• HPI: A 60-year-old man with a 3 year history of increasing headache and progressively worsening appendicular ataxia, left greater than right presents to you for evaluation. He had a fall within the last month resulting in abrasions on the face and limb. This was not associated with syncope, loss of consciousness or seizure. Subjectively, he denies hearing loss, changes to voice quality, dysphagia or limb motor/sensory changes. 

    Physical exam 
    Awake, alert and oriented 
    Cranial Nerve Exam: 
    - Diminished sensation in left V1 and V2 distribution 
    - Otherwise intact (including normal hearing) 
    Limb motor strength and sensation are normal. 
    Significant cerebellar ataxia and left sided dysdiadokinesia and intention tremor is present. 
    No pathologic reflexes. 

    Past medical history: 
    1. Paranoid schizophrenic 
    2. Hypothyroidism 
    3. Hypertension 

    Social and Family History 
    Non-contributory

    Figure 2. (Below): Contrast-enhanced MRI brain - a large extra-axial, dural- based enhancing lesion centered within the left petroclival region extending into the cerebellopontine angle cistern. The mass extends to the level of the porus acousticus. No widening of the porus is noted and there is no enhancement along the 7-8 nerve complex. Superiorly, the mass extends to the level of the midbrain partially encroaching upon the left posterior lateral aspect of the tentorial incisura. Inferiorly, the mass extends to the level of the inferior pons with significant mass effect upon the middle cerebellar peduncle and causes partial effacement of the fourth ventricle. The tumor has displaced the basilar artery to the right of midline. 

    Figure 1. Non-contrast CT scan - axial sections reveal a mass, measuring 4cm x 4 cm x 5 cm with intralesional calcification resulting in brainstem compression. No evidence of hydrocephalus.

     

    Figure 2. Contrast-enhanced MRI brain

     

    Figure 3. Left petroclival region mass seen on T2 axial, coronal and sagittal contrast-enhanced images.

    1. An audiogram is performed and reveals the presence of serviceable hearing (PTA50%). I would manage this patient in the following manner:

    2. A decision to proceed with surgery is made and a anterior petrosectomy is performed via KawaseÂ’s triangle, the boundaries of which are formed by the following structures except:

     3. Which of the following statements regarding petroclival meningiomas is false?

    4. Which of the following describes you?

    5. I practice in one of the following locations.

    6. Please add any suggestions or comments regarding this case:

    • I believe you should have offered surgical options including: -anterior petrosectomy -transphenoidal endoscopic approach Other than "perform surgery" debulking vs GTR Thanks
    • This is a very complex case but with a good surgery even with a CO2 laser beam could be extirped completely without touch the brain stem.
    • As this case seems symptomatic I will recommend resection via anterior petrosal approach, though there is a large calcification part. It depends on the extent of the adhesion of the tumor to the brain stem whether total removal can be possible. I'd like to see the fast spin echo sequence of MRI with contrast enhancement for this purpose, and angiography to see the pattern of the venous drainage around the left middle skull base, and the feeder of the tumor.
    • Safe resection(about 90% if feasible) followed by MRI after 3-6months,then radiosurgery.
    • Moderators: Can you please provide answer for question 2 & 3?
    • subtotal resection followed by GKRS
    • I'd argue thar retrosigmoid approach or a combined anterior petrosal / retrosig could provide better exposure than anterior petrosectomy alone, as substantial part of tumor is in the CPA area infratentorially.
    • Many of these lesions can perhaps be approached by the suboccipital retromastoid approach with good results.The calcified tough and densely fibrous and tough tumour characteristics and of course vascularity can be factors that can decide outcomes.Staged resection or treating smaller or residual lesion with radiosurgery or observation is another option.
    • Good case for Kawase's approach. Even a subtotal removal with subsequent observation and possible radiosurgery if an increase of the mass volume is noticed, would be a wise management strategy
    • dr ahmed a salam al atraqchi consultant neurosurgeon FICMS,FICS,ATLS
    • it is also a good suggestion to follow the case at least for a year and then decide for intervention.
    • Will need combined middle and posterior fossa approach.
    • Radiosurgery is an alternative treatment if patient is not fit for surgery.
    • I prefer rertrosigmoidal approach by pontocerebelar angle because as i saw in MRI there is a goood dpace in the cisterna.
    • I would think seriously about a retromastoid approach
    • good case...i will be participatinng regularly
    • I would recommend transpetrosal presigmoid approach with or without partial labirintethectomy
    • Radiosurgery is the best option.
    • would prefer Al Mefty's combined approach
    • combined far lateral supracerebellar infratentorial and retrosig
    • with the aim of total resection i will prefer surgery followed by radiosurgery, if require
    • please have an expert discuss the case for everyone's education
    • Could be interesting to ask for a angiotomography and a angioresoonance magnetic in order to have more information and a better understanding of the risks in surgery.

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