Two step approach for surgical removal of petroclival meningiomas with large supratentorial extension

The treatment of petroclival meningiomas is still a matter of controversy in literature. In the last decades, many approaches have been introduced. Our strategy for the treatment of such tumors having large supratentorial extension with encasement of the internal carotid artery or compression of optic and oculomotor nerves has evolved in the attempt to improve the outcome. Currently, we favor a surgical technique consisting of two steps. As first step, we perform a retrosigmoid suprameatal approach in order to resect the posterior part of the tumor and obtain brainstem decompression. In the second step, carried out after patient’s recovery from the first surgery, we remove the supratentorial portion of the lesion using a frontotemporal craniotomy to achieve the decompression of the optic nerve, oculomotor nerve, and carotid artery. The retrosigmoid suprameatal approach allows for adequate brainstem decompression: the tumor itself creates a surgical channel increasing the accessibility to the lower and upper petroclival surface. Moreover, this route allows for early visualization of cranial nerves in the posterior fossa and safe tumor removal under direct visual control, reducing the risk of postoperative deficits. Via the simple and safe frontotemporal craniotomy, the supratentorial part of the lesion can be removed thus avoiding the need of invasive approaches. We propose a two-stage surgery for treatment of petroclival meningiomas combining two simple routes such as retrosigmoid suprameatal and frontotemporal craniotomy. This approach reflects our philosophy to use simple and less invasive approaches in order to preserve neurological function and a good quality of life of the patient.