Commentary

The management of petroclival cholesterol granulomas remains controversial. Although some authors have recommended drainage of the cyst through a trans-sphenoidal approach or infralabyrinthine approach, I and others have recommended direct excision through a subtemporal-transzygomatic or preauricular subtemporal-infratemporal approach.[1] [2] In the past 8 years, I have performed endoscope-assisted microsurgical resection, which has reduced the extent of exposure needed.

Using a direct approach, I have had only one recurrence of an extensive lesion during the past 20 years. However, there is a risk of injury to the petrous internal carotid artery, whose wall may be inflamed because of the tumor cyst. In such cases (∼4%), I have successfully repaired the artery with sutures.

Many of these lesions remain unchanged over the years. The indications for treatment are progressive growth of the lesion or the appearance of cranial nerve palsies. Older patients should still be considered for drainage procedures, especially if the cyst can be drained through a trans-sphenoidal approach.

REFERENCES

• 1 Altschuler E M, Jungreis C A, Sekhar L N, Janetta P J, Sheptak P. Operative treatment of intracranial epidermoid cysts and cholesterol granulomas: a report of 21 cases.  Neurosurgery. 1990;  26 606-613 discussion 614
• 2 Sekhar L N, Salas E L. The subtemporal transzygomatic approach and the subtemporal infratemporal approach. In: Sekhar LN, Olivera E Cranial Microsurgery Approaches and Techniques. New York, NY; Thieme Medical Publishing 1999: 413-431