Precision "Dual-Incision" Strategy Skillfully Resolves Challenging Recurrent Meningioma

Two years ago, Ms. Li underwent surgical treatment for a meningioma at our hospital and recovered well post-operatively. However, during follow-up examinations, a head MRI revealed tumor recurrence six months ago, with continued slow growth. One month ago, Ms. Li began experiencing symptoms including numbness on the left side of her face, veering to the left while walking, and occasional choking while eating. The progression of the disease caused Ms. Li significant anxiety, leading her to return to the Neurosurgery Department at Beijing Tiantan Puhua Hospital.

Dr. Qin Shusen from our Neurosurgery Department conducted a comprehensive and meticulous evaluation of Ms. Li's condition. Based on the latest imaging results, the tumor had indeed recurred and was large in volume, involving the clivus, both sides of the petrous bone, and the sphenoid sinus. Complete resection via a single surgical approach was extremely challenging, as it was difficult to remove the tumor completely from all three locations through one incision. The hospital consulted renowned neurosurgical expert, Professor Zhang Junting, Director of Neurosurgery at Beijing Tiantan Hospital, to assist in the treatment.

"Operating in the petroclival region is like walking a tightrope over an abyss," explained Dr. Qin. The petroclival region has a unique anatomical position, adjacent to critical structures such as the brainstem, vertebrobasilar artery, trigeminal nerve, facial and acoustic nerves, and lower cranial nerves. The surgical working space is extremely narrow, where even a minor misstep could cause severe neurological damage. After repeated simulations and planning by the medical team, a personalized craniotomy strategy was finalized – a combined approach utilizing the left pre-auricular subtemporal previous incision plus a retroauricular cerebellopontine angle (CPA) approach for tumor resection.

The design of this "dual-incision" approach was particularly ingenious: The original pre-auricular incision utilized the previous surgical pathway, minimizing new tissue trauma for the patient, while a slight extension towards the frontal area allowed adequate exposure of the tumor portion located at the temporal side of the petrous bone, enabling maximal possible resection of the tumor within the sphenoid sinus based on intraoperative findings. The retroauricular approach, meanwhile, provided exposure to the main mass of the petroclival tumor. The two incisions worked in concert, creating a "pincer" strategy from anterior and posterior directions, allowing for comprehensive tumor removal while maximizing protection of the surrounding neurovascular structures.

The surgery was performed by Director Zhang Junting himself, meticulously executed in three stages via the combined dual-incision approach:

Stage 1: Dual-Incision Craniotomy

The surgical team first reopened the original incision, removed the bone flap, exposed the dura mater, and preserved it for later use. Subsequently, a retroauricular CPA approach craniotomy was performed.

Stage 2: Tumor Resection

Via the CPA approach, the tumor at the dorsal clival region of the petrous bone was carefully totally resected, and the tumor base was coagulated. This surgical site was temporarily left unclosed.

The dura at the pre-auricular bone window was opened, and the tumor at the temporal side of the petrous bone was resected via this approach. The tumor texture was firm and encased the internal carotid artery; the tumor base in this area was coagulated.

Repeated exploration for residual tumor was conducted via both approaches, with coagulation of any remaining tumor bases.

Stage 3: Wound Closure

After achieving complete hemostasis in the operative field, the dura in the CPA region was meticulously sutured first. Then, via the pre-auricular incision, warm saline was used to replace the intracranial air. Once the air was completely expelled, the dura in this region was tightly sutured. The bone flaps for both incisions were repositioned simultaneously, and the wounds were closed.

After 7 hours and 40 minutes, the surgery was successfully completed. Ms. Li regained consciousness from anesthesia and was safely transferred to the ICU. Post-operatively, the medical team provided Ms. Li with comprehensive treatment and closely monitored her condition. Under the careful attention of the medical staff, Ms. Li's recovery progressed well. Her pre-operative symptoms gradually alleviated, and no new neurological deficits appeared. Seeing the smile return to Ms. Li's face brought immense satisfaction to every member of the neurosurgery team. Regarding the residual tumor in the sphenoid sinus, close observation was recommended; should changes occur, consideration could be given to transsphenoidal endoscopic resection or Gamma Knife therapy.

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Reminder from Dr. Qin Shusen of Puhua Neurosurgery:

The recurrence rate after meningioma surgery is approximately 10%-20%, making regular follow-up crucial.

It is recommended that post-operative patients undergo contrast-enhanced MRI scans every 6 months.

If new symptoms such as headache, limb numbness, or blurred vision appear, immediate medical attention is necessary for timely intervention.

Beijing Tiantan Puhua Hospital's Neurosurgery Department consistently maintains a patient-centered approach, continuously advancing techniques and innovating in the field of complex brain tumor surgery, committed to tailoring the optimal treatment plan for each patient. In the future, the team will continue to delve deeply into the challenges of diagnosing and treating cranial diseases, using their expertise and compassionate care to bring hope for renewed health to more patients.