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Medial Parieto-occipital Glioma: Transfalcine Approach

January 19, 2016


Let's review a resection of a large Medial Parieto-Occipital Glioma to discuss the maximum reach of The Transfalcine Approach for resection of periatrial tumors. This is a 52 year old female who presented with intractable headaches and nausea. And on MRI evaluation was diagnosed with a relatively large heterogeneously enhancing mass within the area of the medial parieto-occipital area around the area of the trigon. The approaches for resection of the mass include the transcortical approach, which will most likely place the optic radiation at risk. I chose to use the transfalcine approach in this case, coming from the left side and going across the falx to avoid the optic radiations and hope for maximum resection of the tumor. Obviously the large size of the mass and its extensive anterior expansion, tests the far reach of the transfalcine approach. Let's go ahead and discuss what I found out in surgery. The left side was placed down so that the unaffected hemisphere is under gravity retraction. A lumbar drain was used, again here's the unaffected hemisphere. This is this super sagittal sinus, the craniotomy extended toward the side ipsilateral to the tumor. Here's the unaffected hemisphere, CSF drainage relaxes the normal hemisphere. The bridging veins are untethered. One of the smaller ones is sacrificed and the larger ones again are mobilized from their adherent bands. Two retraction sutures are placed over the superior aspect of the falx to mobilize the sinus out of our operative corridor. The dural incision was extended more medially. Some bleeding from the edge of the sinus was encountered. In this situation, further use of the bipolar forceps is not productive and can lead to further bleeding. As you will retract and shrink the torn dura, a suture is the most effective way to tie off the site of the bleeding. Neuro navigation guides the operative trajectory since this tumor is very posteriorly located. I have to be very careful with the falcotentorial junction and avoid injury to the venous lakes around this straight sinus. The first falcine incision is parallel to this superior sagittal sinus extending anteriorly. Here is the parieto-occipital junction. Here you can see the falcotentorial junction and the straight sinus. One again has to be careful to stay away from this junction. The other cut again, angles obliquely anteriorly to avoid the Falcotentorial junction, the inferior sagittal sinuses, coagulated and cut. Here's the final cut to release the falx. The two falcine flaps are mobilized using sutures. Now we enter the precuneus to reach the tumor tangentially. You can see the discoloration of the tumor along its medial capsule. Angiogenesis corticotomy is completed. The tumor appears very necrotic, consistent with a high grade glioma. This tumor proved to be highly vascular. It would have been beneficial if I had stayed around the capsule of the tumor rather than debulking it first. The only definitive way for me to control the bleeding was to continue to remove the tumor and try to find the pre-tumoral areas as you can see here. So I continued tumor debulking in the face of bleeding. You can see the bleeding under better control after the relatively normal white matter is encountered. The capsule of the tumor again is mobilized. The temporal horn was encountered. You see the choroid plexus. The blind spot of the surgeon is really along the superior aspect of the resection cavity underneath the affected hemisphere parieto-occipital junction. And here's an area that the surgeon has to be very careful not to leave tumor behind. The falx was further incised superiorly toward this superior sagittal sinus so the operative blind spot is reduced. Additional sutures are placed within the edges of the falx. Again, these are modifications of this technique in order to expand its operative corridor. Now I can see further underneath the lip of the normal cortex. Here is additional tumor that is being removed until the relatively white glistening pre-tumoral area is identified. Here is the temporal horn as well as the area of the trigone. Further inspection reveals no obvious evidence of residual tumor. The falcine flaps are returned to their normal position. You can see all the parasagittal veins are intact. The dura is approximated. The post operative MRI demonstrates good resection of the tumor without any complicating features. You can see that the area of the optic radiations is very much intact and this patient did not suffer from any visual deterioration after surgery. Thank you.

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