Skip to main content
SpringerLink
Log in

Anatomic comparison of anterior petrosectomy versus the expanded endoscopic endonasal approach: interest in petroclival tumors surgery

  • Original Article
  • Published:
Surgical and Radiologic Anatomy Aims and scope Submit manuscript

Abstract

Purpose

Since the petroclival region is deep-seated with close neurovascular relationships, the removal of petroclival tumors still represents a fascinating surgical challenge. Although the classical anterior petrosectomy (AP) offers a meaningful access to this petroclival region, the expanded endoscopic endonasal approach (EEEA) recently leads to overcome difficulties from trans-cranial approaches. Herein, we present an anatomic comparison of AP versus EEEA. We aim to describe the limits of these both approaches helping the choice of the optimal surgical route for petroclival tumors.

Methods

Six fresh cadaveric heads were harvested and injected with colored latex. Each approach was step-by-step detailed until its final surgical exposure.

Results

The AP provided a narrow direct supero-lateral access to the petroclival area that can also reach the cavernous sinus, the retrochiasmatic region and perimesencephalic cisterns. However, this corridor anterior to the internal acoustic meatus passed on each side of the trigeminal nerve. Moreover, tumor extensions toward the foramen jugularis, inside the clivus or behind the internal acoustic meatus were difficult to control. The EEEA brought a straightforward access to the clivus but the petrous apex was hidden behind the internal carotid artery. Several variants were described: a medial transclival, a lateral through the Meckel’s cave and an inferior trans-pterygoid route. Elsewhere, tumor extension behind the internal acoustic meatus or above the tentorium could not be satisfactorily assessed.

Discussion and conclusion

PA and EEEA have their own limits in reaching the petroclival region in accordance with the tumor characteristics. The AP should be preferred for radical removal of middle-sized petrous apex intradural tumors like meningiomas. The EEEA would be of interest for extradural midline tumors like chordomas or for petrous apex cysts drainage.

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

Similar content being viewed by others

Abbreviations

AP:

Anterior petrosectomy

EEEA:

Expanded endoscopic endonasal approach

IAM:

Internal acoustic meatus

ICA:

Internal carotid artery

SPN:

Superficial petrosal nerve

UPR:

Upper petrous ridge

References

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

    Article  CAS  PubMed  Google Scholar 

  2. Al-Mefty O, Sekhar LN, Sen C, van Loveren HR (2001) Petroclival meningioma: case history and responses. Skull Base 11:143–148

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  3. Bambakidis NC, Kakarla UK, Kim LJ, Nakaji P, Porter RW, Daspit CP et al (2007) Evolution of surgical approaches in the treatment of petroclival meningiomas: a retrospective review. Neurosurgery 61:202–211

    Article  PubMed  Google Scholar 

  4. Berhouma M, Messerer M, Jouanneau E (2012) Shifting paradigm in skull base surgery: roots, current state of the art and future trends of endonasal endoscopic approaches. Rev Neurol (Paris) 168:121–134

    Article  CAS  Google Scholar 

  5. Campbell E, Whitfield RD (1948) Posterior fossa meningiomas. J Neurosurg 5:131–153

    Article  CAS  PubMed  Google Scholar 

  6. Cavallo LM, Cappabianca P, Galzio R, Iaconetta G, de Divitiis E, Tschabitscher M (2005) Endoscopic transnasal approach to the cavernous sinus versus transcranial route: anatomic study. Neurosurgery 56:379–389

    Article  PubMed  Google Scholar 

  7. Chanda A, Nanda A (2006) Retrosigmoid intradural suprameatal approach: advantages and disadvantages from an anatomical perspective. Neurosurgery 59:ONS–1–ONS–6 10.1227

  8. Chang SW, Wu A, Gore P, Beres E, Porter RW, Preul MC et al (2009) Quantitative comparison of Kawase’s approach versus the retrosigmoid approach: implications for tumors involving both middle and posterior fossae. Neurosurgery 64:ons44–ons52

    Article  PubMed  Google Scholar 

  9. Chen L, Yu X, Bu B, Xu B, Zhou D (2011) The retrosigmoid approach to petroclival meningioma surgery. J Clin Neurosci Off J Neurosurg Soc Australas 18:1656–1661

    Google Scholar 

  10. Cherington M, Schneck SA (1966) Clivus meningiomas. Neurology 16:86–92

    Article  CAS  PubMed  Google Scholar 

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

    Article  CAS  PubMed  Google Scholar 

  12. Day JD, Fukushima T, Giannotta SL (1994) Microanatomical study of the extradural middle fossa approach to the petroclival and posterior cavernous sinus region: description of the rhomboid construct. Neurosurgery 34:1009–1016 (discussion 1016)

    Article  CAS  PubMed  Google Scholar 

  13. De Notaris M, Cavallo LM, Prats-Galino A, Esposito I, Benet A, Poblete J et al (2009) Endoscopic endonasal transclival approach and retrosigmoid approach to the clival and petroclival regions. Neurosurgery 65:42–50 (discussion 50–520)

    Article  PubMed  Google Scholar 

  14. Fournier H-D, Mercier P, Roche P-H (2007) Surgical anatomy of the petrous apex and petroclival region. Adv Tech Stand Neurosurg 32:91–146

    Article  CAS  PubMed  Google Scholar 

  15. François P, Ben Ismail M, Hamel O, Bataille B, Jan M, Velut S (2010) Anterior transpetrosal and subtemporal transtentorial approaches for pontine cavernomas. Acta Neurochir (Wien) 152:1321–1329 (discussion 1329)

    Article  Google Scholar 

  16. Horgan MA, Anderson GJ, Kellogg JX, Schwartz MS, Spektor S, McMenomey SO et al (2000) Classification and quantification of the petrosal approach to the petroclival region. J Neurosurg 93:108–112

    Article  CAS  PubMed  Google Scholar 

  17. Kassam AB, Gardner P, Snyderman C, Mintz A, Carrau R (2005) Expanded endonasal approach: fully endoscopic, completely transnasal approach to the middle third of the clivus, petrous bone, middle cranial fossa, and infratemporal fossa. Neurosurg Focus 19:E6

    PubMed  Google Scholar 

  18. Kassam AB, Prevedello DM, Carrau RL, Snyderman CH, Gardner P, Osawa S et al (2009) The front door to Meckel’s cave: an anteromedial corridor via expanded endoscopic endonasal approach—technical considerations and clinical series. Neurosurgery 64:ons71–ons82 (discussion ons82–83)

    Article  PubMed  Google Scholar 

  19. Kassam AB, Vescan AD, Carrau RL, Prevedello DM, Gardner P, Mintz AH et al (2008) Expanded endonasal approach: vidian canal as a landmark to the petrous internal carotid artery: technical Note. J Neurosurg 108:177–183

    Article  PubMed  Google Scholar 

  20. 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 

  21. McElveen JT, Dorfman BE, Fukushima T (2001) Petroclival tumors: a synthesis. Otolaryngol Clin N Am 34:1219–1230

    Article  Google Scholar 

  22. Rhoton AL (1979) The suboccipital approach to removal of acoustic neuromas. Head Neck Surg 1:313–333

    Article  PubMed  Google Scholar 

  23. Roche P-H, Lubrano VF, Noudel R (2011) How I do it: epidural anterior petrosectomy. Acta Neurochir (Wien) 153:1161–1167

    Article  Google Scholar 

  24. Samii M, Ammirati M, Mahran A, Bini W, Sepehrnia A (1989) Surgery of petroclival meningiomas: report of 24 cases. Neurosurgery 24:12–17

    Article  CAS  PubMed  Google Scholar 

  25. Samii M, Tatagiba M (1992) Experience with 36 surgical cases of petroclival meningiomas. Acta Neurochir (Wien) 118:27–32

    Article  CAS  Google Scholar 

  26. Samii M, Tatagiba M, Carvalho GA (2000) Retrosigmoid intradural suprameatal approach to Meckel’s cave and the middle fossa: surgical technique and outcome. J Neurosurg 92:235–241

    Article  CAS  PubMed  Google Scholar 

  27. Sennaroglu L, Slattery WH (2003) Petrous anatomy for middle fossa approach. Laryngoscope 113:332–342

    Article  PubMed  Google Scholar 

  28. 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 104:137–142

    Article  PubMed  Google Scholar 

  29. Tedeschi H, Rhoton AL (1994) Lateral approaches to the petroclival region. Surg Neurol 41:180–216

    Article  CAS  PubMed  Google Scholar 

  30. Van Gompel JJ, Alikhani P, Tabor MH, van Loveren HR, Agazzi S, Froelich S et al (2014) Anterior inferior petrosectomy: defining the role of endonasal endoscopic techniques for petrous apex approaches. J Neurosurg 120:1321–1325

    Article  PubMed  Google Scholar 

  31. Velut S, Jan M (1988) Petrectomy of the point during approach to the clivus: technic, values and limitations. Apropos of a case of meningioma. Neurochirurgie 34(1):17–25

    CAS  PubMed  Google Scholar 

  32. Xu F, Karampelas I, Megerian CA, Selman WR, Bambakidis NC (2013) Petroclival meningiomas: an update on surgical approaches, decision making, and treatment results. Neurosurg Focus 35:E11

    Article  PubMed  Google Scholar 

Download references

Acknowledgments

We thank the technical staff of the Department of Anatomy for their preparation of specimens.

Conflict of interest

I hereby confirm that the authors have no conflict of interest in this manuscript.

Author information

Authors and Affiliations

  1. Skull Base Multi-disciplinary Unit, Department of Neurosurgery B, Neurological Hospital Pierre Wertheimer, Hospices Civils de Lyon, 59 Bd Pinel, 69677, Lyon Cedex, France

    Timothée Jacquesson, Moncef Berhouma & Emmanuel Jouanneau

  2. Department of Anatomy, University of Lyon 1, 8 Avenue Rockefeller, 69003, Lyon, France

    Timothée Jacquesson & Emile Simon

Authors
  1. Timothée Jacquesson
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Emile Simon
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Moncef Berhouma
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Emmanuel Jouanneau
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Timothée Jacquesson.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Jacquesson, T., Simon, E., Berhouma, M. et al. Anatomic comparison of anterior petrosectomy versus the expanded endoscopic endonasal approach: interest in petroclival tumors surgery. Surg Radiol Anat 37, 1199–1207 (2015). https://doi.org/10.1007/s00276-015-1497-5

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00276-015-1497-5

Keywords

Search

Navigation