Update: Skull base meningioma

Skull base meningioma

Epidemiology

As with intracranial meningiomas in other regions, skull base meningiomas demonstrate a femalepredominance, with a female-to-male ratio as high as 3:1.
Approximately 15% of meningiomas grow along the sphenoid ridge, with 10% developing in the posterior cranial fossa and 5% in the olfactory groove.
Meningiomas of the floor of the middle fossa are uncommon and tend to grow quite large before diagnosis.
Skull-base meningiomas are characterized by other recurrent mutations, including AKT1, SMOKLF4TRAF7 and POLR2A.

Classification

Treatment

Efforts to achieve a radical resection with dural margin are not suitable in many cases of skull base meningiomas, because of the neurovascular structures around the tumors.
Gamma knife radiosurgery (GKRS) is well established in the management of inaccessible, recurrent, or residual benign skull base meningiomas. Most series report clinical outcome parameters and complications in the short intermediate period after radiosurgery.
GKRS offers a highly durable rate of tumor control for World Health Organization grade 1 meningioma, with an acceptably low incidence of neurological deficits. The Karnofsky Performance Scale at the time of radiosurgery serves as a reliable long-term predictor of overall outcome 1).

Outcome

Peritumoral edema (PTE) in skull base meningiomas correlates to the absence of an arachnoid plane and difference in outcome.
A subset of benign (WHO grade I) skull base meningiomas show early progression/recurrence (P/R) in the first years after surgical resection.
Ko et al. retrospectively investigated the preoperative CT and MR imaging features for the prediction of P/R in skull base meningiomas, with emphasis on quantitative ADC values. Only patients had postoperative MRI follow-ups for more than 1 year (at least every 6 months) were included. From October 2006 to December 2015, total 73 patients diagnosed with benign (WHO grade I) skull base meningiomas were included (median follow-up time 41 months), and 17 (23.3%) patients had P/R (median time to P/R 28 months). Skull base meningiomas with spheno-orbital location, adjacent bone invasion, high DWI, and lower ADC value/ratio were significantly associated with P/R (P < 0.05). The cut-off points of ADC value and ADC ratio for prediction of P/R are 0.83 × 10- 3 mm2/s and 1.09 respectively, with excellent area under curve (AUC) values (0.86 and 0.91) (P < 0.05). In multivariate logistic regression, low ADC values (< 0.83 × 10- 3 mm2/s) and adjacent bone invasion are high-risk factors of P/R (P < 0.05), with odds ratios of 31.53 and 17.59 respectively. The preoperative CT and MRI features for prediction of P/R offered clinically vital information for the planning of treatment in skull base meningiomas 2).

Case series

2018

From a prospectively maintained database of 2022 meningioma patients who underwent Leksell stereotactic radiosurgery (SRS) during a 30-year interval, we found 98 patients with petroclival, 242 with cavernous sinus, and 55 patients with cerebellopontine angle meningiomas. Primary radiosurgery was performed in 245 patients. Patients included in this report had at least one CN deficit at the time of initial presentation and a minimum of 12 month follow up. Median age at the time of SRS was 58 years. Median follow up was 58 months (range 12-300 months), Median tumor volume treated with SRS was 5.9 cm3 (range 0.5-37.5 cm3), and median margin dose was 13 Gy (range 9-20Gy).
Tumor control was achieved in 229 patients (93.5%) at a median follow up of 58 months. Progression free survival rate (PFS) after SRS was 98.7% at 1 year, 96.4% at 3 years, 93.7% at 5 years, and 86.4% at 10 years Overall, 114 of the 245 patients (46.5%) reported improvement of CN function. Patients with CP angle meningiomas demonstrated lower rates of CN improvement compared to petroclival and cavernous sinus meningioma patients. Deterioration of CN function after SRS developed in 24 patients (10%). The rate of deterioration was 2.8% at 1 year, 5.2% at 3 years, and 8% at 10 years.
Primary SRS provides effective tumor control and favorable rate of improvement of preexisting CN deficit 3).

2011

Fourty-six patients harboring a skull base meningioma underwent an endoscope-assisted microsurgical resection. In 30 patients (65%), tumor parts which could not be visualized under the microscope were detected with the endoscope. In 26 patients (56%), these tumor remnants were removed under endoscopic view. Gross total resection was achieved in 35 patients (76%) and near-total resection in 11 (24%). There was no surgical mortality. The major complication was new cranial nerve deficit. The application of endoscopes was most useful in the small supraorbital craniotomies to look under the ipsilateral optic nerve and internal carotid artery as well as to visualize the diaphragm sellae and olfactory groove. In the retrosigmoid craniotomies, the endoscope was beneficial to inspect the internal auditory canal, to look into Meckel’s cave, or to inspect areas hidden behind the jugular tubercle and tentorial edge. There was no obvious complication related to the application of the endoscope. Endoscope assistance is particularly of value when skull base meningiomas are to be removed via small craniotomies to inspect blind corners which cannot be visualized in a straight line with the microscope. In addition, there is a benefit of using endoscopes with various angles of view in standard craniotomies and skull base approaches to look around bony and dural corners or to look behind neurovascular structures, by which the amount of skull base drilling and retraction to expose the tumor can be reduced 4).
1)

Cohen-Inbar O, Lee CC, Schlesinger D, Xu Z, Sheehan JP. Long-Term Results of Stereotactic Radiosurgery for Skull Base Meningiomas. Neurosurgery. 2016 Jul;79(1):58-68. doi: 10.1227/NEU.0000000000001045. PubMed PMID: 26421592.
2)

Ko CC, Lim SW, Chen TY, Chen JH, Li CF, Shiue YL. Prediction of progression in skull base meningiomas: additional benefits of apparent diffusion coefficient value. J Neurooncol. 2018 Jan 20. doi: 10.1007/s11060-018-2769-9. [Epub ahead of print] PubMed PMID: 29353434.
3)

Faramand A, Kano H, Niranjan A, Johnson SA, Hassib M, Park KJ, Arai Y, Flickinger JC, Lunsford LD. Cranial nerve outcomes after primary stereotactic radiosurgery for symptomatic skull base meningiomas. J Neurooncol. 2018 Apr 24. doi: 10.1007/s11060-018-2866-9. [Epub ahead of print] PubMed PMID: 29691775.
4)

Schroeder HW, Hickmann AK, Baldauf J. Endoscope-assisted microsurgical resection of skull base meningiomas. Neurosurg Rev. 2011 Oct;34(4):441-55. doi: 10.1007/s10143-011-0322-9. Epub 2011 May 26. PubMed PMID: 21614425.

The Pittsburgh Course: Comprehensive Endoscopic Endonasal Surgery of the Skull Base

The Pittsburgh Course: Comprehensive Endoscopic Endonasal Surgery of the Skull Base

November 8 — November 11

Pittsburgh, PA, USA

2017 Skull Base Course and Microvascular Workshop Rotterdam

2017 Skull Base Course and Microvascular Workshop Rotterdam

September 5 — September 8

Rotterdam, The Netherlands
Taking place at Erasmus MC Rotterdam, The Netherlands, Simulation Center.
Pre-course flyer (September 5)
Course flyer
Website: https://www.erasmusmc.nl/cs-skillslab/3454337/3427570/4242460/skullbase?lang=en5

Surgical Approaches to the Skull Base – Hands-on dissection course with 3-D lectures

Surgical Approaches to the Skull Base – Hands-on dissection course with 3-D lectures

June 28 — July 1

Arezzo, Italy
Course Directors: Antonio Bernardo, Paolo Perrini.

Faculty:
Vinko V Dolenc
Mario Sanna
Marco Cenzato
Renato J Galzio
Francesco Tomasello

Please click HERE for full details

4th Endoscopic Skull Base Masterclass & Mini Symposium

4th Endoscopic Skull Base Masterclass & Mini Symposium

June 28 — June 30

Leiden, Netherlands
CME course and mini-Symposium: Treatment of skull base meningioma: surgical strategy, approaches and outcomes.
Course flyer.
More information available at: http://www.skullbasecourse.nl/

Microscopic and Endoscopic Approaches to the Skull Base

Microscopic and Endoscopic Approaches to the Skull Base

June 7 — June 9

Strasbourg, France
Taking place at IRCAD in Strasbourg – http://www.ircad.fr/ 
Course directors:
Prof. Froelich – Lariboisière Hospital Paris and Prof. Debry – University Hospital of Strasbourg.
Course flyer.
Registration:  http://www.ircad.fr/training-center/course-calendar/?type=advanced&spec=neuro
Course description:
This workshop is intended for neurosurgeons or ENTs from the world over, to learn and practice the technical skills required for skull base surgery. It has been structured to provide both didactic lectures and intensive hands-on cadaver dissection sessions, covering a broad spectrum of transcranial and endoscopic approaches. A panel of distinguished leaders in these fields will deliver lectures focusing on skull base anatomy, transcranial and endoscopic approaches as well as therapeutic strategies for skull base lesions. The scientific program will include a guest speaker session on a topic related to skull base neurosurgery, with lectures given by world-renowned experts. Topics previously discussed included acoustic neuroma, microvascular decompression, radiosurgery for skull base lesions, pediatric skull base neurosurgery and revascularization techniques. Attendees will benefit from the outstanding surgical lab environment of the IRCAD with state-of-the-art equipment provided by our dedicated sponsors. For hands-on sessions, a demonstration will be performed at the master station, transmitted onto a screen at each workstation. In the meantime, participants will work as a team of two on prepared injected fixed specimens under the guidance of a distinguished expert Faculty.  

Target audience:
Practicing neurosurgeons and ENT specialists, fellows and residents in training 

Course objectives:
– To provide an overview of the complex anatomy of the skull base
–  To cover a broad spectrum of the skull base approaches and describe the technical steps of each specific approach
– To discuss indications of skull base approaches and surgical strategies
– To provide hands-on sessions on cadaveric specimens and improve skills
– To become more familiar with endoscopic endonasal approaches
– To understand the rationale and challenge of endoscopic endonasal approaches to the skull base
– To allow case discussions between experts and trainees Educational methods
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