University of Medicine And Pharmacy [632177]

University of Medicine And Pharmacy
"Iuliu Hatieganu"
Cluj-Napoca
Faculty of Medicine

LICENCE THESIS
Petroclival Meningiomas

Coordinator:
Conf.Dr.Ioan Stefan Florian

Graduate:
Zain Tanveer Syed
2019

GENERAL PART

Introduction
Meningiomas are tumors that originate from the meninges ,
which are the membranes that encapsulate the brain and the
spinal cord. They are one of the most common types of tumors
that are found in the head.
Most of the meningiomas do not affect the patient as they
progress and grow with a slow speed. Thus , meningiomas can
grow over a number of years without leading to symptoms , and
are mostly diagnosed only when they invade the surrounding
structures which lead to the appearance of numerous symptoms .
Meningiomas can lead to a number of disabilities due to their late
detection , and can even be life threatening.
Meningiomas are mostly diagnosed in women. Women are
twice as likely to be diagnosed with meningiomas.Meningiomas
are also diagnosed mainly at older age groups. Despite that , it
must be stressed that meningiomas can occur in any age group
and can affect every group , regardless of gender or ethnici ty.
Meningiomas represent around 20 -30% of all the tumors that are
found in the head.
Meningiomas can be classified into many subtypes based
on the location of the tumours. (1) Meningiomas can be divided
as :
 Cavernous sinus meningiomas
 Cerebral c onvexity meningiomas
 Foramen magnum meningiomas
 Olfactory groove meningiomas
 Parasagittal meningiomas

 Posterior fossa meningiomas
 Sphenoid meningiomas
 Spinal meningiomas
 Tentorium meningiomas
 Suprasellar meningiomas
 Intraventricle meningiomas
 Intraorbital meningiomas
Petroclival meningiomas are found in the posterior fossa.
Posterior fossas themselves are classified in to six different sub –
types based on their location. ( 2) They are divided as follows :
 Type 1 – Cerebellar convexity : They span the
tentorium , the sigmoid and the transverse sinus.
 Type 2 – Cerebellopontine angle : They span the
petrous ridge and the internal aud itory meatus
 Type 3 – Jugular foramen : They span the
cerebello -medullary angle , internal jugular vein
and extracrania l.
 Type 4 – Petroclival : They span the anterior two –
thirds of the clivus , meckles cave and petrous
ridge
 Type 5 – Foramen magnum : They span the lower
one-thirds of the clivus and the C1, C2 area.
 Type 6 – Unclassified : They span the entire clivus
, mid and lower clivus .

Anatomy
The brain is encapsulated by three layers , which serve to
protect it , and which extend down the spinal cord. The three
layers are called meninges , and they are divided into the dura
mater, the arachnoid mater and the pia mater. The meninges
extend anteriorly covering the spinal cord. At the upper limit , the
dura is attached to the foramen magnum. The dura also goes
down to the second sacral vertebrae.
The dura mater is a thick and a strong memb rane which
lies proximally to the ve rtebrae. Next to it is located the arachnoid
mater which is a thinner membrane as compared to the dura
mater and it extends into the subarachnoid space and makes a
connection to the pia mater. The pia mater encapsulates the
spinal cord and the outline of the brain. The subarachnoid mater
consists of the cerebrospinal fluid. It also has major arteries
which extend down the pia mater in to the central nervous
system. At some points , mainly in the brainstem, the
subarachnoi d space increases in size to form cisterns.
Petrocliv al meningiomas are f ormed in the meninges and
are found in the anterior two -thirds of the clivus. They can affect
the surrounding anatomical structures as demonstrated by the
following image :

Neurosurgical Review, 2015, Volume 38, Number 1, Page 71
Da Li, Shu -Yu Hao, Liang Wang

Petroclival meningiomas are supplied by three arteries ,
the vertebral artery , the occipital artery and the ascending
pharyngeal artery. As far as the innervation of petroclival tumors
is concerned , they are innervated by the sensory meningeal
branch of the vagus nerve and th e glossopharyngeal nerve. T hey
are also innervated by the trigeminal nerve.

Signs and Sym ptoms
Petroclival meningiomas are tumors which invade the
surrounding strucutures , and thus we can have a number of
different symptoms . T he symptoms are largely diagnosed only
when the tumor increases in size. On average , it takes between
3 and 5 years for the symptoms to manifest themselves and for a
positive diagnosis to be made. The symptoms are related to the
craninal nerves , and the compression of the brainstem.
The symptoms of petroclival meningiomas include :
 Headaches
 Fatigue
 Gait alteration
 Hearing loss
 Facial paralysis
 Loss of memory
 Blurred vision
 Diplopia
 Seizures
 Nausea
 Vomiting
 Difficulty in swallowing
 Trouble in walking
 Facial muscle spasms
 Inreased intracranial pressure

It must be mentioned that amongst the cranial nerves , the
trigeminal nerve is the most commonly affected nerve . The
trigeminal nerve can be affected in up to 30% of patients. Other
cranial nerves which are frequently affected are the
glossopharyngeal nerve and the vagus nerve.
One of the main reasons that the mortality rate of
petroclival meningiomas was so high (around 50%) was because
of the delay in the diagnosis. Nowadays , the mortality rate has
decreased due better treatment procedures and due to earlier
diagnosis. Thus it is highly recommended to go to a doctor
immediately when the patient experienc es the aforementioned
symptoms and signs.

Histology and Physiology
Meningiomas are classified into three subtypes by the
World Health Organisation (WHO):
 Grade I : Benign
 Grade II : Atypical
 Grade III : Malignant

Diagnosis

SPECIAL PART

Introduction
Petroclival meningiomas are tumors th at are located in the
upper two -thirds of the clivus. Petroclival meningiomas are found
at the petroclival junction and are located medially as compared
to the trigeminal nerve. These tumors originate in the m eninges,
which are the membranes which surround and cover the brain
and the spinal cord. Even though petroclival meningiomas are
found in the meninges , they are still classified as brain tumors
since they directly affect the brainstem,nerve and vessels.Th ese
tumors are known to move the brainstem and also the basilar
artery to oppsite sides.
Petroclival meningiomas can be found in the posterior
fossa or they can be found in the posterior and middle fossas.
Petroclival meningiomas are very complex tumors since they
usually invade the surrounding vessels and structures. Thus they
are very difficult to treat and to resect.
In the past, mortality rates for petroclival meningiomas used
to be greater than 50% in the 1970s. However, due to rapid
advances in medicine and better understanding of these tumors
has resulted in a mortality rate less than 10% today .

BIBLIOGRAPHY
1. https://www.aans.org/en/Patients/Neurosurgical -Conditions –
and-Treatments/Meningiomas
2. https://www.ncbi.nlm .nih.gov/pmc/articles/PMC353275
3. Neurosurgical Review, 2015, Volume 38, Number 1, Page 71
Da Li, Shu-Yu Hao, Liang Wang
4. Developmental patterns and characteristic symptoms of
petroclival meningiomas, KawaseT1, Shiobara R , Ohira T , Toya S

5. Meningiomas. American Association of Neurological Surgeons.
http://www.aans.org/Patient Information/Conditions and
Treatments/Meningiomas.aspx