Endoscopic Extended Transclival Approach for Lower Clival Meningioma

We present a case of lower clival meningioma treated with the endoscopic transnasal extended transclival approach.^1,2 A 52-year-old woman with a large clival meningioma had undergone transcondylar approach³ and posterolateral approach⁴ in the previous hospital and presented with mild swallowing difficulty and hypoglossal nerve palsy in the right side. The tumor compressed the medulla oblongata, involving the lower cranial nerves bilaterally and facial nerve on the right side. The patient underwent the endoscopic transnasal extended transclival approach (Video 1). The anterior aspect and the floor of the sphenoid sinus were drilled off, and the sella, bilateral carotid prominences, and clivus were revealed. The clival bone and jugular tubercles were then removed. The dura mater on the clivus was widely exposed and coagulated to manage the arterial blood supply for the tumor. The dura was incised in a rectangular shape, and the successful mass reduction was achieved except for the tumor components strongly adherent to the lower cranial nerves on the right side. For skull base reconstruction, fascia lata was placed in and on the dural defect with multilayer fashion and the pharyngeal flap was rectified. The balloon catheter was inserted and inflated to compress the fascia and pharyngeal flap, and lumber drainage with the pressure-control valve system was performed for 72 hours.⁵ After surgery, her symptoms gradually improved. The residual tumor was treated with Gamma Knife surgery. The tumor was successfully controlled for 3 years, and the patient didn't show any neurologic symptom at the last follow-up.