Combined petrosal approach for resection of petroclival meningioma. 2D operative video.

Petroclival meningiomas are rare skull base lesions, which originate at the upper two thirds of the clivus, medially to cranial nerves V–XI. Interposition of the cranial nerves between the tumor and surgeon and the proximity/involvement of the basilar artery and brainstem make surgical treatment challenging. Nevertheless, documented growth, brainstem compression, and neurologic symptoms argue in favor of resection. Depending on the size of the lesion, its medial origin along the clivus, extension into the middle fossa, and preoperative hearing, different approaches have been described. A 44-year-old male had a large petroclival meningioma with brainstem compression, which was diagnosed during work-up for stroke. On examination he only had facial numbness in the V2 distribution, but normal hearing and facial function. Due to the size of the lesion, extensive dural attachment along the petroclival junction, a significant middle fossa component, and preserved hearing, a combined petrosal approach using presigmoid, retrolabyrinthine, and subtemporal exposures was chosen. The chosen approach provides a wide exposure with multiple degrees of freedom in both the petroclival region and middle fossa. Furthermore, it allows for hearing preservation without limiting surgical exposure. Gross total resection (Simpson grade II) was achieved. Intraoperatively, the fourth cranial nerve was transected and treated with primary end-to-end neurorrhaphy. The patient had a good neurologic outcome, with a trochlear nerve deficit, which partially improved over 12 months.