Microsurgical Resection of Petroclival Meningioma via the Posterior Petrosal Approach: Three-Dimensional Operative Video.

ABSTRACT

Petroclival meningiomas are complex, deep-seated lesions related to many critical neurovascular structures. We present the case of a 44-year-old woman who had presented with a history of severe facial pain, hearing loss, and tinnitus on the left side, associated with left facial hypoesthesia (Video 1). Preoperative magnetic resonance imaging demonstrated a mass highly suggestive of a left petroclival meningioma. Considering the worsening symptoms and important mass effect, microsurgical resection using the posterior petrosal approach was performed. Mastoidectomy was performed first, followed by craniotomy encompassing both posterior and middle cranial fossae. The posterior fossa and middle fossa dural incisions were connected, coagulating and sectioning the superior petrosal sinus. Next, the tentorium was cut all the way toward the incisura, with care to preserve the fourth nerve in the last cut. After completion of the tentorium incision, the presigmoid space increased. The lesion was totally resected using microsurgical techniques, with the aid of an ultrasonic aspirator to debulk the mass and allow for its circumferential dissection. Postoperative magnetic resonance imaging demonstrated complete tumor resection. The patient presented with improvement of symptoms and no new neurological deficit during follow-up. Skull base approaches, such as the posterior petrosal approach, are useful for successfully treating challenging lesions such as the one presented, with low morbidity. Laboratory training is essential to be familiarized with the complex intraoperative neuroanatomical nuances. The patient provided written informed consent for the report of her case and operative video. The anatomical images were provided courtesy of the Rhoton Collection, American Association of Neurological Surgeons/Neurosurgical Research and Education Foundation.