Extended Middle Fossa Approach for Resection of Spheno-Cavernous-Tentorial Meningioma

Here we illustrate the surgical technique for resection of a spheno-cavernous-tentorial meningioma. The patient is a 51-year-old woman that presented with proptosis and partial cranial nerves III and VI palsies. The goal of surgery was to achieve maximal resection excluding the component of tumor inside the cavernous sinus.

We performed a right fronto-temporal craniotomy with orbito-zygomatic osteotomies. The meningo-orbital dural fold was first transected to allow for mobilization of the temporal lobe dura away from the lateral wall of the cavernous sinus, V2, and V3 (Hakuba’s technique). A posterior to anterior dural dissection technique (Kawase’s technique) was then applied to expose the petrous apex medial to greater superficial petrosal nerve. Drilling of the petrous apex provided access to the posterior fossa. Next, the anterior clinoid process was removed extradurally.

The intradural stage started by opening the basal cisterns and proximal sylvian fissure. All arachnoids attachments around oculomotor nerve were dissected to facilitate full mobilization of the temporal lobe. The anterior petroclinoidal ligament was transected at the oculomotor triangle to dissect the temporal lobe dura from superior to inferior (Dolenc’s technique). Next, the posterior fossa dura was opened to identify the posterior root of trigeminal nerve. The dural ring at Meckel’s cave was opened to facilitate tumor removal here. Then, the tentorium was transected from lateral to medial. Trochlear nerve was preserved along the tentorial incisura.

Patient had an excellent recovery with transient worsening of oculomotor nerve palsy, new trochlear nerve palsy, and improvement of her abducens nerve palsy and proptosis.

Видео Extended Middle Fossa Approach for Resection of Spheno-Cavernous-Tentorial Meningioma канала NEUROSURGERY Journal