Parasagittal Meningioma: Principles of Resection

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Let's talk about another classic parasagittal meningioma, and techniques for advancing resection of these tumors. This is a 50-year-old male, with progressive left-sided weakness. MRI evaluation reveals the typical starburst appearance of this meningioma. The enhancement pattern was somewhat unusual for this meningioma. You can see that the majority of the enhancement, actually, is at the periphery, and the area of the septation within the center of the tumor. The tumor is primarily based over the angle between the falx and the convexity dura, and most likely also involves part of the falx, within the internal hemispheric space. I prefer the linear incision because it heals better. You can see the midline is marked with a shorter, straight line. The head positioning and placement of the skull clamp are rather standard. Here's the performance of the craniotomy. Obviously one of the other advantages of the linear incision, is that I can stay behind the hairline. Therefore, this incision configuration is more cosmetically acceptable. Two burr holes are placed just about over the superior sagittal sinus. I like to use a lumbar drain at the beginning of the procedure, to slowly and gradually drain CSF, and achieve brain decompression, so that the dura can be readily dissected away from the inner aspect of the calvarium. Also, the superior sagittal sinus can be readily dissected away from the bone with lumbar CSF drainage. The initial bony cut is placed over the convexity. The last bony cut is placed, or performed, over the superior sagittal sinus. Following elevation of the craniotomy. You can see the extent of dural exposure. The dural incision is based over the superior sagittal sinus. The tumor is initially devascularized from the falx and the dura. You can see the aggressive decompression, but more important, the devascularization tumor, where it's based over the falx. Now that part of the tumor is decompressed and the mass is significantly devascularized, I will go ahead and dissect the tumor, and the capsule of the tumor away from the surrounding brain. Sharp dissection is always preferable. All the adhesions are disconnected. The tumor may be coagulated, so it's reduced and shrunken away from the brain peel surfaces. Here's the aggressive decompression of the tumor. Internal debulking continues. Internal debulking allows mobilization of the tumor capsule away from the brain, atraumatically. Now the capsule is delivered, while carefully watching for pericallosal and callosomarginal arteries. Postoperative MRI demonstrates excellent resection of the tumor, without any untoward effects. Thank you.

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