Lateral supracerebellar transtentorial approach for petroclival meningiomas: operative technique and outcome

Clinical article

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Object

The retrosigmoid intradural suprameatal approach with the patient in a semisitting position is an effective alternative to transpetrosal approaches for the treatment of petroclival meningiomas. The authors have made a simple modification to the retrosigmoid intradural suprameatal approach by using the lateral oblique position and preferentially dividing the tentorium with limited drilling of the suprameatal bone, which is termed the “lateral supracerebellar transtentorial approach.”

Methods

Twenty-six patients with petroclival meningiomas surgically treated via the lateral supracerebellar transtentorial approach were analyzed. All tumors had most of their bulk in the posterior fossa with some degree of extension into the middle fossa and/or Meckel cave. The patient is placed in the lateral oblique position, and a standard retrosigmoid craniotomy is performed. The tentorium medial to the trigeminal nerve is incised toward the free edge, which improves exposure to the petroclival region without extensive resection of the suprameatal petrous bone.

Results

Gross-total resection was achieved in 11 patients (42%). Ten patients (38%) underwent subtotal resection, and 5 patients (19%) underwent partial resection. There was no incidence of operative death, and the postoperative permanent morbidity rate was 15%. All patients except one did well postoperatively and were independent at the time of their last follow-up examinations.

Conclusions

The lateral supracerebellar transtentorial approach provides the simplest and safest access to the petroclival region. It offers an advantageous approach to petroclival meningiomas exclusively located in the posterior fossa with minimal extension into the Meckel cave and middle fossa.

Abbreviations used in this paper: CN = cranial nerve; IAM = internal auditory meatus.

Article Information

Address correspondence to: Takao Watanabe, M.D., Ph.D., Department of Neurological Surgery, Nihon University School of Medicine, 30-1 Oyaguchi-kamimachi, Itabashi-ku, Tokyo 173-8610, Japan. email: takao@med.nihon-u.ac.jp.

Please include this information when citing this paper: published online March 18, 2011; DOI: 10.3171/2011.2.JNS101759.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    Schematic showing the lateral oblique position for the lateral supracerebellar transtentorial approach. The head is fixed in a Mayfield 3-point headrest and maintained at 0° rotation. To reduce intracranial venous pressure, the thorax is elevated 15°. A gelatin pad is placed in the axilla to avoid compression of the brachial plexus and obstruction of the venous return. The operator is positioned at the side of the patient's dependent shoulder.

  • View in gallery

    Intraoperative photographs demonstrating the skin incision and craniotomy. Left: A hockey-stick incision is made from the retroauricular portion to the midline at the C-5 level with the patient in a lateral oblique position. Right: Extended retrosigmoid craniotomy is performed to expose the transverse and sigmoid sinuses.

  • View in gallery

    Schematics showing the relationships of anatomical structures encountered in the right lateral supracerebellar transtentorial route. The amount of suprameatal petrous bone resection varies in relation to the pyramid's anatomy and the extent of tumor invasion into the Meckel cave (left). After partial drilling of the suprameatal bone, the tentorium medial to the trigeminal nerve is incised toward the free edge, which improves exposure to the petroclival area (right). When it remains difficult to remove the tumor portion in the Meckel cave, additional extensive bony removal is required to achieve complete resection of the part of the tumor lying within this region.

  • View in gallery

    Intraoperative views demonstrating tumor resection via the right lateral supracerebellar transtentorial route. Left: Radical internal decompression is achieved, and the main part of the tumor is detached from the tentorium. Right: With partial resection of the suprameatal portion of the petrous bone followed by division of the tentorium, rapid entrance into the region of the middle fossa and the posterior part of the Meckel cave are achieved, and complete tumor resection is accomplished. PCA = posterior cerebellar artery; SCA = superior cerebellar artery.

  • View in gallery

    Images obtained in a 69-year-old woman harboring a left petroclival meningioma with a large supratentorial extension. A CT scan (A) demonstrating a calcification mass at the cerebellopontine angle. Axial (B) and coronal (C) MR images with contrast medium revealing a large enhancing tumor extending into both the posterior and middle fossae.

  • View in gallery

    Postoperative contrast-enhanced axial (left) and coronal (right) MR images obtained in the patient mentioned in Fig. 5, revealing a small supratentorial tumor remnant.

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