Clival and Petroclival Meningiomas are rare, slow-growing tumors arising from the dura mater at the clivus or petroclival junction. Although benign, their deep location near the brainstem, cranial nerves, and major arteries (basilar, internal carotid, vertebral) makes them among the most challenging skull base tumors to treat. Advances in microsurgical and endoscopic skull base approaches now allow safe removal with excellent outcomes and neurological preservation.
Symptoms
These tumors grow slowly, causing symptoms as adjacent structures are compressed:
- Double vision (abducens nerve palsy — CN VI)
- Facial numbness or tingling (trigeminal nerve — CN V)
- Facial weakness or twitching (facial nerve — CN VII)
- Hearing loss or tinnitus
- Swallowing difficulty, hoarseness, or imbalance (lower cranial nerves IX–XI)
- Headache and neck pain
- Unsteady gait or limb weakness from brainstem compression
Very large tumors can cause hydrocephalus, leading to nausea, vomiting, and drowsiness.
Diagnosis
- MRI Brain with Contrast: Shows a dural-based, enhancing mass along the clivus or petroclival junction; assesses tumor extent, cranial nerve involvement, and brainstem compression.
- CT Scan (Bone Window): Reveals bony erosion or hyperostosis of clivus/petrous apex for surgical planning.
- Angiography (CTA/MRA or DSA): Evaluates relationship to basilar and carotid arteries and identifies feeding vessels for preoperative embolization if needed.
Treatment Options
1. Microsurgical Resection
Mainstay treatment for symptomatic or growing tumors; aims for maximal safe resection while preserving the brainstem and cranial nerves.
- Retrosigmoid (lateral suboccipital) approach: For laterally located lesions extending to the CPA.
- Extended retrosigmoid or presigmoid petrosal approach: For petroclival tumors encasing cranial nerves.
- Anterior petrosal (Kawase) approach: For upper clival/petroclival junction tumors.
- Endoscopic endonasal transclival approach: For midline clival tumors; direct access through the nose without brain retraction.
Modern advances include intraoperative cranial nerve monitoring, neuronavigation, angled endoscopes, fluorescence-guided resection, and vascularized flap reconstruction to prevent CSF leaks. Subtotal resection followed by radiosurgery may be chosen if complete removal is unsafe.
2. Stereotactic Radiosurgery (SRS)
- Used for small, residual, or recurrent tumors, or in patients unfit for surgery.
- Techniques like Gamma Knife or LINAC deliver focused radiation while sparing critical structures.
- Tumor control rates >90% with minimal cranial nerve risk.
3. Combined or Staged Treatment
- First stage: partial microsurgical resection to decompress brainstem.
- Second stage: radiosurgery for residual tumor.
- Reduces surgical risk while achieving long-term control.
Risks & Complications
- Temporary cranial nerve palsies (facial weakness, diplopia, swallowing difficulty)
- CSF leakage or meningitis (rare with multilayer closure)
- Vascular injury or stroke (extremely rare)
- Hearing loss or balance disturbance
- Residual tumor if complete removal is unsafe
Most cranial nerve deficits improve gradually with rehabilitation.
Recovery & Prognosis
- Hospital stay: 7–10 days
- Postoperative rehabilitation: eye coordination, swallowing, balance training
- MRI follow-up: every 6–12 months
- Prognosis:
Excellent long-term control with gross-total or near-total resection
Radiosurgery provides durable stability in residual cases
High quality of life recovery with experienced skull base teams
Patient Advisory
Clival and petroclival meningiomas require specialized skull base expertise due to proximity to brainstem and lower cranial nerves. Individualized surgical planning is essential to balance tumor removal with neurological preservation. Modern combined microsurgical and radiosurgical approaches offer safe, durable, and life-improving results. Always consult your neurosurgeon for personalized evaluation — do not rely solely on online information.