Parasagittal/Parafalcine Meningioma: Avoiding Ischemia

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Large parafalcine meningiomas can infiltrate and significantly affect the pericallosal arteries, increasing their risk of their resection. Let's go ahead and review the case of this 26 year old female who presented with left sided clumsiness and subtle weakness. And on MRI evaluation was noted to harbor a very large meningioma a parafalcine one, causing significant evidence of mass effect as expected. The tumor is most likely affecting the pericallosal arteries at its deepest pole. This patient subsequently underwent a right frontal craniotomy. Placement of the skull clamp is demonstrated. Lumbar drain was used, but CSF was not drained until the dura was incised. You can see the linear incision, location of the midline, extension of incision toward the contralateral side to expose the superior sagittal sinus. Two burr holes are placed over the sinus, bone flap is elevated. You can see the setup in our operating room. The surgical assistant stands across the table for easy transfer of the instruments. They use of their on rest and chair are advisable. After curvilinear opening of the incision, you can see the dura is reflected toward the superior sagittal sinus. Sutures are placed over the superior aspect of the falx. The tumors devascularized from its space at the level of the falx. Next, the affected part of the falx is removed to assure the contralateral portion of the tumor is also removed. This is an important finding here. One of the pericallosal arteries is very much infiltrated by the tumor and I attempted gross total removal of the mass. in this patient who is very young. However, I was not sure about the collateral support to this vessel. A temporary clip was placed at the proximal aspect of this pericallosal artery and intraoperative ICG angiography demonstrated robust retrograde flow to the level of the clip, as you will see. On this ICG angiogram, you can see the filling goes all the way to the level of the clip. I was definitely assured that I can remove the tumor with relatively minimal risk in terms of distal ischemia, as well as resect the effected portion of the artery by the tumor Here, you can see two permanent clips were placed. The effected portion of the artery was removed. Post operative MRI demonstrates gross total resection of the tumor without any evidence of distal schema. Thank you.

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