Surgical Strategies for Resection of Petroclival Meningiomas: Indications and Multi-stage Approaches

Introduction: Petroclival meningiomas are among the most formidable and technically challenging tumors in skull base surgery owing to their deep-seated location and proximity to critical neurovascular structures. Selection of surgical approach should be tailored to each individual patient and dependent upon the location and extension of the tumor and adjoining neurovascular structures, as well as patient hearing status on audiological evaluation. To complement the variety of approaches that exist for petroclival meningioma resection, a strategy that has previously been described involves separating the procedure into two or more “stages.” In conducting this study, we are seeking to understand why skull base surgeons preoperatively plan the staged excision of petroclival meningiomas.

Methods: PubMed, Scopus and Web of Science databases were queried to identify studies describing the rationale behind and indications for staging surgical resection of petroclival meningiomas. All studies returned by the query were screened for possible inclusion in a systematic process performed by two authors.

Results: Fourteen studies describing 187 patients (59.3% female, age range: 5–81 years. met criteria for inclusion. The most common presenting symptom at diagnosis was headache (24.6%). Other common symptoms included cerebellar signs (16.0%) and gait disturbances (13.4%). Petroclival meningiomas were most observed extending to the cavernous sinus (52.88%) and Meckel’s cave (49.04%). With respect to critical neurovasculature, the trigeminal nerve was involved in a majority (54.59%) of petroclival meningiomas, while other cranial nerves with tumor involvement included the facial (16.22%) and vestibulocochlear (12.43%). Additionally, the involved vascular structures were the basilar (2.16%) and superior cerebellar arteries (1.62%). Of the 187 patients who underwent surgical resection of petroclival meningioma, 144 (77%) underwent surgery involving a single stage, while 43 (23%) underwent surgery in which a two-stage approach was used. The most common single-stage approaches were the retrosigmoid (n = 35. and transpetrosal (n = 22), while the most common approaches employed in a multi-stage fashion were the subtemporal (n = 6), pterional (n = 5), and suboccipital (n = 4) approaches. To clarify, these approaches were each performed as one half of a two-stage surgery involving a second, separate approach.

Conclusions: Petroclival meningiomas are distinguished by the considerable challenges they pose to skull base neurosurgeons. Surgical access is technically complex and can involve a wide range of approaches. Surgical staging is a strategy that involves separating tumor removal into two or more sessions. During these sessions, separate skull base approaches are often employed for debulking and resection of petroclival meningiomas; these include the retrosigmoid, anterior petrosectomy, posterior petrosectomy, orbitozygomatic, translabyrinthine, and various combinations thereof. Indications for performing surgery in this manner include coexistence of lesion in both middle and posterior skull base compartments, absence of meaningful hearing function, tumor size, and surgeon preference. Regardless of the approach(es. used, a comprehensive skull base team can provide the maximum versatility needed to address almost any petroclival meningioma.

Publication History

Article published online:
05 February 2024