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Sphenoorbital Meningioma: Techniques for Resection

October 28, 2019

Transcript

This video describes the techniques for maximal and gross total resection of Sphenoorbital Meningioma's. This is a 32 year old female who presented with right-sided proptosis, MRI evaluation. As you can see reveals some evidence of proptosis in the right eye as well as evidence of hyperostosis and meningioma growth over the medial aspect of this sphenoid wing and the orbit. The CT scan demonstrates again, the infiltration of the bone and the lateral part of the orbit and this sphenoid wing by the tumor. The strategy in this case is a frontotemporal craniotomy, I split the temporalis muscle just at area of the tumor, and then I'll go ahead and aggressively remove and drill the affected bone, the affected per orbiter and the affected dura and intradural meningioma. Lumbar drain is installed at the beginning of the procedure is the right front temporal craniotomy. Here's the incision, here's the area of the keyhole. Instead of reflecting the entire Temporalis muscle, I just make an incision, just to push straight to the fat pad and reflect the muscle anteriorly this way, the entire bulk of the Temporalis muscle would not be obstructive on my way, doing the anterior mobilization of the temporalis muscle. In, just behind the fat pad linear incision made and the muscle reflected anteriorly. There was some excessive bleeding from the bone due to its infiltration by the tumor. Gel foam is used, soaked in Thrombin The area of this sphenoid lateral sphenoidal wing is exposed. I'll go ahead and create a bar hole and then bite the tumor when possible. Next and air drill is used to drill the affected lateral aspect of this sphenoid wing at the area of the Pterion. Bone is very thick in this area. As the bone is drilled down and made thinner, the kerosene is used to remove the tumor. Here's the area of the pterion, again, the bone is exceedingly thick, due to high prosthesis by the tumor. I'll go ahead and dissect the Dura Way. I know there's going to be some tumor underneath this dura, and then I'll go ahead and drill or bite this part of the tumor or affected bone by a big long jaw. We'll go ahead and drill the bone more laterally and just stay on the bone until they're sphenoid wing is drilled away. And I'm able to expose the lateral wall of the orbit. Whenever possible around juror is used for removal of the affected bone. Entering the orbit, again, removing this sphenoid wing the orbit is more exposed. Here's a more de magnified view of our work. I'll go ahead and drill the more medial aspect of this sphenoid wing and get close to the area of the clinoid process. I see that the kind of process appears also affected by the tumor. Here's the area of the lateral orbital fissure. I'll go ahead and reflect the lateral wall of the cavernous sinus dura. This would allow me to expose the effected anterior clinoid process. Now their clinoid process is more in view, I'll go ahead and drill that out as well until the optic nerve is apparent. Then you can see the clinoid process, very high protist. During all the way first identifying the roof of the optic nerve and decompressing the nerve. You can see part of the nerve and avoiding the drill directly on the nerve and removing the bone, using various instruments. Okay, that part of the bone appears very thick. The clinoid process is being mobilized. Peer is very adherent. Okay, here is the optic nerve clinoid process is being mobilized out of its pocket. Just have to toggle it very carefully and then may have to use sharp scissors at times until it's been delivered. So the clinoid process is now removed view of the optic nerve. No obvious tumor is apparent anteriorly in this area. Go ahead and clear away any part of Dura along the anterior crown fossa. Here you can see the wall of the orbit, the effected dura, by the tumor. Now I'll go ahead and remove some of the residual bone around the anterior aspect of the lateral orbital wall also part of the orbital roof affected by the tumor that appears soft. This part of the bone appears more normal. Again, inspecting the bony edges, making sure that I get as much normal bone as possible around the edges. Now inspecting the pre orbiter, making sure that there is no residual tumor or the pre orbiter is not affected. Maximal and grosture resurrection is critical as the first time is the best time to achieve cure and recurrence of these tumors can be quite difficult to handle. Since no obvious tumor was found within the pre orbiter. I went ahead and open the dura. Now that the affected dural was removed, I inspected the area of the tumor anteriorly. This part was also removed until the optic nerve was reached. Here's the final product piece of temporalis muscle was placed within the Clinodactylism pocket to avoid any risk of post operative CSF leak. Closure was completed in standard fashion. As you can see, post operative, CT demonstrated adequate resection of the affected bone. In other words, the lateral wall of the orbit, the clinoid process, the sphenoid wing and titanium mesh cranioclasty was used to reconstruct a bony defect that was relatively small, that eye was nicely mobilized back in place. In post operative MRIs demonstrated gross total resection of this tumor and this patient made a nice recovery. Again, this video demonstrates techniques for maximal resection of sphenoidal orbital meningiomas. Obviously drilling the bone aggressively inspecting the pre orbiter, removing the affected clinoid process as was aggressive resection of the affected Dura. And obviously the intradural portion of the tumor. Thank you.

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