Meningiomas originate from the dura mater in the slope and apical region, and are quite difficult to treat because of their deep location and involvement of the central region of the skull base. Currently, surgical resection is still the best treatment option for rock slope meningioma, and the extent of surgical resection will directly affect the prognosis and survival time of patients. Therefore, it has become a long-term research topic and a relentless pursuit for neurosurgeons to remove the tumor as completely as possible, while avoiding or minimizing postoperative complications and improving the quality of life of patients. Surgery for rock oblique meningioma represents one of the most difficult categories of skull base surgery and requires a high level of microscopic skill from the neurosurgeon. The difficulties in surgical treatment are: the tumor occupies a major area and is difficult to reveal; the tumor is adjacent to the brainstem and can involve almost all cranial nerves; and there is a close relationship with important blood vessels and penetrating branches in the basal pool of the brain. The appropriate surgical approach is a prerequisite for the successful resection of rock-slope meningioma. Depending on the relationship with the cranial orientation and the canopy, there are various surgical approaches involved in rock oblique meningioma, which can be roughly divided into supratentorial approach, including inferior temporal approach, transcranial approach and expanded pterygoid point-transtemporal lobe transcranial approach; inferior transcranial approach, including posterior occipital sigmoid sinus approach, transmural approach and inferior distal lateral occipital approach; combined superior and inferior transcranial approach, including inferior temporal-sigmoid sinus anterior approach, etc. The inferior temporal approach is suitable for meningioma in the rock slope area, which is located in the middle cranial fossa, and has the advantages of relatively short surgical route and simple craniotomy. However, the process of temporal lobe elevation during the treatment of large and giant meningiomas in the rock oblique area will inevitably lead to excessive stretching of the inferior temporal gyrus, causing contusion of the temporal lobe, as well as unfavorable preservation of the Labbe vein. The evolution of the transosseous approach is varied, and the degree of resection of the rock bone varies. However, it should be noted that some of the rock tip should be appropriately preserved when grinding away the rock bone to avoid damage to the rock bone segment of the internal carotid artery. The enlarged pterygopoint-trans-temporal lobe transcanal approach is a modification of the pterygopoint approach. By enlarging the pterygopoint incision, part of the temporal pole can be removed to reveal the canal fissure area, and the middle and posterior cranial fossa can be fully exposed after cutting the canal. The advantages of this approach include easy craniotomy, clear anatomy, and good exposure of meningiomas in the middle cranial fossa or huge meningiomas in the posterior cranial fossa that invade the cavernous sinus and paracranial area. Some patients may require temporal pole resection for better visualization, which may also be a criticism of this approach. However, we believe that it may be more beneficial for the patient to have a greater extent of tumor exposure at the cost of removing the temporal pole, which is not functionally important. The posterior suboccipital sigmoid sinus approach is the most commonly used surgical approach for tumors of the pontocerebellar horn and is also indicated for meningiomas of the rocky diagonal region where the main body is located in the posterior cranial fossa growing down the slope, and the supratentorial portion of the tumor can be treated by grinding away the superior crest of the internal auditory canal and cutting the free edge of the cerebellar curtain if necessary. However, the operation needs to be performed within the gap of multiple cranial nerves, increasing the difficulty of the operation and the possibility of nerve injury. The transcranial approach is a type of anterior approach to the sigmoid sinus. This approach is suitable for meningiomas that invade the middle and posterior cranial fossa, especially those located in the middle and upper slopes as well as in the rock-slope area. However, it is still not good for pterygoid meningiomas with extensive tumor base and invasion of the cavernous sinus area, and it does not preserve hearing and has the risk of postoperative cerebrospinal fluid leakage from the ear. The suboccipital distolateral approach is suitable for inferior slope meningiomas, and the location of the distolateral incision can be chosen according to the degree of pressure displacement of the brainstem, so as to minimize the strain on the brainstem. The inferior temporal-sigmoid sinus anterior approach is one of the combined inferior and superior approaches through the rocky curtain, which is the shortest route to the rocky slope area through the inferior temporal and inferior occipital craniotomy, with an open surgical field, good exposure, and lighter brain tissue involvement, and can be operated from multiple views above and below the curtain. However, it takes longer time to open the skull and affects the revealing effect for patients with anterior position of the sigmoid sinus. When the Labbe vein converges into the venous sinus in an anterior position, the temporal lobe elevation may also damage the vein. The resection of meningioma in the rocky oblique area is done in the process of releasing the compression of the tumor on blood vessels, nerves and brainstem, and intra-tumoral resection is done in blocks, eventually approaching and achieving total resection as much as possible. The separation of the tumor envelope from the surrounding normal structures should be performed in the arachnoid plane. Firstly, the tumor should be electrocoagulated and incised in the appropriate area on the surface of the tumor, and the volume and tension of the tumor should be reduced by intratumoral resection first, and then the attachment point of the tumor should be electrocoagulated to cut off the blood supply artery. In most cases, the blood supply of meningioma in the oblique region of the rock comes mainly from the branches emanating from the external carotid artery system or the cavernous sinus segment of the internal carotid artery. The large vessels that may be involved during the surgical operation are the internal carotid artery, the basilar artery, the posterior cerebral artery and the superior cerebellar artery, the anterior superior cerebellar artery and the anterior inferior cerebellar artery. The tumor may push the above vessels out of place or partially encase them, or even encase them completely. In order to separate the tumor from the blood vessels, we should first clarify the course of the blood vessels, reveal the orientation of the blood vessels after adequate intratumoral resection and decompression, create sufficient operating space and direct vision conditions, separate the tumor from the proximal to the distal end of the arterial vessels in the direction of blood flow as much as possible, and avoid excessive pulling of the blood vessels as much as possible. Since the arterial vessels have certain elasticity and the outer sheath is relatively smooth, the tumor can be detached from the vessels more thoroughly in most cases. For cases where the penetrating vessels are wrapped, it is not necessary to force the separation when it is difficult. Another factor affecting the outcome of surgery is the degree of brainstem invasion. According to Kawase et al, the compression of brainstem by tumor can be divided into three levels: Level I, the tumor pushes on the brainstem, but the arachnoid interface between the two exists, and there is no or only a slight degree of subarachnoid invasion; Level II, the tumor invades the subarachnoid space and wraps the soft meningeal artery, so that the arachnoid interface between the tumor and brainstem disappears; Level III, the tumor causes the soft meningeal artery in the brainstem to disappear. In Grade 3, the tumor causes destruction of the soft meninges of the brainstem, and there is no clear arachnoid interface between the tumor and the brainstem, or even infiltrates into the brainstem, and the brainstem develops perineural edema. When the relationship between the tumor and surrounding blood vessels and nerves is relatively simple and the arachnoid membrane boundary between the tumor and brainstem exists, total resection of the tumor can be achieved. However, when the compression of the tumor on the brainstem reaches grade II or grade III, if the tumor is forcibly separated from the brainstem, it will inevitably cause contusions on the brainstem and lead to serious complications. Nerve decompression should also be moderate, and try to avoid nerve paralysis caused by thermal stimulation of electrocoagulation. If the nerve is displaced by the tumor, a cotton pad can be used to slowly push away the adherent tumor; if the nerve is completely wrapped by the tumor, a small amount of residual is acceptable. Although there are many surgical approaches for meningioma in the rocky diagonal area, each has its own advantages and disadvantages, and it is difficult to have a perfect approach. In the surgical management of meningioma in the rocky diagonal region, a proper surgical approach can provide good exposure and lay the foundation for complete resection of the tumor as much as possible. The choice of surgical approach should reflect the concept of “simple and less invasive”, rather than just pursuing the complexity of the approach. Some classical approaches commonly used in clinical practice can be improved and explored to achieve good results. In addition, the characteristics of the meningioma itself can also affect the final extent and outcome of resection. When the tumor is too large, too hard and rich in blood supply, it is very difficult to complete total resection. For tumors with posterior circulation involved in blood supply, the soft meninges of the brainstem may be involved and should be appropriately residual to avoid brainstem ischemia when excessively stripping the tumor. Tumors with soft texture are easier to be removed by aspiration. Some tumors, although huge, have average texture, less rich blood supply and less complicated relationship with blood vessels and brainstem, so total resection can be attempted. Samii M et al. proposed that the posterior cranial fossa tumor should be resected through the posterior-superior occipital sigmoid sinus approach to decompress the brainstem, and then the supratentorial part of the tumor located in the middle cranial fossa should be resected through the frontotemporal approach to complete the decompression of the optic nerve, articulocutaneous nerve and internal carotid artery. The treatment of a huge supratentorially extensive meningioma also provides us with new ideas. In the surgical treatment of meningioma of the rock oblique area, the neurosurgeon should first analyze all factors of the patient, including age, physical condition and the characteristics of the tumor itself, to determine the possibility of total resection and decide on the appropriate treatment plan and surgical approach. In the process of surgery, we should be familiar with the anatomical structure, fully reveal it, and control the bleeding at an early stage. In the process of decompression of blood vessels, nerves and brainstem, we should operate under direct vision as much as possible, and achieve a moderate pull, a combination of blunt and sharp separation, and a combination of fast and slow. Always control the surgical process, balance the resection results and pay the price, and achieve the trade-off. Do not over-emphasize the total resection of tumor, and should maximize the resection of tumor while preserving the patient’s nerve and vascular function to improve the patient’s quality of life.