Petro-Clival Tumours: Role and Indications of Transoral and Transsphenoidal Approaches Followed by Hypofractionated Stereotactic Radiotherapy

Abstract

Background: Petro-clival,clivalandspheno-petro-clivaltumoursarestillaneurosurgicalchallenge. Usually,theclassicalskullbase transpetrousapproachesareemployed,althoughtheyareburdenedbyanimportantrateof morbidity,andaverylowrateof radical removal is reported. Objectives: We present our indications and results with minimally invasive transnasal and transoral approaches. Patients and Methods: We present 14 patients affected by petro-clival, clival and spheno-petro-clival meningiomas/chordomas with prevalent extension ventrally to the brainstem; cranial nerves V to XII and vertebra-basilar arterial complex resulted posterior and laterally displaced. Preoperative clinical symptoms were represented by aspecific headache in 6 patients, mild and moderate contralateral hemiparesis in 3 and 2 patients respectively, mild and moderate tetraparesis in 2 and 1 patients respectively and cranial nerves deficit in 11 ones. Preoperative planning considered three objectives: to avoid operative and post-operative mor-tality/morbidity, to achieve satisfactory tumour removal and to avoid tumour regrowth. Anterior approach (transoral in 6 and transsphenoidal in 8 other) was selected for these patients according to postero-lateral approaches complexity due to the anterior-medial position of the tumour in respect of cranial nerves and vascular arteries. Results: In no patient radical removal was performed because gross total/subtotal removal had been programmed preoperatively on the basis of tumours extension. Concerning the 4 clival chordomas, gross total in two patients and subtotal removal in the two otheroneswasperformed. Grosstotalremovalwasaccomplishedintheclivalmeningioma,whilesubtotalremovalwasachievedin 5 petro-clival and in 2 spheno-petro-clival meningiomas; partial removal was performed in one spheno-petro-clival and one petro-clivalmeningioma. Nomortalityandnoneurologicdeficitswereregisteredaftersurgery. Preoperativeneurologicdeficitimproved in the majority of patients. Conclusions: Anterior transoral and transsphenoidal approaches are indicated for clival and spheno-petro-clival region tumours located ventrally to the brainstem and medially to acoustic meatus, to perform a prevalently median tumour debulking; these approaches allowed an extremely low rate of new neurological deficit and a rapid resumption of vital activities, obviously in relation with preoperative clinical status in our patients.