Recurrent Parasagittal Intrasinusal Meningioma
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Let's talk about resection of intrasinusal parasagittal meningiomas, especially a case of a recurrent meningioma and how the occluded sinus can be resected. This is a 48-year-old female who previously underwent resection of a left sided parasagittal meningioma, however, two years later, demonstrated continued growth of the tumor within the posterior sagittal sinus. Due to her young age and continuous growth of this tumor, she underwent resection. Before undergoing surgery, a CT venogram was performed which revealed complete occlusion of the sinus at the area of the tumor. Similarly, an MR venogram also confirmed occlusion of the corresponding segment of the posterior sagittal sinus. There were no obvious dominant parasagittal veins in the area as well. Therefore resection was noted to be relatively low risk. This is her previous incision, a horseshoe incision. It was teed off to be able to expose the more anterior part of the tumor invading the superior sagittal sinus. Here's the dural opening on both sides of the sinus. Again, the patient is in the lateral position. Here's a flap of the dura. Here's the other flap of the dura. This is the segment of the dural sinus affected by the tumor. Lumbar drain was used at the beginning of the procedure. After CSF drainage through the lumbar drain and brain relaxation, the lobes were mobilized away from the falx and the affected portion of the dural sinus. Essentially, the affected portion of the dural sinus and the falx were skeletonized. An all silk suture was used to ligate the part of the superior sagittal sinus just anterior to the tumor. Similarly, the more posterior part of the dural sinus affected by the tumor was also exposed. Here's the torcula at the tip of my arrow. Cottonoid patties were placed in expectation of passing the all silk suture along or through the superior part of the falx and ligating the part of the sinus just caudal to the tumor. Now that the affected part of the sinus is ligated, we have to resect the part of the dural sinus affected by the tumor. You can see the most anterior part of the tumor that was present upon cutting the superior sagittal sinus. Subsequently, the superior portion of the falx that was not affected by the tumor was also transected. Here's cutting the more posterior part of the affected segment of the dural sinus. This part of the tumor that was involving the dural sinus was also removed using pituitary rongeurs. Here's the extrasinusal part of the tumor. After removal of the affected segment of the sinus, I usually coagulate the part of the falx to minimize the future chance of tumor recurrence. Hemostasis was secured and a piece of allograft dura was used for closure of the large dural defect. Here's the three months postoperative MRI, which revealed gross total removal of the tumor without any complicating features or venous infarction. And this patient made an excellent recovery. Thank you.
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