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Intrasinusal Meningioma: Maximizing Resection

August 13, 2016

Transcript

Here is another case of a Meningioma within the posterior Superior Sagittal Sinus, or a case of an Intrasinusal Meningioma, let's go ahead and review the principles for resection. This is a 44-year old male who presented with a Parasagittal Meningioma two years before this operation underwent a gross total resection. However, surveillance imaging revealed a growing a recurrent Meningioma within the posterior Superior Sagittal Sinus. And my evolution revealed that most of the tumor is essentially within the dural venous sinus. There is minimal or no adema. This tumor continued to grow on further imaging, a CT angiogram, again demonstrated complete occlusion of the segment of the sinus affected by the tumor. This patient underwent to reopening of his previous craniotomy as this tumor continued to grow, the craniotomy was extended so that the normal portion of the sinus is also identifiable. Here's the torcula transverse sinus. And tree aspect of this supernatural sinus patient is in the lateral position. The dura was opened on both sides of the sinus. Here's the previous area of the resection cavity. The first important principle is to isolate the portion of the sinus that is affected by the tumor, as well as the portion of the falx corresponding to the portion of the sinus infiltrated by the tumor, A lumbar drain was placed at the beginning of the procedure to achieve brain relaxation. Here you can see the exposure of the falx and the normal segment of the sinus, just along the anterior aspect of the tumor. Here's the tumor within the sinus. It's entirely limited into the wall of the sinus. Similarly just posterior to tumor and normal segment of the falx and the dural venous sinus are exposed. Similar maneuvers are repeated on the left side. All the parasagittal veins are protected and you can see the bulk of the tumor within the sinus. Cottonnoid patties are used to maintain the dissection plains. Dural opening is extended to the level of the sinus. and all silk sutures used to ligate the part of a superior sagittal sinus, just anterior to the location of the tumor. Intraoperative MRI or CT venogram may be used for guiding the exact area of ligation. You can see the tumor that is being removed from within the sinus. Capsule of the tumor remains intact Now the falx is being disconnected from the tumor. The hypervascular part of the falx is coagulated before it is cut. Again, using neuro navigation to complete the same set of maneuvers, just posterior to the tumor capsule within the Superior Sagittal sinus and the suture passes all the way underneath the sinus into the falx. The dural sinuses, ligated just distal to the tumor Dural venous sinus is disconnected, just anterior to the it ligated sinus, and the falx in disconnection is completed. Here's part of the dural venous sinus affected by the tumor hemostasis secured. I usually further coagulate the edges of the falx to decrease the future recurrence rates. Piece of allograft duro is used to repair the dural defect. And the postoperative MRI in this case revealed complete resection of the tumor and the affected segment of the dural venous sinus without any complicating features. And this patient recovered from his surgery without any deficits or any signs of venous infarction, thank you.

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