Commentary

The authors describe the unusual case of a primary malignant cerebellopontine angle melanoma that was presumed to be a meningioma involving the jugular foramen and internal auditory canal at presentation. The appropriate management for this unusual case would likely not be readily apparent to most neurosurgeons and neurotologists. The authors achieved a gross total resection at the cost of sacrificing cranial nerves IX, X, and XI. Preoperative embolization of the inferior petrosal sinus was performed apparently to reduce blood loss when the jugular bulb was opened. Why the bulb was opened is not entirely clear. Whether occluding this sinus would limit blood loss in this situation is questionable. It seems that this strategy would only further obstruct venous outflow and increase peritumoral edema.

During surgery, the authors presumably lacked a histologic diagnosis. If the lesion was presumed to be a metastatic melanoma or meningioma, why did they sacrifice cranial nerves IX, X, and XI? If we treated either a metastatic lesion or a meningioma, we would preserve the cranial nerves and perform a subtotal resection and plan postoperative radiosurgery. Perhaps it is fortuitous that the authors decided to sacrifice these cranial nerves.

Finally, we disagree with the authors' surgical approach to this lesion. We would use a retrosigmoid or translabyrinthine approach instead of the transcochlear approach. The former would preserve facial nerve function and allow adequate exposure of the jugular foramen and internal auditory canal. If drilling of the occipital condyle or modified far-lateral extension were required, it also could easily be performed with the retrosigmoid approach.