Meningiomas do forame magno: tratamento cirúrgico em uma
                        instituição pública em um país em desenvolvimento

Colli, Benedicto Oscar; Carlotti Junior, Carlos Gilberto; Assirati Junior, João Alberto; Borba, Luis Alencar Biurrum; Coelho Junior, Vicente de Paulo Martins; Neder, Luciano

doi:10.1590/0004-282X20140101

Benedicto Oscar Colli

Divisão de Neurocirurgia, Departamento de Cirurgia e Anatomia, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirao Preto SP, Brazil;

Carlos Gilberto Carlotti Junior

Divisão de Neurocirurgia, Departamento de Cirurgia e Anatomia, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirao Preto SP, Brazil;

João Alberto Assirati Junior

Divisão de Neurocirurgia, Departamento de Cirurgia e Anatomia, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirao Preto SP, Brazil;

Luis Alencar Biurrum Borba

Universidade do Paraná, Curitiba PR, Brazil;

Vicente de Paulo Martins Coelho Junior

Divisão de Neurocirurgia, Departamento de Cirurgia e Anatomia, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirao Preto SP, Brazil;

Luciano Neder

Departamento de Patologia, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirao Preto SP, Brazil.

Correspondence:
Benedicto Oscar Colli; Departamento de Cirurgia e Anatomia, Faculdade de Medicina Ribeirão Preto; Campus Universitário USP - Bairro Monte Alegre; 14048-900 Ribeirão Preto SP, Brasil; E-mail: bocolli@fmrp.usp.br

Conflict of interest: There is no conflict of interest to declare.

Figuras (5)
Tabelas (1)

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Figure 1
. Pre- (A,B) and postoperative (G,H) resonance magnetic images with gadolinium and operative findings of a 70-year-old female with recent memory disturbance, seizures, walking imbalance and dizziness and ataxic gait, horizontal nistagmus, left IX,X, XI and XII cranial nerve (CN) palsies at examination. A-B. T1-weighted images showing an anterolateral craniospinal tumor in the foramen magnum, displacing the medulla posterolaterally. C. Incision used for suboccipital lateral approach to the tumor. Exposure of the dura-mater of the posterior fossa after craniotomy and of the entry point of the vertebral artery (VA) in dura. E. exposure of the tumor (tu) displacing the medulla (MO), the VA into the posterior fossa behind the tumor, and the XI and XII CN displaced posteriorly, over the tumor. F. VA, XI and XII CN and medulla after tumor resection. G-H. Four years postoperative T1-weighted images showing unchanged residual tumor in the right anterolateral dura-mater.

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Figure 2
. Resonance magnetic images with gadolinium of a 30-years-old male with progressive weakness in the left upper limb and right lower limb, gait difficult, and. constipation and neck pain and paretic gait, and left hemiparesis at examination. A-C. Preoperative T1-weighted images showing an anterolateral spinocranial tumor in the foramen magnum, displacing the medulla and the upper cord posterolaterally. D-E. Eight months postoperative T1-weighted images showing no residual tumor.

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Figure 3
. Pre- (A,B) and postoperative (G,H) resonance magnetic images with gadolinium and operative findings of a 58-year-old female with paresthesias on the right hand, weakness/paresthesias in the lower limbs. Wheelchair restricted, global weakness, deep hyperreflexia, Babinski +. A-B. Preoperative T1-weighted images showing an anterior craniospinal tumor in the foramen magnum, displacing the medulla posteriorly. C-D. exposure of the tumor (tu) displacing the medulla (MO), the posterior inferior cerebellar artery (PICA) and the IX and X and XI cranial nerve (CN), and VA, and medulla after tumor resection. F-G. Ninety months postoperative T1-weighted images showing no residual tumor.

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Figure 4
. Resonance magnetic images with gadolinium of a 28-years-old female with hemicranial headache, nauseas, dizziness and photo / phonophobia and bilateral + Babinski at examination. A-B. Preoperative T1-weighted images showing a posterolateral craniospinal tumor in the foramen magnum, displacing the medulla and the upper cord anterolaterally. C-D. Five months postoperative T1-weighted images showing no residual tumor and a residual fluid collection in the subcutaneous layers originated from a cerebrospinal fluid fistula.

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Figure 5
. Resonance magnetic images with gadolinium of a 47-years-old male with headache and double vision and with left VI, IX-XII cranial nerve (CN) palsies at examination. A-C. Preoperative T1-weighted images showing an anteroposterolateral tumor in the foramen magnum extending to the opposite side. displacing the medulla and the upper cord posterolaterally. D-F. 10 months after partial resection T1- weighted images showing an en plaque spreading of the tumor through the dura mater. G-J. 3 years after the partial resection T1- weighted images showing an en plaque spreading of the tumor through the dura mater, including invasion of CN of foramina.

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Table
. Tumor size, sign and symptoms, imaging, surgical findings and follow up of the patients.

Patient	Age/sex	Signs and symptoms	MRI features	Surgery/surgical findings	Postoperative signs and symptoms	Simpson grade	Clinical findings at follow-up
AMA 0270461H	54/F	Occipito-cervical pain paresthesias/ weakness in the arms and legs (8 mos). Spastic tetraparesis, deep hyperreflexia, Rt dysmetria, Romberg+.	Lower-Middle- Clivus Craniospinal Anterior 4,3 x 4,0 x 3,8 cm	SLC (Two Stages) - Spinal XI CN displaced. Vertebral a. displaced supero-anteriorly	Aspirative pneumonia, tracheotomy. Meningitis, seizures, Rt IX-XI CN palsies.	I	Rt IX-XI CN palsy, tetraparesis, traqueotomy. Dependent for daily life activities.
MCBS 0049754E	74/F	Global progressive weakeness. Spastic tetraparesis	Lower Clivus - Craniospinal Anterolateral - 2,5x2,5x2,0 cm	SLC - Spinal XI CN / Vertebral a. free.	Improved from weakness.	I	Normal Examination. Discharged from the outpatient department.
EMO 0408583F	74/F	Paresthesias in the hands, difficult for walking. Spastic tetraparesis.	Lower Clivus - C1 Craniospinal - Anterior 3, 1 x 1,3 x 2,0 cm	SLC + C2-C3 - Hemilaminectomy Spinal XI CN / Vertebral a. free.	Tetraparesis.	II	Walking with support, monoparesis of the upper Rt limb.
JFS 0469216F	59/F	Paresthesias in the fingers, arms and neck. Arms weakness, Lt dysmetria, Romberg+	Lower Clivus - C1 Spinocranial - Anterior 2,2 x 1,6 x 1,2 cm	SLC + Posterior 1/3 of OC Spinal XI CN / Vertebral a. free	Lt IX-IX CN palsies.	I	Mild dysphagia. Lt IX, X, and XI CNs mild paresis.
SM 0490129I	47/M	Headache, double vision. Lt VI, IX-XII CN palsies.	Lower Clivus - Craniospinal Anterior, lateral, posterior - En Plaque - 5,0 x 2,0 x 3,5 cm	SLC - Vertebral a. + Posterior Inferior, Cerebellar a. involved.	Abdominal respiratory pattern, tracheotomy. Subcutaneous CSF leak (LD). Ataxia, dysmetria, dysdiadochokinesia, Mild rt hemiparesis. VI, IX-XI CN palsies worsening.	III	Abdominal respiratory pattern, tracheotomy. Walking with support Lt VI, IX-XI CN palsies. No dysphagia. Death to tumor progression (39 month)
JCT 0763629D	58/F	Paresthesias (rt hand), weakness/paresthesias in the lower limbs. Wheelchair restricted. Global weakness. Deep hyperreflexia, Babinski+.	Lower Clivus - Craniospinal Anterior - 2,5 x 2,9 x 2,6 cm	SLC - XI CN displaced posteriorly, XII CN displaced superiorly. Vertebral a. free.	Progressive improvement.	II	Very well, Complete recovery
JBZ 0737882E	77/F	Recent memory disturbance, seizure, walking imbalance and dizziness. Ataxic gait, horizontal nistagmus, Lt IX,X, XI and XII CN palsies.	C1 - Lower Clivus Craniospinal Anterolateral 3,2 x 2,2 x 2,1 cm	SLC - Posterior 1/3 of OC X and XII CN displaced. Proximal vertebral a. involved.	Progressive improvement.	IV	Complete recovery.

IM 0840344B	54/F	Gait deviation, difficult for swallowing and nasal voice. Lt IX-XII CN palsies.	C1- Lower Clivus Craniospinal. Anterolateral 3,0 x 4,0 x 3,0 cm	SLC - Posterior 1/3 of OC XII CN involved and displaced. Vertebral a. partially involved.	Aspirative pneumonia, hypoxia, depression of consciousness, tracheotomy. Recovered well. Discharged walking, tracheotomy, gastrostomy. Lt VI, IX-XII CN palsies.	I	Nasal voice, walking normally, paresis of IX-XII CN. Mild dysphasia.
CMMOI 0860891B	52/F	Occipital pain. Global exaggerated deep reflexes.	Lower Clivus - Craniospinal Anterior - 2,0 x 2,5 x 2,5 cm	SLC - Spinal XI CN displaced; bulbar XI partially and VI CN involved. Vertebral a. free	Difficult to recover respiratory drive. Recovered after tracheotomy. Gastrostomy. Lt VI, IX, X and XI CN palsies.	I	Progressive complete recovery.
FBS 0913929H	30/M	Progressive weakness in the lt upper limb and Rt lower limb, gait difficult, and. constipation and neck pain. Paretic gait, lt hemiparesis.	C1 - Lower Clivus Spinocranial Anterolateral 1,5 x 2,0 x 2,0 cm	SLC - Posterior 1/3 of OC Spinal XI CN and C1-C2 displaced. Vertebral a. partially involved.	Improving the muscular strength and decrease of the paresthesias.	I	Progressive complete recovery
MIAB 0126708C	28/F	Hemicranial headache, nauseas, dizziness and photo / phonophobia. Bilateral + Babinski.	Lower Clivus - C1 Spinocranial-Posterolateral 1,5 x 2,0 x 1,0 cm	SLC - Spinal XI CN and C1-C2 displaced. Vertebral a. partially involved..	Subcutaneous CSF leak (LD).	I	Complete recovery. Presenting psychiatric disturbances. Refused admission.
SVC 0277434A	56/F	Neck pain, incoordination, weakeness and contractures in the limbs. Tetraparesis, bilateral + Hoffman and Babinski.	C2-C1-Lower Clivus Spinocranial - Anterolateral 2,0 x 3,5 x 1,7 cm	SLC - Spinal XI CN and C1-C2 displaced. Vertebral a. partially involved..	Subcutaneous CSF leak (LD).	II	Complete recovery.
EAS 1091202K	41/F	Neck and throat pain. Lf V1, V2 V3 hypoesthesia, Lt IX-XII CN deficits.	Middle/Lower Clivus Craniospinal Anterolateral 3,0 x 4,0 x 2,0 cm	SLC - Subtemporal/Suboccipital Spinal XI CN and C1-C2 displaced. Vertebral a. involved.	V-VII, IX-XII left CN palsies.	IV	Feeding normally, Lf V, IX-XII CN palsies. Improvement from diplopia.

[1] Correspondence:
Benedicto Oscar Colli; Departamento de Cirurgia e Anatomia, Faculdade de Medicina Ribeirão Preto; Campus Universitário USP - Bairro Monte Alegre; 14048-900 Ribeirão Preto SP, Brasil; E-mail: bocolli@fmrp.usp.br

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Meningiomas do forame magno: tratamento cirúrgico em uma instituição pública em um país em desenvolvimento

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