Bilateral Parasagittal Meningioma with Sinus Invasion

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Let's review techniques for a section of parasagittal meningiomas with involvement or occlusion of the corresponding segment of the superior sagittal sinus. This is a 62 year old male with a single seizure. MRI evaluation revealed a parasagittal parafalcine meningioma affecting the midsection of the superior sagittal sinus. MRV evaluation revealed complete occlusion of this segment of the superior sagittal sinus interfacing the tumor. However, there is a prominent parasagittal draining vein that is intact and enters the patent segment of the sinus, just along the posterior border of the tumor. A bilateral parasagittal craniotomy was elevated, portion of the tumor on both sides of the superior sagittal sinus, as well as the segment of the sinus affected by the tumor were removed. I used six sutures to ligate the most interior part of the tumor interfacing the patent part of the superior sagittal sinus. The tricky part of removal of this tumor, is its posterior section and this video focuses on this part of the surgery. You can see the part of the falx affected by the tumor. Here are the portions of the tumor on both sides of the falx that are being removed piecemeal. Now, I focus my attention towards the posterior portion of the tumor. You can see the prominent vein that I suspected on preoperative MRV. The effected section of the falx is being resected. One has to be careful not to injure the pericallosal arteries located just along the inferior edge of the falx. Now the portion of the falx that is affected is being mobilized posteriorly. The posterior border of the falx affected by the tumor is also being disconnected, all this mess obviously is not safe. Now I investigate the feasibility of removing the tumor engulfing this prominent vein. I now feel aggressive removal of the tumor at the expense of placing this dominant vein would be warranted. This vein appears patent on ICG angiogram, and therefore I felt a small piece of the tumor had to be left behind to protect the vein. Postoperative MRI demonstrated good resection of the mass without evidence of venous infarction. I think this video emphasizes the importance of preserving the parasagittal dominant veins for the meningiomas that affect the middle third part of the superior sagittal sinus. Same principle applies for those meningiomas affecting the posterior one third of the superior sagittal sinus. I do not believe a resection of segments of the sinus that is partial occluded is warranted as the benefits of resection outweighs the risk of venous infarction in this area. Thank you.

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