January 18, 2016
A resection of symptomatic convexity and spinal cord meningiomas, is one of the most satisfying procedures in neurological surgery. This is a 48 year-old male who presented with a generalized seizure, and on MRI evaluation was noted to have a left parietal convexity meningioma. You can see this starburst appearance of the meningioma, which is quite typical. There is also a small neural tails, associated with this tumor. There's also, at times, a cleft of CSF between the cortex and tumor. The vascularity of the tumor is most likely from the posterior branches of the middle meningeal artery. This patient subsequently underwent resection of this tumor. I believe the lateral position is more ideal, as the operative field would be the highest point on the head. However, in this case, we proceeded with the supine position using a bulky gel under the ipsilateral shoulder, turning the head toward the contralateral side. You can see the single pin can potentially interfere with incision, but it is somewhat at the lower pole of incision. And we should be most likely, okay. Most meningioma, especially the large ones require large horseshoe flap, but long linear incisions can be quite effective. And linear incisions tend to heal more efficiently and effectively. Let's review the details of exposure and resection of this mass. Here is again, another view of the incision. The belly of the knife is used to complete the incision. Hemostasis is obtained using bipolar forceps. When the linear incision is used, the subgaleal space is dissected, and the scalp flap is heavily mobilized. You can see further mobilization on the scalp flap, using monopolar cautery. Pericranium is harvested for closure of the dural defect. And a portion of dural will be resected, which is affected by the tumor. I use a T-incision within the temporalis muscle, to effectively mobilize the temporalis muscle. A simple linear incision can often compromise the lateral exposures of the calvarial. Self retaining retractors are positioned in place, and a generous barrel is completed. The use of lumbar drain is very reasonable to provide adequate brain relaxation, and minimizing the risk of brain herniation, during dural incision. You saw some epidural bleeding related to middle meningeal arteries. You can see the hypertrophied poster branches of the middle meningeal arteries, which lead to the center of the tumor. Early devascularization of the tumor is complete. Adequate epidural hemostasis is secured. The dural is opened around the base of the tumor. I make sure all the affected dural resected. Neuronavigation may be used. Again, the edges of the dural are coagulated to reach hemostasis. The affected piece of dural is mobilized in the middle of the resection cavity. An important operative maneuver is the use of long carotenoid patties to mobilize the tumor, away from the brain. First, obviously the arachnoid planes between the tumor and the surrounding peel surfaces are developed. You can see that the maneuver of mobilizing the tumor, and dissecting the planes at the tumor parenchyma interface is quite useful. Now that the tumor has been dissected from surrounding white matter, pre cranium is used to reconstruct it dural defect. Postoperative MRI in this case demonstrates a reasonable resection of the mass. There was some enhancement around the area of resection cavity, which has remained stable for a few years after the surgical procedure, and most likely denotes operative scar, rather than residual versus recurrent tumor. Thank you.
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