Two-Stage Double Petrosal Approach for the Total Resection of Petroclival-Cavernous Meningioma: 2-Dimensional Operative Video.

The utilization of skull base approaches has markedly facilitated the safe surgical removal of challenging petroclival meningiomas.1 The anterior petrosal approach has been utilized for tumors limited to the upper clivus, above the meatus, whereas the posterior petrosal approach has been the workhorse for the resection of larger tumors in the posterior fossa extending down the clivus.2 Giant cases with extension in the middle fossa, cavernous sinus, and ventral to the brain stem would benefit from a wider exposure than each of these approaches provide. This could be achieved by total petrosectomy. However, in patients with serviceable hearing anterior and posterior petrosals can be combined while preserving the hearing apparatus.2,3 This procedure is lengthy; hence, we tend to stage it in 2 subsequent days. The first stage is focused on the soft tissue and bone work including the mastoidectomy, sigmoid transverse sinus, and jugular bulb skeletonization, as well as anterior petrosectomy. The second stage is dedicated to tumor exposure through tentorial sectioning and microsurgical resection. We report the case of a 40-yr-old woman diagnosed with large left-sided petroclival meningioma with significant extension into the cavernous sinus and Meckel's cave. The patient had neurological deficits including cranial nerves, cerebellar dysfunction, and hydrocephalus, although her hearing was intact. Total tumor resection was achieved through the double petrosal approach in 2002. Extensive anatomic knowledge and thorough preoperative clinical and radiological evaluation, particularly the venous system, are key in the successful planning of this procedure. The patient consented for surgery and publication of their image.  Figures at 2:40 and 3:47, ©Ossama Al-Mefty, used with permission.