Dural Opening/Removal for Combined Petrosal Approach: Technical Note

ABSTRACT

Detailed descriptions of stepwise dural opening/removal for combined petrosal approach are presented. Following maximum bone work, the first dural incision was made along the undersurface of the temporal lobe parallel to the superior petrosal sinus. Posterior extension of the dural incision was made in a curved fashion, keeping away from the transverse-sigmoid junction and taking care to preserve the vein of Labbé. A second incision was made perpendicular to the first incision. After sectioning the superior petrosal sinus around the porus trigeminus, the incision was extended toward the posterior fossa dura in the middle fossa region. The tentorium was incised toward the incisura at a point just posterior to the entrance of the trochlear nerve. A third incision was made longitudinally between the superior petrosal sinus and the jugular bulb. A final incision was initiated perpendicular to the third incision in the presigmoid region and extended parallel to the superior petrosal sinus connecting the second incision. The dural complex consisting of the temporal lobe dura, the posterior fossa dura, and the freed tentorium could then be removed. In addition to extensive bone resection, our strategic cranial base dural opening/removal can yield true advantages for the combined petrosal approach.

Combined petrosal approach - dural opening - petroclival lesion - skull base surgery

REFERENCES

• 1 Hakuba A, Nishimura S, Jang B J. A combined retroauricular and preauricular transpetrosal-transtentorial approach to clivus meningiomas.  Surg Neurol. 1988;  30 108-116
• 2 Samii M, Ammirati M, Mahran A, Bini W, Sepehrnia A. Surgery of petroclival meningiomas: report of 24 cases.  Neurosurgery. 1989;  24 12-17
• 3 Couldwell W T, Fukushima T, Giannotta S L, Weiss M H. Petroclival meningiomas: surgical experience in 109 cases.  J Neurosurg. 1996;  84 20-28
• 4 Sekhar L N, Jannetta P J, Burkhart L E, Janosky J E. Meningiomas involving the clivus: a six-year experience with 41 patients.  Neurosurgery. 1990;  27 764-781 discussion 781
• 5 Al-Mefty O, Fox J L, Smith R R. Petrosal approach for petroclival meningiomas.  Neurosurgery. 1988;  22 510-517
• 6 Little K M, Friedman A H, Sampson J H, Wanibuchi M, Fukushima T. Surgical management of petroclival meningiomas: defining resection goals based on risk of neurological morbidity and tumor recurrence rates in 137 patients.  Neurosurgery. 2005;  56 546-559 discussion 546-559
• 7 Erkmen K, Pravdenkova S, Al-Mefty O. Surgical management of petroclival meningiomas: factors determining the choice of approach.  Neurosurg Focus. 2005;  19 E7
• 8 Abdel Aziz K M, Sanan A, van Loveren H R, Tew Jr J M, Keller J T, Pensak M L. Petroclival meningiomas: predictive parameters for transpetrosal approaches.  Neurosurgery. 2000;  47 139-150 discussion 150-152
• 9 Sekhar L N, Schessel D A, Bucur S D, Raso J L, Wright D C. Partial labyrinthectomy petrous apicectomy approach to neoplastic and vascular lesions of the petroclival area.  Neurosurgery. 1999;  44 537-550 discussion 550-552
• 10 Day J D, Fukushima T, Giannotta S L. Microanatomical study of the extradural middle fossa approach to the petroclival and posterior cavernous sinus region: description of the rhomboid construct.  Neurosurgery. 1994;  34 1009-1016 discussion 1016
• 11 Kawase T, Shiobara R, Toya S. Middle fossa transpetrosal-transtentorial approaches for petroclival meningiomas. Selective pyramid resection and radicality.  Acta Neurochir (Wien). 1994;  129 113-120
• 12 Tummala R P, Coscarella E, Morcos J J. Transpetrosal approaches to the posterior fossa.  Neurosurg Focus. 2005;  19 E6
• 13 Siwanuwatn R, Deshmukh P, Figueiredo E G, Crawford N R, Spetzler R F, Preul M C. Quantitative analysis of the working area and angle of attack for the retrosigmoid, combined petrosal, and transcochlear approaches to the petroclival region.  J Neurosurg. 2006;  104 137-142
• 14 Cho C W, Al-Mefty O. Combined petrosal approach to petroclival meningiomas.  Neurosurgery. 2002;  51 708-716 discussion 716-718
• 15 Kawase T, Shiobara R, Toya S. Anterior transpetrosal-transtentorial approach for sphenopetroclival meningiomas: surgical method and results in 10 patients.  Neurosurgery. 1991;  28 869-875 discussion 875-876
• 16 Sakata K, Al-Mefty O, Yamamoto I. Venous consideration in petrosal approach: microsurgical anatomy of the temporal bridging vein.  Neurosurgery. 2000;  47 153-160 discussion 160-161
• 17 Kirsch W M, Zhu Y H, Hardesty R A, Chapolini R. A new method for microvascular anastomosis: report of experimental and clinical research.  Am Surg. 1992;  58 722-727
• 18 Kirsch W M, Zhu Y H, Hardesty R A, Petti G, Furnas D. Nonpenetrating clips successfully replacing sutures in base of skull surgery.  Skull Base Surg. 1993;  3 171-181
• 19 Terasaka S, Iwasaki Y, Shinya N, Uchida T. Fibrin glue and polyglycolic Acid nonwoven fabric as a biocompatible dural substitute.  Neurosurgery. 2006;  58 (1 Suppl) ONS134-ONS139 discussion ONS134-ONS139
• 20 Al-Mefty O. Petrosal approach to clival tumors. In: Sekhar L N, Janecka I P Surgery of Cranial Base Tumors. New York: Raven Press; 1993: 307-315