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Let's review a case of a large frontal transosseous meningioma. This is a 65 year old female who presented with personality change. MRI evaluation revealed a large anterior frontal meningioma, affecting both the pier and the parenchyma of the right frontal lobe associated with edema. Also affecting the bone and leading to a swelling in the frontal area. You can see the evidence of edema and really the transosseous, transdural and transpeel extent of invasion of this tumor. Here's the position of the patient during the operation a bifrontal incision was used behind the tumor. In this case, the tumor is fusing both the bone, dura and the pier altogether. And the tumor is quite fibrous. And the bone that is affected by the tumor may not be readily removed in a separate layer from the dura. Let's go ahead and review some of the tricks of the trade. In order to remove this tumor. Here, you can see the exposure of the tumor. It's affecting part of the galea. Obviously the pre-cranium is affected by the tumor at this stage. Short dissection is employed. Piece of pre-cranium that is not affected by the tumor may be utilized for dural closure at the end of the operation. Here's the more anterior margin of the tumor. In order to be able to remove the extra-cranial tumor. The affected piece of the calvarium as well as the dura, I place multiple burr holes around the periphery of the tumor. Using the perforator in this case to add efficiency. So I essentially line up burr holes all the way around the circumference of this tumor, the area of this superior sagittal sinus, the dura is released. And the bone is removed using Kerisson Ronjours. Next, I work within the burr holes and disconnected dura again around the circumference of the tumor. These high prostatic tumors can lead to significant hypervascularity of their calvarium. And placement of the burr holes individually gives us plenty of opportunity to control the bleeding. The affected portion of the superior sagittal sinus was then ligated. Next the dura was incised around the periphery of the tumor through the burr holes. Here's the area of faux cartilage. patties are used to protect the brain as the affected part of the faux is being disconnected. Next, I gently elevate the part of the bone and the dura affected by the tumor and work underneath the dura to disconnect the intradural part of the tumor from underneath the calvarium. Obviously I don't wanna remove all the tumor in one layer. I leave the intradural part alone. To minimize any significant traction on the brain parenchyma. You can see how the dura, the bone are all affected by the tumor. Next, I use carotenoid patties to gently mobilize the tumor away from the brain. Here's the final result. Titanium cranioplasty was also completed, after dura was closed using a piece of pre-cranium. This patient made an excellent recovery. This is a post-operative CT scan And ultimately this edema resolved on the three months scans. Thank you.
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