike T points out, and

agree that the first therapy should be an attempt at surgical resection, with the understanding that an incomplete resection can be followed by focussed radiotherapy. The radiotherapy might be conventional radiosurgery, or more likely, since the residual tumor will have an irregular shape, IMRT. Knowing that radiosurgery is available as a backup, the operating surgeon should not try too hard for a complete resection. I am taking the liberty of forwarding this letter to Dave Rowed and Farhad Pirouzmand, who do the skull base surgery at Sunnybrook.

Mike S

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