A two-stage combined anterolateral and endoscopic endonasal approach to the petroclival region: an anatomical study and clinical application

Mohamed A Labib; Xiaochun Zhao; Lena Mary Houlihan; Irakliy Abramov; Mizuho Inoue; Rafael Martinez-Perez; Joshua S Catapano; Michael T Lawton; Mark C Preul; A Samy Youssef

doi:10.1007/s00701-022-05201-1

A two-stage combined anterolateral and endoscopic endonasal approach to the petroclival region: an anatomical study and clinical application

Acta Neurochir (Wien). 2022 Jul;164(7):1899-1910. doi: 10.1007/s00701-022-05201-1. Epub 2022 Apr 13.

Authors

Affiliations

¹ Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA.
² Department of Neurosurgery, University of Colorado, Denver, CO, USA.
³ Department of Neurosurgery, University of Colorado, Denver, CO, USA. samy.youssef@cuanschutz.edu.
⁴ Departments of Neurosurgery and Otolaryngology, University of Colorado, Aurora, CO, USA. samy.youssef@cuanschutz.edu.

^# Contributed equally.

PMID: 35416540
DOI: 10.1007/s00701-022-05201-1

Abstract

Object: The pretemporal transcavernous anterior petrosal (PTAP) approach and the combined petrosal (CP) approach have been used to resect petroclival meningiomas (PCMs). In this cadaveric anatomical study, a two-stage combined PTAP and endoscopic endonasal far medial (EEFM) approach (the PTAPE approach) was compared morphometrically to the CP approach. A case study provides a clinical example of using the PTAPE approach to treat a patient with a PCM. The key elements of the approach selection process are outlined.

Methods: Five cadaveric specimens underwent a CP approach and 5 underwent a PTAPE approach. The area of drilled clivus, length of multiple cranial nerves (CNs), and the area of brain stem exposure were measured, reported as means (standard deviations) by group, and compared.

Results: The total area of the clivus drilled in the PTAPE group (695.3 [121.7] mm²) was greater than in the CP group (88.7 [17.06] mm², P < 0.01). Longer segments of CN VI were exposed via the PTAPE than the CP approach (35.6 [9.07] vs. 16.3 [6.02] mm, P < 0.01). CN XII (8.8 [1.06] mm) was exposed only in the PTAPE group. Above the pontomedullary sulcus, the total area of brain stem exposed was greater with the PTAPE than the CP approach (1003.4 [219.5] mm² vs. 437.6 [83.7] mm², P < 0.01). Similarly, the total exposure of the medulla was greater after the PTAPE than the CP exposure (240.2 [57.06] mm² vs. 48.1 [19.9] mm², P < 0.01).

Conclusion: A combined open-endoscopic paradigm is proposed for managing large PCMs. This approach incorporates the EEFM approach to address the limitations of the PTAP and the CP approach in a systematic fashion. Understanding the anatomical findings of this study will aid in tailoring surgical approaches to patients with these complex lesions.

Keywords: Anterior petrosal; Combined petrosal; Endoscopic endonasal far medial; Petroclival meningioma; Petroclival region; Pretemporal transcavernous anterior petrosal.

Publication types

Research Support, Non-U.S. Gov't

MeSH terms

Cadaver
Cranial Fossa, Posterior / anatomy & histology
Cranial Fossa, Posterior / surgery
Humans
Meningeal Neoplasms* / surgery
Meningioma* / surgery
Neurosurgical Procedures
Petrous Bone / surgery
Skull Base Neoplasms* / surgery