Object Although they provide excellent ventral and lateral exposure of the brainstem, petrosal approaches to brainstem cavernous malformations (CMs) are infrequently reported. Methods The authors reviewed their experience with petrosal approaches to brainstem CMs in combination with a comprehensive review of the literature to elucidate resection rates, complication rates, and outcomes. Results Including their own results, the authors found 65 cases in 20 reports of brainstem CMs treated with petrosal approaches. The specific approaches were posterior petrosal in 37 cases (57%), anterior petrosal in 17 (26%), extended posterior petrosal in 10 (15%), and a combined petrosal approach in 1 case (2%). For 50 cases in 16 reports with detailed outcome information, the overall complete resection rate was 90%, with early postoperative morbidity reported in 30% of cases and permanent morbidity in 14%. The rate of CSF leakage was 6%. Conclusions The versatile petrosal approaches to brainstem CMs are associated with good outcomes and an acceptable morbidity rate. More expansive lesions can be approached using a combination of the standard anterior and posterior petrosal approach, preserving hearing and avoiding the greater complication rates associated with extended posterior petrosal approaches.
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