Surgical management of petrous apex lesions: a descriptive analysis of outcomes by anatomical location for the Kawase, retrosigmoid, and pterional approaches

This study is a descriptive analysis that systematically delineates the perioperative outcome profiles of Kawase, endoscope-assisted retrosigmoid, and pterional approaches for resecting petrous apex lesions within the clinical decision-making framework of "anatomical location first." A retrospective series of 27 patients was included. Based on the core anatomical location of the lesion, surgery was performed via the Kawase approach (anteromedial region, <i>n</i> = 14), the endoscope-assisted retrosigmoid approach (posterior region, <i>n</i> = 7), or the pterional approach (superoanterior region, <i>n</i> = 6). The results demonstrate that surgical approaches corresponding to different anatomical subregions exhibited characteristic outcome profiles. For anteromedial petrous apex lesions, the Kawase approach achieved a high gross total resection rate (100%), but was associated with longer operative time and a higher risk of postoperative intracranial infection. For posterior lesions, the endoscope-assisted retrosigmoid approach provided excellent exposure with minimal tissue trauma and a relatively balanced complication spectrum. For superoanterior lesions, the pterional approach, while allowing direct access, was associated with higher rates of postoperative cranial nerve dysfunction (trigeminal nerve injury 50%, facial nerve palsy 67%) and speech impairment (50%). In a subgroup analysis focusing on the predominant pathology (meningioma, <i>n</i> = 20), these outcome differences linked to specific anatomical location-approach pairings persisted. The findings indicate that surgical outcomes for petrous apex lesions are closely associated with the approach dictated by their anatomical location, presenting a predictable characteristic profile. Therefore, clinical decision-making should prioritize the precise anatomical location of the lesion when selecting the surgical approach, and fully acknowledge the inherent perioperative risk profile specific to each "anatomical region-surgical approach" pairing. The integration of ancillary techniques such as neuroendoscopy with classic approaches holds promise for further optimizing outcomes in complex cases. This study is a single-center, retrospective, descriptive analysis with a limited sample size; its conclusions require validation by prospective, large-sample studies.