Anterior Petrosal: A Key Approach to Upper Petroclival Meningiomas: 2-Dimensional Operative Video

Petroclival meningiomas, originating medial to the trigeminal nerve, remain the most challenging tumors owing to the involvement of neurovascular structures at the upper clivus.(1) The advent of skull base approaches provided the exposure to successfully remove these tumorswith low mortality and morbidity.(2-4) The selection of a given approach is individually decided based on the tumor and the patient characteristics,(5) with the temporal bone being the centerpiece of various approaches.(6) Access to the cerebellopontine angle through the middle fossa was initially described for vestibular schwannomas.(7-9) Kawase(4,10) has refined and used this "anterior petrosal approach" for the resection of petroclival meningiomas and described the selection, limitations, and complications. The anterior petrosal is best suited for upper clivus meningioma, particularly if they extend medially in front of the brainstem and basilar artery, as well as lesions with significant extension in the Meckel cave, tentorium, and middle fossa.(4,5) It has a limitation with tumors extending inferior to the internal auditory canal or if anatomic or venous unfavorable variations.(4,5) It has the additional advantage of early interruption of meningiomas blood supply. Debulking allows developing the intra-arachnoidal planes for safer dissection of the brainstem and the cranial nerves.(2,11) As in other skull base procedures, a thorough knowledge of the anatomy and mastery of neurosurgical techniques are pre-requisites to avoid complications. We demonstrate this approach through the removal of a petroclival meningioma in a 48-yr-old patient with an upper petroclival meningioma. The patient consented to the surgery.