Clival Meningioma: Remove the Bone to Pursue Ventral Exposure: 2-Dimensional Operative Video.

Abstract

Clival meningiomas are defined by their wide midline insertion on the upper two-thirds of the clivus.1 They are rarely reported and are some of the least studied meningiomas. Owing to their ventral location, encasement of the basilar artery, compression of the brainstem, and involvement of bilateral cranial nerves, they are truly the most challenging and the highest risk surgical undertaking. Consequently, their surgical resection requires a wide exposure with multitrajectory access, particularly in reaching the ventral surface in front of the basilar artery and brainstem extending to the opposite side. Prior surgery with adhesions to the cranial nerves and cerebral vessels adds further difficulties to the dissection that could be overcome by shortening the distance of the operative corridor and bringing the deep structures closer to the surface for fine microsurgical dissection under high magnification.2-6 Hence, in a patient with unilateral hearing loss, total petrosectomy represents an ideal approach without the need to sacrifice any neural or vascular structure or apply brain retraction.2,7,8 The lengthy and extensive bony drilling is a worthy investment of time and effort to gain advantageous exposure. We demonstrate the exposure obtained by the total petrosectomy and the extent of safe dissection of the brainstem and basilar system in a case of a 53-year-old woman who presented with large recurrent clival meningioma after multiple surgeries in the preceding 10 years. The patient consented to surgery and the publication of images. Image at 1:46 © Ossama Al-Mefty, used with permission. Image at 2:13 reprinted with permission from Al-Mefty O, Operative Atlas of Meningiomas, Vol 1, © LWW, 1998.