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Small Medial Sphenoid Wing Meningioma

July 09, 2014

Transcript

Let's talk about resection of a medial sphenoid wing meningioma. This is a 45 year old female who suffered from right-sided progressive visual field decline. MRI evaluation revealed a relatively small medial sphenoid wing or a clinoidal meningioma infiltrating the optic canal. There is minimal amount of edema associated with this tumor. Patient underwent the right frontotemporal craniotomy, right temporal lobe, frontal lobe. The anterior limb of the Sylvian fissure was dissected. Inside to outside technique was used to identify the MCA branches early on within the fissure. Extension of the fissure split is noted. Here's the tumor along the interclinoid process. The arachnoid bands over the MCA branches. Here's the bulk of the tumor, olfactory nerve. Sub frontal trajectory toward the tumor. Here are the MCA branches draped over the posterior capsule of the mass. These MCA branches are micro surgically separated. Next the tumor is devascularized along its base over the dura of the anterior clinoid process. Heat injury to the optic nerve is avoided. it's best to identify the location of the nerve as early as possible. I continue to dissect along the anterior pole of the tumor, hoping that I can find the nerve or at least approximate it's location. Here you can see the nerve entering its foramen. Now I continue more aggressive devascularization since I'm aware of the location of the nerve. Tumor is also debulked. Now it's dissected from the subfrontal area. Further debulking is performed. I continue to mobilize the tumor away from the optic nerve. You can see portion of the tumor herniating into the canal. Here's the optic nerve. Most of the manipulation occurs at the level of the tumor capsule versus on the nerve. More debulking is warranted at this stage. The tumor is further devascularized away from the nerve. Now the internal carotid artery at the level of the skull base is also apparent Here's the area of the chiasm. I continue to disconnect the tumor at its base over the dura of the internal clinoid process. Now the superior pole of the tumor is mobilized away from the internal carotid artery. You can see the tumor is transected along the route of the ICA. This maneuver allows me to remove the tumor while keeping both neurovascular structures in view. Here now you can see the optic nerve generously decompressed, the internal carotid artery. Both tumor fragments are resected. Further inspection of the optic canal reveals tumor entering the foramen. The dura over the anterior clinoid process was also coagulated to minimize the risk of future tumor recurrence. Postoperative MRI demonstrated complete removal of the mass and this patient's vision improved after the surgery. Thank you.

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