Modified Endoscopic Denker's Approach for a Meckel's Cave Meningioma: 2-Dimensional Operative Video

Meningiomas confined to Meckel's cave represent a small fraction of all meningiomas and most commonly present with trigeminal dysfunction. Open transcranial approaches are traditionally used to approach Meckel's cave. Newer techniques, including trans orbital and endoscopic endonasal approaches, have increased the range of surgical options available for resection of these tumors.(1-5 )Here, we present the case of a 14-year-old male, with a history of receiving craniospinal radiation in infancy for neuroblastoma resulting in short stature, who presented with V2 neuropathy in the setting of a rapidly growing Meckel's cave meningioma. We discuss the relevant anatomy, approaches to Meckel's cave, and a rationale for approach selection in these cases.(6-9 )We provide a video highlighting the key steps of an endoscopic endonasal modified Denker's approach for resection of a Meckel's cave meningioma with a focus on (1) expanding the exposure in this pediatric patient of short stature and (2) complication avoidance. This approach avoids brain retraction and allows for exposure and protection of the trigeminal nerve roots and carotid artery. Performing a modified Denker's approach facilitated a wide exposure to the middle fossa in the coronal plane, an important adjunct to facilitate complete resection of this radiation-induced meningioma given their more aggressive nature.(10,11 )The patient did well postoperatively with transient V2 neuropathy that resolved by the 6-month follow-up visit. This case illustrates how modifications of the endoscopic endonasal approach can be tailored to each patient specifically to achieve optimal approach selection for resection of tumors in Meckel's cave. The patient assented, and the parents consented to the procedure.