Posterior Petrosal Approach for Sphenopetroclival Meningioma: How I Do It? Surgical video.

Introduction: The posterior petrosal approach is one of the most versatile skull base approaches for the treatment of petroclival meningiomas. It provides simultaneous supra- and infratentorial exposure, allowing multidirectional microsurgical access to the petroclival junction while minimizing temporal lobe and cerebellar retraction. Appropriate patient selection depends on careful evaluation of venous anatomy, particularly the drainage pattern of the vein of Labbé. This surgical video demonstrates the step-by-step technique for resection of a sphenopetroclival meningioma through a posterior petrosal presigmoid approach. Case Report: A 39-year-old woman was incidentally diagnosed with a right sphenopetroclival meningioma during neuroimaging performed for unrelated symptoms. Considering the progressive growth potential of petroclival meningiomas and the increasing complexity associated with delayed treatment, microsurgical resection was recommended. Preoperative cerebral angiography demonstrated a conventional drainage pattern of the vein of Labbé into the transverse-sigmoid junction, without anterior displacement, confirming the suitability of the posterior petrosal presigmoid approach. Following mastoidectomy and skeletonization of the sigmoid and transverse sinuses, a combined presigmoid supra- and infratentorial exposure was performed. After sectioning the tentorium and preserving the trochlear nerve, cerebrospinal fluid release provided adequate brain relaxation. The tumor was internally debulked and progressively dissected from the brainstem, basilar artery, cranial nerves, and perforating vessels under high magnification using meticulous arachnoid dissection. The multidirectional exposure provided by the posterior petrosal approach allowed excellent visualization of the petroclival region and ventrolateral brainstem, facilitating safe circumferential tumor removal. A small intracavernous tumor remnant was intentionally preserved due to the high morbidity associated with aggressive cavernous sinus dissection. Results: The postoperative course was notable for an isolated right oculomotor nerve palsy, which completely resolved eight months after surgery. Histopathological examination confirmed a WHO grade 1 meningioma. The patient remains neurologically independent after more than nine years of radiological follow-up, with no recurrence of the extracavernous tumor. The small residual intracavernous component has remained stable and continues to be managed with serial magnetic resonance imaging. Conclusion: The posterior petrosal presigmoid approach remains an excellent option for selected sphenopetroclival meningiomas. Careful preoperative evaluation of the vein of Labbé is essential, as a favorable venous drainage pattern allows safe execution of this approach. The technique provides broad supra- and infratentorial exposure, early cerebrospinal fluid release, excellent visualization of the petroclival region and ventral brainstem, and facilitates maximal safe resection while preserving neurological function. Planned observation of small intracavernous remnants offers durable long-term tumor control while avoiding the morbidity associated with aggressive cavernous sinus surgery.