Approach to Skull Base Tumors

Manohar Bance Professor, Division of Otolaryngology, Dept of Surgery Dalhousie University

Classification:
Where is it? Intra-axial vs extra-axial (outside brain) CPA vs Jugular Foramen Vs Petrous Apex Imaging T1 vs T2 Light up on contrast Shape, boundaries Sometimes CT findings

Quickly Getting Bearings

In bone Petrous Apex: Chol Gran Mucocoele Cholesteatoma (epidermoid) Chrondroma/ Chondrosarc TG schwann Metastasis In CPA: Vest Schwann Meningioma Epidermoid Arachnoid Cyst Lipoma

In Jugular Foramen: Glomus, Vagus Schwannoma, Met

MRI Imaging Characteristics

BRIGHT T1 Acoustic (+C) Meningioma(+C) Lipoma (-C) CG

BRIGHT T2 Epidermoid Arachnoid Cyst

Cerebellopontine Angle
Area of the lateral (quadrimenal) cistern containing CSF, arachnoid tissue, cranial nerves and their associated vessels. Borders
Medial lateral surface of the brainstem Lateral petrous bone Superior middle cerebellar peduncle & cerebellum Inferior arachnoid tissue of lower cranial nerves Posterior cerbellar peduncle

Sup: Middle Cbllr Peduncle and Cbllm

C P A

Medial: Lat surface Brainstem

Lat: Petrous Bone

Post:not shown Cbllr peduncle

Inf: Lower CN and arachnoid

CPA tumors
Vestibular Schwannoma: 70-90% Meningioma: 5-10% Epidermoids: 2-5% Arachnoid Cysts: 1% Others: Facial and TG Schwannoma, Lipoma, ELS tumor, aneurysm AICA etc

AN Features
Centered on Porus Acousticus Acute angles to petrous bone Often involves the IAC Homogeneous enhancement No dural tail No calcifications

Meningioma Features
Arise from surface of petrous bone Obtuse angles to petrous bone Uncommonly involves the IAC Frequently with dural tail Calcifications common

Arachnoid Cyst
Main differential on T1 and T2: Epidermoid FLAIR T1 Epidermoid bright on DWI and FLAIR ACyst follows CSF

T2

DWI

Treatment

Treatment for VS
Observation Surgery
Translabrynthine Retrosigmoid Middle Fossa

Radiotherapy
Conventional radiation therapy Stereotactic radiosurgery

Choice of Surgical Approach

Hearing Preservation Wanted? Yes No Yes Large Tumor: Suboccipital Large Tumor? No Any Size Tumor: Translabyrinthine Small Lateral Tumor: Middle Fossa

Views From Different Approaches

MF

TC/TO

TL SO

Trans-labyrinthine
Indications
Non-serviceable hearing

Advantages:
little cerebellar retraction Good exposure of facial nerve laterally Can do all size tumors

Disadvantages:
Sacrifice hearing, slightly higher CSF leak rate

 Indications

Middle Fossa

Intracanallicular tumor (maybe 0.5cm into IAC) Residual Hearing (50:50 or 70:30 rule)

Contraindications
Large tumors Older patients ( > 60 yrs. may have higher rate of bleeding or stroke)

Advantages:
Perhaps highest hearing preservation rate Good access to lateral fundus

Disadvantages:
Facial nerve first in line of exposure in IAC Limited medial exposure Risk of Seizure

Retrosigmoid
Indications
Serviceable hearing Any size tumor as long as not in lateral fundus only

Contraindications
Lateral IAC tumor (cant get to fundus without risking hearing)

Advantages
Good exposure superior-inferiorly Familiar to most neurosurgeons

Disadvantages
Cerebellar retraction Limited access to lateral fundus

Observation
Still relatively high chance of significant hearing loss, approx 40% Only about 30-50% of tumors require treatment Often used in elderly, medically unfit

Stereotactic Radiosurgery
LINAC, Gamma Knife, Cyber-knife Fractionated vs non-fractionated Tumor control rates well over 90% Risks:
Tumor miss, hydrocephalus, facial pain, facial paralysis (under 5% and usually partial), malignant transformation Similar or increased risk of long term hearing loss to conservative treatment

Special Case: NF2

Scan whole brain, not just IAC Scan spine Screen family Counsel re family planning

Petrous Apex Masses

Petrous Apex Masses

Beware petrous apex asymmetric pneumatization
Table 2. Petrous Apex Lesion Characteristics on MRI Scanning (Intensity Compared with Adjacent Brain)*

Lesion Cholesteatoma Cholesterol granuloma Petrous apicitis Effusion

T1 Images Hypo Hyper Hypo Hypo

T2 Images Hyper Markedly hyper Hyper Hyper Hypo Hyper

T1-Gadolinium No enhancement No enhancement Rim enhancement Mucosal enhancement No enhancement Enhancing

Bone marrow asymmetry Hyper Neoplasia Hypo

From Jackler RK and Parker D: The radiographic differential diagnosis of petrous apex lesions. AJO 1992;13:561-574

Approaches to Petrous Apex

Translabyrinthine, Transcochlear/otic Infracochlear Infralabyrinthine , retrolabyrinthine and other perilabyrinthine approaches Transsphenoid Middle Fossa Partial labyrinthectomy

Transpenoidal
Transphenoidal

Infralab

TL or TC

Infracochlear

Jugulotympanic Paragangliomas
2nd most common temporal bone tumor ( after AN) 4:1 female to male ratio Median age of presentation 50-60 yrs No ethnic or racial predeliction Sporadic and familial forms ( 25 50% multicentricity) Functional secretion about 1-3% Malignancy rate < 5%

Imaging: salt and pepper pattern

Jugulotympanic Paragangliomas Classification

Glasscock-Jackson Classification
I. Small tumor involving jugular bulb, middle ear, and mastoid II. Tumor extending under internal auditory canal; may have intracranial extension (ICE) III. Tumor extending into petrous apex; may have ICE Tumor extending beyond petrous apex into clivus or infratemporal fossa; may have ICE

Fisch Classification

Systemic Considerations
Association with MEN IIA, MEN IIB, VHL Paraganglioma neuropeptides
Norepinephrine, serotonin, vasoactive intestinal peptide, neuron specific enolase

1-3% functional Symptoms

HA, palpitations, flushing, perspiration

Fisch Type A approach

Treatment
Surgical: Fisch Type A or extended mastoidectomy
Mobilize facial nerve anteriorly Isolate tumor between jugular vein in neck and the sigmoid sinus

Stereotactic or conventional radiotherapy Observation

Summary
Diagnosis:
Where is it? What are its imaging characteristics?

Treatment similar for all common ones:

Surgery Watch Radiation (except epidermoid)

Dont forget about rehabilitation afterwards