Combined Petrosal Approach With Transcochlear Extension for Fisch D Jugular Paraganglioma: A Technical Case Report.

Background and importance: Surgery for jugular paragangliomas (JPs) is known to be a formidable challenge because of the tumor's intimate involvement of neurovascular structures. Although radiosurgery is commonly the first-line treatment, recent advances in neuroimaging, surgical techniques, and intraoperative monitoring have positioned surgery as a feasible alternative for aggressive tumors with substantial intradural extension not amenable to upfront radiosurgery, provided the surgeon has an in-depth knowledge of lateral skull-base anatomy and access to safe and effective preoperative embolization.

Clinical presentation: A patient with a Fisch Type D JP with extensive intradural tumor and brainstem compression underwent a combined petrosal approach with transcochlear extension at our institution. The transcochlear extension allowed additional anteromedial access to the petrous apex and internal carotid artery, whereas the combined craniotomy granted access to the supratentorial space for the tumor with transtentorial extension. The surgery's critical steps, along with key neurovascular structures, were documented and reviewed in a surgical video.

Conclusion: The combined petrosal approach with transcochlear extension is a complex but effective surgical approach for large JPs invading the petrous apex and involving the internal carotid artery not amenable to upfront radiosurgical treatment. This procedure relies on a thorough understanding of temporal bone anatomy and should be reserved for experienced multidisciplinary teams in specialized centers.