A surgery by Dr. Juan Carlos Fernández-Miranda
In an impressive demonstration of advanced neurosurgery on the online surgery app SurgSchool, the Dr. Juan Carlos Fernández-Miranda, Professor of Neurosurgery at Stanford University and one of the world's leading experts in skull base surgery, has performed the complete resection of a recurrent petroclival meningioma using a combined transpetrous approachThis intervention was carried out in the Stanford Brain Tumor Center, where Dr. Fernández-Miranda serves as Surgical Director, in addition to leading the programs of Skull Base Surgery, Pituitary Surgery, as well as the Center for Research in Surgical Neuroanatomy, Tractography and Virtual Simulation.
Clinical Case and Justification of the Approach
The 63-year-old patient presented with a meningioma at the superior petroclival junction, which had previously been treated with a retrosigmoid approach. The residual tumor showed progressive growth, brainstem compression, and associated inflammation, prompting further surgery.
Dr. Fernández-Miranda opted for a combined transpetrous approach —a technique that integrates an anterior petrosectomy (Kawase) and a posterior petrosectomy (translabyrinthine mastoidectomy)— to achieve optimal exposure of the petroclival region and allow for complete resection with minimal manipulation of the brainstem and critical neurovascular structures.
Technical Details of the Surgery
- Previous Transpetrosa Exhibition:
- The dissection began with coagulation of the middle meningeal artery and detachment of the dura mater from the middle fossa.
- Key structures such as the greater superficial petrosal nerve (GSPN), the foramen ovale and the mandibular nerve (V3) were identified and carefully dissected.
- The carotid artery was delimited in the foramen lacerum by electrical stimulation and Doppler.
- Anterior petrosectomy was performed including the Kawase triangle, exposing the petrous apex and posterior fossa.
- Posterior Petrosectomy and Exposure of the IAC:
- Given the patient's total hearing loss, a decision was made to mastoidectomy translabyrinthine without the intention of hearing preservation.
- The semicircular canals were perforated and the internal auditory canal (IAC) was accessed.
- Resection of the petrous apex was completed anterior and superior to the IAC.
- Dural Opening and Tumor Resection:
- The tumor was accessed through dural openings below and above the tentorium.
- A major bridging vein was identified and preserved by ligating the superior petrosal sinus and precisely dividing it to maintain venous drainage.
- Essential cranial nerves such as IV (trochlear), V (trigeminal) and VII (facial) were preserved by intraoperative stimulation and meticulous microdissection.
- The tumor was completely dissected from the brainstem, including its medial surface, where branches of the superior cerebellar artery were preserved.
- Reconstruction:
- The dura mater was closed primarily with support from a vascularized pericranium flap and fat graft.
- The closure was intended to minimize the risk of cerebrospinal fluid leaks and other postoperative complications.
Results and Postoperative Evolution
The postoperative period was favorable. The MRI showed complete resection of the tumorThe patient presented with a transient sixth cranial nerve (abducens) paralysis, which completely resolved during follow-up. There were no permanent neurological deficits.
Importance and Contribution of the Procedure
The combined transpetrous approach, although technically demanding, provides a exceptional access to the petroclival junction and the brainstem. This technique allows for the safe management of complex and recurrent injuries, such as this case, with minimal neurological morbidity.
Dr. Fernández-Miranda demonstrates, once again, the relevance of a precise surgical neuroanatomy, the use of advanced technology (such as electrical stimulation, Doppler and ultrasonic aspiration), and strategic planning based on preoperative images and virtual simulation.
