Pretemporal Trans–Meckel’s Cave Transtentorial Approach for Large Petroclival Meningiomas

Background: Despite the advances in skull base techniques, large petroclival meningiomas (PCMs) still pose a challenge to neurosurgeons.

Objective: To describe a pretemporal trans-Meckel’s cave transtentorial approach for large PCMs and to report the surgical outcomes.

Methods: From 2014 to 2017, patients harboring large PCMs (>3 cm) and undergoing their first surgical resection via this procedure in our institute were included. In combination with pretemporal transcavernous and anterior transpetrosal approaches, trans-Meckel’s cave transtentorial route is created. Surgical details are described along with the demonstrative video. Retrospective review of the medical records and image studies was performed.

Results: Eighteen patients (6 males and 12 females) were included in this study, with mean age of 53. The mean sizes of the preoperative and the postoperative PCMs were 4.36 cm × 4.09 cm × 4.13 cm (length × width × height) and 0.83 cm × 1.08 cm × 0.75 cm, respectively. Gross-total removal was done in 7 patients; near-total (> 95%) removal in 7 patients; and subtotal removal in 4 patients (>90% in 3 patients and >85% in 1 patient). There was neither surgical mortality nor patient with postoperative hemiplegia. Surgical complications included transient CN III palsy (all resolved in 3 months), transient CN VI palsy (2 patients), CN IV palsy (3 patients, partial recovery), hydrocephalus (3 patients), and CSF otorrhea (1 patient). Temporal lobe retraction-related neurologic deficits were not observed.

Conclusion: Pretemporal trans-Meckel’s cave transtentorial approach offers large surgical exposure and multiple trajectories to the suprasellar, interpeduncular, prepontine, and upper half clival regions without overt traction, which is mandatory to remove large PCMs. To unlock the Meckel’s cave where a large PCM sits abutting, pretemporal transcavernous and anterior transpetrosal approaches are prerequisite to create adequate exposure for the final trans-Meckel’s cave step.

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