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Bilateral Frontal Parafalcine Meningioma: Vascular Adherence

August 17, 2016


Here is a video of bilateral frontal parafalcine meningioma, partially calcified with significant vascular encasement. This is a 52 year old male who presented with progressive gait imbalance. MRI evaluation revealed a relatively large bilateral and anterior parafalcine meningioma. You see the prominent, peripheral calcification and some evidence of edema. Distal ACA branches, including paracollosal arteries are very intimately associated with the inferior capsular of this tumor, most of these highly calcified tumors tend to encase the vessels pretty aggressively, therefore complicating removal of the tumor. Patient underwent a right sided para sagittal craniotomy here is the Medline, a relatively small linear incision is more than adequate to remove both the right and the left sided, parafalcine meningioma through the transversal in approach. Lumbar drain was also installed at the beginning of the procedure. Approximately 40 CC of CSF was drained. So that early brain decompression is achieved. You can see the dura is being cut based on the location of the important parasagittal veins. Suture is placed into the superior falx so that the superior sagittal sinus is gently retracted. And the inter hemispheric fissure is entered without significant evidence of brain retraction. The interior hemisphere quarter was entered and the first and most important step is aggressive devascularization of the tumor from the falx. Here's the step for devascularization of the mass from the falx as aggressively as possible. Here again, you can see how the dura was opened and adjusted based on location of the important large parasagittal draining vein. I'll continue to devascularize the tumor aggressively, reasonable portion of the tumor has been devascularized. Walking along the falx I further devascularized the tumor. Here some of the distal branches of the, ACA that are being protected. You can see how useful the lumbar drain is for decompressing the brain and allowing early devascularization of the tumor without necessarily significant on the tumor. After tumor is aggressively devascularized I'll go ahead and debulk the tumor. De-bulking can be performed in various ways, including cutting the tumor. In this case, the tumor was quite calcified at its periphery, and therefore a knife was used to cut into the capsule. As the tumor is debulked the capsule can be further mobilized away from the brain. Capsule is coagulated, so the tumor mass can be shrunken. Obviously more aggressive tumor decompression is in order Ultrasonic aspirator is especially useful. Now that the tumor is more debulked, the capsule can be mobilized more aggressively away from the brain. Again, the distal branches of the ACA are recognized. Dissection is carried out under high magnification. Preparing soak gel foam may be used as necessary to relieve vasospasm. You can see how I continue dissecting along the vessel. Further tumor debulking will, although flexible working angles during tumor mobilization and fine microsurgery around the vessels. Here, you see the tumor in, cut across parallel to the axis of the artery. Further tumor debulking in progress. Here's the portion of the brain that was affected and whose peer was violated by the tumor capsule. You see how I use the suction to hold the tumor away from the brain while the ultrasonic aspirator debulks the mass. Again, you see the significant vascular inner casement, as it was expected on preoperative MRI, based on significant peripheral calcification of the tumor. I continue to further de-bulk the tumor away from the artery. The suction device marks the location of the artery and make sure that ultrasonic aspirator is not inadvertently too close to the vessel. Here's corpus callosum. Distal, a two branches. The tumor mass is reduced to a very thin shell so that the tiny capsule or the very thin capsule can be mobilized away from the callosum marginal artery. Any feeding vessel that directly enters the tumor is coagulated and cut. One more time you can see how the suction device holds the tumor away from the artery while the ultrasonic aspirator enucleates the tumor with continued mobilization of the tumor. At times, I place a small carotenoid patty over the vessel so that the tumor can be debulked without the ultrasonic aspirator device placing the artery at risk. Now that most of the tumor on the right side is removed. The phase of tumor resection starts a window within the falx is created. Obviously this window is in the periphery of the tumor going across toward the other side. You can see the mass of the tumor affecting the left hemisphere. A switcher is placed within the falx so that it's mobilized out of our working space. Here's a more de-magnified view of our operative corridor. Very similar steps are repeated, so the tumor on the left side is also removed. The tumor capsule is shrunken again, away from the brain. Further debulking is followed by identification of the distal ACA branches over the corpus callosum. Now I'll go ahead and focus my attention on the anterior pole of the tumor, where the capsule is mobilized away from the pericallosal arteries. Here is again, the dissection process, more along the anterior pole tumor. All the arachnoid bands are mobilized away from the tumor capsule. You can see that ample amount of dissection is necessary to be able to preserve almost all the distal ACA branches. More and more time following the transmarginal artery along the anterior pole of the tumor toward the pericallosal arteries and see how incased these vessels are in the copious calcification noted on the periphery of the tumor. Short dissection along the vascular wall continues. One has to remember that ample amount of preparing soak gel foam is used to relieve the vasospasm periodically. In here's part of the singulam on the left side, gently mobilizing the vessel away from the inferior capsule of the tumor. Very thin shell of the tumor is being mobilized again from the distal ACA branches. This portion of the vessel is especially engulfed by the capsule of the tumor. I'll go ahead and attempt dissection of the vessel away from the tumor mass. For this, portion of the vessel is somewhat dissectable. This is again, the more posterior capsule of the tumor. You can see some of the smaller vessels that are entering the tumor. These should be coagulated and sharply cut. Unfortunately, one of these vessels was avulsed if such and even a purse, I use a piece of thrombin soaked cotton and cover the defect. And some tamper node usually controls the bleeding. The piece of cotton is left behind. Micro-Doppler ultrasonography revealed patency of the vessel. This large piece of the tumor was subsequently delivered the vessels look healthy, very pulsatile. I'm happy with the extent of resection. Additional inspection of the resection cavity is performed. Pericallosal arteries appear very healthy. More demagnified view of the operative cavity. You can see removal of bilateral parafalcine meningiomas via right-sided transversal in approach, further inspection of the vessels using micro-Doppler ultrasonography and a three months MRI revealed gross total resection of the tumor, no complicating features. And this patient did extremely well after the surgery. Thank you.

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