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Huy Q. Truong, Xicai Sun, Emrah Celtikci, Hamid Borghei-Razavi, Eric W. Wang, Carl H. Snyderman, Paul A. Gardner and Juan C. Fernandez-Miranda

M eckel ’s cave is a pouch of dural fold in the middle cranial fossa. Inside the diverticulum dwells the trigeminal nerve as it emerges from the posterior fossa, the Gasserian ganglion, and part of the 3 branches before they enter their respective foramina. 22 , 32 Given the simple contents of the structure, few types of pathology affect the area. The most frequent tumor type that originates from Meckel’s cave is trigeminal schwannoma; 3 , 17 other types include meningioma, 17 , 23 epidermoid cyst, 3 , 8 , 17 , 18 dermoid cyst, 17 melanoma, 7 and

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Chiman Jeon, Chang-Ki Hong, Kyung In Woo, Sang Duk Hong, Do-Hyun Nam, Jung-Il Lee, Jung Won Choi, Ho Jun Seol and Doo-Sik Kong

S kull base lesions involving Meckel’s cave and the middle cranial fossa remain surgically challenging because of the anatomical complexity of this area; the proximity to critical neurovascular structures, including several cranial nerves and the internal carotid artery (ICA); and the risk of profuse bleeding from the venous plexus. 21 , 22 , 31 , 36 , 44 Classic transcranial approaches to such deep regions require extensive removal of bone and muscles and moderate brain retraction. 3 , 20 , 21 , 23 , 31 , 32 , 39 Although each approach has its own benefits

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Alberto Di Somma, Cristobal Langdon, Matteo de Notaris, Luis Reyes, Santiago Ortiz-Perez, Isam Alobid and Joaquim Enseñat

T hroughout the years, Meckel’s cave and cavernous sinus pathologies have been judged to be off-limits because of the high rates of morbidity, like cranial nerve injury and/or massive bleedings. 1–3 During the past 2 decades, several studies have defined various surgical routes with tolerable morbidity and mortality rates. 4–12 Nevertheless, controversy related to the optimal avenue to treat different categories of cavernous sinus neoplasms persists, and the cavernous sinus area is thought to be one of the most challenging spots for many neurosurgeons. With

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Chih-Hsiang Liao, Jui-To Wang, Chun-Fu Lin, Shao-Ching Chen, Chung-Jung Lin, Sanford P. C. Hsu and Min-Hsiung Chen

neurosurgeons. 2 , 9 The pretemporal trans–Meckel’s cave transtentorial approach is conceptually creating a widened gateway between the middle and posterior fossae, which is performed in combination with pretemporal transcavernous 3 , 6 and anterior transpetrosal 5 approaches ( Fig. 1 ). In this study, the authors describe the pretemporal trans–Meckel’s cave transtentorial approach to manage large PCMs, review the surgical outcomes, and discuss the nuances of this surgical procedure. Fig. 1. Illustrations of the pretemporal trans–Meckel’s cave transtentorial approach. A

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James K. Liu

The surgical management of petroclival meningiomas remains a formidable challenge. These tumors are deep in the base of the skull and arise medial to the fifth cranial nerve. In this operative video, the author demonstrates the extended middle fossa approach with anterior petrosectomy to resect an upper petroclival meningioma extending into Meckel’s cave with brainstem compression. This approach is very useful for accessing deep tumors located above and below the tentorium, and between the fifth and seventh cranial nerves. Access to Meckel’s cave is readily achieved by opening the fibrous ring of the porous trigeminus. This video demonstrates the operative technique and surgical nuances of the skull base approach, useful anatomic landmarks of the middle fossa rhomboid for safe petrosectomy drilling, pearls for cranial nerve and neuro-otologic preservation, and exposure of Meckel’s cave. A gross-total resection was achieved, and the patient was neurologically intact. In summary, the extended middle fossa approach with anterior petrosectomy is an important strategy in the armamentarium for surgical management of petroclival meningiomas.

The video can be found here:

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Xavier T. J. Hsu, Chih-Hsiang Liao, Chun-Fu Lin and Sanford P. C. Hsu

was fixed by Mayfield head holder. A standard pterional craniotomy was performed with zygoma fracture. Flatten the sphenoid wing. Expose the periorbita. Peel the lateral wall of the cavernous sinus. Inject tissue glues for hemostasis. Remove the ACP extradurally. Open the Meckel’s cave. Cut the dura along the tentorium horizontally. Open the Liliequist membrane. Expose the fourth nerve. A vertical cut at the tentorium. Connect the vertical and horizontal cuts to release the tentorium. Intraoperative neuromonitoring: subcortical motor tract mapping. A small cortical

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Chih-Hsiang Liao, Chun-Fu Lin, Wei-Hsin Wang, Jui-To Wang, Shao-Ching Chen and Sanford P. C. Hsu

limited, and the traction injury to the dominant temporal lobe was of concern. Hence, the combination of Dolenc and Kawase approaches was adopted. Cut the dura and tentorial incisura along the dashed red line. If the ACP was not removed, mobilization of the third nerve at the oculomotor triangle and the fourth nerve at its entry to the cavernous sinus would be difficult, and the following trans-Meckel’s cave/transtentorial procedures would be impeded as well. The goal of the transcavernous approach is to achieve neurovascular mobilization to gain a wider surgical

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Feng Zhou, Zixiao Yang, Wei Zhu, Liang Chen, Jianping Song, Kai Quan, Sichen Li, Peiliang Li, Zhiguang Pan, Peixi Liu and Ying Mao

performed a literature review of all cases of CS epidermoid cysts reported over the past 40 years. Herein, we report the findings of both our case series and the literature review. Methods Patients We screened the medical data of 726 patients with epidermoid cysts who had been treated in Huashan Hospital, Fudan University, between January 1, 2001, and June 30, 2016. Only patients with epidermoid cysts located in the lateral wall of the CS, inside the CS, and/or protruding toward the subtentorial space via Meckel’s cave were included in our analysis. Thus, a total of 31

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Hiroki Morisako, Takeo Goto, Hiroki Ohata, Sachin Ranganatha Goudihalli, Keisuke Shirosaka and Kenji Ohata

of ridge drilled was minimal as well. Dural Opening The middle fossa dura was opened along the inferior temporal lobe toward the superior petrosal sinus (SPS). The subtemporal dural incision was made as far anterior as possible, and its medial extent ran along the lateral margin of Meckel’s cave. The presigmoid dura was opened along the drilled petrosal portion of the temporal bone as far anterior as possible, and the drainage of the petrosal vein into the SPS was inspected. The SPS was divided by clips at a point anterior to the drainage point of the petrosal vein

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Hun Ho Park, Sang Duk Hong, Yong Hwy Kim, Chang-Ki Hong, Kyung In Woo, In-Sik Yun and Doo-Sik Kong

-related morbidity. Recent advancements in endoscopic surgery have suggested a more minimally invasive and direct route for tumors in and around Meckel’s cave, including the endoscopic endonasal approach (EEA) 21 , 32 , 40 and endoscopic transorbital superior eyelid approach (ETOA). 6 , 26 , 42 However, the role of endoscopic approaches for trigeminal schwannomas is not as well-defined as microscopic skull base approaches. We present a retrospective multicenter analysis of 25 patients who underwent EEA or ETOA for trigeminal schwannomas. The EOR, clinical outcome, and surgical