Arkadiusz Nowak

Benign versus atypical meningiomas: Risk factors predicting recurrence

OBJECTIVE The aim of the study is to determine which clinic, radiologic, and surgical characteristics of benign and atypical meningioma are associated with tumor progression. METHODS 335 patients who underwent gross-total resection of intracranial benign and atypical meningiomas between 2000 and 2009 were followed during the period of at least 3 years. Clinical, radiological and surgical features possibly associated with progression-free survival and influencing tumor recurrence were assessed. RESULTS 291 lesions were benign (WHO Grade I) and 44 were atypical (WHO Grade II). In the median follow-up period of 82 months 34 meningiomas recurred. The 3-, 5- and 10-year progression-free survival (PFS) rates for benign and atypical tumors were 99.7 and 81.4%, 97.5 and 69.7%, 87.5 and 69.7%, respectively. In a Kaplan-Meier analysis subpial plane of surgical dissection (pial invasion) was associated with increased tumor progression both in benign (p=0.0084) and atypical cohort (p=0.0104), and bone involvement (p=0.0033) and peritumoral brain edema (p=0.0073) were associated with increased tumor progression only in atypical meningiomas. In a multivariate analysis pial invasion and WHO Grade II type were significantly associated with tumor recurrence. All recurrences in atypical meningioma group occurred within 4 years of the surgical resection. CONCLUSION Pial invasion is an important predictor of tumor recurrence in benign and atypical meningiomas. In atypical meningiomas bone involvement and large peritumoral brain edema are associated with increased tumor progression.

Surgical treatment of jugular foramen schwannomas.

OBJECTIVE We present our experience with surgery of jugular foramen schwannomas with special consideration of clinical presentation, surgical technique, complications, and outcomes. METHODS This retrospective study includes ten patients with jugular foramen schwannomas treated by the senior author between January 2007 and December 2012. Three patients had undergone partial tumour resection elsewhere. The initial symptom for which they sought medical help was hearing loss, dysphagia, hoarseness, and shoulder weakness. Preoperative glossopharyngeal and vagal nerve deficits were the most common signs. In our series, tumour extension was classified according to Kaye-Pellet grading system. In two cases the tumours were classified into type A and 8 patients presented with type D tumours. A retromastoid suboccipital craniotomy was performed for type A tumours and modifications of cranio-cervical approach were suitable for type D. RESULTS No death occurred in this series. Four patients deteriorated after surgery: in two patients preoperative cranial nerve deficits deteriorated after surgery while new cranial nerve palsy occurred in 2 other patients. In four patients, the cranial nerve dysfunction had improved at the last follow-up examination. In all other patients, the cranial nerve dysfunction remained the same. One patient experienced tumour recurrence over a follow-up period of 40 months. This patient underwent a successful second surgery without further evidence of tumour growth. CONCLUSIONS Jugular foramen schwannomas can be radically managed with the use of skull base surgery techniques. However, the surgical treatment of jugular foramen schwannomas carries a significant risk of the lower CN deficits.

Falcotentorial and velum interpositum meningiomas: Two distinct entities of the pineal region

OBJECTIVE Among pineal region lesions meningiomas are extremely rare and include falcotentorial and velum interpositum meningiomas. It is very difficult to discriminate between these two lesions and description of the clinical presentation and the surgical technique in approaching these tumors is limited. We respectively analyzed a series of patients harboring pineal region meningiomas with regard to clinical features, neuroimaging studies, and results of surgical treatment. METHODS Clinical data of 5 women and 1 man with pineal region meningiomas treated between January 1993 and December 2012 were retrospectively reviewed. All patients were assessed preoperatively with MRI and cerebral angiography. The only surgical approach we used was occipital transtentorial route. RESULTS There were four falcotentorial and two velum interpositum meningiomas. The main presenting symptom was headache, dizziness and gait disturbance. The angiogram revealed that these tumors were fed by tentorial artery, posterior choroidal arteries, and branches of the posterior cerebral artery and in four cases additional evidence of occlusion of the galenic venous system was seen. Two patients had total resection (Simpson Grade I and Grade II) and in four patients small remnants of tumor were left (Simpson Grade III). No death occurred in this series. The most common complication after surgery was homonymous hemianopsia which fully recovered in all patients in the follow-up. CONCLUSION The falcotentorial and velum interpositum meningiomas can be safely managed with the use of occipital transtentorial approach. Homonymous hemianopsia is the most common although always transient complication of surgery.

Surgical treatment of parasagittal and falcine meningiomas invading the superior sagittal sinus.

OBJECTIVE We present our experience with surgery of parasagittal and falcine meningiomas invading the superior sagittal sinus with special consideration of the surgical complications and the incidence of tumour recurrence. MATERIALS AND METHODS The analysis included 37 patients with parasagittal and falcine meningiomas invading the superior sagittal sinus. In 13 cases, the sinus was ligated and resected with tumour. In 14 cases, the sinus was entered with the goal of tumour resection and the sinus was reconstructed, while in 10 patients the sinus was not entered and the remaining residual tumour was observed for growth. RESULTS Out of 13 patients after radical resection of the tumour and invaded part of sinus, 9 revealed haemodynamic complications: venous infarction (4), significant brain oedema (3) and hypoperfusion syndrome (2). 2 out of 14 patients after resection of the tumour from the lumen of the superior sagittal sinus with subsequent sinus repair developed venous infarction after surgery. Among 27 patients after radical tumour excision the remote follow-up revealed recurrence in 2 patients. There were no significant haemodynamic complications in none of 10 cases, in which the residual tumour was left after surgery in the superior sagittal sinus. In this group, 3 cases were subjected to early post-operative radiotherapy and local recurrence was observed in 4 patients. CONCLUSIONS The aggressive surgical treatment of meningiomas infiltrating the superior sagittal sinus is associated with a high surgical risk. The incidence of recurrence of these tumours increases significantly in the case of non-radical excision of the tumour.

Results of surgical treatment of anterior clinoidal meningiomas – our experiences

OBJECTIVE Presentation of our experience in the treatment of anterior clinoidal meningiomas, including evaluation of factors that may affect early and long-term treatment outcomes. METHODS Thirty patients were operated with strategy of complete tumor resection using fronto-orbito-zygomatic approach. Outcomes were assessed by Glasgow Outcome Scale at discharge and by Karnofsky Performance Scale at follow-up. RESULTS There were 6 tumors in group I, 20 in group II, and 4 in group III according to Al-Mefty classification. Complete tumor resection (Simpson I or II) was achieved in 19 patients, incomplete resection (Simpson IV) in 11: due to strict tumor adhesion to cerebral arteries in 5 and tumor extension to cavernous sinus in 6 cases. Operative mortality was 6.7%. Visual acuity improved in six among nine patients with impaired vision but in no one among nine patients with blindness. Normal life activity (80-100 KPS) could be carried out by 88% patients at follow-up. Recurrence was observed in two (11.8%) patients after radical removal and progression of residual tumor in two (25%) after subtotal resection. CONCLUSIONS Complete tumor removal is possible with an acceptable risk of death and severe neurological deficits, except for cases with tumor extension to the cavernous sinus or strict tumor adhesion to cerebral arteries. Visual acuity improvement may be expected in two thirds of patients with impaired vision, but not in cases of blindness. In cases of incomplete tumor removal, use of stereotactic radiosurgery immediately after surgery seems justified.

Diffusion tensor tractography of pyramidal tracts in patients with brainstem and intramedullary spinal cord tumors: Relationship with motor deficits and intraoperative MEP changes

To evaluate whether pyramidal tracts course alterations observed in diffusion tensor tractography (DTT) in cases of brainstem and intramedullary spinal cord tumors reflect patient clinical status and prognosis.

Surgery for sporadic vestibular schwannoma. Part II. Complications (not related to facial and auditory nerves)

INTRODUCTION The aim of this study was to analyze the frequency and consequences of postoperative complications (PC) after surgery for sporadic vestibular schwannoma and to find factors that increase the risk of PC occurrence. MATERIALS AND METHODS The study included 220 consecutive patients (134 women, 86 men; age ranged from 18 to 74) operated on with the retrosigmoid (217) or translabyrinthine (3) approach. Complicated postoperative period was defined as an occurrence of at least one of: cerebrospinal fluid (CSF) leakage, hematoma in the tumor bed, intracerebellar hematoma, cerebellar swelling, brainstem stroke, hydrocephalus (HCP), healing problems, meningitis and cranial nerves (excluding VII-VIII) palsies or cerebellar symptoms. Correlation studies and multivariate regression analysis were performed. RESULTS PC occurred in 55 patients (25%). PC included lower cranial nerve (LCN) palsy (8.2%), cerebellar symptoms (7.3%), CSF leakage (5.9%), HCP (5%), CNVI palsy (3.1%), meningitis (1.8%), cerebellar swelling (1.4%), CNV dysfunction (0.9%), intracerebellar hematoma (0.5%) and lethal brainstem stroke (0.5%). In long term follow-up, LCN deficit was present in 2 patients (0.9%), cerebellar syndrome in 4(1.8%) and facial hypoesthesia in 2(0.9%). One patient (0.5%) developed bilateral blindness, secondary to preoperative optic nerve atrophy. As a result of PC, 10 patients (4.5%) required 11 additional surgical procedures. In statistical analysis, PC were independently related to preoperative cerebellar syndrome (p=0.002) and tumor size (>30 mm vs.<30 mm, p<0.05). The risk of PC diminished significantly with the increased number of performed procedures from 40% at the beginning to 16.4% in the last 55 cases. CONCLUSIONS Tumor size, cerebellar syndrome at presentation and experience of the team were the three most important risk factors for PC occurrence. Permanent deficit secondary to PC remained in only 4% of the patients.

Strategy for the surgical treatment of vestibular schwannomas in patients with neurofibromatosis type 2

OBJECTIVE Guidelines for appropriate management of vestibular schwannomas in NF2 patients are controversial. In this paper we reviewed our experience with patients with NF2 for the results of surgical treatment with particular reference to hearing and facial nerve preservation. METHODS We included in the study 30 patients (16 women and 14 men) with the diagnosis of NF2 treated in our department between 1998 and 2014 who underwent surgery for vestibular schwannoma removal with a follow-up for at least 1 year. In 3 cases, the vestibular schwannomas were unilateral. Six patients with bilateral vestibular schwannomas underwent unilateral procedure. Therefore, 51 acoustic tumors were studied in 30 patients. RESULTS No operative death we noted. Significant deterioration to the non-functional level occurred in 19 out of 22 cases with well-preserved preoperative hearing. Only three ears maintained their preoperative good hearing. Hearing was preserved in cases of small schwannoma not exceeding 2 cm. Among 21 patients who underwent bilateral operations hearing was preserved in 3 out of 7 cases when smaller tumor or better hearing level side was attempted at first surgery. In contrary none of the 14 patients retained hearing when the first operation concerned the worse-hearing ear. Among 14 tumors up to 2 cm there was only one case of moderately severe facial nerve dysfunction (House-Brackmann Grade IV) in the long follow-up. CONCLUSION Early surgical intervention for vestibular schwannoma in NF2 patient is a viable management strategy to maintain hearing function and preserve facial nerve function.

Epidermoid cysts of the cerebellopontine angle: Clinical features and treatment outcomes

OBJECTIVE To report clinical characteristics, treatment outcomes and risk of recurrence in patients with surgically treated cerebellopontine angle epidermoids. METHODS In 1994-2013, we operated 17 patients, including 7 with tumor limited to the cerebellopontine angle, 7 with cerebellopontine angle tumor penetrating supratentorially, and 3 with cerebellopontine angle tumor extending along skull base to contralateral cerebellopontine angle. All patients were followed-up for the mean duration of 126 months. RESULTS On admission cranial nerve symptoms predominated. Total tumor removal was achieved in 5 patients, and incomplete removal (with small tumor remnants left on vessels, nerves, or brainstem) in 12 patients. Postoperatively, preoperative deficits worsened in 2 and new postoperative deficits occurred in 10 patients. The extent of tumor expansion had no effect on postoperative morbidity and risk of recurrence. During long-term follow-up, improvement or resolution of preoperative deficits was seen in 11 of 17 patients, and new postoperative deficits in 8 of 10 patients. Symptomatic recurrences after an average of more than 9 years were noted in 5 patients, 3 of whom were reoperated. Recurrences occurred in some younger patients and always in area of primary tumor. No effect of extent of tumor removal on risk of recurrence was found. CONCLUSIONS The extent of tumor removal had no effect on the risk of recurrence, and thus it may be acceptable to leave tumor capsule fragments adhering closely to nerves, vessels, or brainstem. During long-term follow-up, resolution or improvement of present preoperatively and new postoperative neurological deficits may be expected in most patients.

Surgery for sporadic vestibular schwannoma. Part III: Facial and auditory nerve function

OBJECTIVE The aim of this analysis was to assess short-term and long-term outcomes with respect to the preservation of facial and auditory nerve function following surgery for sporadic vestibular schwannomas. MATERIAL AND METHODS The study included 220 consecutive patients operated on with the retrosigmoid (217) or translabyrinthine (3) approach. The mean extrameatal diameter of the tumor was 30mm. In 217 patients, gross total resection was performed and near-total in 3. Before surgery, the facial nerve (CNVII) weakness was found in 18% of patients and only 20% had serviceable hearing. Intraoperative neurophysiological CNVII monitoring was routinely used (the last 211 procedures). Intraoperative monitoring of the cochlear nerve function was used when the preservation of hearing was attempted (45 procedures). RESULTS The rate of CNVII continuity loss during surgery was 11%, however, this decreased to 6% in the second half of the series. Facial nerve function deteriorated, in 88% of the patients shortly after surgery. However, it improved in 87% in follow-up. Delayed CNVII palsy was found in 5% of the patients and had a good prognosis in 88%. Final satisfactory CNVII function (CNVII-SF, HB grades I-III) was achieved in 76% of the patients when excluding the anastomosis results, and 87% when including them. In recent years, the rate of CNVII-SF has risen to 94%. Non-serviceable hearing was preserved in 49% of the patients, on whom it was attempted. CONCLUSION Considering the size of the tumors and extent of the resections, the preservation of CNVII function is currently very high. A close surveillance of CNVII function evolution following surgery is mandatory, as 2/3 of the patients discharged with deep paresis will need different face reanimation procedures. The preservation of useful hearing is still problematic, especially in patients with large tumors.