Endoscopic trans-sphenoidal surgery for petroclival and clival meningiomas

Petroclival meningiomas are challenging lesions to manage independently of the selected surgical approach and are unique tumors in the type of pathological displacement of the surrounding anatomy. They also represent one of the most controversial entities with regard to approach selection, especially when deciding between an open versus endonasal route. When choosing an approach to the intradural portion of the petroclival region, the location of critical neurovascular structures relative to the lesion must be anticipated, including the abducens and trigeminal nerves. The role of the expanded endoscopic endonasal approach (EEA) in the management of ventral posterior fossa meningiomas is still restricted due to limited surgical indications in selected cases. It is a safe alternative for the rare cases of meningiomas with most part of its dural base at the midline clival region, and it may be used as solely or combination of other approaches. Thus, appropriate case selection may optimize the advantages of the approach and reduce morbidity of this complex pathology. We discuss in this review article the main advantages and limitations of the EEA for clival and petroclival meningiomas.