Skip to main content
SpringerLink
Log in

The mini-combined transpetrosal approach: an anatomical study and comparison with the combined transpetrosal approach

  • Original Article - Brain Tumors
  • Published:
Acta Neurochirurgica Aims and scope Submit manuscript

Abstract

Background

The combined transpetrosal approach (CTPA) is a versatile technique suitable for challenging skull base pathologies. Despite the advantages provided by a wide surgical exposure, the soft tissue trauma, complex and time-consuming bony work, and cosmetic issues make it far from patient expectations. In this study, the authors describe a less invasive modification of the CTPA, the mini-combined transpetrosal approach (mini-CTPA), and perform a quantitative comparison between these two approaches.

Methods

Five human specimens were used for this study. CTPA was performed on one side and mini-CTPA on the opposite side. The surgical freedom, petroclival and brainstem area of exposure, and maneuverability for 6 anatomical targets, provided by the CTPA and mini-CTPA, were calculated and statistically compared. The bony volumes corresponding to each anterior petrosectomy were also measured and compared. Three clinical cases with an operative video are also reported to illustrate the effectiveness of the approach.

Results

The question-mark skin incision done along the muscle attachments permits an optimal cosmetic result. Even though the limited incision, the smaller craniotomy, and the less extensive bone drilling of mini-CTPA provide a smaller area of surgical freedom, the areas of exposure of petroclival region and brainstem were not statistically different between the two approaches. The antero-posterior maneuverability for the oculomotor foramen (OF), Meckel’s cave (MC) and the REZ of trigeminal nerve, and the supero-inferior maneuverability for OF, MC, Dorello’s canal, and REZ of CN VII are significantly reduced by the smaller opening. The bony volume of anterior petrosectomy resulted similar among the approaches.

Conclusions

The mini-CTPA is an interesting alternative to the CTPA, providing comparable surgical exposure both for petroclival region and for brainstem. Although the lesser soft tissue dissection and bony opening decrease the surgical maneuverability, the mini-CTPA may reduce surgical time, potential approach-related morbidities, and improve cosmetic and functional outcomes for the patients.

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

Similar content being viewed by others

Abbreviations

TSSJ:

Transverse-sigmoid sinus junction

SS:

Sigmoid sinus

PFD:

Posterior fossa dura

LSC:

Lateral semicircular canal

SSC:

Superior semicircular canal

PSC:

Posterior semicircular canal

TS:

Transverse sinus

FS:

Foramen spinosum

ACP:

Anterior clinoid process

PCP:

Posterior clinoid process

FR:

Foramen rotundum

FO:

Foramen ovale

FS:

Foramen spinosum

FL:

Foramen lacerum

MC:

Meckel’s cave

IAC:

Internal acoustic meatus

PCJ:

Petroclival junction

JF:

Jugular foramen

OF:

Oculomotor foramen

DC:

Dorello’s canal

AICA:

Anterior inferior cerebellar artery

REZ V and VII:

Root entry zone of trigeminal and facial nerves

References

  1. Abdel Aziz KM, Sanan A, van Loveren HR, Tew JMJ, Keller JT, Pensak ML (2000) Petroclival meningiomas: predictive parameters for transpetrosal approaches. Neurosurgery 47(1):132–139

    Google Scholar 

  2. Al-Mefty O, Ayoubi S, Kadri PAS (2008) The petrosal approach for the resection of retrochiasmatic craniopharyngiomas. Neurosurgery 62(5 Suppl 2):ONS331–ONS335 discussion ONS335-6

    PubMed  Google Scholar 

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

    Article  CAS  Google Scholar 

  4. Aum D, Rassi MS, Al-mefty O (2020) Petroclival meningiomas and the petrosal approach, 1st ed. Meningiomas. https://doi.org/10.1016/B978-0-12-822198-3.00035-5

  5. Bambakidis NC, Kakarla UK, Kim LJ, Nakaji P, Porter RW, Daspit CP, Spetzler RF (2008) Evolution of surgical approaches in the treatment of petroclival meningiomas: a retrospective review. Neurosurgery. https://doi.org/10.1227/01.NEU.0000280119.36270.BA

  6. Cho CW, Al-Mefty O (2002) Combined petrosal approach to petroclival meningiomas. Neurosurgery 51(3):708

    Article  Google Scholar 

  7. Couldwell WT, Fukushima T, Giannotta SL, Weiss MH (1996) Petroclival meningiomas: surgical experience in 109 cases. J Neurosurg 84(1):20–28

    Article  CAS  Google Scholar 

  8. Day JD, Fukushima T, Giannotta SL Cranial base approaches to posterior circulation aneurysms. J Neurosurg 87(4):544–554

  9. de Andrade Júnior FC, de Andrade FC, de Araujo Filho CM, Carcagnolo Filho J (1998) Dysfunction of the temporalis muscle after pterional craniotomy for intracranial aneurysms. Comparative, prospective and randomized study of one flap versus two flaps dieresis. Arq Neuropsiquiatr 56(2):200–205

    Article  Google Scholar 

  10. Di Carlo DT, Capo G, Fava A, Cagnazzo F, Margil-Sànchez M, Champagne PO, Voormolen EHJ, Morganti R, Froelich S, Perrini P (2020) Petroclival meningiomas: the risk of post-operative cranial nerve deficits among different surgical approaches—a systematic review and meta-analysis. Acta Neurochir 162(9):2135–2143

    Article  Google Scholar 

  11. Erkmen K, Pravdenkova S, Al-Mefty O (2005) Surgical management of petroclival meningiomas: factors determining the choice of approach. Neurosurg Focus. https://doi.org/10.3171/foc.2005.19.2.8

  12. Figueiredo EG, Paulo S, Nakaji P, Crawford NDP (2007) Surgical anatomy and technique description and anatomic assessment. Neurosurgery 61(November):256–265

    PubMed  Google Scholar 

  13. Goudihalli SR, Morisako H, Prastarana W, Goto T, Ohata H, Ohata K (2018) Contralateral minimum anterior and posterior combined petrosal approach for retrochiasmatic craniopharyngiomas: an alternative technique. J Neurol Surg Part B Skull Base 79(2):S208–S210

    Google Scholar 

  14. Hakuba A, Nishimura S, Inoue Y (1985) Transpetrosal-transtentorial approach and its application in the therapy of retrochiasmatic craniopharyngiomas. Surg Neurol 24(4):405–415

    Article  CAS  Google Scholar 

  15. Hakuba A, Nishimura S, Jang BJ (1988) A combined retroauricular and preauricular transpetrosal-transtentorial approach to clivus meningiomas. Surg Neurol 30(2):108–116

    Article  CAS  Google Scholar 

  16. Hanakita S, Watanabe K, Champagne P, Froelich S (2019) How I do it: combined petrosectomy.

  17. Ichimura S, Takahara K, Mochizuki Y, Fujii K (2019) Intradural combined transpetrosal approach for primary pontine hemorrhage. World Neurosurg 127:194–198

    Article  Google Scholar 

  18. Janjua MB, Caruso JP, Greenfield JP, Souweidane MM, Schwartz TH (2017) The combined transpetrosal approach: anatomic study and literature review. J Clin Neurosci Off J Neurosurg Soc Australas 41:36–40

    Google Scholar 

  19. Kadri PAS, Al-Mefty O (2004) The anatomical basis for surgical preservation of temporal muscle. J Neurosurg 100(3):517–522

    Article  Google Scholar 

  20. Kunihiro N, Goto T, Ishibashi K, Ohata K (2014) Surgical outcomes of the minimum anterior and posterior combined transpetrosal approach for resection of retrochiasmatic craniopharyngiomas with complicated conditions. J Neurosurg 120(1):1–11

    Article  Google Scholar 

  21. Kusumi M, Fukushima T, Mehta AI, Aliabadi H, Nonaka Y, Friedman AH, Fujii K (2012) Tentorial detachment technique in the combined petrosal approach for petroclival meningiomas: clinical article. J Neurosurg 116(3):566–573

    Article  Google Scholar 

  22. Labidi M, Watanabe K, Loit M-P, Hanakita S, Froelich S (2018) The posterior transpetrosal approach in a case of large retrochiasmatic craniopharyngioma: operative video and technical nuances. J Neurol Surg B Skull Base 79(2):S205–S207

    Google Scholar 

  23. Matano F, di Russo P, Okano A, Passeri T, Penet N, Fava A, Camara B, Polivka M, Giammattei L, Froelich S (2020) Oculomotor neurofibroma: a different histology implying an unsatisfying clinical outcome. World Neurosurg 139:31–38

    Article  Google Scholar 

  24. Mathiesen T, Gerlich Å, Kihlström L, Svensson M, Bagger-Sjöbäck D (2007) Effects of using combined transpetrosal surgical approaches to treat petroclival meningiomas. Neurosurgery 60(6):982–991

    Article  Google Scholar 

  25. Morisako H, Goto T, Goto H, Bohoun CA, Tamrakar S, Ohata K (2016) Aggressive surgery based on an anatomical subclassification of craniopharyngiomas. Neurosurg Focus 41(6):1–15

    Article  Google Scholar 

  26. Morisako H, Ohata H, Shinde B, Nagahama A, Watanabe Y, Goto T (2021) Minimal anterior and posterior combined transpetrosal approach for large petroclival meningiomas. J Neurosurg 135(4):1180–1189

    Article  Google Scholar 

  27. Morisako H, Goto T, Ohata H, Goudihalli SR, Shirosaka K, Ohata K (2018) Safe maximal resection of primary cavernous sinus meningiomas via a minimal anterior and posterior combined transpetrosal approach. Neurosurg Focus 44(4):1–8

    Article  Google Scholar 

  28. Morisako H, Goto T, Ohata K (2015) Petroclival meningiomas resected via a combined transpetrosal approach: surgical outcomes in 60 cases and a new scoring system for clinical evaluation. J Neurosurg 122(February):373–380

    Article  Google Scholar 

  29. Ohue S, Fukushima T, Kumon Y, Ohnishi T, Friedman AH (2010) Surgical management of brainstem cavernomas: selection of approaches and microsurgical techniques. Neurosurg Rev 33(3):314–315

    Article  Google Scholar 

  30. Quiñones-Hinojosa A, Chang EF, Lawton MT (2006) The extended retrosigmoid approach: an alternative to radical cranial base approaches for posterior fossa lesions. Neurosurgery 58(SUPPL. 2):208–214

    Google Scholar 

  31. Rabelo NN, da Costa BBS, Teixeira MJ, Figueiredo EG (2018) Letter to the Editor. Minimally invasive techniques: the new frontier in neurosurgery. J Neurosurg 130(1):330–331

    Article  Google Scholar 

  32. Samii M, Alimohamadi M, Gerganov V (2014) Endoscope-assisted retrosigmoid intradural suprameatal approach for surgical treatment of trigeminal schwannomas. Oper Neurosurg 10(4):565–575

    Article  Google Scholar 

  33. Samii M, Metwali H, Samii A, Gerganov V (2013) Retrosigmoid intradural inframeatal approach: indications and technique. Neurosurgery 73(1 Suppl Operative):53–60

    Google Scholar 

  34. Sekhar LN, Schessel DA, Bucur SD, Raso JL, Wright DC (1999) Partial labyrinthectomy petrous apicectomy approach to neoplastic and vascular lesions of the petroclival area. Neurosurgery 44(3):532–537

    Google Scholar 

  35. Siwanuwatn R, Deshmukh P, Figueiredo EG, Crawford NR, Spetzler RF, Preul MC (2006) Quantitative analysis of the working area and angle of attack for the retrosigmoid, combined petrosal, and transcochlear approaches to the petroclival region. J Neurosurg 104(1):137–142

    Article  Google Scholar 

  36. Tatagiba M, Rigante L, Mesquita Filho P, Ebner FH, Roser F (2015) Endoscopic-assisted posterior intradural petrous apicectomy in petroclival meningiomas: a clinical series and assessment of perioperative morbidity. World Neurosurg 84(6):1708–1718

    Article  Google Scholar 

  37. Teo C (2010) The concept of minimally invasive neurosurgery. Neurosurg Clin N Am 21(4):583–584

    Article  Google Scholar 

  38. Vaca EE, Purnell CA, Gosain AK, Alghoul MS (2017) Postoperative temporal hollowing: is there a surgical approach that prevents this complication? A systematic review and anatomic illustration. J Plast Reconstr Aesthet Surg 70(3):401–415

    Article  Google Scholar 

  39. Watanabe T, Katayama Y, Fukushima T, Kawamata T (2011) Lateral supracerebellar transtentorial approach for petroclival meningiomas: operative technique and outcome: clinical article. J Neurosurg 115(1):49–54

    Article  Google Scholar 

  40. Wang EW, Zanation AM, Gardner PA et al (2019) ICAR: endoscopic skull-base surgery. Int Forum Allergy Rhinol 9(S3):S145–S365

    Article  Google Scholar 

Download references

Acknowledgements

We thank all the women and men who have donated their bodies for the advancement of scientific and surgical knowledge.

Author information

Authors and Affiliations

  1. Department of Neurosurgery, Lariboisière Hospital, Assistance Publique – Hôpitaux de Paris, Paris, France

    Arianna Fava, Paolo di Russo, Thibault Passeri, Breno Camara, Francesco Paglia, Fumihiro Matano, Atsushi Okano, Lorenzo Giammattei & Sébastien Froelich

  2. Laboratory of Experimental and Skull Base Neurosurgery, Department of Neurosurgery, Lariboisière Hospital, 2 rue Ambroise Paré, 75010, Paris, France

    Arianna Fava, Paolo di Russo, Fumihiro Matano, Atsushi Okano, Lorenzo Giammattei & Sébastien Froelich

  3. University of Paris, Paris, France

    Thibault Passeri, Francesco Paglia, Lorenzo Giammattei & Sébastien Froelich

Authors
  1. Arianna Fava
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Paolo di Russo
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Thibault Passeri
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Breno Camara
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Francesco Paglia
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Fumihiro Matano
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Atsushi Okano
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Lorenzo Giammattei
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. Sébastien Froelich
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

Study conception and design: Arianna Fava and Sébastien Froelich. Material preparation, data collection, and analysis were performed by Arianna Fava, Paolo di Russo, Thibault Passeri, Breno Camara, Lorenzo Giammattei, and Sébastien Froelich. The first draft of the manuscript was written by Arianna Fava, and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Arianna Fava.

Ethics declarations

Ethics approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee (Hôpital Lariboisière, Assistance Publique—Hôpitaux de Paris, Université Paris—Diderot) and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Conflict of interest

The authors declare no competing interests.

Additional information

Publisher’s note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

This article is part of the Topical Collection on Brain Tumors

Supplementary information

Video The mini-CTPA used for the treatment of different pathologies: part 1 shows a clival chordoma (case 1), part 2 a cerebellopontine angle epidermoid cyst (case 2), and part 3 a petroclival meningioma (case 3) (AVI 125292 kb)

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Fava, A., di Russo, P., Passeri, T. et al. The mini-combined transpetrosal approach: an anatomical study and comparison with the combined transpetrosal approach. Acta Neurochir 164, 1079–1093 (2022). https://doi.org/10.1007/s00701-022-05124-x

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00701-022-05124-x

Keywords

Search

Navigation