Parieto-Occipital Interhemispheric Transfalcine, Trans-Bitentorial Approach for Radical Resection of Falcotentorial Meningiomas

Surgical Treatment of Falcotentorial Meningioma: An Illustrative Case Report and Literature Review

Falcotentorial meningiomas are rare tumors, representing only 2-3% of all intracranial meningiomas. These tumors can grow rapidly, leading to severe neurological complications. They grow at the junction of the tentorium cerebelli and the falx cerebri, in close proximity to the great vein of Galen. The surgical approach depends on several factors, such as the tumor's size, the patency of the straight sinus, and its location, either above or below the tentorium. Complete removal of the tumor in this area is difficult due to its deep location near major neurovascular structures. Various surgical approaches can be employed to remove these tumors, and the decision on which approach to use should be based on its advantages and disadvantages.

Combined supracerebellar infratentorial and right occipital interhemispheric approach to falcotentorial junction meningioma: A case report

Background

Falcotentorial meningioma is a rare tumor of pineal region, arising from the dural folds where the tentorium and falx meet. Due to the deep location and near closeness to significant neurovascular structures, gross-total tumor resection in this area can be complicated. Pineal meningiomas can be resected using a variety of approaches; however, all these approaches are associated with a significant risk of postoperative complications.

Case Description

A 50-year-old female patient who presented with several headaches and visual field defect and diagnosed with pineal region tumor is discussed in the case report. Patient was successfully managed surgically by combined supracerebellar infratentorial and right occipital interhemispheric approach. Cerebrospinal fluid circulation was restored after surgery and neurological defects were regressed.

Conclusion

Our case shows that it is possible to completely remove giant falcotentorial meningiomas with minimal brain retraction, preserve the straight sinus and vein of Galen, and prevent neurological impairments by combining two approaches.

Falcotentorial Meningiomas: Optimal Surgical Planning and Intraoperative Challenges - Case Report and a Review

Meningiomas arising from the falcotentorial junction are rare, and the selection of the optimal surgical approach is essential. We report a falcotentorial meningioma (FTM) case approached by occipitotranstentorial resection and subtotal tumor resection presenting a satisfactory clinical outcome. The present review sought to reveal the current knowledge regarding the clinical presentation, radiological imaging, and the microsurgical anatomy of FTMs as a form of improving the surgical approach. The selection of the optimal surgical approach is essential for the safe and effective removal of an FTM. Preoperative imaging analysis should identify the anatomical relations of the tumor and guide toward the least disruptive route that preserves the neurovascular structures.

Combined Microscopic and Endoscopic Surgery for Pineal Region Meningiomas Using the Occipital-Parietal Transtentorial Approach

Objective

Pineal region meningiomas are deeply located and adjacent to critical neurovascular structures, making them one of the most challenging areas to access. The authors presented a combined microscopic and endoscopic surgery and investigated its value in resecting pineal region meningiomas.

Methods

Twelve patients with pineal region meningiomas from February 2017 to December 2020 were retrospectively reviewed. All patients underwent combined microscopic and endoscopic surgery using the occipital-parietal transtentorial approach. Perioperative clinical, surgical, and radiographic data were collected.

Results

The endoscope provided a wider view and increased visualization of residual tumors. All tumors were completely resected, and none of the patients died. Total resection was believed to have been achieved in four patients, but the residual tumor was detected after endoscopic exploration and was completely resected with an endoscope. Only one patient had transient visual field deficits. No recurrence was observed during follow-up.

Conclusions

Combined microscopic-endoscopic surgery for pineal region meningiomas eliminates microscopic blind spots, thus compensating for the shortcomings of the traditional occipital transtentorial approach. It is a promising technique for minimally invasive maximal resection of pineal region meningiomas.

Surgical management of tentorial meningiomas: case series

Background

There are several surgical strategies involved in the treatment of patients with tentorial meningioma, and choosing the most appropriate one is not straight forward. Our study aims to illustrate our experience in the management of tentorial meningiomata at our center.

Results

This study included 32 patients with tentorial meningiomas, operated upon, with assessment of the extent of resection and the Glasgow outcome score (GOS). The mean age at the time of surgery for the studied group was 48.4 years ranging from 20 to 70 years. Total removal was considered as Simpson grade I or II and was achieved in 26 cases (81.25%). Subtotal removal was considered as Simpson grade III or IV and was achieved in 6 cases (18.75%). The final Glasgow outcome score (GOS) for all cases was GOS 1 in 4 cases (12.5%), GOS 4 in 9 cases (28.2%), and GOS 5 in 19 cases (59.3%).

Conclusion

Tentorial meningiomas can be very challenging during surgery due to their proximity to vital structures. Subtotal resection should be considered when total removal can be hazardous to the patient or result in severe morbidity.

Angiographic classification of the inferior sagittal sinus based on the venous drainage patterns

PURPOSE

The inferior sagittal sinus (ISS) and its tributaries have received little attention because of its inconspicuous appearance, and its anatomical variations are also unknown. This study aimed to evaluate the morphological variations of the ISS.

MATERIALS AND METHODS

We retrospectively reviewed 518 patients in whom cerebral angiography was clinically indicated. The detailed angioarchitecture of the cerebral venous system, including the ISS and their tributaries, and the morphological variations of the ISS were evaluated. Abnormalities of the rostral third superior sagittal sinus (SSS) were also evaluated.

RESULTS

The ISS was visualized in 270 (52.1%) patients. We proposed an angiographic ISS classification according to the venous drainage patterns: Type 0, not visualized; Type 1, small ISS with faint tributaries; Type 2, moderate ISS with developed tributaries; and Type 3: large ISS with well-developed tributaries, which are responsible for the venous drainage of the anterior frontal lobe. The frequency of each ISS type was as follows: Type 0, 248 (47.9%); Type 1, 211 (40.7%); Type 2, 44 (8.5%); and Type 3, 15 (2.9%). The mean ISS size was significantly larger with an increase in the type of ISS (p < 0.0001). The rostral third SSS hypoplasia was observed in all cases of Type 3. The hypoplasia of the rostral third SSS and development of the ISS were strongly correlated and complementary to each other.

CONCLUSION

This study provided the angiographic ISS classification, and our proposed angiographic ISS classification could be helpful in better understanding of the ISS anatomy and its venous drainage pattern.