Surgical management of petroclival meningiomas: factors determining the choice of approach

Abstract

<jats:p>Petroclival meningiomas remain one of the most challenging intracranial tumors to treat surgically. This is attributable to their location deep within the skull base and their association with multiple critical neural and vascular structures. Over the years, many skull base approaches have been described that are meant to improve resection and decrease patient morbidity. Appropriate selection of the surgical approach requires a thorough preoperative evaluation of clinical and radiological factors. In this paper the authors retrospectively reviewed 97 patients treated surgically for petroclival meningiomas by the senior author (O.A.M.) between 1995 and 2005 to assess the factors used to determine the choice of surgical approach, and to assess complication rates based on the approach selected. The skull base approaches used in these patients included the middle fossa anterior petrosal, posterior petrosal, and combined petrosal approaches, and complete petrosectomy. Factors found to be important in determining the selection of approach included the size, location, and extension of the tumor, preoperative hearing evaluation, and venous sinus anatomy.</jats:p>

Petrosal approaches to posterior circulation aneurysms

“…Originally conceptualized by Hakuba, 21 a combined posterior petrosal and anterior petrosal approach may be used instead. 10,13 The combined approach is particularly advantageous in the context of aneurysm clip reconstruction, as the line of sight need not be obstructed by the clip applier during placement of the clip. Instead, the surgeon's line of sight may be in one working corridor (for example, the posterior petrosal corridor, visualizing basilar perforators), while the working angle of clip application may be in the other (for example, the anterior petrosal corridor).…”

“…In our experience, dividing the sigmoid sinus is unnecessary, as it can be preserved and mobilized instead with the modern posterior petrosal approach. 1,13 The modern posterior petrosal approach is based on a combined supra-and infratentorial exposure. 1 The concept of performing a temporooccipital craniotomy and mobilizing a skeletonized sigmoid sinus after dividing the superior petrosal sinus and tentorium, the crucial maneuver of this approach, was originally devised by Hakuba in 1977.…”

“…1,21,26,50,55 Lauded for their usage in the management of complex neoplastic lesions such as meningiomas, schwannomas, and chordomas, 1,10,13,[19][20][21]26,48,50,55 petrosal approaches have also been employed for decades in the management of complex cerebrovascular lesions, particularly posterior circulation aneurysms. 4,11,30,31,37,43,50 In this manuscript, we review the evolutionary application of the standard anterior and posterior petrosal approaches to complex posterior circulation aneurysms.…”

Petro-Clival Tumours: Role and Indications of Transoral and Transsphenoidal Approaches Followed by Hypofractionated Stereotactic Radiotherapy

“…Petro-clival, clival and spheno-petro-clival tumors are still a neurosurgical challenge (1)(2)(3). Usually, the classical skull base transpetrous approaches (middle fossa anterior petrosal, posterior petrosal, combined petrosal approaches and complete petrosectomy) (1,(4)(5)(6) are employed although they are burdened by an important rate of morbidity and a very low rate of radical removal is reported (3,(7)(8)(9)(10)(11)(12)(13)(14).…”

“…Usually, the classical skull base transpetrous approaches (middle fossa anterior petrosal, posterior petrosal, combined petrosal approaches and complete petrosectomy) (1,(4)(5)(6) are employed although they are burdened by an important rate of morbidity and a very low rate of radical removal is reported (3,(7)(8)(9)(10)(11)(12)(13)(14). Because tumour growth is slow and neurovascular structures present a various degree of adjustment, diagnosis is usually performed when tumour is large, and this fact implies the need to perform surgery as first therapeutic step; the problem is that if surgical removal is too extended, rate of postoperative deficit is too high, and on the contrary if surgical removal is too little, control of postoperative tumor remnant is problematic also with radiotherapy.…”