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The purpose of this article is to detail our experience in treating 69 patients over the past 6 years with pathologic processes involving the petrous apex. These included 25 (36%) primary petrous apex lesions, 40 (58%) lesions that involved the petrous apex by direct invasion from an adjacent region, and four (6%) lesions that were the result of metastatic spread from a distant site. Although lesions of the petrous apex are uncommon, they may present significant morbidity to the patient. The symptoms elicited by these lesions are usually vague and nonlocalizing in the early stages but may progress to include multiple cranial neuropathies. Successful results are contingent on early diagnosis, which requires a high index of suspicion and use of appropriate imaging modalities. Thorough preoperative assessment with use of computed tomography, magnetic resonance imaging, and carotid arteriography is essential to plan the surgical approach. We present this collection of patients in order to aid in the further preoperative characterization of the differences in primary and secondary lesions of the petrous apex.