Staged Surgery for Resection of a Giant Petroclival Meningioma: Careful Incisional Planning and Surgical Nuances to Overcome the Challenge

Introduction: Petroclival meningiomas are challenging tumors to treat surgically. Due to their location and their involvement of cranial nerves, multiple skull base approaches have been used to offer a maximal safe resection. Despite numerous case reports and studies, it is still difficult to assess which procedure will provide adequate access and the lowest postoperative morbidity and mortality. Here, we review a case in which a staged approach was performed and discuss surgical nuances and incision planning that can be critical to success.

Methods: A 59-year-old female with a PMHx of meningioma presented with right-sided facial tingling and normal hearing. Imaging demonstrated a large right petroclival meningioma ([Fig. 1]). The first stage of the surgery involved an anterior and retrolabyrinthine posterior petrosectomy with hearing preservation. At the second stage, a low retrosigmoid suboccipital craniotomy approach was performed.

Results: The goals of the first stage included devascularization and removal of the middle fossa and supratentorial portion of the tumor. Approximately 80% of the tumor was removed and the brainstem decompressed ([Fig. 2]). At the second stage, 9 days after the first surgery, a low retrosigmoid suboccipital craniotomy approach was performed. The previous supra-auricular and retroauricular incision was identified. With the first incision too anterior, a posterior extension T-shaped off the prior incision was made to accommodate the low suboccipital retrosigmoid craniotomy. Brainstem decompression could be the best achieved with the inferior to superior trajectory and the best angle to the ventral brainstem. A near-total resection was ultimately achieved, with residual left in the posterior cavernous sinus and Meckel's cave ([Fig. 3]). The patient had no complications and is recovering from a right Trochlear nerve palsy.

Conclusion: Due to the size of the tumor and involvement with nearby neurovascular structures, a staged approach can provide the best and safest strategy: bone removal and devascularization, followed by tumor removal. The different modules, that is, anterior petrosectomy, retrolabyrinthine posterior petrosectomy, and retrosigmoid craniotomy afford different benefits and limitations. To ensure all approaches are accommodated for, meticulous incision planning should be done with the neurosurgeon and ENT collaboratively.

Fig. 1 Preoperative MRI T1 scans with contrast showing a giant right petroclival meningioma (size). (A) Axial view. (B) Coronal view. MRI, magnetic resonance imaging.

Fig. 2 First stage postoperative MRI T1 scans with contrast showing interval resection of the supratentorial portion of the tumor. (A) Axial view. (B) Coronal view. MRI, magnetic resonance imaging.

Fig. 3 Second stage postoperative MRI T1 scans with contrast showing a near-total removal of the right petroclival meningioma and residual within posterior cavernous sinus and Meckel's cave. Brainstem has been completely decompressed. (A) Axial view. (B) Coronal view. MRI, magnetic resonance imaging.

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Artikel online veröffentlicht:
12. Februar 2021