A Tailored Combined Petrosal Approach for the Resection of a Petroclival Meningioma With Pneumatized Apex: Checkmate to the Trigeminal Nerve: 2-Dimensional Operative Video

Abstract

Petroclival meningiomas are a challenge in skull base surgery, despite the advances in the knowledge of this pathology, there are still many controversies regarding their optimal treatment. 1 The proximity and adherence to cranial nerves, major vessels such as the basilar artery, and brainstem compression explain the significant surgical risk. 2,3 We present the case of a woman with a petroclival meningioma (WHO grade I) and pneumatization of the petrous apex. A tailored combined petrosal approach with a wide pedicled flap was performed for reconstruction of the pneumatized petrous apex. The decision to choose an appropriate surgical approach in this type of tumor depends on multiple factors including the surgeon's skill. We believe that in this particular case the pneumatization of the petrosal apex and the involvement of the trigeminal nerve by the tumor demanded a surgical approach that allowed a 360-degree view of the trigeminal nerve and at all angles of attack on the site of tumor implantation, we call this a checkmate of the trigeminal nerve. Transposition of the trigeminal nerve may be necessary in cases such as the one we present for adequate visualization of the petroclival region. This surgical video discusses the nuances of technique, surgical pearls, and anatomic landmarks in the combined petrosal approach. The patient consented to the procedure and to the publication of her image, and appropriate consent was obtained for publication of the cadaver's image.