Brain Tumor Removal | Prof. Zhou Lianfang (Neurosurgery) | CMCS Shanghai

About Prof. Zhou Lianfang

Prof. Zhou Lianfang is a distinguished neurosurgeon at Huashan Hospital, Fudan University. He specializes in microsurgical resection of intracranial tumors, including gliomas and meningiomas. He is widely regarded as one of China's foremost experts in skull base and deep brain surgery.

Case Overview

A 48-year-old woman presented with a three-month history of progressive headache, diplopia, and dysphagia. MRI revealed a giant 5.5 cm petroclival meningioma encasing one-third of the basilar artery circumference, displacing the right vertebral artery, and compressing the pons and cerebellum — with involvement of six cranial nerves. Prof. Zhou Lianfang's team at Huashan Hospital, Fudan University performed microsurgical resection via the far-lateral transcondylar approach under full intraoperative neurophysiological monitoring (IONM). Simpson Grade I resection was confirmed on 72-hour postoperative MRI. The patient was discharged on day 14 with improved facial sensation, restored swallowing function, and no limb deficits.

Patient Background

• Age / Sex: 48-year-old female
• Chief Complaint: Progressive headache with diplopia and dysphagia for 3 months
• Medical History: No hypertension, diabetes, or prior neurological conditions
• Neurological Examination:
  • Alert; GCS 15
  • Right facial numbness (V2, V3 distribution); reduced corneal reflex
  • Left lateral gaze restriction (CN VI palsy)
  • Soft palate elevation impaired (CN IX, X involvement); tongue deviation to the right (CN XII)
  • Limb strength Grade V bilaterally; no pathological reflexes

Pre-operative Workup

Imaging (Enhanced MRI + MRA + 3D CT Reconstruction)

• Origin: Clival dura, with bilateral extension to the petrous apex — "dumbbell" morphology
• Size: 5.5 cm × 4.0 cm × 3.5 cm
• Vascular Involvement: Basilar artery encased ~1/3 of its circumference; right vertebral artery (V4 segment) displaced by tumor
• Bone Involvement: CT showed petrous apex erosion and clival hyperostosis

Pre-operative Assessment

• Presumed Diagnosis: Petroclival meningioma (WHO Grade I most likely)
• Surgical Risk: Extremely high — proximity to lower cranial nerves (CN IX–XII), facial and auditory nerves (CN VII–VIII), vertebrobasilar system, and brainstem vital centers
• Approach Selection: Standard infratentorial supracerebellar or presigmoid approaches were insufficient to expose the inferior tumor pole and vertebral artery. Prof. Zhou selected the far-lateral transcondylar approach, with planned partial occipital condyle resection to achieve a direct ventral corridor to the brainstem

Surgical Strategy

Primary Goal: Simpson Grade I resection (gross total removal including invaded dura) while preserving cranial nerve and brainstem function.

Key Technologies

• Multimodal Neuronavigation: DTI (diffusion tensor imaging) tractography to map corticospinal tract and cranial nerve trajectories
• Intraoperative Neurophysiological Monitoring (IONM):
  • Brainstem Auditory Evoked Potentials (BAEP): hearing and brainstem function surveillance
  • Motor Evoked Potentials (MEP): continuous limb motor monitoring
  • Electromyography (EMG): real-time monitoring of CN V, VII, IX, X, XI, XII
• Vascular Control: Temporary aneurysm clips pre-positioned for emergent vertebral or basilar artery control

Operative Procedure

• Position & Fixation: Lateral decubitus; three-point Mayfield head fixation with neck flexion and rotation to bring the jugular foramen to the highest point
• Anesthesia: General anesthesia; intraoperative wake-up testing protocol prepared
• Incision & Exposure: Retroauricular "question mark" incision; exposure of occipital squama, C1 lamina, and atlantoaxial lateral mass

Transcondylar Key Step

• Lateral one-third of the occipital condyle drilled away (approximately 1/3–1/2 of condyle volume), opening the posterior lip of the jugular foramen and exposing the jugular bulb and lower cranial nerve dural canals
• This maneuver critically shortened the working distance to the ventral brainstem and eliminated the need for cerebellar retraction

Tumor Resection — Microsurgical Technique

• Dural Opening: Curvilinear durotomy; dural flap suspended; clival tumor base devascularized with bipolar coagulation
• Internal Decompression: CUSA (Cavitron Ultrasonic Surgical Aspirator) used for piecemeal internal debulking to reduce tumor volume before capsule dissection
• Neurovascular Dissection (Critical Phase):
  • Under high-power microscopy, microsurgical dissectors used to separate tumor from CN IX (glossopharyngeal), CN X (vagus), and CN XI (accessory nerve); at points of dense adhesion, small tumor remnants were deliberately left rather than risk avulsion injury — consistent with Prof. Zhou's "function first" philosophy
  • Vertebral artery dissection: normal proximal segment exposed first; temporary clip applied; tumor peeled from the encased segment; Teflon cotton pledget placed for vessel protection
  • Brainstem interface: no glial reaction plane identified; low-power bipolar coagulation with continuous irrigation used to separate tumor from pial surface without thermal injury

Skull Base Closure

• Watertight dural repair using autologous fascia and synthetic dural substitute
• Bone flap repositioned and fixed; drain placed

Operative Data

• Operative Time: 420 minutes (7 hours)
• Estimated Blood Loss: ~600 mL (400 mL autologous cell salvage returned)
• Transfusion: 2 units packed red blood cells

Pathology & Post-operative Recovery

Pathology Report

• Gross: Grey-white, firm, highly vascular
• Histology: Meningothelial meningioma, WHO Grade I; Ki-67 <3%

Post-operative Course

• ICU: Transferred intubated; extubated at 2 hours; alert and following commands; bilateral limb movement intact (MEP stable intraoperatively)
• Transient Dysphagia: Aspiration on swallowing noted day 3 — attributed to lower cranial nerve edema; nasogastric tube placed; intensive swallowing rehabilitation commenced
• CSF Leak: None (watertight dural closure)
• Day 14: Discharged — right facial numbness improved; swallowing function restored; no limb weakness

Imaging

• 72-hour MRI: Simpson Grade I resection confirmed; brainstem decompressed and repositioned; DWI showed no brainstem infarction

Follow-up & Long-term Management

• 3 Months Post-op: MRI showed no recurrence; nasogastric tube removed; tolerating liquid diet without aspiration; mild right-sided hearing reduction noted (BAEP amplitude fluctuation was observed intraoperatively — an anticipated risk given tumor proximity to CN VIII)
• Adjuvant Therapy: WHO Grade I meningioma with Simpson Grade I resection — no radiotherapy or chemotherapy indicated; annual MRI surveillance recommended

Expert Commentary — Prof. Zhou Lianfang

1. Anatomical Mastery of the Petroclival Region

The petroclival region has been called the "crown jewel" of neurosurgery — a convergence of the most critical vascular and neural structures in the posterior fossa. The far-lateral transcondylar approach is one of the gold-standard corridors for ventral clival tumors precisely because it provides a direct line of sight to the brainstem without requiring cerebellar retraction. The decision to remove one-third of the occipital condyle is not taken lightly — it must be calibrated to maximize exposure while preserving atlanto-occipital stability. In this case, that calibration was the key that unlocked the entire operation.

2. Function-Preserving Microsurgery — The Modern Standard

The era of "total resection at any cost" in skull base meningioma surgery is over. For benign tumors encasing critical neurovascular structures, the goal is maximal safe resection — not anatomical completeness at the expense of the patient's quality of life. In this case, small tumor remnants were deliberately left at points of dense cranial nerve adhesion. Those remnants can be addressed with stereotactic radiosurgery if they grow. What cannot be restored is a permanently paralyzed vocal cord or a patient who cannot swallow. Our patients must be able to live with dignity after surgery — that principle guides every decision at the microscope.

3. Intraoperative Neurophysiological Monitoring as a Surgical Compass

In a seven-hour operation within millimeters of the brainstem and vertebrobasilar system, IONM is not a safety net — it is a real-time navigational instrument. Every fluctuation in BAEP amplitude, every EMG burst from a cranial nerve, is a signal that demands an immediate surgical response: pause, irrigate, reposition, or withdraw. The absence of new permanent deficits in this case is not luck. It is the result of a team that treats electrophysiological signals with the same respect as anatomical landmarks.

How CMCS Shanghai Coordinated This Case

China Medical Concierge Shanghai (CMCS) supported this patient's care pathway from initial overseas inquiry through discharge and follow-up planning. Our coordination included:

• Pre-arrival MRI image review and specialist referral to Prof. Zhou Lianfang's neurosurgery team at Huashan Hospital
• Arrangement of enhanced MRI, MRA, and 3D CT reconstruction at Huashan Hospital
• Bilingual interpretation during pre-operative risk counseling and surgical consent — including detailed discussion of cranial nerve risks and the "function first" surgical philosophy
• Surgical admission logistics, including hospital registration and family accommodation support
• On-site medical interpretation throughout the ICU and ward stay, including daily updates to the patient's family
• Post-discharge coordination of swallowing rehabilitation referral, audiology assessment, and MRI surveillance scheduling at 3 months

For international patients facing a complex intracranial tumor diagnosis, the stakes — and the anxiety — are immense. CMCS exists to ensure that no patient has to navigate China's most advanced neurosurgical care alone. We connect patients with the right surgeon, at the right institution, with every clinical and logistical detail managed from first contact to long-term follow-up.

This case report is de-identified and published for educational purposes. All clinical details have been anonymized in accordance with patient privacy standards. CMCS Shanghai is a medical concierge service and does not provide direct medical care.