42 Giant Olfactory Groove Meningioma

AARON S. DUMONT, CHARLES A. SANSUR, AND JOHN A. JANE JR.

Diagnosis Giant olfactory groove meningioma

Problems and Tactics A previously healthy young male presented with an acute decline in mental status and nausea with vomiting after having been institutionalized for progressive depression and cognitive/behavorial decline 7 years prior to presentation. He was found to have an olfactory groove meningioma measuring >10 cm in maximum diameter. The decision was made to attempt total resection of this lesion.

Keywords Olfactory groove meningioma, anterior cranial base surgery

Clinical Presentation

This 46-year-old right-handed male was admitted to a nursing home 6 years prior for a progressive decline in cognitive function, apathy, and depression. On the day of presentation he became acutely obtunded and developed nausea and vomiting. His mental status improved considerably over the course of hours. He was, however, taken to an outside emergency room where he underwent a work-up including routine laboratories and a head computed tomographic (CT) scan revealing hyponatremia (Na⁺ 124 mmol/L) and a 10-cm mass of the anterior cranial base. He was subsequently transferred to the University of Virginia for further evaluation and treatment. His admission neurological examination was that he was mildly disoriented and was neurologically nonfocal with the exception of papilledema and anosmia. He was started on high-dose intravenous dexamethasone and was fluid restricted and loaded with phenytoin. He underwent magnetic resonance imaging (MRI) preoperatively to delineate better the nature and extent of the tumor (Fig. 42–1).

Surgical Technique

Difficulty in treatment of this tumor arose by virtue of its size and vascularity. Although conventional wisdom suggests the best chance for total resection is the first one and that gross total resection should be attempted during one procedure, this tumor was purposely resected in stages. It was felt that the patient’s cerebrum would not adequately tolerate total resection and rapid reexpansion at one time, and that embolization of this lesion was dangerous with significant risk of grave postembolization edema. As a result, the tumor was resected in two stages.

The patient was brought to the operating room for the first procedure. Before induction of anesthesisa, an intraparenchymal intracranial pressure monitor was placed to maintain vigilance in maintaining optimal intracranial pressure during induction and intubation and to guide the extent of resection at this first sitting.¹

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