SURGICAL ANATOMY AND TECHNIQUES

THE SUBTEMPORAL INTERDURAL APPROACH TO

DUMBBELL-SHAPED TRIGEMINAL SCHWANNOMAS:
CADAVERIC PROSECTION
Samy Youssef, M.D., Ph.D.
Department of Neurosurgery,
University of South Florida,
Tampa, Florida
Eun-Young Kim, M.D.
Department of Neurosurgery,
University of Cincinnati
College of Medicine,
Cincinnati, Ohio
Khaled M.A. Aziz, M.D., Ph.D.
Department of Neurosurgery,
University of Cincinnati
College of Medicine,
Cincinnati, Ohio
Salah Hemida, M.D.
Department of Neurosurgery,
University of Cincinnati
College of Medicine,
Cincinnati, Ohio
Jeffrey T. Keller, Ph.D.
Department of Neurosurgery,
The Neuroscience Institute,
University of Cincinnati
College of Medicine and the
Mayfield Clinic,
Cincinnati, Ohio
Harry R. van Loveren, M.D.
Department of Neurosurgery,
University of South Florida,
Tampa, Florida
OBJECTIVE: Successful resection of dumbbell-shaped trigeminal schwannomas via a
subtemporal interdural approach requires an understanding of both the anatomy
related to the bone dissection of the petrous apex (Kawases triangle or quadrilateral)
and meningeal anatomy. We studied the meningeal anatomy related to this approach
and describe the dural incisions and stepwise mobilization.
METHODS: Meningeal anatomy around Meckels cave and porus trigeminus was
examined during the subtemporal interdural anterior transpetrosal approach in both
sides of 15 cadaveric heads. Histological study of the Meckels cave region was
performed in two cadaveric heads.
RESULTS: The Gasserian ganglion and trigeminal roots have two layers of dura propria
on their dorsolateral surface: an inner layer from the posterior fossa dura propria that
constitutes the dorsolateral wall of Meckels cave and an outer layer from the dura
propria of the middle fossa. The cleavage plane between these two layers continues
distally as the cleavage plane between the epineural sheaths of the trigeminal divisions
and the dura propria of the middle fossa. This cleavage plane serves as the anatomic
landmark for the interdural exposure of the contents of Meckels cave. The superior
petrosal sinus is sectioned at the medial aspect of Kawases triangle and reflected along
with the porus trigeminus roof.
CONCLUSION: Understanding the critical meningeal architecture in and around
Meckels cave allows experienced cranial neurosurgeons to develop a subtemporal
interdural approach to dumbbell-shaped trigeminal schwannomas that effectively
converts a multiple-compartment tumor into a single-compartment tumor. Dural
incisions and stepwise mobilization complements our previous description of the bony
dissection for this approach.
KEY WORDS: Anterior petrosal approach, Cavernous sinus, Meckels cave, Meningeal anatomy, Trigeminal
schwannoma
Neurosurgery 59[ONS Suppl 4]:ONS-270ONS-278, 2006 DOI: 10.1227/01.NEU.0000227590.70254.02

Reprint requests:
Jeffrey T. Keller, Ph.D.,
c/o Editorial Office,
The Neuroscience Institute,
Department of Neurosurgery,
ML 0515, 231 Albert Sabin Way,
Cincinnati, OH 45267-0515.
Email: editor@mayfieldclinic.com
Received, November 8, 2005.
Accepted, May, 5, 2006.
T
he typical trigeminal schwannoma arises
from Schwann cells within Meckels cave
and grows through the porus trigeminus
into the posterior fossa. The designation dumb-
bell trigeminal schwannoma is based on shape
formed by the constriction of the tumor between
the roof of the porus trigeminus and its impres-
sion in the petrous ridge that forms its floor.
Dumbbell trigeminal schwannomas usually
consist of two components: the body of the tu-
mor in Meckels cave and a posterior extension
through the porus trigeminus into the subarach-
noid space of the posterior fossa. A small ante-
rior extension of tumor often occurs along the
ophthalmic (V1), or sometimes the maxillary
(V2) trigeminal division, into the interdural
space of the cavernous sinus lateral wall (i.e.,
between the dura propria and inner membra-
nous layer). Tumor extension along V2 can tra-
verse the pterygopalatine fossa to enter the in-
fraorbital canal and expand into the maxillary
sinus. Tumor extension along V3 can enter in-
fratemporal fossa.
Conventional intradural approaches can be
applied to these tumors. Major disadvantages
can include excessive brain retraction and diffi-

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culties achieving adequate exposures in Meckels cave, the inter-
dural space of the lateral wall of the cavernous sinus, and the
cavernous sinus venous plexus (5, 24, 29, 31, 35, 38). Compared with
conventional surgical approaches, recent innovations in cranial base
surgery allow better exposure and multiple working angles with
minimal brain retraction, thus facilitating one-stage complete resec-
tion of large dumbbell-shaped trigeminal schwannomas without
increased morbidity (3, 10, 13, 39, 41, 45, 49). We have judiciously
applied the interdural anterior transpetrosal approach to dumbbell-
shaped trigeminal schwannomas (45) and various lesions that occur
in the upper petroclival region, such as petroclival meningiomas (1),
retrosellar and upper clival basilar aneurysms (2), and anterior or
anterolateral pontine vascular malformations.
The relative rarity of trigeminal schwannoma has thwarted
efforts to formulate a specific methodology for comprehensive
surgical treatment. We reported in a previous clinical study
(although lacking statistical power) that the application of cranial
base approaches improved the resectability of these tumors (45).
We also described a step-by-step bone dissection required to
expose the area of Meckels cave, but did not describe the dural
incisions (32). Other previously published studies also excluded
step-wise descriptions of the dural incisions because of the com-
plex architecture of the dural coverings of this cave (8, 10, 11, 13,
39, 41, 49). Therefore, we returned to the laboratory to identify
the surgical anatomy of the dural coverings of Meckels cave,
with an emphasis on the surgical technique of middle fossa
approach to dumbbell trigeminal schwannomas. In this study,
we describe the meningeal architecture that allows an increased
space for anterior petrosectomy, a safe peeling of the dura pro-
pria (meningeal layer of dura) of the middle fossa from divisions
of the trigeminal nerve, exposure of the lateral compartment of
the cavernous sinus, opening of Meckels cave, and opening of
the porus trigeminus into the posterior fossa. We describe how
these maneuvers convert a three-compartment tumor into a
single-compartment tumor to afford a greater likelihood of com-
plete resection with lower morbidity.
MATERIALS AND METHODS
Thirty specimens were obtained from 15 adult cadaveric
heads whose arterial and venous systems were pressure injected
with colored silicone rubber (Dow Corning, Midland, MI). The
posteromedial middle cranial fossa, including Meckels cave and
the cavernous sinus, were examined during the subtemporal
interdural anterior transpetrosal approach with 3 to 40 mag-
nification using a Contraves Zeiss microscope (Carl Zeiss Co.,
Oberkochen, Germany). Meningeal anatomy was evaluated re-
lated to the interdural exposure of Meckels cave and the opening
of the porus trigeminus; the relationship between Meckels cave
and lateral compartment of the cavernous sinus was identified.
In two cadaveric heads prepared for histological study, the
Meckels cave region (including the cavernous sinus) was
removed en bloc and placed in 10% neutral buffered formal-
dehyde for 2 weeks. Specimens were decalcified in Decalcifier
I and II (Surgipath, Richmond, IL) for 4 weeks. Specimens
were then dehydrated, processed in a Citadel 2000 (Shandon,
Pittsburgh, PA) processor, and embedded in paraffin. Six mi-
NEUROSURGERY
MENINGEAL ANATOMY OF MECKELS CAVE
crometer sections, which were obtained using a Reichert-Jung
2055 microtome (Cambridge Instruments, Heidelberg, Ger-
many), were baked at 65C for 98 hours and stained in
Gomeris one-step trichrome with aniline blue.
RESULTS
Meningeal Anatomy around Meckels Cave and
Relationships to Surrounding Structures
The dura mater consists of two layers: an outer periosteal layer
and inner meningeal layer (dura propria). These two layers
tightly fuse except where they are separated to provide space for
the dural venous sinuses, venous plexi, and cranial nerves that
pass through the parasellar region. The periosteal layer of the
dura remains tightly attached to the inner surface of the cranium
and is considered to be the internal periosteum of the cranial
bone. The periosteal layer of the dura is continuous with the
outer periosteum, which covers the external surface of the cranial
bone through the suture lines and foramina for nerves and
vessels. The dura propria faces the brain surface covered by
arachnoid. The dura propria and arachnoid typically follow cra-
nial nerves for varying distances as they leave the cranial cavity
(9, 46). The dura propria that follows each cranial nerve becomes
the epineurium, whereas the pia-arachnoid continues as the per-
ineurium that invests each nerve fascicle (4, 33, 37, 43, 46).
The trigeminal nerve passes from the posterior fossa over the
trigeminal impression of the petrous apex between the periosteal
and meningeal (dura propria) layers of middle fossa dura, car-
rying with it arachnoid and dura propria from the posterior
fossa. Meckels cave is a cleft-like dural pocket that originates
from the dura propria of the posterior fossa, between the two
layers of the middle fossa dura (7, 1721, 25, 28, 46). The contents
of the Meckels cave are the sensory and motor roots of the
trigeminal nerve, gasserian ganglion (GG), and arachnoid layer.
At its dorsolateral and ventromedial surfaces, the GG tightly
adheres to the overlying arachnoid and dura propria of Meckels
cave without any potential subarachnoid space. The subarach-
noid space within Meckels cave is behind the GG and is the
actual space that constitutes the trigeminal cistern. At the anterior
convex margin of the GG, the dura propria of Meckels cave
becomes the epineural sheath of each division of the trigeminal
nerve; the pia-arachnoid becomes the perineurium that invests
each fascicle of the trigeminal nerve divisions (Fig. 1). This men-
ingeal architecture is identical to that of the spinal ganglion and
nerve (36), with the dura propria and pia-arachnoid becoming
epineurium and perineurium, respectively.
The GG and trigeminal roots have two layers of dura propria
on their dorsolateral aspects. The inner layer, the dura propria,
constitutes the dorsolateral wall of Meckels cave. The outer layer
is the dura propria of the middle fossa. The cleavage plane
between these two layers of dura propria continues distally as
the cleavage plane between the epineural sheaths of the trigem-
inal nerve divisions and the dura propria of the middle fossa.
This cleavage plane serves as the anatomic basis for the interdu-
ral exposure of the contents of Meckels cave (3, 14, 27, 49).
The transition from the petrous segment (C2) (6) through the
lacerum segment (C3) to the cavernous segment (C4) of the
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YOUSSEF ET AL.
FIGURE 1. Meckels cave is a dural pocket of dura propria from posterior fossa
located between two layers of middle fossa dura that house trigeminal roots and
ganglion. The trigeminal impression in the petrous ridge and roof of the porus
trigeminus constricts trigeminal schwannomas, causing a dumbbell-shaped appear-
ance. A, oblique coronal section along the line between the porous trigeminus and the
foramen ovale. At the anterior margin of the GG, the dorsolateral and ventromedial
walls of Meckels cave become an epineural sheath of each division of trigeminal
nerve. Trigeminal cistern is the subarachnoid space behind the GG. SPS courses
between two layers of dura propria (from middle and posterior fossae) at the porous
trigeminus roof. B, the dorsolateral wall of Meckels cave (dotted line) behind the
anterior margin of the GG (dashed line) was exposed by mobilization of the dura
propria of the middle fossa via a subtemporal interdural approach. C, removal of the
outer dural layer (dura propria) of the cavernous sinus lateral wall, tentorium, and
the small posterior portion of dorsolateral wall of MC shows the whole segment of the
trigeminal nerve (TN). This nerve enters between the periosteal and meningeal layers
of the middle fossa dura. Dura propria of posterior fossa follows the TN and wraps
around its roots and ganglion to make a cleft-like dural pocket,
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internal carotid artery (ICA) occurs ventromedial to the GG (Fig.
2). The petrolingual ligament is the continuation of the perios-
teum of the carotid canal. This canal spans between the lingula of
the sphenoid bone anteriorly and the petrous apex posteriorly
and serves as the lateral ring of the ICA (6, 50). The upper margin
of the petrolingual ligament marks the inferior boundary of the
posterior compartment of the cavernous sinus. The anterior por-
tion of the ventromedial wall of Meckels cave can be divided
into two parts: an upper one-third and lower two-third. The
upper one-third, covering a portion of the GG, gives rise to the
ophthalmic division (V1). Sometimes, the upper part of the max-
illary division (V2) forms the lateral wall of the posteroinferior
portion of the cavernous sinus venous plexus. The lateral wall of
the posteroinferior portion of this plexus rests against the vertical
segment of the cavernous ICA, abducens nerve, and cavernous
sinus venous plexus. The lower two-thirds are separated from
the ICA lacerum segment (C3) and the medial portion of the
horizontal part of the ICA petrous segment by the petrolingual
ligament and the periosteum that covers the roof of the carotid
canal (Figs. 1C and 2B). After the abducens nerve passes under-
neath the petrosphenoidal ligament (Grubers ligament), it then
courses medial to the upper portion of the medial wall of Meck-
els cave toward the posterior and lateral aspects of the vertical
segment of the intracavernous ICA, making an anterior and
downward angulation at the petrous apex tip (47) (Fig. 1C).
The porus trigeminus is an oval-shaped opening of MC
posteriorly that communicates with the posterior fossa. Two
layers of dura propria (from the middle and posterior fossae)
form the roof of the porus trigeminus. The superior petrosal
sinus (SPS) lies between these two layers. The two-layered
roof of the porus trigeminus continues posteriorly as the ten-
torium cerebelli. If the cleavage plane between the two layers
of dura propria covering the GG and trigeminal roots on their
dorsolateral aspect is followed toward the porus trigeminus,
the SPS will be opened (Fig. 3). The cavernous sinus venous
plexus gives rise to the SPS through a space defined inferiorly
by the superior border of MC and superiorly by the trochlear
nerve (i.e., posterior portion of Parkinsons triangle) (12, 34).
The middle meningeal artery enters the cranial cavity through
the foramen spinosum, which is just posterolateral to the fora-
men ovale. This artery courses in the periosteal layer of middle
fossa dura (9). Consequently, dividing this artery near the fora-
men spinosum can lead to the cleavage plane between the
epineural sheath of the mandibular nerve (V3) and the dura
propria of the middle fossa.
Surgical Steps of Subtemporal Interdural Approach
We describe the surgical procedures that focus on the exposure of
Meckels cave with extension through the porus trigeminus into the
posterior fossa. We briefly review the step-by-step anterior petrosec-
tomy that focused on the bony anatomy in our earlier publication (32).
Meckels cave, which ends at the anterior margin of the GG (dashed line).
DPMF, dura propria of middle fossa; ICA, internal carotid artery; GG, gasserian
ganglion; II, optic nerve; III, oculomotor nerve; IV, trochlear nerve; V1, ophthal-
mic division; V2, maxillary division; V3, mandibular division. (With permission
from the Mayfield Clinic.)
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FIGURE 2. Relationship of Meckels cave and the ICA. The oblique coronal
section along the angle of the petrous ICA. A, histological section passing
through the foramen lacerum showing the relationship of the ventromedial wall
and surrounding anatomy. B, upper one-third of the ventromedial wall of
Meckels cave forms the lateral wall of the posteroinferior portion of the cavern-
ous sinus. The lower two-thirds of the wall lie on the petrolingual ligament and
periosteum of the roof of the carotid canal. C, axial section through the course of
V1. Posterior CS directly contacts the superior part of the ventromedial wall of
Meckels cave. D, the GG and root were incised between V1, V2, and V3; the
middle part of the GG was reflected anteriorly to show the ventromedial wall
Positioning and Craniotomy
A lumbar drain placed before positioning facilitates brain
relaxation during the subtemporal dissection. The final patient
position is supine with the head rotated to the contralateral side
until the sagittal suture is parallel to the floor. In older patients,
an ipsilateral shoulder roll may be needed to decrease torsion of
NEUROSURGERY
MENINGEAL ANATOMY OF MECKELS CAVE
(asterisk) of Meckels cave, petrolingual ligament (PLL), and C3 segment of
ICA. The upper one-third of this wall forms the lateral wall of the posteroinferior
portion of the CS. E, upper part of Meckels cave and the V1 were retracted
inferolaterally to show the vertical cavernous (C4) segment of the ICA. The
abducens nerve passes underneath the petrosphenoidal ligament (PSL) and then
courses medial to the upper portion of the medial wall of Meckels cave. C5,
clinoidal segment of ICA; II, optic nerve; III, oculomotor nerve; IV, trochlear
nerve; V1, ophthalmic division; MR, motor root; CS, cavernous sinus; SS, sphenoid
sinus; GG, gasserian ganglion; PLL, petrolingual ligament; PG, pituitary gland;
TC, trigeminal cistern. (With permission from the Mayfield Clinic.)
the neck. The vertex is tilted down so that the zygoma is the
highest point in the surgical field. A question-mark shaped skin
incision begins anterior to the tragus and swings posteriorly
above the pinna. The craniotomy is frontotemporal with a small
frontal component. Burr holes are placed at the pterion and just
above the supramastoid crest 1 cm posterior to the external
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YOUSSEF ET AL.
FIGURE 3. Illustration of the coronal section along the line between the porous
trigeminus and the foramen ovale showing the dural layers. The endosteal incision
near the foramen ovale leads to a cleavage plane between the outer layer (dura propria
of middle fossa) and the epineural sheath of the V3 and mobilization from the
epineural sheath of the V3. Peeling the dura propria of the middle fossa from the
dorsolateral wall of Meckels cave should stop before peeling open the SPS, which lies
within the cleavage plane. (With permission from the Mayfield Clinic.)
auditory meatus. The craniotomy is extended to be flush with the
floor of the middle fossa. A zygomatic osteotomy helps improve
subtemporal exposure and minimize temporal lobe retraction.
The lateral part of the sphenoid wing is resected until the lateral
dural covering of the superior orbital fissure is exposed.
Dural Elevation and Peeling of Meningeal Dura of the
Middle Fossa
Elevation of the dura of the middle fossa floor in a posterior to
anterior direction protects the greater superficial petrosal nerve
(GSPN), which enters the middle fossa epidural space through
the facial hiatus. The arcuate eminence is identified (Fig. 4, A and
B). The middle meningeal artery is cauterized and cut at the
foramen spinosum. The cleavage plane between the dura propria
and periosteal dura, which contains this artery, is identified and
developed by dissection. The dura propria layer is peeled from
the periosteal layer in an anterior direction toward the foramen
ovale. This cleavage plane continues as the plane between the
dura propria of the middle fossa and the epineural sheath of V3
at the foramen ovale. The V2 division is exposed by incising the
periosteal layer of dura that covers the anterior margin of the
foramen rotundum and by peeling the dura propria of the mid-
dle fossa from the epineural sheath of the V2 division. Continued
peeling of the dura propria superomedially toward the superior
orbital fissure exposes the V1 invested by its epineural sheath,
which is continuous with the inner membranous layer of the
cavernous sinus lateral wall. The dura propria is then progres-
sively peeled from the epineural sheath of each division of the
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trigeminal nerve back toward Meckels cave. The periosteal layer of
the dura is cut along the posterior aspect of V3 and Meckels cave.
Peeling the dura propria of the middle fossa from the dorsolateral
wall of Meckels cave is stopped short of opening the SPS, which lies
within the termination of that cleavage plane (Fig. 4C).
Anterior Petrosectomy
Drilling with a diamond burr under irrigation in Kawases
triangle medial to the GSPN exposes the horizontal part of the
petrous (C2) segment of the ICA (26). The ICA is often observed
through a dehiscence in the roof of the carotid canal near V3.
Drilling proceeds from V3 posteriorly up to the posterior loop of
the ICA. Drilling farther posteriorly results in a cochlear opening.
An imaginary bisection of the angle formed by the GSPN and the
arcuate eminence estimates the path of the internal auditory
canal (IAC) (15). The dural sleeve of the IAC is also exposed by
drilling with a diamond burr under irrigation. The hard bone in
the lateral aspect of the ICA-IAC angle defines the cochlea (Fig. 4,
B and D). Two other methods for exposing the IAC have been
described. In one method, the GSPN is followed to the geniculate
ganglion. The bone is then drilled off the arcuate eminence to
skeletonize the superior semicircular canal. This marks the pos-
terior boundary of the dissection of the IAC. The facial nerve is
followed from the geniculate ganglion to the lateral end of the
IAC (22). In the second method, an imaginary line 60 degrees to
the anterior limit of the skeletonized superior semicircular canal
is extended medially. This roughly corresponds to the location of
the underlying IAC (16). After identification of the ICA, IAC, and
cochlea, the remaining bone of Kawases triangle and the lateral
portion of the trigeminal impression (floor of the porus trigemi-
nus) are drilled away. Drilling down to the level of the inferior
petrosal sinus exposes an area of posterior fossa dura, which
rests against the posterior face of the petrous bone above the
inferior petrosal sinus and anterior to the IAC.
Dural and Tentorial Incision
A linear incision is made on the middle fossa dura just
above and parallel to the SPS from the region of the arcuate
eminence toward the petrous apex tip. The posterior fossa
dura is incised just below and parallel to the SPS toward the
lateral portion of the floor of the porus trigeminus. Cutting the
SPS between two titanium clips near the porus trigeminus
preserves venous drainage from the superior petrosal vein.
The cut made across the SPS is continued across the tentorium
and through the tentorial incisura posterior to the entry of the
trochlear nerve into the tentorial edge (Fig. 4E). The anterior
and posterior leaflets of the divided tentorium are retracted
with sutures that hang on hemostats outside the cranium.
Excision of the posterior fossa dura gains exposure (Fig. 4F).
Porus Trigeminus Opening
The dural sleeve that surrounds the trigeminal root as it
traverses the porus trigeminus is incised along its lateral as-
pect below the SPS, which is within the roof of the porus
trigeminus. Extension of the incision along the dorsolateral
wall of MC allows the roof of the porus trigeminus and part of
the dorsolateral wall of Meckels cave to be reflected medially
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 MENINGEAL ANATOMY OF MECKELS CAVE

FIGURE 4. Step-by-step procedure of the

subtemporal approach for dumbbell-shaped
trigeminal schwannomas. A, elevation of
the dura of middle fossa floor in posterior-
to-anterior direction protects the GSPN,
which enters the middle epidural space
through the facial hiatus. B, illustration
showing the relationship among the C2
segment, GSPN, IAC, trochlear, and arcu-
ate eminence. C, Kawases quadrilateral
and/or triangle after mobilization of the
dura propria of the middle fossa from the
epineural sheaths of the trigeminal divi-
sions and the dorsolateral wall of Meckels
cave. D, anterior petrosectomy showing
C2, the inferior petrosal sinus (IPS), and
the posterior fossa dura (PFD). E, after a
dural incision on the middle and posterior
fossa dura, the trochlear nerve was identi-
fied. Tentorial incision between the SPS
near the trigeminal nerve and entry of the
cochlear nerve into the tentorial edge
(dashed line). F, after cutting the SPS
between the clips and tentorium, the su-
tures retract anterior and posterior leaflets
of the divided tentorium. Excision of the
posterior fossa dura increases exposure. G,
the incision then extends along the dorso-
lateral roof of Meckels cave. H, roof of the
porous trigeminus and part of dorsolateral
wall of Meckels cave are reflected medially
along with the tentorium. AE, arcuate em-
inence; C2, petrous segment of ICA; Coc,
cochlea; Epi, epineurium; FH, facial hia-
tus; LSC, lateral semicircular canal; MFD,
middle fossa dura; PCA, posterior cerebral
artery; PSC, posterior semicircular canal;
PT, porous trigeminus; SS, sigmoid sinus;
SSC, superior semicircular canal; TE, ten-
torial edge; TNR, trigeminal nerve root;
III, oculomotor nerve; IV, trochlear nerve;
VI, abducens nerve; VII, facial nerve;
MMA, middle meningeal artery. (With
permission from Mayfield Clinic.)

along with the tentorium (Fig. 4, G and H). Controlled traction
on this leaflet of dura avoids traction injury to the trochlear
nerve, which enters the tentorial edge.
DISCUSSION
In this cadaveric study, we find that knowledge of the
meningeal architecture was important to help create an in-
creased space for anterior petrosectomy, allows safe peeling of
the dura propria (meningeal layer of dura) of the middle fossa
from divisions of the trigeminal nerve, exposes the lateral
compartment of the cavernous sinus, opens Meckels cave,
and opens the porus trigeminus into the posterior fossa. These
maneuvers effectively converted a three-compartment tumor
into a single-compartment tumor that affords a greater likeli-
hood of complete resection with lower morbidity.
Trigeminal schwannomas can originate anywhere along the
course of the trigeminal nerve. The nerve passes through four ana-
tomic compartments including the trigeminal root in the posterior
fossa; the trigeminal root or GG in Meckels cave; divisions of the

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YOUSSEF ET AL.
trigeminal nerve in the interdural space (between the dura propria
and inner membranous layer); and the peripheral branches of tri-
geminal nerve in the extracranial space (e.g., orbit, infratemporal
fossa, pterygopalatine fossa, infraorbital canal in the roof of the
maxillary sinus). Penetration of trigeminal schwannomas through
the inner membranous layer into the true cavernous sinus space
remains a questionable observation. Extension of trigeminal schw-
annomas through multiple anatomic compartments contributes to
the complexity of exposure and resection. Surgical approaches must
be tailored to the exposure required (10, 13, 23, 39, 41, 49).
Conventional approaches applied to typical dumbbell-shaped
trigeminal schwannomas include the subtemporal intradural tran-
stentorial approach (31, 38), the combined subtemporal and suboc-
cipital transtentorial approach, with or without division of the trans-
verse sinus (5, 30), and a staged subtemporal intradural or
frontotemporal transsylvian approach and a separate suboccipital
approach to the posterior fossa component (35). Although
dumbbell-shaped trigeminal schwannomas represent 18 to 37% of
trigeminal schwannomas (24, 31, 49), the incidence of involvement
of Meckels cave is much higher. The incidence of Meckels cave
involvement was 14 (93%) out of the 15 initial trigeminal schwan-
nomas reported in our series (45) and 78% (21 out of 27 trigeminal
schwannomas) in the series of Yoshida and Kawase (49). Rate of
tumor recurrence after excision through the conventional ap-
proaches has exceeded 50% (31, 44, 45). Common locations of tumor
recurrence reported are MC, the interdural space, or the cavernous
sinus venous plexus. In our report of 12 recurrent trigeminal schw-
annomas, recurrences were in Meckels cave and the porus trigemi-
nus in 8 (67%), in the interdural space in 10 (83%), and in the
posterior fossa in two (17%) (45).
Recent innovations in cranial base surgery have facilitated the
total removal of tumors that involve multiple anatomic compart-
ments with acceptable morbidity in a one-stage operation. Four
cranial base approaches used for dumbbell-shaped trigeminal
schwannomas with significant components in both the middle
and posterior fossae include a frontotemporal interdural anterior
transpetrosal approach (13), a subtemporal interdural anterior
transpetrosal approach (45, 49), a posterior transpetrosal ap-
proach (39, 41), and a combined anterior and posterior trans-
petrosal approach (10). If the posterior fossa component is rela-
tively small, it can be removed through the expanded porus
trigeminus without anterior petrosectomy (3). A retrosigmoid
intradural suprameatal approach was described for posterior
fossa trigeminal schwannoma with limited extension into Meck-
els cave (40, 42). For small tumors in the middle fossa and
tumors with relatively small extensions into the posterior fossa,
an infratemporal fossa interdural approach has been reported to
provide adequate exposure (18, 19).
Tracking a trigeminal schwannoma from Meckels cave into
the posterior fossa requires the opening of the porus trigeminus.
Among the various methods of handling the dura around the
porus trigeminus, Al-Mefty et al. (3) reported division of the
upper margin of the porus trigeminus via an upward incision
toward the SPS without petrosectomy or section of the tento-
rium. Yoshida and Kawase (49) routinely used a middle fossa
approach with anterior petrosectomy with the method of dural
incision varying according to the size of the posterior fossa tumor
component. For posterior fossa components exceeding 1 cm in
ONS-276 | VOLUME 59 | OPERATIVE NEUROSURGERY 4 | OCTOBER 2006
diameter, the SPS and tentorium are sectioned and the dural
incision along the lateral wall of Meckels cave is extended to-
ward the IAC. For posterior fossa components smaller than 1 cm
in diameter, the same dural incision is made along the lateral
wall of Meckels cave with preservation of the SPS and tentorium
(49). Day and Fukushima (10) and Day et al. (11) described
opening the dural ring around the trigeminal nerve root as it
enters the porus trigeminus after ligation of the SPS near the
trigeminal nerve and parasagittal tentorial incision. Dolenc (13)
used a frontotemporal epidural-transdural-transpetrous ap-
proach. After a frontotemporal extradural-interdural exposure of
the Meckels cave and an anterior petrosectomy, incisions were
made of the tentorium, SPS, and posterior fossa dura toward
Cranial Nerves VII and VIII. Dolenc cut the dura rectangularly
over the root of the trigeminal nerve in an anterior direction
toward the entry point of the trochlear nerve into the lateral wall
of the cavernous sinus.
CONCLUSION
The subtemporal interdural approach, which has become our
standard approach to most dumbbell-shaped trigeminal schwanno-
mas, allows simultaneous access to the posterior part of the cavern-
ous sinus, the interdural space of the lateral wall of the cavernous
sinus, Meckels cave, and upper-medial posterior fossa. Extension of
tumor into other cavernous sinus compartments warrants a more
comprehensive mobilization of the entire lateral wall of cavernous
sinus and requires a frontotemporo-orbitozygomtaic approach with
the extradural bony steps of Dolenc (13, 48). Extension of tumor in
the posterior fossa significantly below or posterior to IAC requires
addition of a posterior petrosectomy with presigmoid approach to
the posterior fossa component (3).
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Acknowledgments
We thank The Neuroscience Institute, specifically Tonya Hines, C.M.F., and
Martha Cooper-Headworth, M.S., for medical illustration and Mary Kemper, B.S.,
for editorial assistance.
COMMENTS
K im et al. report on the meningeal anatomy of Meckels cave and
the medial petrous region. Using a series of detailed cadaveric
dissections, the authors have performed an analysis of the surgical
anatomy in this area as it pertains to resection dumbbell-shaped
trigeminal schwannomas and have described the surgical steps that
can be used to expose such tumors.
We have used a similar approach for dumbbell-shaped trigeminal
schwannomas and have found that the posterior fossa component can
be removed even in cases with extension beyond the internal auditory
canal. In these cases, resectability of the posterior fossa component is
influenced by the size of the temporal component. When the superior
portion of the tumor is large, access into the posterior fossa through an
anterior petrous resection is greatly facilitated. Resection of the pos-
terior fossa component in these cases is also limited by retraction on
the temporal lobe, which may be required to provide appropriate
visualization of the ipsilateral portion of the most inferior extent of the
tumor. It is not clear whether or not an interdural approach, compared
with an intradural or epidural approach with medial petrous resection
and mobilization of the trigeminal complex, would specifically ad-
dress this issue.
Joshua Bederson
Kalmon D. Post
New York, New York
K im et al. report a detailed study with schematic and cadaveric
illustrations of the petrous apex and the porus trigeminus. The
transition from dura to dura propria is appropriately highlighted.
The authors provided succinct and meticulous descriptions that
will clearly be an important aid in dealing with these infrequent
tumors.
At our institution, we have unabashed enthusiasm for the extra-
dural approach to this area because the morbidity is much less than
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YOUSSEF ET AL.

the conventional, if not anachronistic, intradural approach. For larger
trigeminal neurinomas, the tumor creates the space that allows sur-
geons to peel it off the posterior and middle fossa dura. However, as
this article highlights, the relationship to the petrosal sinus is some-
thing that one should approach with caution. For aficionados of
cranial base surgery, this seminal contribution will add to the techni-
cal nuances and anatomical secrets of trigeminal schwannomas.
Anil Nanda
Shreveport, Louisiana
of this approach is to convert a complex three-compartment cranial
base procedure into a single compartment approach. Ultimately,
the authors hope to provide a greater likelihood of complete sur-
gical resection while decreasing patient morbidity and complica-
tion rates.
In this study, a total of 30 cadaveric dissections were performed in
which the posteromedial middle cranial fossa was examined through
the subtemporal interdural anterior transpetrosal approach. The dis-
sections are meticulous and the illustrations supplement the text.
Anthony DAmbrosio

K im et al. elegantly describe the subtemporal interdural ap-

proach to dumbbell trigeminal schwannomas. The overall goal
Jeffrey N. Bruce
New York, New York

Achille Louis Foville, 1799-1978, Trait Complet de lanatomie, de la Physiologie et de la Patholo-

gie du Systme Nerveux Crbro-spinal. Paris: Fortin, Masson, 1844 (Courtesy, Rare Book Room,
Norris Medical Library, Keek School of Medicine, University of Southern California, Los Angeles,
California.)

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