Combined Transcavernous and Anterior Transpetrous Approach: Technical Aspects and Lessons Learned from 14 Cases with Emphasis on a “Tag Team” Approach and a Novel CSF Release Technique

Introduction: Pathologies involving the central skull base and upper posterior fossa are often multicompartmental and difficult to access without endangering important neurovascular structures. A combined transcavernous (described by Dolenc) and anterior transpetrous approach (described by Kawase) provides an excellent anterolateral visualization of this area, complimenting advantages of each of these classical approaches. In this article, the surgical technique and results of this approach in 14 patients is reported. We wish to highlight a two surgeon “tag team” technique and our novel technique for CSF release during extradural phase of surgery.

Methods: This series includes patients operated by three senior skullbase neurosurgeons (KKD, AKS, and AKJ) of our department. All the procedures were done by two surgeons as a single day, single-stage procedure, dividing the surgery into extra- and intradural parts. Data of last 1 year were analyzed focussing on the preoperative clinical, radiological, intraoperative surgical video and postoperative surgical outcomes. We devised and utilized a novel technique of CSF release from the chiasmatic cistern following the deroofing of optic canal during the extradural phase of surgery before proceeding further.

Results: Fourteen patients were operated by this approach over the last year. The mean age of patient was 41.6 years (M:F = 4:3). Different pathologies operated includes meningioma (6 cases = 42.8%), epidermoid (2 cases = 14.2%), trigeminal schwannoma (2 cases = 14.2%), brainstem exophytic pilocytic astrocytoma (2 cases = 14.2%), pituitary macroadenoma with cavernous sinus extension (one case = 7.14%) and clival chordoma (one case =7.14%). Mean size of tumor was 4.25 cm. Extent of resection was classified into gross total (8 cases = 57.14%), near total (5 cases = 35.71%) and subtotal (one case = 7.14%) based on intraoperative judgement. During postoperative period, 2 (14.2%) patients developed 3rd nerve paresis, 2 (14.2%) patients developed 7th nerve paresis, and one (7.14%) patient developed 5th nerve paresis. Two (14.2%) patients developed wound site leak for which one (7.14%) required theco peritoneal shunt. One (7.14%) patient developed post operative hydrocephalus requiring ventriculoperitoneal shunt. No patient developed venous complications or temporal lobe contusions.

Conclusion: The key to success of this procedure is having a relaxed brain during the tedious extradural phase and fresh hands for both the equally important segments of the surgery viz extra- and intradural phase. Our tag team approach, where one surgeon provides access and the other surgeon predominantly operates on the pathology optimizes patient outcomes. Also, the CSF drainage technique devised by the authors provides an excellent working space during the extradural phase of the surgery. It is important in avoiding intraoperative complications.

Publication History

Article published online:
07 February 2025