Oncological and Functional Outcome for Large and Giant Petroclival Meningioma: The Lariboisière Experience of 81 Patients

Background: Large and giant petroclival meningiomas (PCMs) are one of the most challenging tumor to treat. Despite the current shift toward quality-of-life preservation as a primary goal in the management of PCMs, robust long-term clinical data remain essential to determine the most appropriate and individualized surgical strategy for each patient. Materials and Methods: A retrospective review was conducted of all large (maximum cisternal diameter >3 cm) and giant (>4 cm) PCMs surgically treated between 2012 and 2025. Clinical, radiological, and surgical data were analyzed. Results: 81 patients underwent surgery including 21 (26%) large and 60 (74%) giant PCMs. According to the dural attachment, meningiomas were classified as: Petroclival (PC-PCMs, n = 12; 15%), cavernous-petroclival (CPC-CPMs, n = 19; 23%), inferior petroclival (IPC-PCMs, n = 3; 4%), clival (C-PCMs, n = 4; 5%), petrous apex (PA-PCMs, n = 10; 12%), spheno-cavernous petroclival (SCPC-PCMs, n = 7; 9%), Tentorial (T-PCMs, n = 26; 32%). 16 patients (20%) required a shunt before surgery. 85% of patients presented with at least one cranial nerve deficit and 43% had brainstem edema. 47% of PC-PCMs had posterior cavernous sinus (CS) infiltration. Preoperative embolization was performed in 81% of all meningiomas. Surgical approaches included combined petrosal ( n = 28; 35%), mini-combined petrosal ( n = 28; 35%), anterior petrosal ( n = 12; 15%), complete combined translabyrithine ( n = 4; 5%), retrosigmoid ( n = 2; 2%), mononostril endoscopic endonasal approach ( n = 1; 1%), combination of different approaches ( n = 6; 7%). Gross total resection (GTR) was achieved in 100% of C-PCMs, 36% of T-PCMs, 20% of PAPCMs, and 20% of PC-PCMs. Near total resection (NTR) predominated in T-PCMs (48%), PAPCMs (60%), and PC-PCMs (60%) cases, while subtotal resection (STR) was most frequent in CPCPCMs (52.6%) and IPC-PCMs (100%). Partial resection (PR) occurred mainly in SCPC-PCMs (50%) and CPC-PCMs (15.8%) tumors. 85% of PCMs had more than 80% EOR. Residual tumor was most located in the cavernous sinus (49%), along the brainstem (32%), into Meckel’s cave (30%), Dorello’s canal (19%), internal auditory canal (17%), and jugular foramen (8%). EOR significantly correlated with meningioma type ( p < 0.001), CS invasion ( p = 0.007), brainstem edema ( p = 0.007), and vessels encasement ( p < 0.001). The most frequent postoperative deficits were diplopia (16%), trigeminal hypoesthesia (8.1%), hypoacusia (6.8%), and facial paresis (6.8%), with recovery observed in 89%, 27%, 33%, and 40% of cases, respectively. One patient with vessels encasement experienced a stroke due to perforating artery injury resulting with severe hemiparesis with long-term sequalae. One patient died from pulmonary embolism after discharge. Tumor regrowth occurred in seven patients (9.4%) and was managed with radiotherapy ( n = 4), observation ( n = 2), and surgery ( n = 1). Conclusion: Transpetrosal approaches allow effective tumor removal with acceptable morbidity in large and giant PCMs. A comprehensive understanding of each patient’s profile, the tumor’s molecular characteristics, and its specific pattern of extension is crucial to achieve the optimal balance between long-term tumor control and preservation of quality of life. Future advances in elucidating the molecular and biological determinants of PCMs behavior and radiosensitivity will further refine individualized, function-preserving management strategies. Publication History Article published online: 27 February 2026 © 2026. Thieme. All rights reserved. Georg Thieme Verlag KG Oswald-Hesse-Straße 50, 70469 Stuttgart, Germany