Original Article

The Minimally Invasive Posterolateral Transcavernous-Transtentorial Approach.

Technical Nuances, Proof of Feasibility, and Surgical Outcomes Throughout a Case
Series of Sphenopetroclival Meningiomas
Rafael Martı́nez-Pérez1,2, Asterios Tsimpas5, Francisco Marin-Contreras2, Rolando Maturana2,
Victor Hernandez-Alvarez4, Mohamed A. Labib6, Tomas Poblete2,9, Pablo Rubino7, Jorge Mura2,3,8

- OBJECTIVE: Sphenopetroclival (SPC) meningiomas are neuropathies, 15 (39%) improved, 20 (53%) remained stable,
considered among the most complex skull-base neoplasms and 3 (8%) worsened postoperatively. Four new CN deficits
to approach surgically. We aim to determine whether some were observed postoperatively in 3 patients (fourth CN, 2
SPC meningiomas can be safely and effectively treated patients; third CN, 1; fifth CN, 1).
using a modified minimally invasive pterional posterolat- - CONCLUSIONS: MIPLATTA is a useful and safe treatment
eral transcavernous-transtentorial approach (MIPLATTA).
alternative that allows resection of large SPC tumors with
- METHODS: Fourteen patients harboring SPC meningi- dominant invasion of cavernous sinus and middle fossa,
omas were surgically treated through a MIPLATTA. preserves hearing and facial motor function, and provides
MIPLATTA includes a minipterional craniotomy, anterior good chances of recovery of visual and oculomotor deficits.
extradural clinoidectomy, peeling of the temporal fossa,
decompression of cranial nerves (CNs) in the cavernous
sinus, and sectioning of the tentorium to reach the upper
part of the posterior fossa.
INTRODUCTION
- RESULTS: Gross total resection was achieved in 11 of 14
patients (78%), whereas near-total resection was accom-
plished in the other 3 patients (22%), each of whom under-
went a further complementary retrosigmoid approach for
gross total tumor resection. There were no deaths, and 13 of
R elatively little is known about the optimal surgical treat-
ment of tumors located in the sphenopetroclival (SPC)
region, with meningiomas being the most frequent
tumors in this location.1 SPC meningiomas are considered to be a
variant of petroclival meningiomas that secondarily extend into
14 patients were independent at 6 months follow-up the middle fossa, invading structures such as the cavernous
(modified Rankin Scale score £2). One patient had pontine sinus and the Meckel cave.2
infarction after the procedure and experienced moderate Before the 1980s, these tumors were considered to be inoper-
disability at follow-up (modified Rankin Scale score 3). All able. Development of new surgical techniques and skull-base
patients had some degree of CN impairment. Of 38 cranial approaches in the years to follow allowed treatment of those

Key words From the 1Department of Neurosurgery, Neuroscience Institute, Geisinger Health System and
- Cavernous Geisinger Commonwealth School of Medicine, Wilkes-Barre, Pennsylvania, USA;
2
- Meningioma Department of Cerebrovascular and Skull Base Pathologies, Instituto Nacional de
- Minipterional Neurocirugía Dr Asenjo, 3Department of Neurological Sciences, and 4Department of
- Pretemporal Neurological Surgery, Universidad de Chile, Santiago, Chile; 5Department of Neurosurgery,
- Simpson grade
Advocate Illinois Masonic Medical Center, Chicago, Illinois, USA; 6Department of
Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA; 7Department of
- Skull base
Neurosurgery, Hospital el Cruce, Buenos Aires, Argentina; 8Department of Neurosurgery,
- Skull base neoplasms
Clinica Las Condes, Santiago, Chile; and 9Department of Anatomy and Legal Medicine,
University of Chile School of Medicine, Santiago, Chile
Abbreviations and Acronyms
CN: Cranial nerve To whom correspondence should be addressed: Rafael Martínez-Pérez, MD, PhD.
CSF: Cerebrospinal fluid [E-mail: [email protected]]
ICA: Internal carotid artery Citation: World Neurosurg. (2021).
MIPLATTA: Minimally invasive posterolateral transcavernous-transtentorial https://doi.org/10.1016/j.wneu.2021.08.108
approach Journal homepage: www.journals.elsevier.com/world-neurosurgery
MPT: Minipterional
Available online: www.sciencedirect.com
mRS: modified Rankin Scale
SPC: Sphenopetroclival 1878-8750/$ - see front matter ª 2021 Elsevier Inc. All rights reserved.

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tumors with acceptable mortality.3-5 The choice of the optimal previously described elsewhere,11-13 so it is summarized here
approach depends largely on the tumor extension.6,7 For tumors (Figure 1). A pterion-centered craniotomy is performed, consid-
with significant growth into the temporal fossa, extended ering its superior limit to be located right beneath the superior
middle fossa approaches are often selected.8,9 Transpetrosal temporal line.14,15 The posterior limit of our craniotomy is marked
routes (e.g., anterior petrosectomy) have gained traction in the by the vertical line that crosses the tragus, so that enough
surgical community for the distinctive advantage of further exposure of the sylvian fissure is warranted.15 Thereafter, the
exposing the SPC region, compared with other skull-base ap- sphenoid ridge is drilled away until the superior orbital fissure
proaches. Nevertheless, our increasing experience dealing with is exposed. At this point, the periosteal dura forms a fold that
these lesions has led us to believe that several of these tumors can reaches the lateral edge of the superior orbital fissure, the
be safely treated without drilling the petrous bone.10 Avoidance of so-called meningo-orbital band. Interdural dissection, separating
large petrous bone resections may significantly reduce surgical the 2 dural layers at the level of the meningo-orbital band, is then
time and operative risks such as hearing loss, facial palsy, and performed.8 The temporal lobe is untethered from the lateral wall
cerebrospinal fluid (CSF) leak, as well as major complications, of the cavernous sinus and retracted posteriorly until the Meckel
such as injury of the internal carotid artery (ICA).1 cave and the tip of the anterior clinoid process are exposed.10,16
The technique described in this article combines anterior The extradural anterior clinoidectomy starts with the bony
extradural clinoidectomy and peeling (also known as interdural decompression of the optic canal. This maneuver permits 270

dissection) of the middle fossa performed throughout a mini- optic nerve decompression. Once the optic sheath is visualized
pterional (MPT) craniotomy. The minimally invasive posterolateral along the optic canal, the anterior clinoid process is detached
transcavernous-transtentorial approach (MIPLATTA) includes from the optic strut and the petroclinoid ligament entirely.17
microsurgical liberation (neurolysis) of the cranial nerves (CNs) The final step before tumor removal consists of dural opening
within the cavernous sinus and tentorium division to expose the along the lateral and superior wall of the cavernous sinus and the
upper part of the posterior fossa. To study the outcomes of pa- tentorium division. Dural incisions should maximize the intra-
tients treated with MIPLATTA for SPC tumors, we reviewed 14 dural extent of exposure. This move is composed of 1 curvilinear
cases of meningiomas that were resected using this approach at incision over the temporal dura and 4 consecutive longitudinal
our respective institutions over an 8-year period. linear incisions (Figure 2):

METHODS 1) Along the axis of the sylvian fissure, the incision is continued
anteriorly over the optic sheath and reaches the space between
Patient Cohort
the optic and ICA. The temporal leaflet of the dura is gently
After receiving institutional review board approval, we performed
pulled downward to facilitate the section of the distal dural ring
a retrospective chart review of the SPC meningiomas treated at our
over the ICA.
institutions between January 2010 and January 2018. In 14 patients
with SPC meningiomas, the standard MPT approach was extended 2) At the level of the petroclinoid ligament, following an anterior
to allow additional exposure of the posterior fossa through the trajectory, to open the oculomotor triangle and the roof of the
tentorium and surgical neurolysis of the CNs between the cavernous sinus, right above the third CN.
cavernous sinus and the tumor bed, which constituted MIPLATTA. 3) Between the fourth and fifth CN along the lateral wall of the
Only patients with an adequate radiologic study, including cavernous sinus; this incision is thereafter continued backward in
preoperative and postoperative imaging, were included in the the direction of the superior petrosal sinus to divide the tentorium.
analysis. Patients with a follow-up shorter than 6 months were
excluded. Patients’ demographic data, clinical presentation, 4) Over the Meckel cave, following the axis of the fifth CN.
radiologic characteristics based on the preoperative magnetic
resonance imaging, grade of resection, preoperative and post- Once the fourth CN is identified at the entrance of the cavernous
operative physical examination, functional status based on the sinus, the tentorial division is performed in a T-shaped fashion. The
modified Rankin Scale (mRS) score at 6 months follow-up, use of first incision is made along the axis of the temporal lobe, parallel
adjuvant therapies, surgical complications within the first 30 days, and continuing backward the incision described in 3). The second
and long-term complications were reviewed and analyzed. cut is perpendicular to the first in the direction of superior petrosal
sinus and represents the continuation of incision 4 above the
Technique Meckel cave (Figure 2).
Surgical key steps are highlighted in Video 1. The By opening the roof of the cavernous sinus and
patient is placed in a supine position. The head is sectioning the distal dural ring, the surgeon is able to
slightly hyperextended and attached to a Mayfield mobilize the ICA and find the oculomotor nerve
head holder. An arcuate scalp incision from the piercing the dura at the oculomotor triangle (also
midpupillary line to approximately 1 cm above the Video available at known as the middle or Hakuba triangle) (Figure 3).
zygoma and 1 cm behind the hairline is performed. www.sciencedirect.com Likewise, sectioning the petroclinoid ligament allows
The temporalis muscle is dissected in an interfascial liberation of the oculomotor nerve, so that it can be
fashion and retracted inferiorly, so that the pterion and the mobilized to allow tumor removal with a reduced risk of CN injury.
orbital rim are both exposed. The combination of MPT Middle meningeal arterial feeders are coagulated during the
craniotomy with extradural anterior clinoidectomy has been peeling of the middle fossa. The portion of the tumor that is

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Figure 1. Summary of surgical technique used for sphenopetroclival nerve fibers are dissected free (G and H). The third longitudinal incision is
meningioma resection throughout the minimally invasive posterolateral performed right beneath the fourth cranial nerve (yellow dashed lines) and is
transcavernous-transtentorial approach (MIPLATTA). After a minipterional continued posteriorly to divide the tentorium between the trochlear and the
craniotomy (A), the lateral sphenoid wing is drilled to decompress the lateral ophthalmic nerve (blue dashed lines) (I). The trochlear nerve is dissected
orbit and superior orbital fissure (B). An interdural dissection of the temporal carefully from the lateral wall of the cavernous sinus, allowing nerve
lobe exposes the Meckel cave and the lateral wall of the cavernous sinus mobilization and increase tumor piecemeal removal (J). The Meckel cave is
(C). A curvilinear C-shaped incision over the temporal dura is performed to incised in the direction of the trigeminal nerve (K). The component invading
expose the subdural face of the tumor (green dashed line) (D). A first the Meckel cave and posterior fossa is in addition removed using delicate
longitudinal incision following the axis of the sylvian fissure is continued dissection techniques (L and M). Final view of the subdural space (middle
anteriorly over the optic sheath to expose the optic nerve and the internal and posterior fossa) after the lateral decompression of the cavernous sinus
carotid artery (yellow dashed line) (E). The roof of the cavernous sinus is and the division of the tentorium (N and O). III, third cranial nerve; ACP,
then decompressed by opening the oculomotor triangle and incising the anterior clinoid process; IV, fourth cranial nerve; V, trigeminal nerve; V1,
petroclinoidal ligament (yellow dashed lines) (F). The previous incision is ophthalmic nerve; GG, gasserian ganglion; ICA, internal carotid artery; ON,
continued anteriorly and connected with incision previously performed over optic nerve; SCA, superior cerebellar artery; SOF, superior orbital fissure;
the optic sheath and the distal dural ring, and fibrous adhesions stretching V2, maxillary nerve; V3, mandibular nerve.

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Figure 2. Sketch diagrams (A, B) and cadaveric anteriorly to open the oculomotor triangle over the
dissections (C, D) showing key incisions over the oculomotor nerve; third incision, from anterior to
cavernous sinus and the tentorium in the minimally posterior between the trochlear nerve and the
invasive posterolateral transcavernous-transtentorial ophthalmic branch of the trigeminal nerve; fourth
approach. Four longitudinal incisions are placed over incision is placed over the Meckel cave in the direction
the roof and lateral wall of the cavernous sinus to of the trigeminal nerve. The tentorium is incised
decompress cranial nerves (CNs) in the middle fossa following posteriorly the third cut between the
and cavernous sinus (red arrows, A and C): first trochlear and ophthalmic nerve (blue arrow, B and D).
incision, extending from normal dura in the convexity Once the fourth cranial nerve is identified at the
following the axis of the sylvian fissure is directed tentorial margin, a second cut, tangential to the
anteriorly over the optic sheath; second incision is previous one is performed to increase the surgical
started posteriorly at the normal dura and followed exposure of the posterior fossa.

lateral to the cavernous ICA is removed using a piecemeal tech- clinical symptom at presentation (8 of 14 patients), followed by
nique among the third and fourth CNs and the distal branches of headache and trigeminal neuropathy.
the trigeminal nerve. At the same time, neurolysis of CNs is Intraoperative findings and grade of resection are summarized in
performed, as clinically indicated. Table 2. Figure 4 shows intraoperative findings throughout a
Opening of the Meckel cave allows mobilization of the tri- stepwise MIPLATTA and Figure 5 shows preoperative and
geminal nerve, which allows a view into the posterior fossa, after postoperative magnetic resonance imaging for the same patient. In
the tentorial leaflets are divided. Microsurgical techniques are 11 of 14 patients (78%), a complete resection was achieved,
used to remove the posterior fossa component of the tumor. A whereas subtotal resection was accomplished in the other 3
combination of sharp and blunt dissection is required to decom- patients. Pathologic results, surgical outcomes, and supplementary
press the brainstem and liberate the adherences between the treatments are summarized in Table 3. Ten patients were classified
tumor and neurovascular structures in the posterior fossa, avoid- as a grade I, according to the World Health Organization
ing disruption of perforating branches. classification for intracranial tumors. The other 4 patients were
If needed, the procedure can be combined with an anterior classified as grade II.
petrosectomy. This maneuver might add a wider angle of exposure Patients were followed up for a median of 11 months (range, 6e38
to the upper clivus and the lateral pontine region in select cases. months). There were no tumor recurrences during the follow-up
Similarly, for lesions extending toward the contralateral side and period. Three patients in our series received radiosurgery. Two of
into the interpeduncular fossa, a posterior clinoidectomy can be them received radiosurgery after incomplete grade II tumor resec-
added. tion. Another patient with a grade I meningioma was further treated
with radiosurgery, because of tumor recurrence (he was operated on
for the first time at another institution) and a high Ki-67 level in the
RESULTS inmunohistochemical analysis. None of the tumors included in this
Patients’ demographics, clinical, and radiologic data are summa- series received preoperative endovascular embolization.
rized in Table 1. There were 5 men and 9 women, with a mean age Mortality was 0% in this series. A patient experienced a pontine
of 56 years (range, 41e69 years). Diplopia was the most common infarct and moderate disability at last follow-up (mRS score 3),

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A B

Figure 3. Key neurovascular landmarks and anatomic nerve and the trochlear nerve. The posterior bend on
relationships in the cavernous sinus. (A) Lateral view of the intracavernous internal carotid artery can be found
the cavernous sinus and middle cranial fossa. Middle in this triangle. The anteromedial triangle is located
fossa triangles are delimited by the confluence and between the first and second branches of the
divergence of the cranial nerves and ligaments trigeminal nerve. The anterior limit of this triangle is
embedded within the cavernous sinus. (B) The lateral constituted by the line that extends between foramen
wall of the cavernous sinus, the tentorium, Meckel rotundum and the superior orbital fissure. Opening the
cave, and lateral wall of the sphenoid sinus have been anteromedial triangle provides access to the cavernous
removed to show the deep relationship between these sinus. From superior to inferior, the third cranial
structures and middle fossa triangles. Anterolateral (oculomotor) nerve, trochlear, and first branch of the
aspect of the pons and midbrain forms the posterior trigeminal nerve (ophthalmic nerve) run in the lateral
wall of this region and faces the posterior wall of the wall of the cavernous sinus, and the abducens nerve
cavernous sinus. The clinoidal triangle is exposed after (sixth cranial nerve) enters the cavernous sinus at its
removal of the anterior clinoid process. The oculomotor posterior margin through the Dorello canal and runs in
triangle is located behind the clinoidal triangle and the lateral compartment of the cavernous sinus
forms the posterior half of the superior roof of the between the internal carotid artery and the lateral wall
cavernous sinus. The oculomotor triangle is delimited of the cavernous sinus at the level of the ophthalmic
by the interclinoidal ligament and the anterior and nerve. III, third cranial nerve; IV, fourth cranial nerve; V,
posterior folds of the petroclinoidal ligament. The third trigeminal nerve; V1, ophthalmic nerve; Bas, basilar
cranial nerve pierces the dura at this level to enter the artery; GG, gasserian ganglion; ICA, internal carotid
cavernous sinus. The supratrochlear triangle is located artery; ON, optic nerve; PCA, posterior cerebral artery;
between the trochlear and the inferior surface of the SCA, superior cerebellar artery; V2, maxillary nerve; V3,
third cranial nerve. The infratrochlear triangle is mandibular nerve.
delimited between the first branch of the trigeminal

after treatment of an invasive SPC meningioma without a good with cranial neuropathies (39%) improved, 20 (53%) remained
dissection plane with the pons. One patient developed temporal stable, and 3 (8%) worsened after surgery. Similarly, 4 new CN
lobe infarction after surgery, yet he did not require any further deficits were observed postoperatively in 3 patients (o1ne patient
intervention and was discharged in good functional condition had a complete and 2 an incomplete fourth CN palsy, and 1 patient
without additional neurologic deficits. One patient with preexist- had a mild third and fourth CN palsy). Up to 50% of the patients
ing facial numbness developed a complex trigeminal pain syn- experienced mild hypoesthesia right after the procedure, but
drome after the procedure, despite achieving complete tumor improved fully at follow-up. Optic neuropathy and deficits of the
resection. No CSF leak or infectious complications were encoun- seventh and eight CN complex were those that improved more
tered. No ICA injuries or occlusion were noted in any patient frequently (66% and 60%, respectively).
included in this series. All but the 1 patient mentioned earlier were
independent at last follow-up (mRS score 0, 1 patient; mRS score
1, 10 patients; mRS score 2, 2 patients). DISCUSSION
All patients had CN deficits preoperatively. Among the 14 pa- Given the associated morbidity related to treatment and the slow-
tients included, 38 CN deficits were observed preoperatively. The growing pattern of these tumors, decision making in the
third CN was the most commonly affected nerve (10 patients, management of SPC meningiomas remains difficult and contro-
71%), followed by the fifth CN (9 patients, 64%). Fifteen patients versial.9,18 Results of the present work suggest that the

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Table 1. Patients’ Demographics, Clinical, and Radiologic Data

Case Patient Age Size Meckel Cavernous Petrous Upper Lower Cerebellopontine Perifocal
Number (Years)/Sex Preoperative Symptoms (mm) Cave* Sinus* Apex* Extracranial* Clivus* Clivus* Tentorium* Angle* Edema*

1 45/F Diplopia and facial palsy 34 þ þ þ -e e e þ þ e

2 62/F Visual impairment and facial 41 þ þ þ e þ e þ þ e
hypoesthesia
3 69/F Trigeminal neuralgia and 30 e þ þ e þ e þ þ þ
headache
4 59/M Diplopia 60 e þ þ þ e e þ e þ
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5 59/F Headache 44 e þ þ þ þ þ þ þ e
6 56/M Facial palsy 38 þ þ e e þ þ þ þ e
7 48/F Diplopia and headache 27 þ e þ e e e þ þ e
8 53/F Headache 45 þ þ þ þ þ þ þ þ e
9 59/M Diplopia and facial palsy 44 þ þ þ þ þ þ þ þ e
10 41/F Hemiparesis and diplopia 47 þ þ þ þ þ e þ þ þ
11 57/F Diplopia and headache 53 e þ þ e þ þ þ þ e
12 64/F Trigeminal neuralgia and 37 þ þ e e þ e þ þ e
hemiparesis
13 42/M Hemiparesis, facial palsy, and 65 þ þ þ e þ þ þ þ e
diplopia
14 50/M Diplopia and headache 72 þ þ þ e þ þ þ e e

F, female; M, male.
*Radiologic features or other structures invasion.

MIPLATTA TECHNIQUE

ORIGINAL ARTICLE
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approach was considered as an initial treatment.21 A multistage

Table 2. Intraoperative Findings and Grade of Excision approach was considered for large tumors that invaded >1
Intraoperative Findings compartment.
The initial signs and symptoms are another factor that is taken
into consideration before approach selection. Patients with normal
Case Brainstem Brainstem Pial Surgical
Number Contact Destruction Consistency Excision hearing were not treated through a presigmoid approach. Simi-
larly, MIPLATTA was prioritized in patients presenting with
1 þ e Mixed Total diplopia or a frozen eye and cavernous sinus invasion, so the third
2 þ þ Hard Total
CN could be decompressed quickly.
Access to the SPC region through a middle fossa approach is not a
3 þ e Mixed Total new concept. Kawase anterior petrosectomy was initially described
4 e e Hard Total to provide a wider access to lower basilar tip aneurysms.22 Later, the
5 þ þ Soft Subtotal same investigator presented his surgical outcomes after treating
several cases of SPC meningiomas with this approach.9 In their
6 þ þ Hard Total surgical series, Kawase et al.9 achieved gross total resection in
7 þ þ Soft Total 70% of cases in a series of SPC meningiomas with a median
8 þ e Hard Subtotal diameter of 3 cm. In another series, which included 51 patients
with petroclival meningiomas, gross total resection (Simpson
9 þ þ Soft Total
1 or 2) was achieved in 63% of cases, although neither the
10 þ þ Hard Total number of real SPC meningiomas nor the tumor diameter are
11 þ þ Mixed Total clearly specified.2 Our MIPLATTA successfully achieved complete
tumor resection in 79% of the cases in a series of SPC
12 e þ Hard Subtotal
meningiomas with a median diameter of 4.5 cm.
13 þ þ Hard Total MIPLATTA is a versatile approach. We were able to combine
14 þ e Mixed Total MIPLATTA with an anterior petrosectomy, when there was
significant tumor extension in the posterior fossa, lateral to the
trigeminal nerve. Similarly, an anterior petrosectomy was per-
microsurgical resection of SPC meningiomas via MIPLATTA is formed when tumors extensively invaded the Meckel cave,10 in 3 of
safe and effective, by maximizing tumor resection and retaining 14 patients in our series. The inferior petrosal sinus is the lowest
or improving neurologic function. anatomic structure in the posterior fossa that may be reached
We propose a modified middle fossa approach consisting of an using Kawase anterior petrosectomy.23,24 Because MIPLATTA
MPT craniotomy, followed by an interdural dissection, mobiliza- can be combined with an anterior petrosectomy in select cases,
tion of the temporal lobe, opening of the lateral wall of the the area of additional inferior exposure should be considered, at
cavernous sinus, and division of the tentorium. The MIPLATTA least, equivalent to the Kawase approach. Notwithstanding, we
technique is based on cardinal principles of skull-base tumor observed that an anterior petrosectomy was not needed for most
resection,19 including interruption of the major blood supply as an cases in the current series.
initial step, minimization of brain retraction, and isolation of the Although anterior petrosectomy is not a particularly risky
neurovascular structures attached to the tumor, to better dissect approach in experienced hands, and we did not experience any
and protect them. complications related to it in our series, injury of the vein of Labbé
and venous infarction is a common complication of this tech-
Indications for MIPLATTA Technique nique.25,26 CSF leak and ICA injuries are also reported
Determining the most appropriate approach to SPC lesions rep- complications, after an anterior petrosal approach. Likewise,
resents another source of controversy. In their surgical series of 97 similar to any other transpetrosal approach, meticulous drilling of
patients with petroclival meningiomas, Erkmen et al.20 proposed the temporal bone results in significantly longer operative times,
selection criteria of the most suitable operative technique, based with all the associated risks. Sectioning of the anterior tentorial
on the location of the tumor along the clivus and its relation to incisura, in the area between the ophthalmic and trochlear nerves,
the internal auditory meatus. These investigators used the is usually enough to expose the upper clivus. Moreover, the
middle fossa approach to treat tumors medial to the internal peeling of the middle fossa and the opening of the Meckel cave
auditory meatus and without extensive invasion of the posterior release the trigeminal nerve and allows its lateral mobilization,
fossa. Posterior fossa approaches were selected to reach those which improves the working view further. Compared with the
tumors that extended laterally to the internal acoustic meatus. Kawase approach, MIPLATTA offers a more anterior view of the
We developed, therefore, a similar protocol. Lesions with a interpeduncular fossa and exposure of the contralateral side,
major component located underneath the petrous ridge were whereas anterior petrosectomy seems to be superior in terms of
tackled through a posterior fossa approach (e.g., retrosigmoid exposing the lateral pons behind the trigeminal nerve.
and presigmoid), whereas masses with a predominant Early control of the blood supply and partial debulking of the
component invading the middle fossa were treated using tumor from its anterolateral margin allow, in most cases, adequate
MIPLATTA. For those lesions crossing the midline or causing decompression of the brainstem and tumor devascularization. An
lateral displacement of the sixth CN, the endoscopic endonasal additional posterior fossa approach (presigmoid, retrosigmoid, or

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Figure 4. Contrast-enhanced T1-weighted magnetic resonance images clivus and with invasion of the cavernous sinus (Hirsch 3). The tumor
obtained in a patient harboring a sphenopetroclival meningioma that was enhanced homogeneously and compressed the brainstem. Postoperative
treated via a minimally invasive posterolateral transcavernous-transtentorial axial (E and F) and coronal (G and H) magnetic resonance images showing
approach. Preoperative axial (A and B) and coronal (C and D) images gross total tumor resection of the extracavernous component without brain
showing the sphenopetroclival meningioma originating from the upper injury.

extended far lateral) is a safer procedure, because neurovascular with acceptable levels of morbidity for meningiomas in the
structures might be better mobilized and brainstem retraction is cavernous sinus. Abdel-Aziz et al.16 advocate the limited
reduced. resection of only the lateral portion of the intracavernous tumor,
Early identification of the third and fourth CN in the cisternal leaving treatment of the residual lesion to radiosurgery. The
segment, before their entrance at the cavernous sinus, eases safe percentage of patients with ocular dysfunction during the late
division of the tentorium and neural decompression. Moreover, postoperative period decreased from 55% to 15%. Because most
the incision over the tentorium is placed anteriorly to the SPC meningiomas are compressive rather than invasive,29 the
trigeminal nerve and lateral to the fourth CN. Thus, there is a goal of our strategy is to decompress and release the cavernous
decreased risk of inadvertent injury to the bridging veins of the sinus and preserve the blood supply to all CNs, thereby allowing
middle fossa or to the tentorial sinus.26 better functional recovery. Identifying the third CN entering the
oculomotor triangle facilitates its dissection from the tumor
CN Impairment anteriorly. The fourth and the branches of the trigeminal nerve
CN III, IV, and VI. The reported incidence of morbidity, especially are found in the lateral wall of the cavernous sinus. Sectioning
cranial neuropathies, associated with the aggressive resection of the stretching fibers of the tumor from these CNs (neurolysis)
the cavernous tumor component remains high.27,28 Up to 70% of allows manipulation of the intracavernous mass without further
patients with normal preoperative oculomotor function damage. Some improvement after surgery was experienced by
experienced a significant permanent ocular deficit 33% of patients presenting with oculomotor dysfunction and by
postoperatively in an older series.28 DeMonte et al.29 reported 40% of those with preoperative fourth CN palsy, but
the occurrence of new cranial neuropathies in 18% of patients improvement was not so common when the sixth CN was
postoperatively. Gross total resection cannot always be achieved affected (20%). On the other hand, worsening or new-onset CN

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Figure 5. Contrast-enhanced T1-weighted magnetic (D, E, and F) after minimally invasive posterolateral
resonance images showing preoperative tumor burden transcavernous-transtentorial approach.
(A, B, and C) and postoperative gross total resection

palsies were not a rare finding (4 of 14 patients, 28%). Our results stage of the disease.2 The optic nerve, oculomotor nerve, and the
were similar to those of Gozal et al.,18 who observed that the ICA are involved at a later stage and, hence, the dissection plane is
oculomotor nerve was the most likely to improve, as opposed to usually preserved around these structures. This tumor behavior
the trochlear nerve, which did not improve in any patient in that may explain the large volume that may be achieved before
series. Overall, we believe that cavernous sinus decompression becoming symptomatic and why the optic nerve is affected less
may be beneficial when there is some degree of oculomotor commonly than nerves within the cavernous sinus. For instance,
impairment, but it should be discouraged in patients without although visual disturbances were present in 84% of cases of
impairment of extraocular muscles. clinoidal meningiomas reported by Al-Mefty,30 only 10% in the
series of SPC meningiomas reported by Kawase et al.9 caused
CN V. Following the goal of the neural decompression, we visual impairment. Accordingly, only 3 patients in our series had
experienced satisfactory results by opening the Meckel cave. Along initial visual impairment. Two experienced full recovery of their
with the functional improvement, this technique enables the vision. High rates of visual improvements have been also seen
mobilization of the trigeminal nerve and increases the operative in other series with cavernous sinus meningiomas.16,29 As in
corridor, as described earlier. One patient developed trigeminal decompression of the cavernous sinus for the oculomotor nerve,
neuropathy, despite complete tumor resection. This complication early decompression of the optic nerve at the time of anterior
is likely caused by excessive manipulation of an already impaired clinoidectomy is key for achieving visual improvement.
trigeminal nerve, because the patient already had facial hypo-
esthesia in the same distribution before surgical intervention. CN VII and VIII. Probably one of the most notable advantages of
Trigeminal neuropathy secondary to tumor compression is highly MIPLATTA, as opposed to posterior transpetrosal approaches, is
likely to improve, but still, some patients might experience tran- the reduced rate of facial and hearing impairment. With
sient or definitive numbness after the procedure, and, therefore, MIPLATTA, tumors are encountered anteriorly, and the facial-
the patients’ expectations should be discussed preoperatively. acoustic complex does not need to be manipulated for the
resection. Although 12 of 14 patients in our series showed radio-
CN II. SPC meningiomas are believed to arise from petro-occipital logic invasion of the cerebellopontine angle, we did not experi-
synchondrosis and often invade the cavernous sinus at an early ence postoperative facial or hearing impairment in any of the

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RAFAEL MARTÍNEZ-PÉREZ ET AL. MIPLATTA TECHNIQUE

Table 3. Pathologic Results, Surgical Outcomes, and Coadjuvant Therapies

Cranial Nerve
Pathologic Type Modified Rankin
Case (World Health Scale Score at 6
Number Organization Grade) II III IV V VI VII-VIII Long Tract Signs Months Complications Follow-Up Radiosurgery

1 I e U I U U U None 1 None 26 No
2 I I e e I e e None 1 None 13 No
3 I e e e U I I None 1 None 26 Yes
4 II U I U e U e None 2 None 38 No
5 I e U M e e e None 1 None 21 No
6 I e e e e e I None 1 None 13 No
7 II e I e e e U Temporary 1 Venous Infarction 11 No
hemiparesis
8 II e M S W e e None 1 Trigeminal neuralgia 10 Yes
9 I e e e U U I None 1 None 8 No
10 I e U U U U e Hemiparesis 3 Brainstem infarction 7 No
11 I e U e e W e None 1 None 7 No
12 II e U W I e e Temporary 2 Temporary 6 Yes
hemiparesis hemiparesis
13 I I U S I e U Left hemiparesis 1 None 6 No
without improvement
after surgery
14 I e I I I e e None 0 None 6 No

U, preoperative deficit, unchanged; I, preoperative deficit, improved; M, postoperative deficit, mild; S, postoperative deficit, severe; W, preoperative deficit, worsened.

patients included in our series, and 50% of the patients’ preop- investigators have shown that surgical decompression is more
erative deficits improved after tumor resection (hearing loss in 5 effective in improving visual impairment.16,18,39
patients and facial palsy in 4). We strongly recommend this We recommend observation of asymptomatic patients with SPC
middle fossa approach, in which hearing and facial function are meningiomas and surgical treatment for those who are symptom-
preserved. atic, have no significant comorbidities, and are younger than 70
years, especially in tumors with a diameter >3 cm or a minimum
Management of SPC Meningiomas volume of 10 mL. The goal of microsurgical resection is complete
Radiosurgery, conventional radiation, and watchful waiting have resection of the extracavernous tumor component. Likewise,
been advocated as treatment options, especially in the elderly and regarding the component of the tumor extending into the
asymptomatic patients, to overcome the limitations of surgical cavernous sinus, the goal of surgery is, as suggested by Abdel-Aziz
resection.31 Neither the microsurgical nor the radiosurgical et al.,16 to remove just the extension that is lateral to the cavernous
alternatives are considered to be zero-risk procedures for slow- ICA (Hirsch grade 0 and 1). Radiosurgery is usually indicated for
progressing tumors. Radiosurgery is considered to be a safe alter- tumor recurrence/incomplete resection or as an adjuvant therapy
native to surgery for skull-base tumors with a diameter <3 cm.32,33 in World Health Organization grade II and III meningiomas. We
Similarly, radiosurgery has been successfully used as an adjuvant also considered this therapeutic option in tumors with an
therapy after surgical resection.34 It has particularly shown its increased mitotic index. The tumor control in this series was
efficacy and safety in the treatment of localized cavernous sinus 100%. However, we acknowledge that the follow-up is too short
meningiomas.33,35 Nevertheless, this technique has its own to estimate long-term tumor control, and larger series with a longer
pitfalls. Radiosurgery is less effective when the volume of follow-up would be needed to answer this question.
irradiated tumor is increased.36 Similarly, the risk of damaging
nearby structures and causing radiation-induced necrosis is also Complications and Limitations of MIPLATTA
increased.34 Median tumor diameter in our series was 44 mm, and MIPLATTA does have limitations. Similar to any new procedure,
none of the tumors included had a diameter <3 cm. Similarly, there is a learning curve. Challenges associated with this approach
radiosurgery has been shown to provide similar or better results include control of bleeding from the roof of the cavernous sinus
as far as the function of oculomotor nerves in cavernous sinus after anterior clinoidectomy, tearing of the dura while peeling the
meningiomas is concerned.37-39 On the contrary, other temporal fossa or excessive retraction of the temporal lobe.

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As in the case of the patient who experienced a pontine infarction craniotomy for treating deep-seated lesions.43 However, the MPT
(case 10), MIPLATTA alone might be insufficient to safely remove has been shown to provide similar surgical exposure to that
large tumors extending laterally toward the petrous apex and cer- provided by standard pterional craniotomy and to be superior to
ebellopontine angle. In these cases, the tumor bulk obscures the other minimally invasive craniotomies.14,44 We regularly use a
visualization of deep perforators through an anterior view. This minor modification of the original description of the MPT
situation is particularly paramount in firm tumors that cannot be craniotomy, as described by Figueiredo et al.,14 consisting of a
rolled over from the lateral aspect of the pons. In such cases, adding 25.4-mm (1 inch) enlargement of its posterior border. This mini-
a lateral view through a subtemporal approach and anterior petro- mal enlargement has been shown to improve the surgical exposure
sectomy grants the visualization of the posterior aspect of the tumor, and maneuverability along the sylvian fissure and to keep the
and it also increases the working angle. One patient in our series aesthetic benefits of the MPT approach.15 Moreover, the extradural
experienced temporal lobe infarction (case 7). This patient was pretemporal space provided by interdural dissection and
discharged home without further major complications and had a mobilization of the temporal lobe shows a broad corridor to safely
good functional outcome. Venous drainage problems related to expose the SPC region and treat lesions located in this area.17
extradural temporal lobe manipulation have been identified as a Further anatomic and volumetric studies would add some more
potential cause of significant brain edema, mass effect and infarc- information regarding the angle of attack and operative window,
tion and intracerebral hemorrhage.25 We strongly believe that the when using this approach.
risk of temporal lobe infarction might be preoperatively addressed
with a cerebral angiogram. In patients in whom there is a CONCLUSIONS
predominantly anterior flow from the sylvian veins to the
MIPLATTA is a useful and safe extension of the MPT approach,
sphenoparietal sinus, this approach should be discouraged.
which allows resection of large SPC tumors and maintains the
CSF leakage is the most common complication in tumors
benefits of a minimally invasive approach. Although the long-term
located around this region. It may lead to more serious compli-
durability of this technique is unknown, it has potential advan-
cations, such as sepsis and death. This is particularly a major
tages over posterior fossa approaches, such as preservation of
concern when the tumors are approached through a posterior
hearing and facial mobility.
fossa approach or the paranasal sinus is violated.40 None of our
patients experienced this complication. The upper limit of the
MPT craniotomy is always located beneath the superior temporal CRediT AUTHORSHIP CONTRIBUTION STATEMENT
line, which by default avoids the violation of the frontal sinus in Rafael Martínez-Pérez: Conceptualization, Methodology, Funding
all cases. A potential way of CSF leak is through the sphenoid acquisition, Formal analysis, Data curation, Writing e original
sinus, which might be entered during drilling of the optic strut. draft, Approval of the version of the manuscript to be published.
For this reason, we recommend the use of fat or temporalis Asterios Tsimpas: Conceptualization, Methodology, Formal anal-
fascia and fibrin glue to seal any possible defect at this level. ysis, Data curation, Writing e review & editing, Approval of the
The craniotomy size is also of critical importance, not only version of the manuscript to be published. Francisco Marin-
because of the better cosmetic results but also in terms of reducing Contreras: Funding acquisition, Approval of the version of the
postoperative pain and discomfort.41 The fronto-orbitozygomatic manuscript to be published. Rolando Maturana: Funding acqui-
approach have been used by others to access lesions located at sition. Victor Hernandez-Alvarez: Funding acquisition, Approval
the prepontine or interpeduncular fossa. Its wide exposure and a of the version of the manuscript to be published. Mohamed A.
more anterior trajectory provide an excellent angle of attack and Labib: Formal analysis, Data curtion, Approval of the version of
reduce brain retraction.42 Extraocular movement impairment, the manuscript to be published. Tomas Poblete: Funding acqui-
postoperative jaw pain, and exhausting operative times are some sition, Approval of the version of the manuscript to be published.
drawbacks of using a fronto-orbitozygomatic approach. The inva- Pablo Rubino: Writing e review & editing. Jorge Mura: Funding
siveness is reduced by using the MPT approach.14,41 Some acquisition, Writing e review & editing, Approval of the version of
investigators have expressed their concerns in using MPT the manuscript to be published.

4. Hakuba A, Nishimura S, Jang BJ. A combined ret- 7. Cho CW, Al-Mefty O. Combined petrosal
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