Endoscopic Endonasal Expanded-Kawase's Approach: Surgical Technique and Outcome

Background: Petroclival meningiomas are a challenge in neurosurgery. Multiple approaches have been described to safely remove these lesions. These tumors can engulf many vital structures in the three fossae. The risks of these approaches are discussed extensively in the literature and are associated with hearing loss, facial nerve injury, and spinal fluid leakage.

Objectives: The aim of this study is to show the feasibility of endonasal endoscopic expanded approaches to reach multiple skull base compartments, including sella, petrous bone, clivus, and middle and posterior fossae.

Case Illustration: A 58-year-old woman had two previous surgeries for resection of a right cavernous sinus tumor at another facility. The first procedure was a pterional craniotomy with biopsy; partial resection of the tumor was followed by radiation. Unfortunately the tumor recurred, and she had radical resection of the tumor through a combined approach for middle fossa and posterior fossa, with ICA sacrificing by supraclinoid ICA clipping and petrous ICA coiling. The pathology at that time proved it was an atypical meningioma grade II. After that surgery, she ended up with third, fourth, and sixth cranial nerve palsy as well as partial seventh cranial nerve palsy and complete hearing loss on the right side. After 2 years, she had a new recurrence causing brainstem compression. We describe a radical endoscopic endonasal procedure performed to resect this recurrent atypical petroclival-cavernous meningioma.

Conclusion: This is an opportunity for a new route to be considered in cases of recurrence after standard approaches. This option represents an alternative approach with less brain retraction.