Pretemporal Pterional Approach for Sphenopetroclivial Meningioma Causing Trigeminal Neuropathy: Surgical Video
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Abstract
Introduction: Sphenopetroclival meningiomas represent a major surgical challenge because of their intimate relationship with critical neurovascular structures, particularly the cavernous sinus and cranial nerves. Complete resection may be limited by the risk of permanent cranial nerve injury; therefore, selective decompression of symptomatic neural structures followed by radiosurgery for residual tumor has become an effective treatment strategy for cavernous sinus meningioma causing trigeminal neuropathy. The pretemporal pterional approach provides wide exposure of cisternal and cavernous sinus components while minimizing brain retraction.
Case Report: A 33-year-old woman presented with refractory neuropathic pain in the right trigeminal nerve distribution. Contrast-enhanced MRI demonstrated a small sphenopetroclival meningioma with cisternal and intracavernous components. Neurological examination revealed no cranial nerve palsies or extraocular muscle deficits other than trigeminal neuropathy. Because of debilitating pain refractory to conservative management, surgery was indicated to decompress the trigeminal nerve. A pretemporal pterional approach was performed with wide dissection of the Sylvian fissure. Bridging veins from the temporal pole to the sphenoparietal sinus were coagulated and sacrificed to allow gentle temporal lobe retraction. This provided visualization of the right internal carotid artery and the oculomotor and trochlear nerves at the tentorial incisura. After coagulation and sectioning of the tentorial incisura, the cisternal tumor component was removed, achieving trigeminal nerve decompression. The intracavernous component was intentionally left in situ to avoid cranial nerve injury.
Results: Postoperative imaging confirmed successful trigeminal nerve decompression with residual intracavernous tumor. Two years after surgery, growth of the residual component was documented, and the patient was referred for stereotactic radiosurgery. After 14 years of follow-up, no further tumor growth was observed, and the patient remained free of trigeminal symptoms.
Conclusion: This case supports a staged strategy combining pretemporal pterional microsurgical decompression of symptomatic neural structures with radiosurgery for residual cavernous sinus meningioma. The approach provides wide exposure of the suprasellar, interpeduncular, and petroclival regions and enables selective resection of accessible tumor while preserving critical neurovascular structures. Radiosurgery can provide durable control of intentionally retained intracavernous disease, reducing the risk associated with aggressive microsurgical resection.
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