Posterior petrosal approach for microsurgical resection of petroclival meningioma: 3-Dimensional operative video

Guilherme Henrique Weiler Ceccato; Rodolfo Frank Munhoz da Rocha; Anderson Matsubara; Luis Alencar Biurrum Borba

doi:10.25259/SNI_270_2021

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2021

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324

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10.25259/SNI_270_2021

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Posterior petrosal approach for microsurgical resection of petroclival meningioma: 3-Dimensional operative video

Guilherme Henrique Weiler Ceccato¹, Rodolfo Frank Munhoz da Rocha², Anderson Matsubara¹, Luis Alencar Biurrum Borba¹

1Department of Neurosurgery, Mackenzie Evangelical University Hospital, Paraná, Brazil.

2School of Medicine, Mackenzie Evangelical College of Paraná, Curitiba, Paraná, Brazil.

*Corresponding author: Luis Alencar Biurrum Borba, Department of Neurosurgery, Mackenzie Evangelical University Hospital, Curitiba, Paraná, Brazil. luisalencarborba@gmail.com

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Received: 2021-03-15, Accepted: 2021-05-25, Published: 2021-07-06

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This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-Share Alike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.

How to cite this article: Ceccato GH, da Rocha RF, Matsubara A, Borba LA. Posterior petrosal approach for microsurgical resection of petroclival meningioma: 3-Dimensional operative video. Surg Neurol Int 2021;12:324.

Abstract

Background:

Petroclival meningiomas are challenging lesions considering their deep location and close relationship with many vital neurovascular structures.[1-8]

Case Description:

We present the case of a 54-year-old male presenting a history of headache, dizziness, and tinnitus on the left side, associated with left facial hypoesthesia. Preoperative imaging depicted a lesion highly suggestive of a petroclival meningioma with important compression of the brainstem. Considering worsening of symptoms, size, and location of this lesion, microsurgical resection was indicated. A left posterior petrosal approach was employed with aid of neurophysiological monitoring. The patient was placed in a true lateral position and an arciform incision was done. First, the mastoidectomy was performed and then the craniotomy around encompassing both posterior and middle cranial fossae. Middle and posterior fossa dural incisions were connected through coagulation of the superior petrosal sinus. Then tentorium was all the way cut to the incisura. After that, sigmoid sinus can be mobilized posteriorly, increasing exposure of presigmoid space. The area since jugular foramen up to the supratentorial region was fully exposed, allowing safe total resection of the lesion. Postoperative imaging demonstrated complete tumor removal. Patient presented improvement of symptoms, with no new neurological deficits on follow-up.

Conclusion:

The posterior petrosal approach provided a shorter pathway and direct angle of attack to the tumor attachment, allowing successful resection.[1,6] Extensive laboratory training is essential to get familiarized with the complex anatomical relationships in that area. Informed consent was obtained from the patient for the procedure and publication of this operative video.

Keywords

Meningioma

Petroclival

Posterior petrosal

Skull base

Tumor

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Annotations[1-8]

0:07 - Clinical Presentation
0:21 - Neuro-imaging Findings
0:59 - Tumor 3D Model
1:11 - Rationale for the Procedure
1:33 - Approach 3D Model
2:25 - Risks of the Procedure and its Potential Benefits
2:30 - Alternatives and Why They Were not Chosen
2:36 – Anatomy
4:27 - Description of the Setup
4:34 – Procedure
8:37 - Disease Background
8:44 - Postoperative Imaging
9:24 - Outcome

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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REFERENCES

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Annotations[1-8]

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[1] Almefty R, Dunn IF, Pravdenkova S, Abolfotoh M, AlMefty O. True petroclival meningiomas: Results of surgical management. J Neurosurg. 2014;120:40-51.
[Google Scholar]

[2] Coppens JR, Couldwell WT. Clival and petroclival meningiomas. In: DeMonte F, McDermott MW, Al-Mefty O, eds. Al-Mefty’s Meningiomas (2nd ed). New York: Thieme Medical Publishers; 2011. p. 270-82.
[Google Scholar]

[3] DiLuna ML, Bulsara KR. Surgery for petroclival meningiomas: A comprehensive review of outcomes in the skull base surgery era. Skull Base. 2010;20:337-42.
[Google Scholar]

[4] Giammattei L, di Russo P, Starnoni D, Passeri T, Bruneau M, Meling TR, . Petroclival meningiomas: Update of current treatment and consensus by the EANS skull base section. Acta Neurochir (Wien). 2021;163:1639-63.
[Google Scholar]

[5] Gosal JS, Behari S, Joseph J, Jaiswal AK, Sardhara JC, Iqbal M, . Surgical excision of large-to-giant petroclival meningiomas focusing on the middle fossa approaches: The lessons learnt. Neurol India. 2018;66:1434-46.
[Google Scholar]

[6] Havenbergh TV, Carvalho G, Tatagiba M, Plets C, Samii M. Natural history of petroclival meningiomas. Neurosurgery. 2003;52:55-62.
[Google Scholar]

[7] Hunter JB, Yawn RJ, Wang R, O’Connell BP, Carlson ML, Mistry A, . The natural history of petroclival meningiomas: A volumetric study. Otol Neurotol. 2017;38:123-8.
[Google Scholar]

[8] Jung HW, Yoo H, Paek SH, Choi KS. Long-term outcome and growth rate of subtotally resected petroclival meningiomas: Experience with 38 cases. Neurosurgery. 2000;46:567-74.
[Google Scholar]