Anterior Transpetrosal-Transtentorial Approach for Removal of a Large Petrous Apex Meningioma: 2-Dimensional Operative Video

Video 1 demonstrates the microsurgical resection of petrous apex meningioma. Even small lesions by general rules are regarded as large due to the delicate nature of anatomic localization. The intricate relationship between the tumor and vascular supply of the brainstem and interposition of cranial nerves makes them challenging lesions to resect.1A 67-year-old female patient presented with a 6-month history of trigeminal neuralgia in the V2 and V3 branches. She underwent gross total resection of an extraaxial homogenously enhancing dural-based tumor in the right petroclival region, consistent with a large (3–4.5 cm) petrous apex meningioma, the least frequently reported subtype of petroclival meningiomas.2,3 Skull base approaches for surgical resection of these tumors include high-speed drilling of petrous bone to create a corridor that facilitates access to the lesion.1 Preserved hearing with suprameatal extension of the infratentorial component and absence of a tumor laterally and inferiorly to the internal auditory canal provided the rationale for selecting a subtemporal approach combined with anterior petrosectomy.1,4,5Identification of anatomic landmarks of the Kawase triangle is the key first step for determining the bony removal corridor, outlined by the greater superficial petrosal nerve, the arcuate eminence, and the petrous ridge.1,6 An important step in surgical removal is the devascularization of feeding arteries arising from the meningohypophyseal trunk.7,8 Subsequent piecemeal removal and circumferential detachment while making sure to preserve major vascular and nerve elements is crucial for successful removal. The patient consented to the procedure. The postoperative course was uneventful. The patient’s trigeminal neuralgia completely regressed with no new neurologic deficit.