小脑桥脑角脑膜瘤（内听道前）

 

　　A 55-year-old man presented to us with left-sided deafness of 1-year duration.  Neurological examination, other than for the left ear deafness was unremarkable.   CT scan showed a homogeneously enhancing tumor of the left posterior pyramid with enlargement of the internal auditory meatus. A tumor located anterior to the internal auditory meatus was removed via the usual lateral suboccipital approach. The tumor was also growing inside the internal auditory meatus and was completely surrounding the anterior inferior cerebellar artery while pushing the lower cranial nerves caudally.  Both structures were carefully preserved.  The VII-VIII nerve complex was clearly seen to be infiltrated by the tumor, starting 3mm lateral to the brainstem all the way to the fundus of the internal auditory c**, whose posterior wall had to be totally drilled off. The tumor, together with its attachment on anterior dural of the internal auditory meatus was completely removed, with sacrifice of the involved VII-VIII nerve complex. Due to the impossibility of finding an uninvolved distal portion of the facial nerve in the internal auditory c**, after harvesting a 20-cm dural cable graft, we exposed the facial nerve in the neck, in proximity to the stylomastoid foramen. The proximal end of the graft was then secured to the intracranial facial nerve stump 4mm lateral to the brainstem with a drop of fibrin glue while the distal end of the graft, after exiting through the dura incision and after having been tunneled beneath the neck muscles,  was connected to the distal stump of the facial nerve in the neck using 10-0 sutures and fibrin glue. The defect in the posterior pyramid and internal auditory c** was closed with a free myofacial graft held in place with fibrin glue. The dura was closed as usual.The patient's postoperative course was uneventful,and he left the hospital 2 weeks after the operation. Postoperative CT scan showed no evidence of tumor. At follow-up 1 year after the operation,the patient showed electromyographic and clinical evidence of early facial nerve reinnervation.

 

　　Case 26:Cerebellopontine angle meningioma (located posterior to the IAM)

 

　　小脑桥脑角脑膜瘤（内听道后）

 

　　A 42-year-old woman presented to us with a few months' history of headache and some intermittent difficulties in walking. CT and MRI scans revealed the presence of a large tumor of the left posterior pyramid located posterior to the internal auditory eatus. Neurological examination was negative.  At surgery via a left suboccipital approach, a large (5x5cm) meningioma origina-ting from the undersurface of the tentorium and presenting in correspondence of the posterior pyramid posterior to the internal auditory meatus was completely removed. Postoperative CT scan showed a complete tumor removal. The postoperative neurological examination remained negative.

 

　　Case 27: Incisural meningioma

 

　　小脑幕切迹脑膜瘤

 

　　A 52-year-old woman had been complaining for the past few years of generalized headache. An incisural meningioma was e-ventually diagnosed， and she was operated on elsewhere through a temporooccipital approach that failed to remove the whole tumor. At the time of her presentation to us she showed negative neurological examination results,and a left incisural meningioma was demonstrated by CT and MRI scans. Through a frontotem-poral craniotomy with wide opening of the Sylvian fissure an incisural supra-infratentorial meningioma extending into the posterior portion of the cavernous sinus and  around the basilar artery was completely removed with preservation of all cranial nerves. The postoperative course was uneventful, and she was discharged with no neurological deficit.   Postoperative CT scan confirmed total tumor removal.

 

　　Case 28: Jugular foramen meningioma

 

　　颈静脉孔区脑膜瘤

 

　　A 30-year-old man presented to us with a 12-year history of hoarseness, 10-year history of right shoulder weakness, and 1-year history of decreased tongue function. The neurological examination was positive for a IX-XII cranial nerve palsy on the rieht side. CT scans showed a hyperostotic tumor in the region of the right jugular foramen with a soft tissue mass in the pos-terolateral inferior skull base.  MRI scans confirmed the presence of a mass in the right jugular foramen region.

 

　　The patient was operated on in the supine position with the head turned to the left and slightly fixed.A conventional suboccipital paramedian skin incision, 1cm medial to the mastoid and starting 2 cm above the superior nuchal line, was extended inferiorly to about the midportion of the anterior border of the sternocleidomastoid muscle. The sternocleidomastoid as well as the splenium capitis, the posterior belly of the digastric, and the oblique capitts superior muscles were then detached from the mastoid and from the occipital squama, thus exposing the facial nerve at the stylomastoid foramen,cranial nerves IX-XII at the exit point from the skull,   and the proximal internal jugular vein. A subbccipital craniectomy was then performed which, together with a mastoidectomy, exposed the whole length of the sigmoid sinus to the level of the jugular foramen.The posteroinferior and posterosuperior parts of the jugular foramen were found to be hyperostotic due to tumor invasion and needed to be removed using the high-speed drill. After having thus opened jugular foramen, the jugular bulb, the distal sigmoid sinus, related dura,and the distal  intracranial and proximal extracranial portions of cranial nerves IX-XII were  found to be involved with tumor and deeded to be excised. A cable graft using the great auricular nerve was transplanted between the proximal (intracranial) and e distal (extracranial) stumps of cranial verve XI.The dura was closed using lyodura, secured with stitches and fibrin glue, and the resection cavity was filled with a free piece of digastric muscle.A lumbar drain was inserted and left in place for 10 days. The postoperative course was uncomplicated, and the patient was discharged with no new neurological deficit.

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