101ties of daily living [ 11 ]. The trochlear nerve is
most commonly involved, followed by oculomo-
tor and abducens nerve paresis [ 11 ]. Mortality in
the perioperative period has reduced over the past
few decades, and it varies from 0% to 7% in
recently published series [ 11 ]. It is primarily due
to poor neurological outcome secondary to a
brainstem stroke, which reemphasizes the impor-
tance of preoperative and intraoperative assess-
ment of the tumor-brainstem interface.
Tumor recurrence and progression rates up to
42% after surgical resection of PC meningiomas
have been reported [ 11 ]. The primary factors con-
tributing to higher risk of tumor recurrence include
less extensive surgical resection, malignant histol-
ogy, and cavernous sinus involvement. Use of adju-
vant SRS for any residual tumor demonstrating
progressive growth reduces the potential for tumor
recurrence to approximately 4.5–22% with length
of follow-up ranging from 6 to 8 years [ 12 , 27 , 28 ].
The studies assessing the role of SRS as a primary
treatment modality for PC meningiomas have
reported excellent tumor control rates (~100%),
with an average follow-up of 3–4 years [ 28 – 30 ].
They also demonstrated favorable neurological
outcome in 96–100% of patients [ 28 , 30 ], along
with improvement in cranial nerve function in
~50% of cases [ 29 ]. However, SRS has its own set
of risks and side effects. Benign skull base menin-
giomas have been demonstrated to exhibit aggres-
sive behavior following treatment failure with
radiation treatment, especially with unpredictable
growth pattern and growth rate. Primary radiosur-
gery treatment-resistant tumors are much more dif-
ficult to resect after receiving radiation therapy
because of increased adhesiveness of the tumor,
and surgery is often associated with higher compli-
cation rates if complete resection is attempted.
Residual tumors >8 ml in volume are often associ-
ated with reduced efficacy of SRS treatment, high-
lighting the importance of adequate tumor resection
as the primary modality for large tumors [ 17 ].
Because we lack sufficient data on long-term risks
of SRS, the risk of radiation- induced malignancy
must be considered. Finally, the limited long-term
data available on the role of SRS in meningioma
treatment have demonstrated less optimistic long-
term survival. Rowe et al. [ 31 ] found a 53% 15-year
survival, with 67% of patient mortality caused by
meningioma after SRS treatment.
Direct comparison of radiation treatment and
microsurgical resection cannot be aptly performed
because of the lack of randomized controlled trials
to assess the difference in treatment outcome and
complications. In addition, the rarity of petroclival
meningiomas, the heterogeneity in the clinical
profile of patients, differential tumor characteris-
tics among various studies, and institutional bias
toward one modality over the other do not allow
proper comparison of the two treatment modali-
ties. These comparisons should be judiciously
applied on a case-by-case basis. It is imperative to
understand that the treatment modalities are not
competitive but complementary to each other, and
together they form an integral part of the arma-
mentarium of the present-day neurosurgeon. The
development of microneurosurgical skull base
approaches, a better understanding of the surgical
anatomy, the availability of newer imaging tech-
niques, optimal electrophysiological monitoring
and modern neuroanesthesia setups, and the intro-
duction of radiosurgery have led to the modern
multimodality management. In the current era of
multimodality treatment aimed at preservation of
the patient’s functional status and quality of life,
mortality rates have reduced to ~0% in the most
recent reports, and a permanent morbidity rate of
~20% is observed, primarily in the form of cranial
nerve deficits, which are often well compensated
by patients in their day-to-day life [ 4 ].Conclusions
During the inevitable evolution of modern-day
neurosurgery, the aim for treatment of PC menin-
giomas has gradually shifted from primary
aggressive resection and long-term survival to
more selective resection and preservation of
patient’s quality of life using a multimodality
approach comprising surgery, radiation treat-
ment, and conservative management with close
radiological surveillance. Therefore, appropriate
decision-making is vital in choosing the best pos-
sible treatment strategy tailored to the individual
patient’s needs.7 Petroclival Meningiomas