Zhao Xiaochun, Belykh Evgenii, Przybylowski Colin J, Borba Moreira Leandro, Gandhi Sirin, Tayebi Meybodi Ali, Cavallo Claudio, Valli Daniel, Wicks Robert T, Nakaji Peter
1Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona; and.
2Irkutsk State Medical University, Irkutsk, Russia.
J Neurosurg. 2019 Aug 2;133(3):630-641. doi: 10.3171/2019.4.JNS19208. Print 2020 Sep 1.
Meningiomas at the falcotentorial junction represent a rare subgroup of complex meningiomas. Debate remains regarding the appropriate treatment strategy for and optimal surgical approach to these tumors, and surgical outcomes have not been well described in the literature. The authors reviewed their single-institution experience in the management, approach selection, and outcomes for patients with falcotentorial meningiomas.
From the medical records, the authors identified all patients with falcotentorial meningiomas treated with resection at the Barrow Neurological Institute between January 2007 and October 2017. Perioperative clinical, surgical, and radiographic data were retrospectively collected. For patients who underwent the supracerebellar infratentorial approach, the tentorial angle was defined as the angle between the line joining the nasion with the tuberculum sellae and the tentorium in the midsagittal plane.
Falcotentorial meningiomas occurred in 0.97% (14/1441) of the patients with meningiomas. Most of the patients (13/14) were female, and the mean patient age was 59.8 ± 11.3 years. Of 17 total surgeries (20 procedures), 11 were single-stage primary surgeries, 3 were two-stage primary surgeries (6 procedures), 2 were reoperations for recurrence, and 1 was a reoperation after surgery had been aborted because of brain edema. Hydrocephalus was present in 5 of 17 cases, 4 of which required additional treatment. Various approaches were used, including the supracerebellar infratentorial (4/17), occipital transtentorial/transfalcine (4/17), anterior interhemispheric transsplenial (3/17), parietal transventricular (1/17), torcular (2/17), and staged supracerebellar infratentorial and occipital transtentorial/transfalcine (3/17) approaches. Of the 17 surgeries, 9 resulted in Simpson grade IV resection, and 3, 1, and 4 surgeries resulted in Simpson grades III, II, and I resection, respectively. The tentorial angle in cases with Simpson grade I resection was significantly smaller than in those with an unfavorable resection grade (43.3° ± 4.67° vs 54.0° ± 3.67°, p = 0.04). Complications occurred in 10 of 22 approaches (17 surgeries) and included visual field defects (6 cases, 2 permanent and 4 transient), hemiparesis (2 cases), hemidysesthesia (1 case), and cerebellar hematoma (1 case).
Falcotentorial meningiomas are challenging lesions. A steep tentorial angle is an unfavorable preoperative radiographic factor for achieving maximal resection with the supracerebellar infratentorial approach. Collectively, the study findings show that versatility is required to treat patients with falcotentorial meningiomas and that treatment goals and surgical approach must be individualized to obtain optimal surgical results.
小脑幕切迹脑膜瘤是复杂脑膜瘤中的一个罕见亚组。对于这些肿瘤的合适治疗策略和最佳手术入路仍存在争议，且手术结果在文献中尚未得到充分描述。作者回顾了他们在单一机构对小脑幕切迹脑膜瘤患者的管理、入路选择及手术结果的经验。
作者从病历中识别出2007年1月至2017年10月期间在巴罗神经学研究所接受手术切除的所有小脑幕切迹脑膜瘤患者。回顾性收集围手术期的临床、手术及影像学资料。对于采用小脑幕下小脑上入路的患者，小脑幕角定义为在正中矢状面连接鼻根与鞍结节的线与小脑幕之间的夹角。
小脑幕切迹脑膜瘤占脑膜瘤患者的0.97%（14/1441）。大多数患者（13/14）为女性，患者平均年龄为59.8±11.3岁。在总共17例手术（20次操作）中，11例为一期初次手术，3例为二期初次手术（6次操作），2例为复发再次手术，1例为因脑水肿手术中止后再次手术。17例中有5例存在脑积水，其中4例需要额外治疗。采用了多种入路，包括小脑幕下小脑上入路（4/17）、枕下入路经小脑幕/经大脑镰（4/17）、前纵裂经胼胝体入路（3/17）、顶叶经脑室入路（1/17）、窦汇区入路（2/17）以及分期小脑幕下小脑上入路和枕下入路经小脑幕/经大脑镰入路（3/17）。17例手术中，9例达到Simpson Ⅳ级切除，3例、1例和4例手术分别达到Simpson Ⅲ级、Ⅱ级和Ⅰ级切除。Simpson Ⅰ级切除病例的小脑幕角明显小于切除效果不佳的病例（43.3°±4.67°对54.0°±3.67°，p = 0.04）。22次入路（17例手术）中有10例发生并发症，包括视野缺损（6例，2例永久性和4例暂时性）、偏瘫（2例）、偏身感觉障碍（1例）和小脑血肿（1例）。
小脑幕切迹脑膜瘤是具有挑战性的病变。陡峭的小脑幕角是采用小脑幕下小脑上入路实现最大程度切除的不利术前影像学因素。总体而言，研究结果表明治疗小脑幕切迹脑膜瘤患者需要灵活性，治疗目标和手术入路必须个体化以获得最佳手术效果。
