Peri-atrial Meningioma: Transfalcine Approach

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This is another video in this series of procedures aimed at resection of pre-atrial tumors using the contralateral poster interhemispheric transfalcine transprecuneus approach. This is a 62 year old female who presented with confusion and headaches and underwent imaging which demonstrated a left sided tumor within the trigone of the lateral ventricle. The tumor is relatively homogeneously enhancing, associated with a minimal amount of edema, intimately involved with the choroid plexus and potentially with a dural tail along the choroid plexus. The differential diagnosis obviously contains a meningioma, which turned out to be the final diagnosis in this patient. As discussed in the transfalcine approach chapter, there are numerous ways to approach this tumor, including that transtemporal approach, potentially the subtemporal approach or the interhemispheric ipsilateral approach. All of these approaches are either associated with significant amount of retraction or potential transgression of speech codesis. The contralateral interhemispheric transfalcine approach provides a favorable trajectory to remove this tumor. Importantly, it allows early devascularization of the tumor from its vascular pedicles from the choroid plexus, and also allows early identification of the vital ventricular walls. This patient was placed in the lateral position with a normal hemisphere down so gravity retraction can be used for mobilization of the right hemisphere. Lumbar drain was installed at the beginning of the procedure. The incision extends to the affected side so that the superior sagittal sinus is unroofed. The use of lumbar drain is especially important in these cases. You can see the sutures along the falx. Moving this superior sagittal sinus gently out of the way. Gravity retraction is mobilizing the ipsilateral brain. The falx is cut in a shape of a T. You can see the portion of the T parallel to the contour of the super sagittal sinus. The precuneus over the tumor is exposed. The two falcine flaps are reflected over pieces of Cottonoid. CSF is drained via the lumbar drain and an incision within the precuneus exposes the tumor. You can see early identification of the tumor and its pedicle from the choroid plexus. I go ahead and devascularize the tumor early on after it's slightly debulked so I can avoid significant brain retraction to reach the pedicle of the tumor. You can see the choroid plexus here, that part of the plexus that is adhering to the tumor and providing its feeding vessels. Here is the wall of the ventricle exposed early on and protected during our dissection. The capsule of the tumor is reduced after the tumors further debulked using ultrasonic aspirator device. Early devascularization of the tumor is very advantageous in minimizing blood loss and providing a clear operative field during the dissection. Here's the more poster aspect of the tumor that is also been dissected from the walls of the ventricle. Cottonoid patties are used to maintain this section plains inferiorally and allow drainage of the blood into the remaining ventricular spaces. Here's the dissection of the tumor again across the effected ventricular wall. Here's dissection along the inferior aspect of the capsule. Here's the portion of the ventricle wall that has been very much intimately involved with the tumor. Here's the larger piece of the tumor removed. Here's the funnel view of the resection cavity, superior sagittal sinus. Here's interior, here's posterior, the unaffected right hemisphere. The transcortical incision within the precuneus, up there the falcine flaps have been reflected. You can see the amount of transgression of the normal brain is relatively small. During closure, the falcine flaps are not sutured but just mobilized to their normal anatomical position. A ventricular catheter was placed because of the bleeding during tumor resection within the ventricle. Three months post operative MRI demonstrates postal remove the tumor without any significant transgression of the normal brain. Incidentally, there was another small, an edema along the junction of the falx and the tentorium that was left untouched during the operation. Thank you.

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