Parasagittal/Parafalcine meningioma: Resection Principles
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Let's review one more time the principles of resection for large parasagittal and parafalcine meningiomas. This is a 32-year-old female, who presented with a seizure. MRI evaluation revealed that a relatively large parafalcine or parasaggital meningioma primarily on the right side with deformity of the falx. There was reasonable amount of edema present, indicating evidence of invasion. You can see that the tumor, is essentially underneath the coronal suture. Patient underwent resection via the right-sided parasagittal craniotomy. Here's this superior sagittal sinus. The dura was incised based on the dural sinus. Epidural hemostasis was secured. Piece of may be used to further a secured hemostasis. Lumbar drain was also utilized at the beginning of the procedure and about 40cc of CSF gradually drained during dural opening. The first and most important step, is aggressive devascularization of the tumor from the falx. Again, CSF drainage allows safe mob position of the brain in the face of cerebral edema and early access to the base of the tumor without its debulking so that the tumor is aggressively devascularized. After the tumor is devascularized, the arachnoid membranes overlaying the tumor are dissected. Surface of the tumor is coagulated. Next, the tumor is mobilized. Here's the phase of tumor debulking. Devascularization of the tumor, sometimes makes the tumor more amenable to removal by means of the suction device. After the tumor is debulked, tumor capsule is dissected away from the brain tissue. Also the capsule is cauterized and reduced. More debulking is performed. You can see the tumor is reduced to a thin capsule. Cottonoid patties are also used to mobilize the brain away from the tumor capsule. Here's the more interior part of the tumor, obviously all the distal A2 branches, have to be carefully protected. After the bulk of the tumor is excised, hemostasis is secured and I divert my attention to the area of the falx. There's a small window created in the falx and then the portion of the falx, that is affected by the tumor is excised. In addition to edges of the falx are heavily coagulated to minimize the future risk of tumor recurrence. I am reaching the level of the inferior sagittal sinus. You can see further coagulation of the falx. In the interior part of the falx is also inspected and coagulated to further minimize the risk of future recurrence. Since this part of the falx was affected by the tumor, it was resected as well. Here is the final view of our resection cavity. Cavity is carefully inspected to make sure no residual tumor is left behind. Here's the three months postoperative MRI, which revealed complete removal of the tumor in the affected portion of the falx. There is no evidence of any complicating feature and this patient recovered from her surgery, uneventfully. Thank you.
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