Let's review some of the unfortunate events that can occur with the resection of large adherent Medial Sphenoid Wing Meningiomas. This is a 53 year-old female with subtle confusion and mild right-sided hemiparesis. Imaging demonstrated a large Medial Sphenoid Meningioma, significantly encasing a very small caliber ICA and MCA. This tumor was associated with certain level of hyperostosis at the level of the interclinoid process. Here, you can see a portion of the ICA and proximal branches of the M2 that are engulfed by the tumor. She underwent a left frontotemporal craniotomy. An extradural clinoidectomy was completed. And the optic nerve was decompressed early. In addition, the hyperostotic bone infiltrated by the tumor was removed. Here's the optic nerve that's being unroofed. In addition, this tumor was devascularized, extradurally doing this portion of the osteotomy. Drilling continues. The clinoid process was hollowed out. Here is the removal of the clinoid process, generous decompression of the optic nerve as demonstrated here. Next I store the intradural per the operation. Here's the intradural portion of the tumor. You can see the tumor capsule, that is still MCA branches were exposed through the transsylvian route and the tumor was devascularized at its base. Here's the frontal lobe interclinoid fossa and the anterior edge of the tumor that is being devascularized. Next, the tumor is debulked. Again, frontal lobe temporal lobe tumor debulking, or on the left side, to me is quite vascular. You can see some of the vascular structures involved by the tumor. I'm able to find these vessels at the base of the skull. Early identification of the cerebrovascular structures protects them during the early or later stages of the operation. Here's the section of the proximal M-two branches, as well as the ICA within the tumor as demonstrated here. These vessels appear to have very small caliber, most likely caused by the compression of the tumor. All the perforating vessels were carefully protected, tumor appeared again very adherent around the circumference of these vessels. Now, I diverted my attention to where the temporal portion of the tumor, this part of the tumor was also debulked and mobilized away from the anterior temporal lobe. Here's further dissection along the proximal aspect of the ICA. I was not planning to dissect the portion of the tumor adhering to the anterior choroidal artery. Most of the tumor is now removed. Here are the MCA branches and two trunks. The optic nerve is also generously decompressed. Tumor around the canal is evacuated. Small part of the tumor was left behind around the base or the very proximal part of the ICA at the level of the skull base. I did not want to manipulate the anterior choroidal artery or its perforators, to minimize the risk of ischemia. And pulmonary of the Pavin was used around the vessel to minimize the risk of significant vasospasm. You can see this inspection reveals the adherence of the tumor around the circumference of the ICA. Another small piece of the tumor was resectable, despite the measures taken to decrease the risk of post operative ischemia. Unfortunately, this patient suffered from a small perforator infarct. Her hemiparesis worsen after surgery tumors that significantly in case the vessels obviously compromised, the capacity of these vessels for recovery, and additional measures should be taken to minimize the risk of injury to perforating vessels. Thank you.
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