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Petrotentorial Meningioma: Suprameatal Approach

November 04, 2015

Transcript

Let's discuss another case of a petrotentorial meningioma and also review some of the technical neurosis related to the resection of this mass. This is a 52 year-old male who presented with trigeminal neuralgia. MRI evaluation demonstrated a small meningioma at the level of the junction of the tentorium and the petrous bone dura. The tumor appear to also infiltrate the more medial portion of the Meckel's cave. A right-sided, retromastoid craniotomy was completed. Here's a location of the sigmoid sinus, transfer sinus. The dural was opened along the venous sinuses and meningeal arterial ranch was coagulated and cut. Here you can see the tumor, the petrous bone dura, the tentorium, the junction of the two, the superior petrosal vain is infiltrated by the tumor. This vein will be coagulated and cut. Subsequently I dissect around this small tumor to be able to identify the neurovascular structures early. Early identification of these structures obviously keeps them out of harm's way. Here's more medial capsule of the tumor. I'm devascularizing some of the tumor capsule, the tumor appears quite fibrous and it's resisting easy debulking. It also appears to be very adherent to the root entry zone of the trigeminal nerve. I continue the use of sharp dissection, as much as possible. You can see more anterior capsule of the tumor and the trigeminal nerve that is being displaced and compressed by the tumor capsule. Here's a more healthy part of the trigeminal nerve. Again further debulking has completed. Tumor appears quite fibrous. Devascularization of the tumor along the petrous dura is quite important. Here, there is the more inferior capsule of the tumor that is been shredded away from the petrous dura and its entry into the Meckel's cave. I continue to remove the tumor that is infiltrating into the Meckel's cave, using Pituitary Rongeurs. Here's the seven and eighth cranial nerve along the inferior aspect of our operative corridor. Continuation of my sharp dissection to mobilize the tumor from the posterior wall of the trigeminal nerve. Here is the portion of the tumor. Again, following the nerve into the Meckel's cave. This part of the tumor is also being gently pulled out and removed. Additional piece of the tumor through the Meckel's cave is removed. Part of the bone over the only tubercle can be removed to expand operative corridor into the Meckel's cave. As you can see here, I continue to gently curate away the bone and pour the tumor that is infiltrating the Meckel's cave. The nerve appears much more released now. Here's the last pieces of the tumor through the Meckel's cave. You can see the bone over the tubercle was drilled away using this superior medial approach. To expose the part of the Meckel's cave infiltrated by the tumor. The nervous is quiet intact. Small piece of the tumor remaining is being further dissected. I don't see any other obvious tumor visible at the end of our resection. Here's the funnel operative corridor And the post-operative MRI demonstrated complete removal of the tumor. Including its segment that was infiltrating the Meckel's cave. And this patients trigeminal neuralgia resolved postoperatively. Thank you.

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