Neurosurgical Review

https://doi.org/10.1007/s10143-020-01266-7

ORIGINAL ARTICLE

Single-stage endoscopic endonasal approach for the complete

removal of trigeminal schwannomas occupying both the middle
and posterior fossae
Xiao Wu 1 & Shen Hao Xie 1 & Bin Tang 1 & Le Yang 1 & Li Min Xiao 1 & Han Ding 1 & You Yuan Bao 1 & Zhi Gao Tong 1 &
Tao Hong 1

Received: 11 November 2019 / Revised: 3 January 2020 / Accepted: 10 February 2020

# Springer-Verlag GmbH Germany, part of Springer Nature 2020

Abstract
To introduce a purely endoscopic endonasal trans-Meckel’s cave approach or a transclival approach for trigeminal schwannomas
(TSs) involving both the middle and posterior fossae. This retrospective study reviewed the medical records and intraoperative
videos of 8 patients with TSs occupying both the middle and posterior fossae who underwent an endoscopic endonasal approach
(EEA) between January 2017 and October 2019. All 8 patients received total resection under a single-stage EEA. Six patients
underwent endoscopic endonasal resection via a purely trans-Meckel’s cave approach, and 2 patients underwent endoscopic
endonasal resection via a trans-Meckel’s cave approach combined with a transclival approach. There was no surgical-related
hemorrhage or mortality and no cerebrospinal fluid leakage. All headache symptoms completely improved postoperatively (n = 3
patients). All cranial nerve (CN) symptoms (CN IX and CN VI) improved postoperatively. The most common preoperative
symptom was facial numbness (n = 5 patients); 2 of these 5 patients showed a partial improvement, 1 patient experienced
worsening, and 2 patients remained unchanged at the last follow-up. Four patients developed postoperative complications,
including CN VI palsy (n = 2), dry eye (n = 2), mastication weakness (n = 1), and facial numbness (n = 2). All complications
except for dry eye were relieved at the last follow-up, but the patients with dry eye did not develop corneal keratopathy. The
endoscopic endonasal trans-Meckel’s cave and transclival approaches provide adequate exposure and improve the rate of total
resection for TSs occupying both the middle and posterior fossae with minimal invasion. It may be possible to use these
approaches as a safe alternative to conventional surgical approaches.

Keywords Endoscopic endonasal approach . Meckel’s cave . Single stage . Trigeminal schwannomas

Introduction
Although trigeminal schwannomas (TSs) are uncommon,
comprising 0.36% of all intracranial tumors and 0.8%–8%
of all intracranial schwannomas, they are the second most
common type of intracranial schwannoma [3, 6, 9, 12, 13,
21]. TSs often displace surrounding neurovascular structures
Xiao Wu and Shen Hao Xie contributed equally to this work.
Electronic supplementary material The online version of this article
(https://doi.org/10.1007/s10143-020-01266-7) contains supplementary
material, which is available to authorized users.
* Tao Hong
ht2000@vip.sina.com
1
Department of Neurosurgery, The First Affiliated Hospital of
Nanchang University, 17 Yong Wai Zheng Street, Nanchang, China
rather than infiltrate them. They are usually histologically be-
nign tumors and are generally considered curable via gross
total resection (GTR) [22]. TSs most frequently originate from
the gasserian ganglion and can spread along the course of the
trigeminal nerve with extension into multiple cranial compo-
nents. Therefore, TSs can be located in the middle fossa, pos-
terior fossa, and along peripheral branches such as cranial
nerve (CN) V1 into the orbit, CN V2 into the pterygopalatine
fossa, and CN V3 into the infratemporal fossa. When the
tumor is located in the middle fossa with posterior fossa ex-
tension, it is called a dumbbell-shaped TS and is considered
the most challenging type.
Recently, with the wide application of endoscopic technol-
ogy, the endoscopic endonasal approach (EEA) seems to be an
ideal surgical approach for skull base pathology. There have
been extensive reports on resecting TSs via the EEA, but only
a few cases have been described for TSs occupying both the

middle and posterior fossae [7, 12, 13, 15, 16, 22, 24]. Most of
these reports have suggested two-stage surgery that resects the
middle fossa component via the EEA followed by a
retrosigmoid craniectomy or stereotactic radiosurgery (SRS)
for the residual posterior fossa component [7, 12, 16, 22]. The
reason for two-stage surgery is that there is not enough space
for surgical manipulation and exposure of the posterior com-
ponent. In this study, we describe the technical details of the
management of TSs occupying both the middle and posterior
fossae via a single-stage EEA. According to the location of
posterior fossa extension, a purely trans-Meckel’s cave ap-
proach or a trans-Meckel’s cave approach combined with a
transclival approach is proposed here. The surgical results of
these new techniques were also analyzed in eight patients to
optimize the management of TSs occupying both the middle
and posterior fossae.
Methods
This retrospective study was authorized by the University of
Nanchang University Institutional Review Board. A total of
eight patients were histopathologically confirmed as having
TSs between January 2017 and October 2019, and radio-
graphic findings revealed involvement of both the middle
and posterior fossae. All patients underwent T1-enhanced
MRI and were followed to examine clinical symptoms
3 months after surgery and annually thereafter. The size and
major component of the tumor, clinical symptoms, surgical
complications, histopathological examination results, and
postoperative follow-up data were retrospectively reviewed
through medical records and intraoperative videos. All pa-
tients in this study signed informed consent.
Surgical techniques
Surgical approach
For the selection of the approach, it depends on whether the
tumor with the “waist” sign caused by the porus trigeminus or
which part is the major component. The indications for purely
trans-Meckel’s cave approach were as follows: (1) TS has no
“waist” sign based on preoperative images; (2) TS has a
“waist” sign but only small-sized posterior fossa extension
through the porus trigeminus. The indications for assisted
transclival approach were as follows: (1) TS has a “waist”
sign; (2) TS is equally located in the middle and posterior
fossae. For patients whose major component is located in the
posterior fossa with small-sized middle fossa extension, we
choose transcranial surgery. Patients were excluded if the tu-
mor is obviously extended laterally to the internal auditory
canal or inferiorly to the inferior clivus. In addition, patients
with a history of radiotherapy were excluded from our case.
Neurosurg Rev
Preparation
All of the TSs in our series were resected via a purely
trans-Meckel’s cave approach or via a purely trans-
Meckel’s cave approach combined with a transclival ap-
proach under electrophysiological monitoring (somatosen-
sory evoked potentials and CN electromyography). Two
surgeons (four hands) performed the surgery via a
binostril EEA. After anesthesia induction, the heads of
the patients were positioned supine and tilted 15° to the
right (Mayfield). Cotton patties with 1:100,000 epineph-
rine were applied to decongest the branches of the
sphenopalatine artery. A target lesion-side middle
turbinectomy was completed under direct visualization
with a 0° endoscope (Karl Storz). We prepared the con-
tralateral nasoseptal flap for skull base reconstruction at
the end of the surgical procedure. In general, the
nasoseptal flap was stored in the nasopharynx to provide
adequate working space. Autologous fat and the fascia
lata in the lateral thigh can also be prepared for recon-
struction. The dimensions of these multilayer closures
should depend on the anticipated defect to avoid postop-
erative cerebrospinal fluid (CSF) leakage.
Trans-Meckel’s cave approach
The early stage of the trans-Meckel’s cave approach in-
volves a transpterygoid approach, which should begin
with a sequential uncinectomy, ethmoidectomy, and
sphenoidectomy. A wide unilateral sphenoidotomy of the
target lesion side was possible if it could provide enough
access to the instruments and endoscope for tumor resec-
tion. After identification of the maxillary sinus ostium, we
performed wide maxillary antrostomy using backbiting
rongeurs and a diamond burr. At that time, the posterior
wall of the maxillary sinus and sphenopalatine artery were
visualized. The sphenopalatine artery, a terminal branch
of the maxillary artery, was transected after thorough co-
agulation to facilitate visualization.
To fully expose the pterygopalatine fossa (PPF), the
mucosa of the posterior maxillary sinus was exenterated,
and then the posterior wall of the maxillary sinus was
drilled with a diamond burr. The vidian nerve was identi-
fiable posterior to the contents of the PPF at the base of
the pterygoid plates, and it was used to localize the
lacerum segment of the internal carotid artery (ICA)
(Fig. 1a). The neuronavigation system and an intraopera-
tive Doppler probe were also used to accurately identify
the localization of the ICA. Once the course of the ICA
was exposed, the vidian nerve and the content of the
palatovaginal canal were coagulated and transected, and
then the content of the PPF was easily transposed laterally
and fixed on the medial wall of the orbit using fibrin glue.
Neurosurg Rev
Fig. 1 Patient 4. Intraoperative images with right-sided TS. a After open-
ing the pterygopalatine fossa (Pterygop. fossa), use the vidian nerve to
localize the lacerum segment of the internal carotid artery (ICA). b After
drilling off the ventral bone overlying Meckel’s cave, the dura mater
(DM) anterior to the tumor was exposed. The paraclival segment of the
ICA was located ventromedial to Meckel’s cave (dotted line). c Further
When exposure was completed, the foramen rotundum/
CN V2 was identified. The course of the CN V2 was used
as an anatomical landmark to expose the quadrangular
space, which was delimited inferiorly and medially by
the ICA, superiorly by the CN VI and laterally by the
CN V2.
Once the quadrangular space was exposed, the ventral
bone overlying Meckel’s cave was drilled off, and the
dura mater was incised (Fig. 1b, c). TSs usually have a
soft internal consistency, and intratumoral decompression
can be completed easily (Fig. 1d, e). When resecting the
superior margin of CN V2, attention should be paid to
protect the abductor nerve (CN VI). In addition, we need
to protect the superior cerebellar artery when resecting the
posterior fossa component through the enlarged porus
trigeminus. Whenever the tumor does not break through
the posterior wall of the cavernous sinus into the posterior
fossa (Fig. 2a, c) or extend along the porus trigeminus but
the posterior fossa component is small in size, we resect
the tumor via a purely trans-Meckel’s cave approach
(Fig. 3).
Transclival approach
When the tumor extends along the relatively enlarged
porus trigeminus to the posterior fossa with an extension
exposure of the tumor (Tu) in Meckel’s cave after incising the dura mater.
d Intratumoral decompression was performed in Meckel’s cave. e The
intact posterior wall of the cavernous sinus (PWCS) was viewed after the
TS was totally removed. f The fascia lata from the thigh and a nasoseptal
flap were used to reconstruct the skull base
into the prepontine cistern and even invades the contralat-
eral side (Fig. 2b, d), assisted transclival approaches are
performed (Fig. 4). A trans-Meckel’s cave can be used to
resect the middle fossa component as previously de-
scribed, and a relatively enlarged porus trigeminus can
be seen in the surgical field (Fig. 5a–c). The sellar floor
and the paraclival ICA were the superior and lateral lim-
itation of the bone resection. Generally, medial drilling
was limited by the middle line (basilar artery); inferior
drilling was limited by the junction of middle and lower
parts of the middle clivus (Fig. 5d). Because of the clear
boundaries between the TSs and surrounding structures
such as the pons, CN V and perforating vessels around
the brainstem, resection must involve gentle separation
along the tumor capsule. When resected the posterior fos-
sa component, CN VI and the basilar artery were usually
displaced below and contralateral to the tumor, respective-
ly (Fig. 5e–g). Attention should be paid to protect these
neurovascular structures.
Transclival approach is easy to cause bleeding in the basal
sinuses, but this kind of venous hemorrhage can usually be
stopped with gelatin sponge or fluid gelatin oppression.
Usually, lesions on the right side are easier than those on the
left since there was no need to cross the ICA to remove the
bone in the clivus. The paraclival ICA should be protected
when the lesions on the left side.
 Neurosurg Rev

Fig. 2 a, c Illustration
demonstrating that the tumor does
not break through the PWCS
(white line) into the posterior
fossa. b, d Illustration
demonstrating that the dumbbell-
shaped tumor with a “waist” sign
extends along the relatively
enlarged porus trigeminus (white
line) to the posterior fossa with a
large extension to the prepontine
cistern and even invades the
contralateral side (a, b:
transcranial view; c, d:
endoscopic view)

Fig. 3 Patient 4. A 40-year-old man presented with asymptomatic, but enhancing mass without a “waist” sign occupying both Meckel’s cave
with obvious brainstem compression. Preoperative sagittal (a), coronal and the posterior fossa. Postoperative MR images show GTR of the tumor
(b), and axial (c) T1-enhanced MR images show a nonhomogenously (d–f)
Neurosurg Rev
Fig. 4 Patient 3. A 41-year-old man presented with left-sided V3 pain,
headache, and CN IX palsy. Preoperative sagittal (a), coronal (in the
middle and posterior fossae; b and c, respectively) and axial (d) T1-
enhanced MR images demonstrate a well-marginated dumbbell-shaped
Reconstruction
When the tumor was completely resected, a multilayer recon-
struction technique was performed. First, autologous fat
Fig. 5 Patient 3. Intraoperative images with left-sided TS. a After
completion of the sphenoidotomy, an enlarged Meckel’s cave (MC),
clivus recess (CR), and bony prominence projecting from the ICA can
be seen under an endoscopic view. b The tumor was exposed after drilling
off the ventral bone overlying MC. The ICA (dotted line) was observed in
the field. c After resection of the tumor from the middle fossa, a relatively
enlarged porus trigeminus (dotted circle) was visible. d The tumor (Tu)
mass with a “waist” sign occupying the left cerebellopontine angle cistern
and Meckel’s cave. Postoperative MR images show GTR of the tumor (e–
h)
partially filled the tumor cavity. Second, we used the method
of inlay patch with the artificial dura that was fixed with fibrin
glue (Fig. 5h). Usually, a fascia lata is placed into the artificial
dura which is then covered with a nasoseptal flap (Fig. 1f). A
from the posterior fossa can be observed after drilling off the CR. e Blunt
dissection was carefully performed between the basilar artery (BA) and
the tumor. f Dissection strictly along the boundary between the tumor and
the brain stem. The abductor nerve (CN VI) was displaced under the
tumor. g The posterior component was completely excised. h
Reconstructing the dural defects with the artificial dura
 Neurosurg Rev

Foley catheter balloon was placed superficially over the
nasoseptal flaps to support the surgery field. Finally, the nasal
cavity was packed with iodoform gauze.
Postoperative management
The patient was extubated immediately after the procedure
and admitted to the intensive care unit for neurologic moni-
toring for 24 h. A soft diet was started 24 h after surgery. The
Foley balloon was removed from the nose 7 days after surgery.
The biggest concern with this approach is the CSF leak. To
avoid postoperative CSF leakage, lumbar drainage was rou-
tinely placed for all patients, and approximately 200 ml of
CSF was drained postoperatively each day for 1 week with
bed rest. Natural tears are prescribed in patients with dry eyes
to prevent corneal keratopathy. After discharge, patients usu-
ally undergo debridement of nasal crusting every 2 weeks for
a total of two times.
Results
Postoperative outcome
Six patients underwent endoscopic endonasal resection via
purely a trans-Meckel’s cave approach. Two patients
underwent endoscopic endonasal resection via a trans-
Meckel’s cave approach combined with a transclival ap-
proach. All patients achieved GTR via the EEA.
Preoperative symptoms included facial numbness (n = 5), fa-
cial pain (n = 3), headache (n = 3), mastication weakness (n =
2), dysphagia (n = 1), and diplopia (n = 1). No patient experi-
enced hearing loss, ataxia, or hydrocephalus. Two of these
five patients with facial numbness showed a partial improve-
ment, one patient experienced worsening, and two patients
remained unchanged at the last follow-up. One patient (patient
3) had extensive posterior fossa extension, and dysphagia
symptoms related to com pressive effects on the
glossopharyngeal nerve completely improved after surgery.
Headache symptoms (n = 3 patients) completely improved
postoperatively. In addition, one patient (patient 5) with pre-
operative CN VI palsy, presumably caused by compressive
effects on the cavernous sinus, improved after resection of
the tumor.

Our group included eight patients, including 5 males and 3 Complications

females, with an average age of 45.3 years. One patient had
previously undergone a transcranial approach with subtotal
resection in our institution, and the other patients were prima-
ry. No patient had a history of SRS. The average follow-up
time was 13.8 months (range 3–24 months). No surgical-
related hemorrhage or mortality was noted. Table 1 summa-
rizes the demographics, tumor size/location, preoperative
symptoms, postoperative outcomes, complications, and
follow-up times.
Two patients (patients 2 and 3) experienced dry eye symp-
toms, but there was no corneal keratopathy, which may have
been caused by transection of the vidian nerve. One patient
(patient 3) developed postoperative CN VI palsy partially re-
solved 2 months after surgery. Two patients (patients 4 and 8)
were without a CN deficit preoperatively. Patient 8 was diag-
nosed with TS after brain trauma. After the trauma, he expe-
rienced intermittent headaches. We were unable to determine

Table 1 Overview of outcomes in eight patients with TSs occupying both the middle and posterior fossae

Patient Age/ Tumor size (cm)/ Preoperative symptoms Approach Postoperative outcome Complications Follow-up
sex location (months)

1 50/M 3.6 × 2.5 × 2.2/Mp V1–2 numbness and pain; TMCA Worsened Previous symptoms 16
mastication weakness aggravation
2 38/M 2.2 × 1.8 × 1.9/Mp V1–3 numbness; V3 pain TMCA Previous symptoms Mastication weakness 20
Improved (12M); dry eye
3 41/M 6.1 × 3.8 × 4.3/MP V3 pain; HA; CN IX palsy TMCA+ Improved CN VI palsy (2M); 12
TCA dry eye
4 40/M 5.0 × 3.3 × 2.8/MP None TMCA Worsened V1–2 numbness and; 24
CN VI palsy (6M)
5 41/F 4.0 × 2.1 × 1.9/Mp V1–3 numbness; HA; CN TMCA Improved CN VI palsy and HA; None 11
VI palsy unchanged V1–3 numbness
6 62/M 4.2 × 3.2 × 2.6/MP V1–3 numbness TMCA+ Unchanged None 13
TCA
7 41/F 3.1 × 1.8 × 2.9/Mp V1–3 numbness; HA; TMCA Improved None 12
mastication weakness
8 50/F 4.3 × 2.2 × 2.1/Mp HA TMCA Worsened V1–2 numbness (2M) 3

F, female; M, male; TMCA, trans-Meckel’ cave approach; TCA, transclival approach; HA, headache; CN, cranial nerve; M, months; MP, equally located
in the middle and posterior fossae; Mp, major component is the middle fossa with posterior fossa extension
Neurosurg Rev
whether the headache was caused by the tumor. Patient 4 was
asymptomatic, and we told him that radiotherapy and conser-
vative treatment are feasible with regular follow-up. However,
the patient refused it and requested surgical treatment. From
the preoperative MRI, the brainstem compression was obvi-
ous, so he was treated with endoscopic surgery. Fortunately,
although two patients experienced short-term complications,
they all resolved within 6 months. One patient (patient 2)
developed postoperative mastication weakness that began to
improve gradually after 12 months. No CSF leak was ob-
served in this series of patients with a multilayer reconstruc-
tion technique as previously described.
Illustrative cases
Patient 3
This 41-year-old man presented with left-sided V3 pain, head-
ache, and CN IX palsy. His preoperative T1-enhanced MR
images (Fig. 4 upper) demonstrate a well-marginated dumb-
bell-shaped mass with a “waist” sign occupying the left
cerebellopontine angle cistern and Meckel’s cave. He was
underwent endoscopic endonasal trans-Meckel’s cave and
transclival approaches; intraoperative images are shown in
Fig. 5 and Video 1. Postoperative imaging confirmed gross
total resection (Fig. 4 lower).
Discussion
There are many classification systems used to describe TSs
occupying both the middle and posterior fossae. According to
the Jefferson classification system, TSs are categorized into 3
types, and a tumor involving both the middle and posterior
fossae is classified as type C [5]. Yoshida and Kawase cate-
gorized TSs into six types depending on tumor location and
described them as type MP [23]. A more recent classification
according to location, shape, and extension further classified
type MP into 3 subgroups: type MP, which is equally located
in the middle and posterior fossae; type Mp, in which the
major component is the middle fossa with posterior fossa ex-
tension; and type mP, in which the major component is the
posterior fossa with middle fossa extension [6].
TSs can arise from a root to distal extracranial branches and
involve multiple cranial compartments [23]. The traditional
view is that type MP TSs have two compartments, an
interdural space in Meckel’s cave and a subdural space in
the posterior fossa, and are described as having a dumbbell
shape. It is true that some cases fit this radiographic appear-
ance. However, this type also includes cases such as the one
shown in Fig. 3, where there is no actual dumbbell shape.
Rather, it is a tumor extending from Meckel’s cave into the
posterior fossa without any constriction or “waist” caused by
the porus trigeminus. Early in their development, such tumors
may have a dumbbell shape but lose it as chronic compression
eliminates the point of constriction, which results in tumors
with expansive growth rather than tumors extending through
the porus trigeminus. Thus, we believe it may be possible to
avoid classifying all tumors as “dumbbell” tumors, because
this terminology causes confusion about what the surgical
method is actually aiming at. These tumors should be de-
scribed according to their type, and the dumbbell description
should be used only when they actually maintain a dumbbell
shape in a meaningful way. Concerning tumor growth charac-
teristics, type MP in the Yoshida and Kawase classification is
more suitable to describe TSs occupying both the middle and
posterior fossae, while dumbbell tumors are only one subtype.
The management of TSs includes microsurgical resection,
endoscopic resection, SRS, and observation with serial imag-
ing. SRS is suitable for small- to medium-sized TSs and post-
operative residuals or recurrences [10, 17]. Although Sun et al.
reported the results of SRS for 58 TS patients, the overall
tumor growth control rate was 93.1% [18]. Pan et al. described
outcomes for 56 TS patients, and the growth control rate in
this group was 93% [11]. When TSs have posterior extension,
the mass effect on the brain stem and neurologic symptoms
cannot be relieved within a short period. On the other hand, for
patients with a history of SRS, reoperation can be difficult,
and we usually do not select the EEA.
Because of the unique type of this tumor consisting of
Meckel’s cave and posterior fossa components, the paraclival
ICA is located ventromedial to Meckel’s cave and adjacent to
the CN in the cavernous sinus. All of these anatomical features
often bring a great challenge for surgical access. However,
various transcranial approaches have been described to re-
move this kind of tumor [1–4, 6, 9, 14, 20, 21, 23]. Goel
et al. advocated that two-stage surgeries (pterional and
retrosigmoid approaches), with low morbidity rates, are better
for patients [4]. Konovalov et al. described two-stage surger-
ies (retrosigmoid suboccipital approach and lateral extended
transsphenoidal endoscopic approach) to resect type MP TSs,
and the sequence of these approaches depended on whether
the patient had a mass effect on the brain stem and/or cerebel-
lum [9]. There are also some authors who perform single-
stage resection of type MP TSs. Al-Mefty et al. proposed a
zygomatic middle fossa approach that can resect TSs from the
cerebellopontine angle via an incision and coagulation of the
superior petrosal sinus, which is the roof of the porus
trigeminus [1]. Yoshida and Kawase described an anterior
transpetrosal approach for type MP TSs in a single stage
[23]. By drilling Kawase’s triangle, the cerebellopontine angle
area can be safely accessed. M. Samii et al. advocated the
classic or endoscope-assisted retrosigmoid intradural
suprameatal approach for type MP TSs [14].
Frontotemporal–orbitozygomatic and pterional craniotomies
have also been described to resect type MP TSs in a single

stage [2, 20]. There is no doubt that all of these transcranial
approaches provide sufficient exposure and operating space
for the treatment of type MP TSs. However, both need tem-
poral lobe or cerebellum retraction, which may lead to post-
operative injury of the vein of Labbé or brain contusion.
To date, with its good exposure and multiple working an-
gles, the EEA is commonly used for skull base surgery, espe-
cially for pituitary adenomas, craniopharyngiomas, and
tuberculum sellae meningiomas. It has great advantages in
the treatment of lesions in the midline and lateral to the skull
base area. The endoscopic endonasal transpterygoid approach
entering Meckel’s cave has been extensively reported in ca-
daveric studies and clinical applications [8, 19]. However, an
endoscopic transpterygoid approach to the posterior fossa
through an enlarged porus trigeminus or clivus recess has
not been reported. The region of the ventral surface of the
brain stem is still challenging for neurosurgeons. When a TS
does not have a “waist” sign or does have a “waist” sign but
only small-sized posterior fossa extension through the porus
trigeminus, it is suitable to select a purely trans-Meckel’s cave
approach. In contrast, once a TS has an obvious “waist” sign
and posterior fossa extension to the prepontine cistern, even to
the contralateral side and a displaced basilar artery, it is usually
difficult to resect the posterior component by a trans-Meckel’s
cave approach alone. To relieve the mass effect on the brain
stem and protect neighboring neurovascular structures, the
assisted transclival approach is then selected. In this study,
we found that a mass effect on the brain stem or headache
could be relieved after surgery in a short period of time.
Fig. 6 Patient 2. A 38-year-old
man presented with right-sided
V1–3 numbness and V3 pain. a A
preoperative axial T1-enhanced
MR image demonstrates a well-
marginated dumbbell-shaped
mass occupying the right
prepontine cistern and MC. b
Postoperative MR image shows
GTR of the tumor. c After tumor
resection, the trigeminal nerve
(CN V1–3) was visible and me-
dial to the tumor under the endo-
scope. d: From a deeper perspec-
tive, through MC to the posterior
fossa, the pons and superior cere-
bellar artery (SCA) can be ob-
served under the endoscope
Neurosurg Rev
Poor sphenoid pneumatization or deformed bony promi-
nence projecting from the anterior wall of cavernous sinus
may change the normal anatomical landmarks, making it dif-
ficult to determine the location of the ICA. To successfully
perform these approaches, attention should be paid to first
identify the vidian nerve to localize the paraclival ICA. To
avoid its injury, the neuronavigation system and intraoperative
Doppler probe can be used to accurately identify the course of
the ICA. The high-risk cases (with “waist” sign) should re-
move the bone covering the paraclival ICA. Once the ICA
injury during the tumor resection, we can do proximal control
at paraclival segment using temporary arterial occlusion clips,
and the distal clip placement can choose the region above the
bleeding point. At that time, the precise site of bleeding is
visible, and the method of direct suture repair, bipolar coagu-
lation, cottonoid packing, or muscle/fascia grafts should de-
pend on the size and nature of the ICA injury. Whether sub-
sequent endovascular treatment is required depends on post-
operative angiographic results. Generally, TSs are encapsulat-
ed and dissectible from neighboring neurovascular structures.
The separation must be strictly along the boundary to protect
important structures, especially for the preservation of the CN
V–VI and the paraclival ICA, which is usually shifted by the
tumor. Raze et al. reported that the CN V is displaced superi-
orly and laterally by an enlarged tumor [13]. However, based
on our observations, the trigeminal nerve is sometimes medial
to the tumor (Fig. 6). Therefore, the anatomical relationship
between the tumor and nerve remains debatable.
Neurosurg Rev
Compared with conventional cranial base surgical ap-
proaches, the EEA offers a close-up view and better illumina-
tion without brain retraction on either the temporal lobe or the
brainstem. The transclival approach provides a straightfor-
ward trajectory for the better ventral exposure of the midline
area. In addition, avoiding a skin incision can produce better
cosmetic results. The angled lens endoscope is used to help
“see around the corner” and inspect anatomical relationships.
Multiple surgical corridors, such as the trans-Meckel’s cave
approach and the assisted transclival approach, provide anoth-
er option for the total removal of type MP TSs. The main risk
is that the procedure is very close to the ICA. Another concern
is skull base reconstruction to prevent postoperative CSF leak-
age. Special attention should be paid to patients in whom
combined approaches are used because of the extensive dura
mater defect after surgery and the high probability of postop-
erative CSF leakage. Once it occurs, CSF leakage should be
repaired immediately. In our series, by performing reconstruc-
tion and localization techniques as previously described, no
patient experienced ICA injury or CSF leakage. In addition,
due to the small number of patients in this series, the rates of
GTR, complications and postoperative symptoms were diffi-
cult to directly compare with those from other skull base ap-
proaches. Whether the EEA has fewer complications and a
higher symptom remission rate than other skull base ap-
proaches still requires further follow-up assessment.
Conclusion
We described a new single-stage EEA that can provide ade-
quate exposure and improve the surgical outcomes for TSs
occupying both the middle and posterior fossae with minimal
invasion. In addition, this new surgical approach, unlike the
transsphenoidal approach, requires the surgeon to be familiar
with the anatomical structure of the lateral skull base under
endoscopy. Although this report describes only a preliminary
clinical application and the number of patients was small, we
can still conclude that this surgical approach has a unique
advantage for TS exposure and resection.
Acknowledgments We express our sincere appreciation to Miss Jing Liu
for the illustration.
Funding information This work was supported by the National Natural
Science Foundation of China (grant nos. 81560207 and 81460381), the
Ganpo555 Engineering Excellence of Jiangxi Science and Technology
Department (2013), and the Key Research and Invention Plan of Jiangxi
Science and Technology Department (20192BBG70026).
Compliance with ethical standards
Conflict of interest The authors declare that they have no conflicts of
interest.
Ethical approval This study was approved by the ethical review com-
mittee of The First Affiliated Hospital of Nanchang University.
Informed consent Informed consent was obtained from each patient
prior to the study.
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