Neoplasm

Combined Transpetrosal and
Fronto-Orbito-Zygomatic Approach
to a Giant Skull Based Meningioma:
A Case Report
Takahiro Eguchi, M.D., Norihiko Tamaki, M.D., Hiromitsu Kurata, M.D.,
Tatsuya Nagashima, M.D., Atsushi Fujita, M.D., Mitsugu Nakamura, M.D.,
and Yoshie Hara, M.D.
Department of Neurosurgery, Kobe University School of Medicine, Kobe, Japan

Eguchi T, Tamaki N, Kurata H, Nagashima T, Fujita A, Nakamura
M, Hara Y. Combined transpetrosal and fronto-orbito-zygomatic
approach to a giant skull-based meningioma: a case report. Surg
Neurol 1998;50:272– 6.

KEY WORDS

Fronto-orbito-zygomatic approach, transpetrosal approach,
skull base surgery, meningioma.

BACKGROUND

Recently, various surgical approaches to skull base lesions have been developed. Skillful use of the combination of two standard approaches make possible the removal of large brain lesions, which conventionally had
been considered inoperative. In this study, we present a
case of a giant meningioma located in the cerebellopontine angle and middle cranial fossa. A near total resection
was achieved using a combined transpetrosal and frontoorbito-zygomatic approach.
CASE REPORT

A 15-year-old boy presented with a meningioma that
caused a left hearing loss, dysarthria, and cerebellar
ataxia. Preoperative magnetic resonance imaging revealed a giant meningioma located in the right cerebellopontine angle, middle fossa, and cavernous sinus. The
patient underwent a near total resection of the tumor
through a combined transpetrosal and fronto-orbitozygomatic approach. He experienced a marked improvement postoperatively and entered high school the following year.
CONCLUSIONS

An approach from several angles was necessary for the
giant skull based tumor presented here. A combination
approach was selected for obtaining a wide operative
field with minimal brain compression during resection of
neoplasm. According to the individual features of each
case, selection of the operative approach, decisions regarding the extent of excision, and postoperative treatment regimens should be adequately planned in the preoperative period. © 1998 by Elsevier Science Inc.

Address reprint requests to: Takahiro Eguchi, M.D., Department of
Neurosurgery, Kobe University School of Medicine, 7-5-1, Kusunoki-cho,
Chuo-ku, Kobe, Japan 650.
Received January 13, 1996; accepted June 10, 1996.
0090-3019/98/$19.00
PII S0090-3019(96)00333-3

n recent years, various surgical approaches have
been developed for lesions of the skull base, and
surgical treatment has become possible for lesions
that conventionally have been considered inoperative. The usefulness of these approaches has been
described. We report a case of a giant meningioma
located in the cerebellopontine angle and middle
cranial fossa that enlarged, extending into the cavernous sinus. A near total resection was achieved
using a combined transpetrosal and fronto-orbitozygomatic approach.

I

Case Report
This 15-year-old boy presented with a gradual onset
of a right hearing loss, dysarthria, and dizziness
over a 1-year period. These symptoms progressed,
and he visited a local hospital. Computed tomography (CT) and magnetic resonance imaging (MRI)
revealed abnormalities. Subsequently, the patient
was referred to our hospital and was admitted on
February 1, 1994. Neurologic findings on admission
included a sensory loss of the 1st and 2nd divisions
of the right trigeminal nerve, a right facial palsy,
right-sided hearing loss, mild dysphagia, a decrease
in the right pharyngeal reflex, a right hypoglossal
palsy, a right Bruns’ nystagmus, and right-sided
cerebellar ataxic symptoms. CT of the brain revealed a large (7.5 3 6 3 6 cm) lesion that extended
from the right cerebellopontine angle into the right
middle cranial fossa. Calcification was seen within
© 1998 by Elsevier Science Inc.
655 Avenue of the Americas, New York, NY 10010

Giant Skull-Based Meningioma

1

Surg Neurol 273
1998;50:272–6

Preoperative Gd-DTPA MRI, showing a homogeneously enhancing giant tumor extending from the intra-cavernous
sinus to the foramen magnum.

the lesion that was enhanced homogeneously with
contrast media. MRI showed the lesion to be of low
signal on T1-weighted images and of mixed signal on
T2-weighted images, and enhancing with gadolinium administration. The tumor extended into the
right cavernous sinus, encasing the internal carotid
artery. It extended inferiorly into the vicinity of the
foramen magnum (Figure 1). Cerebral angiography
demonstrated compression of the blood vessels
surrounding the tumor and the right internal carotid artery in its cavernous sinus course. A slight
tumor stain and feeding vessels to the lesion were
seen (Figure 2). Three-dimensional CT showed erosion of the right petrosal apex and the anterior and
posterior clinoids (Figure 3).
The tumor was resected by a combined frontoorbito-zygomatic and transpetrosal approach on
March 14, 1994. The patient was placed in the supine position with his head rotated 90 degrees to

the left. A skin incision was made, as shown in
Figure 4. The superior and lateral walls of the orbit
were removed, and the zygomatic arch was mobilized and turned inferiorly with the temporal muscle flap attached. The mastoid process and petrosal
bone on the lateral side of the internal acoustic
foramen were removed (Figure 4). The anterior clinoid was drilled down in order to expose the optic
canal. In the middle cranial fossa, the foramen spinosum was identified, and the middle meningeal
artery was coagulated and cut, which then allowed
dissection of the dura of the middle cranial fossa.
After the right great petrosal nerve had been confirmed and sacrificed with preservation of the
geniculate ganglion, fenestration of Glasscock’s triangle was performed giving exposure of the right
internal carotid artery. A temporary clip applied to
the right internal carotid had been confirmed securing the proximal blood flow. A longitudinal inci-

Preoperative angiography.
Carotid angiogram (left)
showing stenosis and distortion
of the internal carotid artery (C5
portion), and vertebral angiogram (right) showing the compression by the tumor.

2

274 Surg Neurol
1998;50:272–6

3

Preoperative 3D-CT, showing the mass effect of the
tumor.

sion was made in the dura of the middle cranial
fossa, and the presence of tumor in the cavernous
sinus was confirmed. When the lateral wall of the
cavernous sinus was incised, milk-white tumor substance surrounded by a thin capsule was seen. The
tumor was soft, elastic, and moderately hemorrhagic. A posterior incision of the dura allowed
exposure of most of the lateral surface of the tumor.
This wide exposure of the tumor was accomplished
with minimal compression of the brain. Tumor in
the middle cranial fossa and the cavernous sinus
was removed piecemeal. Much of the tumor was
calcified and was excised using an ultrasonic knife.
Following excision of tumor on the lateral side of
the right middle cranial fossa, tumor in the right
cerebellopontine angle was removed. After the tentorium had been incised up to its free edge for

4

Eguchi et al

maximum exposure of the operative field, the infratentorial portion of the tumor was resected. After
total resection of the tumor in the cerebellopontine
angle, tumor tissue extending into the cavernous
sinus and around the internal carotid artery was
excised. The tumor encasing the internal carotid
artery was hard and strongly adherent to the vessel. The internal carotid artery wall was noted to be
fragile and tumor infiltration of the wall was seen.
This allowed for only a subtotal removal of the
tumor in this area. A small piece of abdominal fat
was inserted and the dura was closed using a temporal fascia graft.
Resolution of the right facial palsy, right hearing
disorder, dysphagia, and right hypoglossal palsy
was seen postoperatively. The right trigeminal
nerve palsy and right-sided ataxic symptoms were
unchanged. A mild right abducens paralysis and a
left facial palsy appeared transiently, but resolved
within 2 months. A postoperative MRI demonstrated a near total excision of tumor. Tumor remained in the right cavernous sinus where it had
been strongly adherent (Figure 5). This residual
tumor was treated by local linac irradiation at 60
Gy. The patient was discharged, fully independent,
from the hospital without support on September 2,
1994. The patient entered high school the following
year.

Discussion
Skull base lesions are difficult to access and various
approaches to this area have been described. In
1982, Jane et al. [8] reported a supraorbital approach. Since that time, investigators have employed several approaches through the anterior

Operative position (left), skin incision (center), and craniotomy (right) are shown.

Giant Skull-Based Meningioma

5

Postoperative Gd-DTPA MRI, showing a near total
removal of the tumor.

skull base for lesions of the cavernous sinus and
vascular lesions at the cerebral base [6,7,13]. Fujitsu et al. [3] and Al-Mefty et al. [2] have described
a zygomatic approach that allows access to the
middle skull base. The fronto-orbito-zygomatic approach has been used as an approach combining
several advantages. Approaches through the posterior and middle skull bases by excision of the petrosal bone have also been described for lesions of the
cerebellopontine angle and brainstem [1,5,9,12].
These approaches have the advantage of giving the
surgeon a wide operative field and minimizing brain
compression.
An approach from several angles was necessary
for the giant skull based tumor presented here. A
combination of the fronto-orbito-zygomatic and the
transpetrosal approaches was selected for optimal
tumor resection in this case. The combined use of
these approaches gives the surgeon a wide operative field including good visualization of the cavernous sinus, the ventral side of the brainstem,
and the vicinity of the foramen magnum. This
wide operative field was obtained with minimal
brain compression, combining aspects of the separate approaches.
In this patient, preoperative cerebral angiography revealed an irregular internal carotid artery
lumen in the right cavernous sinus, suggestive of
tumor infiltration into the internal carotid artery.
Internal carotid artery bypass surgery was considered to be necessary for a total resection of the
tumor. A preoperative internal carotid artery occlu-

Surg Neurol 275
1998;50:272–6

sion test was negative; however, there are reports
that have shown that the reliability of this test is
questionable [11]. In this case, we resected as much
tumor as possible while preserving the integrity of
the internal carotid artery. The bulk of the tumor
was able to be removed, however, some residual
tumor remained. The internal carotid artery may
slowly occlude as a result of tumor infiltration. A
total tumor resection after the development of collateral circulation may be possible in the future.
The beneficial use of local irradiation [4] and
gamma-knife [10] in treating residual tumor after
excision of a meningioma has been reported. Goldsmith et al. [4] applied radiotherapy to the site of
residual tumor after subtotal resection of meningiomas and reported tumor control rate that exceeded 90% during a 10-year follow-up period. On
the basis of these reports, this patient was given
local irradiation at 60 Gy. In skull base surgery,
careful attention must be given to the patient’s outcome, particularly the patient’s quality of life. According to the individual features of each case, selection of the operative approach, decisions
regarding the extent of excision, and postoperative
treatment regimens should be adequately planned
in the preoperative period.

Conclusion
We presented a patient with a giant meningioma
that extended into the cerebellopontine angle and
middle cranial fossa and invaded the cavernous
sinus, which was resected by a combined frontoorbito-zygomatic and transpetrosal approach. A
multiangle approach is necessary for such a large
skull based tumor. A wide operative field can be
obtained with minimal brain compression by combining the advantages of these two approaches.
REFERENCES
1. Al-Mefty O, Fox JL, Smith RR. Petrosal approach for
petroclival meningiomas. Neurosurgery 1988;22:510 –
16.
2. Al-Mefty O, Anand VK. Zygomatic approach to skullbase lesions. J Neurosurg 1990;73:668 –73.
3. Fujitsu K, Kuwabara T. Zygomatic approach for lesions in the interpeduncular cistern. J Neurosurg
1985;62:340 – 43.
4. Goldsmith BJ, Wara WM, Wilson CB, Larson DA. Postoperative irradiation for subtotally resected meningiomas. J Neurosurg 1994;80:195–201.
5. Hakuba A, Nishimura S, Inoue Y. Transpetrosaltranstentorial approach and its application in the
therapy of retrochiasmatic craniopharyngiomas. Surg
Neurol 1985;24:405–15.
6. Hakuba A, Liu S, Nishimura S. The orbitozygomatic

276 Surg Neurol
1998;50:272–6

infratemporal approach: a new surgical technique.
Surg Neurol 1986;26:271–76.
7. Ikeda K, Yamashita J, Hashimoto M, Futami K. Orbitozygomatic temporopolar approach for a high
basilar tip aneurysm associated with a short intracranial internal carotid artery: a new surgical approach.
Neurosurgery 1991;28:105–10.
8. Jane JA, Park TS, Pobereskin LH, Winn HR, Butler AB.
The supraorbital approach: technical note. Neurosurgery 1982;11:537– 42.
9. Kawase T, Toya S, Shiobara R, Mine T. Transpetrosal
approach for aneurysms of the lower basilar artery.
J Neurosurg 1985;63:857– 61.
10. Lunsford LD. Contemporary management of meningiomas: radiation therapy as an adjuvant and radiosurgery as an alternative to surgical removal? J Neurosurg 1994;80:187–90.
11. Origitano TC, Al-Mefty O, Leonetti JP, DeMonte F,
Reichman OH. Vascular considerations and complications in cranial base surgery. Neurosurgery 1994;
35:351– 63.
12. Sekhar LN, Jannetta PJ, Burkhart LE, Janosky JE. Meningiomas involving the clivus: a six-year experience
with 41 patients. Neurosurgery 1990;27:764 – 81.
13. Sumith RR, Al-Mefty O, Middleton TH. An orbitocranial approach to complex aneurysms of the anterior
circulation. Neurosurgery 1980;24:385–91.
COMMENTARY

I don’t have any doubt that the combination of the
two techniques gave a very nice exposure for this
large tumor, and undoubtedly that was necessary.
However, I have a few problems with it. I would not
argue with leaving the carotid-involved tumor in
place, although we don’t see the postoperative MR
to see just how much tumor was left. In a 15-yearold, however, I would be a little uncomfortable
about the irradiation. A postoperative MR might
convince me, although it could be that masterful
inactivity waiting for recurrence with an occlusion
of the carotid might be the best course of action.
Then a radical resection of tumor and carotid could
be carried out.

Eguchi et al

The technique the authors used was certainly
highly successful in terms of minimal postoperative
findings, but this only represents a variation on a
theme that everyone is interested in and accomplishing in their own way.
John A. Jane, M.D., Ph.D.
Department of Neurosurgery
University of Virginia
Charlottesville, Virginia
Skull base approaches in children are becoming
much more utilized as the advantages have become
more obvious with time. Initially, skull base surgery
was felt to be reserved almost exclusively for the
adult population; however, many of the lesions seen
in childhood lend themselves well to skull base
techniques. In particular, the orbito-zygomatic approach has afforded excellent exposure of lesions of
the middle cranial fossa, the suprasellar area, and
the anterior upper brainstem. Approaches to those
areas using this particular skull base approach have
resulted in significantly decreased retraction and
decreased morbidity. I now consider it the approach of choice for most craniopharyngiomas and
for lesions of the upper pons and midbrain.
The transpetrosal or parapetrosal approach to
the anterior brainstem is also valuable for lesions in
this area, including lesions within the substance of
the brainstem.
I congratulate the authors on a wise choice for
their surgical approach and for the excellent outcome in this patient with a significantly large
meningioma.
Marion L. Walker, M.D., F.A.C.S., F.A.A.P.
Division of Pediatric Neurosurgery
University of Utah
Salt Lake City, Utah