Complex Spheno-Petroclival Meningioma Resection: A Skull Base Surgery Case
Complex Spheno-Petroclival Meningioma Resection: A Skull Base Surgery Case
The First Hospital of China Medical University recently completed the resection of a complex spheno-petroclival meningioma in a 50-year-old woman. This case is clinically valuable from the perspective of surgical corridor selection, skull base exposure, and preservation of critical neurovascular structures.
The procedure was performed by the neurosurgical team led by Prof. Tao Jun, under the guidance of Prof. Ou Shaowu. The patient recovered well neurologically and was discharged on postoperative day 8.
Case Overview
The patient initially presented with left-sided toothache and facial pain. Contrast-enhanced cranial MRI showed a deep petroclival meningioma measuring approximately 3.8 cm × 3.7 cm.
Further imaging assessment showed that the tumor extended across the middle and posterior cranial fossae, involved the sellar region and cavernous sinus, crossed the midline, and compressed the brainstem. The lesion was also closely related to several major arteries, including the internal carotid artery, basilar artery, anterior cerebral artery, middle cerebral artery, posterior cerebral artery, and superior cerebellar artery, as well as multiple cranial nerves.
The surgical challenge was not only the size of the tumor, but also its deep skull base location, multi-compartment extension, limited operative space, and complex relationship with the brainstem, major arteries, and cranial nerves.
Approach Selection
For spheno-petroclival meningiomas, several surgical strategies may be considered, including the subtemporal approach, presigmoid approach, far-lateral approach, endoscopic endonasal approach, staged surgery, or combined approaches.
Each route has specific indications. The subtemporal approach is useful for lesions involving the middle cranial fossa and upper petrous apex. The presigmoid approach is suitable for posterolateral petroclival tumors. The far-lateral approach is more appropriate for lower clival or foramen magnum lesions. The endoscopic endonasal approach is generally considered for midline ventral skull base tumors.
In this case, the tumor involved the sellar region, cavernous sinus, middle cranial fossa, and posterior cranial fossa, while also compressing the brainstem and involving major arteries. A single surgical corridor might not have provided sufficient exposure or adequate control for safe neurovascular dissection.
Rationale for the Combined Approach
The surgical team selected an extended pterional approach combined with Kawase’s approach.
The extended pterional approach provided access to the sellar and parasellar regions, cavernous sinus area, optic nerve, oculomotor nerve, and related vascular structures. This corridor was important for managing the anterior and parasellar components of the tumor.
Kawase’s approach, performed through anterior petrosectomy, improved exposure of the petroclival region, trigeminal nerve area, and ventrolateral brainstem. This helped create a more direct route to the deep petroclival component of the lesion.
By combining these two corridors, the team was able to approach the tumor from different angles, reduce excessive deep traction, and obtain a more suitable working space for dissection around the basilar artery, brainstem, and cranial nerves.
Technical Points
The operation lasted approximately 12 hours. Key surgical steps included anterior clinoidectomy, tumor removal from the sellar and cavernous sinus regions, tentorial incision, and drilling of Kawase’s triangle.
The tumor was firm, vascular, and closely adherent to important neurovascular structures. During the procedure, sharp dissection was used to reduce the risk of traction injury, thermal injury, and vascular wall injury. Particular attention was paid to the preservation of the brainstem, basilar artery, internal carotid artery, and cranial nerves.
This type of case requires careful balance between tumor removal, surgical exposure, bony corridor creation, neurovascular protection, and functional preservation.
Postoperative Outcome
The patient was extubated approximately 2 hours after surgery. No new major neurological deficit was reported.
Postoperative contrast-enhanced MRI performed on day 5 confirmed complete tumor resection. The patient recovered well neurologically and was discharged on postoperative day 8.
Discussion
Spheno-petroclival meningiomas remain among the most technically demanding skull base tumors because of their deep location and relationship with the brainstem, cavernous sinus, major arteries, and cranial nerves.
In this case, the key decision was not simply how to remove the tumor, but how to choose a surgical corridor that would allow adequate exposure while minimizing manipulation of critical structures. The combined extended pterional and Kawase approach provided complementary access to the anterior, parasellar, petroclival, and ventrolateral brainstem regions.
The case highlights the importance of individualized surgical planning, multimodal imaging assessment, skull base anatomy, and meticulous microsurgical technique in the management of complex petroclival meningiomas.
Images
Preoperative contrast-enhanced MRI showed a 3.8 cm × 3.7 cm petroclival meningioma deep within the intracranial cavity.
MRI and CTA images demonstrated the tumor’s relationship with the sellar region, cavernous sinus, brainstem, major arteries, and cranial nerves.
Postoperative contrast-enhanced MRI showed complete resection of the tumor.