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Feasibility and Limitations of the Retrosigmoid and Presigmoid Approaches Combined With the Anterior Petrosal Approach to Meningiomas in the Petroclival Area

Eguchi, Kuniki PhD*; Tahara, Adriana MD*; Yamaguchi, Satoshi PhD*; Matsushige, Toshinori MD*; Mitsuhara, Takafumi MD*; Panagopoulos, Alexandros Theodoros MD; Aguiar, Paulo Henrique Pires PhD; Kurisu, Kaoru PhD*

doi: 10.1097/WNQ.0b013e31825a6bdd
Original Articles

Meningiomas located in the petroclival junction are difficult lesions to manage. Usually, they are diagnosed when they become large-sized symptomatic lesions and extend to adjacent areas. The curative treatment is surgical resection, but the intricate and eloquent neurovascular anatomy of the petroclival complex and adjacent areas challenges the surgeon while considering total tumor resection against the acceptable morbidity and mortality. The authors report 10 case series of tumors arising from or extending to the petroclival junction; they included 10 meningiomas: 4 petroclival, 3 sphenopetroclival, 2 tentorial at the petroclival area, and 1 anterior petrosal operated from 2007 to 2011 in the Hiroshima University Hospital. They were subjected to the combined approaches: anterior petrosal, presigmoid, and retrosigmoid. The translabyrinth approach was added in 2 cases where hearing was previously lost. Gross total resection was possible in 6 cases. The mortality rate was 0. The main complications were postoperative cerebrospinal fluid leak in 1 case, permanent cranial nerve palsy in 3 cases, and venous congestion in 1 case. The main limiting factors for good outcome are the tumor size, wide attachment, hard consistency, bleeding, and preoperative clinical status. Involvement of the basilar artery and perforators, attachment to the brainstem, and avoidance of venous damage are also important points to be considered. As a rule, the anterior petrosal approach yields direct access to the tumor attachment, permitting early devascularization, and direct approach to medial cranial fossa base content. The retrosigmoid is necessary when the tumor is very large and has extended below the internal acoustic meatus. The presigmoid access is useful for cases where the tumors extend to the medial cranial fossa; it reduces the required amount of retraction of the temporal lobe, as it permits the surgeon to change the angle of attack from the lateral to the inferior range.

*Department of Neurosurgery, University of Hiroshima, Hiroshima, Japan

Division of Neurosurgery, Santa Casa de São Paulo

Department of Neurology, Universidade de São Paulo, São Paulo, Brazil

The authors declare no conflict of interest.

Reprints: Adriana Tahara, MD, Department of Neurosurgery, Hiroshima University Hospital, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan (e-mail:

© 2013 Lippincott Williams & Wilkins, Inc.