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Giant Sphenoid Wing Meningioma: Commando Operation

October 28, 2019


This video very nicely demonstrates techniques for resection of giant vascular sphenoid wing meningiomas. And more specifically how to handle very bloody tumors in terms of proceeding with a "commando" operation and removing the tumor efficiently, in order to achieve hemostasis most effectively. This is a 52 year old male who presented with confusion and hemiparesis. You can see this very large, relatively medial or middle sphenoid wing meningioma, centered over the medial segment of the sphenoid wing. There is some vascular channels within the tumor suspecting the presence of high vascularity. Here you can see the MCA draped over the posterosuperior aspect of the tumor. Let's go ahead and assess the nature of this tumor with a CT angiogram. CT angiogram, again confirms vascularity of the tumor. VMC branch is draped along the more posterior surface of the capsule and no significant hyperostosis associated with this tumor. Let's go ahead and perform a left pterional craniotomy. An important step, is to drill the roof of the orbit and drill as much of this sphenoid wing all the way to the interclinoid process as you can see at the tip of my arrow. This bone removal, not only removes any potentially affected bone by the tumor, also allows me to heavily coagulate the dura and devascularize the tumor earlier on. This is a very important step, especially for vascular tumors to minimize blood loss and allow efficient removal of the tumor. After this step, the dura is opened and again, the tumor is very much devascularized along its base. As I continue to devascularize the tumor, I ran into fair amount of bleeding. However I persisted, and devascularized the tumor all the way along its base, toward the optic nerve. I had placed a lumbar drain at the beginning of the procedure. This allowed a very nice decompression of the brain so I can mobilize the tumor, without as a significant decompression, find the base of the tumor and not necessarily place the brain under significant tension due to high intracranial pressure. Here is going all the way to the optic nerve, devascularizing the base of the tumor. This is a very important step and strategy for minimizing blood loss. Even this tumor that was devascularized, appeared to still bleeding a lot. I continue to de-bulk it. Second stage after devascularization is de-bulking the tumor. Despite my relative good attempts, the tumor appeared to be very bloody, and therefore I proceeded with efficient resection of the tumor to achieve hemostasis. If I had persisted at every stage to achieve hemostasis, I think I would have lost more blood and this operation would have taken much longer. The tumor was relatively soft with insection of it. This could have been related to aggressive devascularization and some necrosis within the tumor. It's important to inspect the operative blind spots underneath the temporal and frontal opercula to make sure that the tumor is completely removed. Again, fighting through the bleeding, remove the tumor, rather than just spending time at every step to achieve hemostasis. Which would be very difficult in these tumors that have very large vascular channels that are not very amenable to coagulation and hemostasis by bipolar electrocautery. As most of the tumor was removed, I achieved a relatively acceptable hemostasis, consistent with the fact that our plan for a commando operation was reasonable. However, I suspect fair amount of tumor is left behind under the temporal and frontal opercula. Here, again inspecting the area of the edge of the tentorium that you saw a moment ago, making sure that I do not aggressively injure any of the cerebrovascular geranium I suction, which is set as at a relatively high level to remove the tumor. Again, a good gauge of a complete tumor resection is automatic achievement of hemostasis. Here's the optic nerve. I'm opening the retinoid bands in order to relieve more pressure and be able to inspect all the areas to make sure that gross total resection within the basal cisterns is completed. Here's the carotid artery very much stretched over the tumor. Here's the left sided optic nerve and chiasm. Here are the lateral articulate arteries that are being carefully protected, and I'm going to now inspect the other areas. Here, you can see the third nerve, carotid artery, optic nerve, edge of the tentorium. Really beautiful anatomy, A1 MCA. The cisterns and their anatomy are beautiful, worth appreciating. Now I'll go ahead and inspect the operative blind spot underneath the frontal lobe. And you can see a large blood clot located there. I'll go ahead and evacuate the clot. Relatively to my surprise, I find a very large piece of the tumor that was hiding there and it was hemorrhagic. You can appreciate this massive piece of tumor that was missed underneath the frontal lobe. This tumor was removed. Hemostasis was secured. Here you can see the perforators, they're all healthy. I'm making sure there's no residual tumor left. Now that the tumor is completely removed, hemostasis is very adequate, I use pledgets of papaverine soaked Gel foam in order to bathe the server vascular structures with papaverine and relieve their vasospasm and minimize the risk of post operative schema, especially from the perforating vessels. This is an important step during the operation to avoid postoperative morbidity. Here's the three months MRI, which demonstrates growth store resection of the tumor. This enhancement was relatively only scarring and has remained stable at the two year followup MRI as well. There was no evidence of ischemia during resection of this tumor. This patient made an excellent recovery and the hemiparesis resolved after surgery. Again, two important points on using the commando operation, for removal of highly vascular tumors when possible to achieve hemostasis and also inspecting all the operative blind spots to assure growth total resection of the mass and avoiding any surprise findings on post-operative MRIs. Thank you.

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