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Tuberculum Sella Meningioma: Transcranial Approach

May 12, 2015


Let's review another case of a medial sphenoid wing meningioma. This is a 58 year-old male who presented after a seizure, and was also found to suffer from a right-sided visual field cut. MRI evaluation reveals a right-sided medial sphenoid wing or clinoidal meningioma with a relatively unusual pattern of growth associated with mild amount of edema. There was no significant amount of hyperostosis associated with this tumor on the axial CT scan. He underwent a right-sided front temporal craniotomy. This is the frontal lobe, temporal lobe. This is one of the older videos where I used fixed retractors. The latter aspect of the tumor was devascularized. It was actually quite hypervascular upon elevation of the frontal lobe. Next, hemostasis was obtained, and the anterior limb of the Sylvian fissure was dissected. Here you can see some of the MCA branches. Here's the anterior clinoid process. The tumor was devascularized just lateral to the optic nerve. Next, I opened the arachnoid bands over the optical carotid sisters. Early on, I was able to find the carotid artery and the optic nerve. I went ahead and disconnected the tumor as much as possible away from the nerve so that the base of the tumor along the medial aspect of the optic nerve, or within the inter optic distance can be devascularized Here's this devascularization of the tumor. Obviously, the contralateral optic nerve has to be kept in mind. This part of the base of the tumor was completely disconnected. Here's the contralateral optic nerve that is being identified through its arachnoid bands. There's no tumor invading the optic frame, and at this level. Now the portion of the tumor that is within the frontal lobe is being dissected. Tumor debulking and dissection continues into the sub-frontal area. Here's the contralateral optic nerve, ipsilateral optic nerve, intraoptic space. Part of the tumor is affecting the more proximal portion of the optic nerve. Debulking continues, and portion of the tumor is delivered into the operative space. Tumor is removed piecemeal. The mass is quite fibrous Here's the ipsilateral carotid artery. The more lateral part of the capsule is also mobilized into the resection cavity, and this part of the tumor was also ultimately removed. Here's the ipsilateral optic nerve. Part of the chiasm appears to be adherent to the tumor. Sharp dissection is used. Here's the area of the chiasm and the lamina terminalis. Now that this piece of the tumor is disconnected from the optic apparatus, is carefully mobilized. Special attention is paid to assure that the posterior capsule of the tumor does not involve the anterior cerebral artery complex. Here's the optic apparatus. The falciform ligament was opened, and the optic framing was inspected for any invasion of the tumor into the canal. Further inspection revealed no evidence of tumor within the canal, and the post-operative MRI demonstrated gross total removal of the mass, and this patient's vision improved after the procedure. Thank you.

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