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Anterior Olfactory Groove Meningioma: Transfalcine Approach

January 05, 2016

Transcript

Let's talk about methods to improve an advanced resection of Anterior Olfactory Groove Meningioma. This is a 43 year old female who presented with a seizure and confusion. And an MRI evaluation was run to have a meningioma located anterior in the cranial fossa. The tumor caused some vascular edema on the left, in the left frontal lobe. You can also see the extent of the tumor around crista galli infiltrating the anterior part of falx cerebri. So we're going to discuss some of the methods to advance resection of this tumor, infiltrating the crista galli and anterior cranial fossa, and the falx cerebri. A left frontotemporal craniotomy was completed. Here's the roof of the orbit, the dura was reflected anteriorly. Here is the area of the tear here on the left frontal lobe. I'll go ahead and devascularize the tumor early on, along the base of the tumor. Here's an oraple suspic of the tumor and the olfactory nerve. Early devascularization is important. Here's going across the tumor toward the contralateral side. Now that the tumor is mainly devascularized, the tumor is debulked and mobilized away from the frontal lobe. A cotton is used to wipe the brain away from the capsule of the tumor while the tumor is mobilized away from the brain. Here's again, the entire part of the tumor that is being mobilized. Knowing that the tumor is also tethered to a crista galli and the falx. Here is a more de-magnified view of our operative cavity for your orientation. Here's the dura on the contralateral anterior cranial fossa. Tumor is being disconnected from the frontal lobe. Next, the tumor is delivered. Now I focus my attention on the part of the dura and the falx that is affected by the tumor. You can see the tumor is infiltrating the anterior aspects of falx cerebri. Here is crista galli, apparently the crista galli is not affected by the tumor. I thread the dura over the anterior cranial fossa to assure complete removal of the tumor because of the contours of the orbital roof. There is a blind spot more medially, just lateral to the crista galli that can contain tumor. After this area has been well curated away, I'll go ahead and cut the portion of the falx affected by the tumor. You can hear a crista galli, the portion of the tumor that is very adherent to the entire part of the falx. I cut the falx just at the level of the crista galli, protecting the contralateral medial frontal lobe. The angle of transection in this location requires use of a knife. It's a portion of the anterior cranial fossa that's feeding the tumor through anterior ethmoidal arteries. Again, the part of the falx that's affected by the tumor is removed in total. There's that piece of the falx that was affected by the tumor. The more superior part of the portion of that falx is removed now. The rest of the surrounding areas of the falx cerebri are heavily coagulated to minimize the risk of future recurrence. The edges are carefully inspected to make sure no residual tumor is left behind. More tumor was found just on the other side of the falx, and therefore I'm going to remove a more superior portion of the falx as well. Use of dynamic retraction to mobilize the frontal lobe assist with adequate exposure. You can see the area of the crista galli, the portion of the falx that was removed. Everything looks relatively clean. No obvious tumor is apparent. Here's the final result. And the postoperative MRI clearly demonstrates gross total removal of the tumor. No evidence of residual tumor in the anterior aspect of the falx, and there is no complicating features. Thank you.

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