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Approach to Skull Base Tumors

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

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

Vagus Schwannoma.In Jugular Foramen: Glomus. 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. cranial nerves and their associated vessels. arachnoid tissue. • 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. aneurysm AICA etc . Lipoma. ELS tumor.

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 .

slightly higher CSF leak rate .Trans-labyrinthine • Indications – Non-serviceable hearing • Advantages: – little cerebellar retraction – Good exposure of facial nerve laterally – Can do all size tumors • Disadvantages: – Sacrifice hearing.

• 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 .

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

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

Special Case: NF2 • • • • Scan whole brain. not just IAC Scan spine Screen family Counsel re family planning .

Petrous Apex Masses .

AJO 1992.13:561-574 . 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.Petrous Apex Masses Beware petrous apex asymmetric pneumatization Table 2.

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 .

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

perspiration . serotonin. flushing.Systemic Considerations • Association with MEN IIA. vasoactive intestinal peptide. neuron specific enolase • 1-3% functional • Symptoms – HA. VHL • Paraganglioma neuropeptides – Norepinephrine. MEN IIB. palpitations.

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) • Don’t forget about rehabilitation afterwards .