© Springer International Publishing AG 2018 55
W.T. Couldwell (ed.), Skull Base Surgery of the Posterior Fossa,
https://doi.org/10.1007/978-3-319-67038-6_4
Posterior and Combined Petrosal
Approaches
David Aum, Omar Arnaout, Marcio S. Rassi,
Walid Ibn Essayed, and Ossama Al-Mefty
D. Aum, MS (*)
University of South Florida Morsani College of
Medicine, Tampa, FL, USA
e-mail: [email protected]
O. Arnaout, MD • W. Ibn Essayed, MD
O. Al-Mefty, MD
Department of Neurosurgery, Brigham and Women’s
Hospital, Boston, MA, USA
e-mail: [email protected];
[email protected];
[email protected];
[email protected]
M.S. Rassi, MD
Department of Neurosurgery, Brigham and Women’s
Hospital, Harvard Medical School,
Boston, MA, USA
e-mail: [email protected]
4
Introduction
The petrosal approach, as an initial concept, was
described by Habuka et al. [ 1 ] in 1977 who per-
formed the approach on a case of clival meningioma
in a combined supra- and infratentorial craniotomy
with a partial labyrinthectomy [ 2 ]. The modern
petrosal approach, also referred to as the “posterior
petrosal,” was described by Al-Mefty et al. [ 3 ] and is
centered on the petrous bone and offers simultane-
ous access to the petroclival junction, middle clivus,
the apical petrous bone, Meckel’s cave, and the cav-
ernous sinus. The petrosal approach offers a wide
exposure while eliminating the need for temporal or
cerebellar retraction and is made possible by retro-
displacement of the sigmoid sinus following sec-
tioning the tentorium. The approach also shortens
the operative distance to the clivus while potentially
preserving the inner ear structures and allowing for
resection of affected skull base bone. Other advan-
tages include that the vascular supply to the tumor is
made accessible early in the dissection and the
approach affords multiple angles of attack to the
lesion [ 4 ]. Finally, the approach is easily combined
with other skull base approaches including the
orbito-zygomatic, the total petrosectomy, and the
transcondylar as the individual situation dictates.
The petrosal and combined petrosal approach
may be used to expose a variety of skull base
lesions including:- Petroclival meningiomas, which arise in the
upper two thirds of the clivus at the petroclival
junction medial to the trigeminal nerve.
Smaller tumors that remain medial to as low
as the internal auditory meatus and cross mid-
line could be approached via a zygomatic
approach and an anterior petrosectomy [ 5 , 6 ]. - Sphenopetroclival meningiomas, which
extend into the middle cranial fossa by way of
Meckel’s cave or the cavernous sinus. These
lesions frequently require a combined petrosal
approach in order to achieve total excision.
Alternatively, in patients who have already