Skip to main content
SpringerLink
Log in

Detailed anatomy knowledge: first step to approach petroclival meningiomas through the petrous apex. Anatomy lab experience and surgical series

  • Original Article
  • Published:
Neurosurgical Review Aims and scope Submit manuscript

Abstract

Petroclival meningiomas are a challenge for neurosurgeons due to the complex anatomy of the region that is rich of vessels and nerves. A perfect and detailed knowledge of the anatomy is very demanding in neurosurgery, especially in skull base surgery. The authors describe the microsurgical anatomy to perform an anterior petrosectomy based on their anatomical and surgical experience and perform a literature review. The temporal bone is the most complex and fascinating bone of skull base. The apex is located in the angle between the greater wing of the sphenoid and the occipital bone. Removing the petrous apex exposes the clivus. The approach directed through the temporal bone in this anatomical area is referred to as an anterior petrosectomy. The area that must be drilled is the rhomboid fossa that is defined by the Kawase, premeatal, and postmeatal triangles. In Division of Neurosurgery - University of Turin, 130 patients, from August 2013 to September 2015, underwent surgical resection of intracranial meningiomas. In this group, we have operated 7 PCMs and 5 of these were approached performing an anterior petrosectomy with good results. In our conclusions, we feel that this surgery require an advanced knowledge of human anatomy and a specialized training in interpretation of radiological and microsurgical anatomy both in the dissection lab and in the operating room.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5
Fig. 6
Fig. 7
Fig. 8
Fig. 9

Similar content being viewed by others

References

  1. Adams Pérez J, Rassier Isolan G, Pires de Aguiar PH, Antunes AM (2014) Volumetry and analysis of anatomical variants of the anterior portion of the petrous apex outlined by the kawase triangle using computed tomography. J Neurol Surg B Skull Base 75:147–151

    Article  PubMed  PubMed Central  Google Scholar 

  2. Aizer AA, Bi WL, Kandola MS, Lee EQ, Nayak L et al (2015) Extent of resection and overall survival for patients with atypical and malignant meningioma. Cancer 121(24):4376–4381. doi:10.1002/cncr.29639

    Article  PubMed  Google Scholar 

  3. Al-Mefty O, Fox JL, Smith RR (1988) Petrosal approach for petroclival meningiomas. Neurosurgery 22:510–517

    Article  CAS  PubMed  Google Scholar 

  4. Altieri R, Agnoletti A, Quattrucci F, Garbossa D, Calamo Specchia FM et al (2014) Molecular biology of gliomas: present and future challenges. Transl Med UniSa 10:29–37

    CAS  PubMed  PubMed Central  Google Scholar 

  5. Bernardo A, Boeris D, Evins AI, Anichini G, Stieg PE (2014) A combined dual-port endoscope-assisted pre- and retrosigmoid approach to the cerebellopontine angle: an extensive anatomo-surgical study. Neurosurg Rev 37:597–608

    Article  PubMed  Google Scholar 

  6. Calbucci F (2011) Treatment strategy for sphenopetroclival meningiomas. World Neurosurg 75:419–420

    Article  PubMed  Google Scholar 

  7. Cavallo LM, de Divitiis O, Aydin S, Messina A, Esposito F et al (2008) Extended endoscopic endonasal transsphenoidal approach to the suprasellar area: anatomic considerations—part 1. Neurosurgery 62:1202–1212

    PubMed  Google Scholar 

  8. Chanda A, Nanda A (2002) Partial labyrinthectomy petrous apicectomy approach to the petroclival region: an anatomic and technical study. Neurosurgery 51(1):147–159, discussion 159–60

    Article  PubMed  Google Scholar 

  9. Cho CW, Al-Mefty O (2002) Combined petrosal approach to petroclival meningiomas. Neurosurgery 51:708–716, discussion 16–8

    Article  PubMed  Google Scholar 

  10. Di Maio S, Ramanathan D, Garcia-Lopez R, Rocha MH, Guerrero FP et al (2012) Evolution and future of skull base surgery: the paradigm of skull base meningiomas. World Neurosurg 78:260–275

    Article  PubMed  Google Scholar 

  11. Fornaro R, Altieri R, Garbossa D, Zenga F, Tartara F, Ducati A (2015) Double concentric craniotomy: safe and effective technique to achieve an en bloc resection of tumor involving both skull and duraa. Int J Surg Case Rep 12:117–119

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  12. Fournier HD, Mercier P, Roche PH (2007) Surgical anatomy of the petrous apex and petroclival region. Adv Tech Stand Neurosurg 32:91–146

    Article  CAS  PubMed  Google Scholar 

  13. Fukushima T, Day JD, Hirahara K (1996) Extradural total petrous apex resection with trigeminal translocation for improved exposure of the posterior cavernous sinus and petroclival region. Skull Base Surg 6:95–103

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  14. Gupta SK, Salunke P (2012) Intradural anterior petrosectomy for petroclival meningiomas: a new surgical technique and results in 5 patients: technical note. J Neurosurg 117(6):1007–1012. doi:10.3171/2012.9.JNS12429

    Article  PubMed  Google Scholar 

  15. Hakuba A, Nishimura S, Jang BJ (1988) A combined retroauricular and preauricular transpetrosal-transtentorial approach to clivus meningiomas. Surg Neurol 30:108–116

    Article  CAS  PubMed  Google Scholar 

  16. Iaconetta G, de Notaris M, Benet A, Rincon J, Cavallo LM et al (2013) The trochlear nerve: microanatomic and endoscopic study. Neurosurg Rev 36:227–237, discussion 37–8

    Article  PubMed  Google Scholar 

  17. Iaconetta G, de Notaris M, Cavallo LM, Benet A, Enseñat J et al (2010) The oculomotor nerve: microanatomical and endoscopic study. Neurosurgery 66:593–601, discussion 01

    Article  PubMed  Google Scholar 

  18. Iaconetta G, Fusco M, Cavallo LM, Cappabianca P, Samii M, Tschabitscher M (2007) The abducens nerve: microanatomic and endoscopic study. Neurosurgery 61:7–14, discussion 14

    PubMed  Google Scholar 

  19. Ichimura S, Hori S, Hecht N, Czabanka M, Vajkoczy P. 2016. Intradural anterior transpetrosal approach. Neurosurg Rev. [Epub ahead of print]

  20. Jacquesson T, Berhouma M, Tringali S, Simon E, Jouanneau E (2015) Which routes for petroclival tumors? A comparison between the anterior expanded endoscopic endonasal approach and lateral or posterior routes. World Neurosurg 83:929–936

    Article  PubMed  Google Scholar 

  21. Joo W, Yoshioka F, Funaki T, Rhoton AL (2012) Microsurgical anatomy of the abducens nerve. Clin Anat 25:1030–1042

    Article  PubMed  Google Scholar 

  22. Juliano AF, Ginat DT, Moonis G (2013) Imaging review of the temporal bone: part I. Anatomy and inflammatory and neoplastic processes. Radiology 269:17–33

    Article  PubMed  Google Scholar 

  23. Kawase T, Shiobara R, Toya S (1991) Anterior transpetrosal-transtentorial approach for sphenopetroclival meningiomas: surgical method and results in 10 patients. Neurosurgery 28:869–875, discussion 75–6

    Article  CAS  PubMed  Google Scholar 

  24. Kawase T, Shiobara R, Toya S (1994) Middle fossa transpetrosal-transtentorial approaches for petroclival meningiomas. Selective pyramid resection and radicality. Acta Neurochir 129:113–120

    Article  CAS  PubMed  Google Scholar 

  25. Kawase T, Toya S, Shiobara R, Mine T (1985) Transpetrosal approach for aneurysms of the lower basilar artery. J Neurosurg 63:857–861

    Article  CAS  PubMed  Google Scholar 

  26. Kim SM, Lee HY, Kim HK, Zabramski JM (2015) Cochlear line: a novel landmark for hearing preservation using the anterior petrosal approach. J Neurosurg 123:9–13

    Article  PubMed  Google Scholar 

  27. Mastronardi L, Sameshima T, Ducati A, De Waele LF, Ferrante L, Fukushima T (2006) Extradural middle fossa approach. Proposal of a learning method: the "rule of two fans." Technical note. Skull Base 16:181–184

    Article  PubMed  PubMed Central  Google Scholar 

  28. Rhoton AL (2000) The temporal bone and transtemporal approaches. Neurosurgery 47:S211–S265

    Article  PubMed  Google Scholar 

  29. Rhoton AL (2002) The cavernous sinus, the cavernous venous plexus, and the carotid collar. Neurosurgery 51:S375–S410

    PubMed  Google Scholar 

  30. Sameshima T, Morita A, Tanikawa R, Fukushima T, Friedman AH et al (2013) Evaluation of variation in the course of the facial nerve, nerve adhesion to tumors, and postoperative facial palsy in acoustic neuroma. J Neurol Surg B Skull Base 74:39–43

    PubMed  Google Scholar 

  31. Sharma M, Ambekar S, Guthikonda B, Nanda A (2014) A comparison between the kawase and extended retrosigmoid approaches (retrosigmoid transtentorial andretrosigmoid intradural suprameatal approaches) for accessing the petroclival tumors. A Cadaveric Study. J Neurol Surg B Skull Base 75(3):171–176. doi:10.1055/s-0033-1359305, Epub 2014 Mar 12

    Article  PubMed  PubMed Central  Google Scholar 

  32. Słoniewski P, Zieliński P, Rynkowski M (2000) Surgical anatomy of anterior petrosectomy. Folia Morphol 59:99–103

    Google Scholar 

  33. Solari D, Chiaramonte C, Di Somma A, Dell’Aversana Orabona G, de Notaris M et al (2014) Endoscopic anatomy of the skull base explored through the nose. World Neurosurg 82:S164–S170

    Article  PubMed  Google Scholar 

  34. Terasaka S, Day JD, Fukushima T (1999) Extended transbasal approach: anatomy, technique, and indications. Skull Base Surg 9:177–184

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  35. Wang X, Xu E, Zhang H, She L, Wang X, Yan Z (2016) Endoscopic intradural subtemporal keyhole kawase approach to the petroclival and ventrolateral brainstem regions. J Craniofac Surg 15 [Epub ahead of print]

  36. Wanibuchi M, Fukushima T, Zenga F, Friedman AH (2009) Simple identification of the third segment of the extracranial vertebral artery by extreme lateral inferior transcondylar-transtubercular exposure (ELITE). Acta Neurochir 151:1499–1503

    Article  PubMed  Google Scholar 

  37. Wanibuchi M, Ohtaki M, Fukushima T, Friedman AH, Houkin K (2010) Skull base training and education using an artificial skull model created by selective laser sintering. Acta Neurochir 152:1055–1059, discussion 59–60

    Article  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Neurosurgical Unit, Department of Neuroscience, University of Turin, Turin, Italy

    Roberto Altieri, Paolo Pacca, Emanuela Crobeddu, Diego Garbossa, Alessandro Ducati & Francesco Zenga

  2. Department of Neurosurgery, Hamamatsu University School of Medicine, University Hospital, Hamamatsu, Japan

    Tetsuro Sameshima

Authors
  1. Roberto Altieri
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Tetsuro Sameshima
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Paolo Pacca
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Emanuela Crobeddu
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Diego Garbossa
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Alessandro Ducati
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Francesco Zenga
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Roberto Altieri.

Ethics declarations

Conflict of interest

The authors declare that they have no conflict of interest.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Altieri, R., Sameshima, T., Pacca, P. et al. Detailed anatomy knowledge: first step to approach petroclival meningiomas through the petrous apex. Anatomy lab experience and surgical series. Neurosurg Rev 40, 231–239 (2017). https://doi.org/10.1007/s10143-016-0754-3

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s10143-016-0754-3

Keywords

Search

Navigation