Zygomatic pretemporal skull base approach for resection of a radiation-induced sphenoid wing meningioma: surgical technique

In this video, we present the surgical technique and operative nuances of the zygomatic pretemporal skull base approach for resection of a large left sphenoid wing and middle cranial fossa radiation-induced meningioma (RIM) with invasion and encasement of the middle cerebral artery (MCA). RIMs represent a distinct and surgically challenging entity due to aggressive biological behavior, altered tissue planes, and frequent vascular involvement. In the present case, prior childhood cranial irradiation resulted in dense tumor adherence to the MCA within radiation-altered tissue, necessitating meticulous microsurgical technique. The zygomatic pretemporal approach effectively converts a deep skull base lesion into a convexity-like lesion, providing a wide basal surgical corridor, reducing working distance, and minimizing frontal and temporal lobe retraction. After zygomatic osteotomy and extradural skull base drilling, early devascularization was achieved through removal of the sphenoid ridge and division of the meningo-orbital band. Intradural microsurgical dissection focused on internal tumor debulking followed by sharp arachnoid dissection to circumferentially separate the tumor from the MCA and its branches. In areas of dense adherence, vessel-preserving strategy was prioritized. A Simpson Grade I resection was achieved without vascular injury. Zygomatic reconstruction using low-profile “dog-bone” plates allowed anatomical realignment of the osteotomized segment, preservation of temporalis muscle function, and excellent cosmetic outcome. Postoperative imaging confirmed gross total resection (GTR) and stable reconstruction. The patient recovered without new neurological deficits and demonstrated complete resolution of preoperative hemiparesis at follow-up. This case highlights the value of the zygomatic pretemporal skull base approach in achieving radical resection of complex sphenoid wing RIMs while facilitating safe dissection of critical neurovascular structures.