2026 Poster Presentations
P113: THREE DIMENSIONAL ROTATIONAL ANGIOGRAPHY IN OPTIMIZING SURGICAL APPROACH IN PETROTENTORIAL MENINGIOMA
Akshay Save, MD; Eytan Raz, MD, PhD; Donato Pacione, MD; NYU Langone Health
Introduction: Petrotentorial meningiomas present a formidable challenge to skull base neurosurgeons due to their deep-seated location, proximity to critical neurovascular structures, and complex patterns of growth. These tumors often displace and encase vital anatomy including the basilar artery, brainstem, and cranial nerves. Their growth patterns are slow, which results in significant mass effect on the brainstem prior to presentation. When patients present with these lesions, they often have cranial neuropathies, symptomatic brainstem compression, and cerebellar symptoms. Even with modern skull base techniques such as the anterior or posterior petrosectomy, complete resection must often be balanced against the preservation of neurological function. With the advent of three-dimensional rotational angiography, we have more information about the vascular supply, arterial encasement, and deep venous drainage for preoperative surgical planning than ever before. These factors should be considered when selecting the optimal surgical route to avoid devastating vascular complications.
Case Presentation: We present the case of a 73-year-old female who underwent resection of a large left petrotentorial meningioma. She had presented to outpatient clinic with headaches, tinnitus, and gait imbalance over a three month time course. Her preoperative MRI revealed a 3.7x3.2x2.0cm mass with partial encasement of the basilar artery, encasement of the left AICA, and extension into Meckel’s cave and the internal acoustic canal (Figure 1). She underwent diagnostic cerebral angiogram for preoperative embolization of the tumor through the meningohypophyseal trunk with reduction in the size of the tumor blush by the end of the procedure. Based on the results of the diagnostic angiogram and three-dimensional high-resolution dyna CT, we determined that the initially planned transpetrosal approach would be extremely high risk because the superior petrosal sinus was thought to be critical in normal cranial drainage of the posterior fossa (Figure 2). Furthermore, the absence of significant pial supply from the tumor was suggestive that the tumor would not be locally invasive
A retrosigmoid craniotomy was performed for resection of tumor. Tumor was intentionally left behind on the superior pons where it was noted to be highly adherent to the pial surface. The 4-8th nerves were all visualized and carefully protected. The patient tolerated surgery well, though she developed a cranial nerve IV palsy after the embolization, which persisted after surgery. Her post-operative MRI showed gross total resection with small amount of residual along the tentorium and the brainstem (Figure 3).
Conclusions: Surgical planning for complex skull base tumors such as petrotentorial meningiomas benefits from the use of three-dimensional rotational angiography. These improved preoperative imaging modalities can better inform surgeons on the risk profile of certain approaches
Figure 1
Axial post-contrast MRI imaging showing petrotentorial meningioma with vascular encasement of the basilar artery and AICA
Figure 2
Fused arterial and venous phase three-dimensional rotational angiography imaging demonstrating critical vasculature for lesion.
Figure 3
Post-operative T1-post contrast weighted MRI after surgical resection