A surgery by Dr. Luis Borba
El Dr. Luis Borba, an international reference in skull base surgery, presents in la app SurgSchool complete microsurgical resection of a giant petroclival meningioma using a posterior petrosal approach, one of the most complex techniques in modern neurosurgery.
This case exemplifies the balance between maximum anatomical exposure and neurovascular preservation, in a region where critical structures of the brainstem, cranial nerves and vertebrobasilar arteries converge.
Clinical presentation and preoperative studies
The patient, a 45-year-old male, had a three-year history of Progressive headache, dysphonia, dysphagia, and tetraparesis, which had put him in a wheelchair.
La magnetic resonance showed a homogeneously capturing extraxial mass in the posterior fossa, 58 × 55 × 37 mm, centered in the prepontine cistern and extending to both cerebellopontine angles, predominating on the left. There was significant compression of the brainstem and signs of obstructive hydrocephalus.
La cerebral angiography revealed tumor irrigation from meningo-hypophyseal branches, of the anterior inferior cerebellar artery and extracranial contributions of the external carotid, which underlined the vascular complexity of the case.
Planning and approach to posterior petrosal
El combined posterior petrosal approach allows simultaneous access to the compartments supratentorial and infratentorial, maximizing exposure of the superior clivus and the ventrolateral aspect of the brainstem.
It has been made mastoidectomy followed by a craniotomy encompassing the middle and posterior fossae, separated by the tentorium. The superior petrosal sinus It was coagulated and sectioned, and the tentorium opened up to the incisura to expose the lower cranial nerves up to the third pair.
During this maneuver, the surgeon emphasizes the importance of identifying the trochlear nerve (IV) and to preserve the Labbé vein, critical structures in this approach.
Tumor exposure and resection
The dural opening allowed access to the presigmoid space, exposing the trigeminal nerve displaced superiorly by the tumor. A initial decompression of the tumor by ultrasonic aspiration, followed by circumferential dissection respecting the arachnoid planes.
El microsurgical detachment He advanced to the point of releasing the neurovascular structures of the brainstem:
- Cranial nerves VI to VIII on the ipsilateral side,
- Arteries vertebral and basilar displaced contralaterally,
- Perforating branches contributing to the anterior spinal artery.
Finally, the agreement was achieved complete resection of the meningioma, preserving the integrity of all cranial nerves and without intraoperative complications.
Postoperative results
El postoperative MRI control confirm the total removal of the tumor and a significant brainstem decompression, with no evidence of heart attack or temporary damage.
The patient presented a progressive neurological improvement, with recovery of walking and resumption of oral diet during follow-up.
Importance of this case in skull base surgery
El giant petroclival meningioma represents one of the greatest challenges of the skull base neurosurgery, due to the proximity of vital structures and the difficulty of access.
El posterior petrosal approach, masterfully employed by the Dr. Borba, offers direct visualization of the clivus and posterior fossa, allowing radical resection with minimal morbidity.
This surgery constitutes a reference teaching material for neurosurgeons in advanced training and skull base specialists, who will be able to observe in detail the microsurgical strategy, dissection planes, and management of venous and dural anatomy.
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