Surgical Management of Petroclival Lesions: Last 3 Years of Experience at Army Hospital (Research and Referral), New Delhi

Aims and Objectives: To analyze the results of surgical management of patients with petroclival lesions operated on over the last 3 years at Army Hospital (R&R), New Delhi, the apex referral center for the Indian Armed Forces.

Materials and Methods: All patients with clinical and radiological evidence of lesions involving the petroclival region operated on between July 2009 and July 2012 were included. Radiological evaluation with CMRI.DSA was reserved for selected cases. Surgical approach was decided based on the size and exact disposition of the lesions. Surgical technique and outcome were reviewed.

Results and Discussion: There were 14 female and 9 male patients. Age range was 19 to 64 years. Clinical presentation included headache (4), cranial nerve involvement (19), cerebellar signs (9), pyramidal signs (8), and raised ICP (9). The lesions were confirmed on CMRI brain scan. The surgical approach was decided based on the exact location of the lesion. Surgical approaches used were anterior petrosal (6), posterior petrosal (9), combined petrosal (2), middle fossa subtemporal (5), and transpharyngeal with Le Fort osteotomy (1). Total excision could be achieved in 14 patients, and 9 had subtotal or partial excision. HPE revealed meningiomas (11), epidermoids (7), chordomas (3), and neurofibroma(2). Postoperatively, 8 patients had worsening of cranial nerve deficits (which subsequently improved), 2 patients had meningitis, and 4 patients developed chest-related complications. There were three deaths (due to meningitis and chest complications). Follow-up has ranged from 1 month to 3 years. Three patients were in GOS 1, 1 in GOS 2, 1 in GOS 3, 4 in GOS 4, and 14 in GOS 5. Overall, 79% had good outcome (GOS 4 or 5).

Conclusions: Petroclival lesions are relatively uncommon. Due to their location, they are typically difficult to manage surgically. With improving neurosurgical skull base techniques, their management is improving; however, they are still associated with significant morbidity due to involvement of lower cranial nerves.