Pediatric Psammomatous Petroclival Meningioma with Aggressive Skull Base and Neck Extension: A Rare Surgical Challenge

Dear Editor, Meningiomas constitute less than 3% of pediatric brain tumors, with petroclival variants being exceedingly uncommon and technically formidable due to their deep skull base location near vital neurovascular structures.1 Pediatric occurrence with extracranial extension into the neck or mastoid remains exceptionally rare. We report an 11-year-old boy presenting with progressive right hearing loss, dysphagia, and gait unsteadiness over 2 years. Magnetic resonance imaging revealed a heterogeneously enhancing extra-axial mass in the right petroclival region extending into the mastoid, occipital condyle, carotid canal, hypoglossal canal, and parapharyngeal space, with bony erosion. A right extended retrosigmoid–mastoid–suboccipital (RMSO) craniectomy with far-lateral approach was performed using neuronavigation and neuromonitoring. The tumor was firm, moderately vascular, and densely adherent to the lower cranial nerves and brainstem. Near-total excision was achieved, followed by mesh reconstruction Figure 1.Figure 1: (A) Computed Tomography (CT) brain plain showing hyperostosis. (B) Magnetic Resonance Imaging (MRI) cervical spine plain and contrast coronal imaging showing extension into neck. (C) Post op CT brain plain showing near total excisionHistopathology confirmed psammomatous meningioma (WHO Grade I) composed of meningothelial whorls and abundant psammoma bodies without atypia. Post-operatively, the patient developed transient lower cranial nerve palsy, causing dysphagia, which gradually improved with physiotherapy and nutritional support. He regained adequate swallowing and facial movement by 3 months. The extensive skull base and extracranial spread in a child highlight the rare invasive pattern of otherwise benign meningiomas. Pediatric meningiomas often exhibit distinct molecular and growth characteristics compared to adult forms, occasionally leading to locally aggressive yet histologically benign behavior.2 The RMSO–far-lateral approach provided multidirectional access to the petroclival and upper cervical corridors, facilitating safe dissection while minimizing brainstem traction. Despite transient deficits, children tend to recover better due to higher neuroplasticity.3 Given the benign histology, long-term prognosis is favorable; however, surveillance imaging remains crucial to detect recurrence. Radiotherapy should be reserved for proven progression to avoid late cognitive and endocrine sequelae. This case emphasizes that early recognition, individualized skull base approach, intraoperative neuromonitoring, and structured rehabilitation are vital for optimal outcomes in complex pediatric skull base meningiomas. Declaration of patient consent Informed written consent was obtained from the patient’s legal guardian for participation and for publication of clinical details and images. Acknowledgement We gratefully acknowledge Sri Balaji Arogya Vara Prasadini (SBAVP) for institutional infrastructure support, including advanced operative microscope, neuronavigation systems, and intraoperative neuromonitoring facilities. We also thank the Departments of Radiology, Pathology, and Anesthesia at SVIMS, and the Department of Neuropathology at NIMHANS for their invaluable contributions. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest. Author contributions P.A.K.R.: Conceptualization, methodology, investigation, data curation, writing – original draft preparation, visualization. V.V.R.C.: Validation, formal analysis, writing – review and editing. K.V.K.: Supervision, project administration, resources, writing – review and editing. All authors have reviewed and approved the final version of the manuscript.