Staged microsurgical resection of supra-/parasellar meningioma with cavernous sinus exenteration and carotid-to–middle cerebral artery bypass

Atypical skull base meningiomas are characterized by aggressive growth and neurovascular invasion, which complicate resection and predispose to high recurrence rates. Lesions encasing major vessels and cranial nerves or refractory to surgery and radiation therapy are associated with significant morbidity, while systemic therapies remain largely ineffective despite ongoing trials. Their management, therefore, necessitates advanced microsurgical strategies. We describe a radiation-induced WHO grade II atypical meningioma extensively involving the cavernous sinus, supra-/parasellar, and petroclival regions in a patient with 6 prior surgeries, 2 Gamma Knife treatments, and multiple systemic therapies, presenting with ophthalmoplegia and right-eye blindness, treated using a three-stage surgical approach. The video can be found here: https://stream.cadmore.media/r10.3171/2025.10.FOCVID25163.