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Michael A. Horgan, Johnny B. Delashaw, Marc S. Schwartz, Jordi X. Kellogg, Sergey Spektor, and Sean O. McMenomey

T he transtentorial—petrosal approach to the petroclival region has been described by a variety of authors 1, 2, 12, 14, 18, 19, 21, 22 and its popularity seems to be burgeoning. As novel variations of the technique continue to evolve, 22 the terminology surrounding the technique has become confusing. The reason is a lack of common nomenclature across specialties to categorize the progressive temporal bone resection that is involved. To simplify matters, we reviewed the otology and neurosurgery literature on the petrosal approach and based our own

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Sam Safavi-Abbasi, Joseph M. Zabramski, Pushpa Deshmukh, Cassius V. Reis, Nicholas C. Bambakidis, Nicholas Theodore, Neil R. Crawford, Robert F. Spetzler, and Mark C. Preul

C hoosing a surgical approach to access lesions of the posterior fossa and petroclival region requires careful preoperative analysis. Because of the narrow working space and restricted angles of approach, surgical planning in this area can be extremely important. Tumors in this region were once considered inoperable 1 , 52 and remain challenging. 5 , 9 , 19 , 32 , 41 With the advent of diagnostic neuroimaging tools and skull base surgery as a discipline, improvements in neuroanesthesia and neurophysiological monitoring, and refinements in neurosurgical

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Mohamed A. Labib, Xiaochun Zhao, Lena Mary Houlihan, Irakliy Abramov, Joshua S. Catapano, Komal Naeem, Mark C. Preul, A. Samy Youssef, and Michael T. Lawton

O nce described as a surgical “no man’s land,” 1 the petroclival region remains one of the most complex skull base territories to approach surgically. This narrow space—between the medial petrous apex laterally, lower two-thirds of the clivus medially, and brainstem posteriorly—is the crossroads for half of the cranial nerves (CNs) en route to their extradural destinations. Similarly, the majority of the posterior circulation vasculature traverses this region. Petroclival meningioma (PCM) arises at the petrous tip, medial to the internal auditory meatus

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Jacob L. Freeman, Raghuram Sampath, Steven Craig Quattlebaum, Michael A. Casey, Zach A. Folzenlogen, Vijay R. Ramakrishnan, and A. Samy Youssef

O ver the last decade, endonasal endoscopic approaches to the petrous apex have been thoroughly evaluated in cadavers and are now being used in the operating room for select diseases involving the lateral skull base. 3 , 9 , 10 , 14 , 26 , 28 The roadmap for the ventral skull base varies greatly from that encountered via traditional transcranial routes to the petrous apex, offering a different set of obstacles to overcome. Approaches to the lateral skull base are generally divided into 2 main modules: 1) infrapetrous to the petrous apex and petroclival region

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Jun Muto, Daniel M. Prevedello, Leo F. S. Ditzel Filho, Ing Ping Tang, Kenichi Oyama, Edward E. Kerr, Bradley A. Otto, Takeshi Kawase, Kazunari Yoshida, and Ricardo L. Carrau

T he petroclival region is one of the most complex skull base territories. The apex of the petrous portion of the temporal bone, the posteroinferior surface of the sphenoid, and the clival process of the occipital bone converge to form the petroclival synchondrosis. Several cranial nerves (CNs) traverse the ventral cisterns on their way to pierce the dura just dorsal to the petroclival synchondrosis. This intricate anatomy and large number of key neurovascular elements in such a small area increase the complexity of approaching any lesions that arise here

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Rungsak Siwanuwatn, Pushpa Deshmukh, Eberval Gadelha Figueiredo, Neil R. Crawford, Robert F. Spetzler, and Mark C. Preul

B efore the advent of microsurgery, lesions in the petroclival region were considered formidable, untreatable, or both. Mortality rates associated with the resection of such lesions, especially meningiomas, were greater than 50%. 5 After the 1970s refinements in neurosurgical instruments, improvements in neuroanesthesia with neuromonitoring, developments in neuroradiology, and the advent of skull base surgery as a discipline allowed lesions to be resected with acceptable morbidity and mortality rates. 1 , 2 , 4 , 7 , 8 , 10 , 12–14 , 16–18 In the 1980s

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Michael A. Horgan, Gregory J. Anderson, Jordi X. Kellogg, Marc S. Schwartz, Sergey Spektor, Sean O. McMenomey, and Johnny B. Delashaw

T he transtentorial petrosal approach to the petroclival region is performed at various medical centers 1, 2, 9, 12, 14–17 in a variety of permutations, and the terminology alone is quite confusing. Furthermore, as novel variations of the technique continue to evolve as a result of efforts to preserve function, 17 a systematic assessment of the benefits and limitations of each approach has lagged behind. The transtentorial petrosal approach can be used for a variety of neoplastic and vascular lesions involving the middle and upper clivus. We review the otology

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Walter C. Jean, Yang Yang, Aneil Srivastava, Alexander X. Tai, Aalap Herur-Raman, H. Jeffrey Kim, Da Li, and Zhen Wu

Accessing the petroclival region remains a challenge to skull base surgeons. Almefty et al. defined “true” petroclival meningiomas as those “originating at the upper two-thirds of the clivus medial to the fifth cranial nerve.” 1 To improve exposure to these structures, transpetrosal approaches were designed to provide the surgeon a more anterolateral line of sight to better visualize these entangled nerves, arteries, and brainstem. 2–5 In their landmark study, Abdel Aziz et al. divided the petroclival region into three zones and designated the best

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Peter M. Grossi, Yoichi Nonaka, Kentaro Watanabe, and Takanori Fukushima

either a retrolabyrinthine mastoidectomy, when attempting to preserve hearing, or a translabyrinthine approach or greater exposure if hearing was to be sacrificed. Perhaps no one has more experience with this approach than the senior author of the present report. Fukushima has further defined and developed the combined petrosal approach to treat lesions of the petroclival region ( Fig. 2 ). His primary approach involves the combination of an extended middle fossa anterior petrosal “rhomboid” approach with a true labyrinth-sparing retrolabyrinthine mastoidectomy

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Varun R. Kshettry, Joung H. Lee, and Mario Ammirati

://www.nobelprize.org/nobel_prizes/medicine/nomination/nomination.php?action=show&showid=495 ). Although credited with the discovery of this canal, Dorello was not the first to describe it. In 1859, Wenzel Gruber described a fibrous ligament that extends from the petrous apex to the lateral dorsum sellae and creates a canal containing the abducent nerve. 18 Controversies in Microsurgical Anatomy Relatively little was published on the anatomy of the petroclival region after Dorello's time until recent developments in the surgical treatment of petroclival tumors led to renewed interest in the anatomy of the region. 1 , 2 , 30 , 31 Additionally