Abstract
Trigeminal schwannomas are rare benign tumors, it is second most common intracranial
schwannomas after vestibular schwannomas. The management includes not limited to observation,
stereotactic radiosurgery/radiotherapy, and/or surgical resection. Tumor size and
patient clinical status are the most important factors in management.
In this video, we describe the technical nuances of an extended middle fossa approach
for large trigeminal schwannoma with cavernous sinus extension resection. A 44-year-old
right-handed female with several months' history of progressive right facial paresthesia
and pain in the distribution of V3 mainly. On physical examination, she had decreased
sensation to light touch over the right V1 to V3 distribution with loss of cornel
reflex. The brain MRI showed 3.5 cm bilobed mass extends from the pontine root entry
zone to the cavernous sinus. Craniotomy was performed and followed by middle fossa
dural peeling, peeling of temporal lobe dura away from the wall of the cavernous sinus,
extradurally anterior clinoidectomy, drilling of the petrous apex, coagulation of
superior petrosal sinus followed incision of the tentorium up to the tentorial notch
with preservation the fourth cranial nerve, and tumor dissected away from V1 and then
gradually removed from the superior wall of the cavernous sinus.
The technique presented here allows for complete tumor resection, safe navigation
through the relative cavernous sinus compartments, and minimizes the possibility of
inadvertent injury to the cranial nerves.
The postoperative course was uneventful except for right eye incomplete ptosis from
the swelling. Her facial pain subsided after the surgery without any extra ocular
movement impairment.
The link to the video can be found at: https://youtu.be/zxi2XK2R9QU.
Keywords
trigeminal schwannoma - cavernous sinus - extended middle fossa approach - peeling
of middle cranial fossa - anterior petrosectomy
