Parasagittal meningioma with sinus obstruction

Introduction

Meningiomas make up approximately 36% of all intracranial tumors, where the most common location for these lesions is abutting the sagittal sinus or falx. This location inevitably makes these tumors involve major venous sinuses and critical cortical draining veins. As a result, meningiomas that involve the sagittal sinus or falx have a two- to threefold increase in complications as compared with their convexity counterparts. Among parasagittal meningiomas, the ones that invade the sagittal sinus have varied management from subtotal resection with avoidance of the venous sinus to gross total resection with sinus reconstruction. In this chapter, we present a case of a parasagittal meningioma with sinus invasion.

Example case

Chief complaint: seizures

History of present illness

A 47-year-old, right-handed woman with no significant past medical history presented after a seizure. She was at work and developed acute onset of loss of consciousness with eye rolling backward, right arm and leg shaking, followed by generalized tonic-clonic activity. She had not been sleeping very much because of tax deadlines. She was taken to the emergency room, where she became more coherent and was at her neurologic baseline. Imaging showed a brain lesion ( Fig. 46.1 ).

Medications : None.
Allergies : No known drug allergies.
Past medical and surgical history : None.
Family history : No history of intracranial malignancies.
Social history : Accountant, no smoking or alcohol.
Physical examination : Awake, alert, oriented to person, place, and time; Cranial nerves II to XII intact and full vision to confrontation; No drift, moves all extremities with full strength.
Magnetic resonance venography : Complete obstruction of the sagittal sinus at the posterior third segment.

	Clark C. Chen, MD, PhD, University of Minnesota, Minneapolis, MN, United States	Mohamed El-Fiki, MBBCh, MS, MD, Alexandria University, Alexandria, Egypt	Gerardo Guinto, MD, Centro Neurologico ABC, Mexico City, Mexico	Michael W. McDermott, MD, Herbert Wertheim College of Medicine, Florida International University, Miami, FL, United States
Preoperative
Additional tests requested	DTI CTA for potential preop embolization CT chest, abdomen, pelvisMedical workup Ophthalmology evaluation	fMRI DTI Venogram Ophthalmology evaluation (visual fields)	fMRI DTI Neuropsychological assessment EEG	DTI Cerebral angiogram Ophthalmology evaluation (visual fields)
Surgical approach selected	Left occipital craniotomy with lumbar drain	Left parieto-occipital craniotomy and SSS repair	Left parieto-occipital craniotomy	Left parieto-occipital craniotomy crossing midline
Anatomic corridor	Left occipital	Left parietal	Left parietal	Left parietal
Goal of surgery	Gross total resection	Simpson grade II or III, maximal safe resection	Simpson grade I	Simpson grade II
Perioperative
Positioning	Right lateral (left-side down)	Sitting position	Prone with head rotated 30–40 degrees to the left	Right three-quarters prone (left side down)
Surgical equipment	Lumbar drain Surgical navigation Surgical microscope IOM Ultrasonic aspirator	Surgical microscope Ultrasonic aspirator, Gore-Tex arterial graft	Surgical navigation Surgical microscope Ultrasonic aspirator	Surgical navigation Ultrasonic aspirator Doppler
Medications	Mannitol Steroids Antiepileptics	Mannitol, furosemide Steroids Antiepileptics	Steroids Antiepileptics	Mannitol Steroids Antiepileptics
Anatomic considerations	SSS, cortical drain veins, optic radiations, primary visual cortex	SSS, draining veins into the sinus, superior parietal lobe, superior optic radiations	SSS (posterior third), falx, parietal and occipital lobes	Parasagittal draining veins
Complications feared with approach chosen	Injury to SSS and cortical draining veins, visual deficit	SSS thrombosis, venous infarct, venous hypertension, visual field deficit	SSS bleeding, venous embolism and infarction, motor deficit, visual deficit	Venous infarct
Intraoperative
Anesthesia	General	General	General	General
Skin incision	Inverted U	Linear bicoronal	Inverted U	Inverted U
Bone opening	Left parieto-occipital craniotomy ipsilateral to SSS	Left parieto-occipital passing middles, burr holes on both sides of sinus	Left parieto-occipital passing midline, burr holes on both sides of sinus	Left parieto-occipital crossing midline
Brain exposure	Left parieto-occipital	Left parieto-occipital	Left parieto-occipital	Left parieto-occipital
Method of resection	Lumbar drain, precordial Doppler, tumor side down, craniotomy ipsilateral to SSS, U-shaped dural opening based on SSS making sure to preserve cortical veins, unclamp lumbar drain allowing free drainage at level of external auditory meatus, debulk tumor with ultrasonic aspirator under microscopic visualization, define plane between tumor and brain, removal of tumor inside SSS and dural reconstruction, resect falx, watertight dural closure with pericranium	Craniotomy on both sides of the sinus, opening dura on left, identify brain interface with microscopic visualization, preserve cortical veins draining into the sinus, open pia arachnoid and dissect veins away from surgical field, use minimal or no retraction, debulk tumor piecemeal or with ultrasonic aspirator, dissect away from falx preserving right side brain, leave SSS component until end, try to safely peel tumor away from sinus wall, if not possible may need removal of occluded SSS segment with venous anastomosis, closure with insertion of subgaleal drain	Myocutaneous flap, craniotomy on both sides of sinus with 3- to 4-cm margin of tumor and burr holes adjacent to sinus, U-shaped dural opening that is 2.5 cm surrounding tumor, dura in contact with the tumor is removed, tumor internally debulked with ultrasonic aspirator and bipolar coagulation, mobilization of capsule and preserving pia as much as possible, removal of tumor implant on falx with 1- to 1.5-cm margin, removal of tumor inside SSS until bleeding seen in front and behind tumor, transient compression of SSS and reconstruction, pericranium for dural reconstruction, drilling of inner side of involved calvarium	Mark midline and borders with navigation, inverted U-shaped incision based inferiorly crossing midline to the right, preserve pericranium for dural graft, left parietal-occipital bone flap 1.5-cm lateral to midline with superior and inferior burr holes, dissect bone from sagittal sinus with direct visualization, second bone flap to the right crossing midline, control midline bleeding with bipolar and gelfoam, peripheral dural tack ups, mark tumor margins on dura with marking pen, navigation and Doppler to define SSS, U-shaped dural opening based on SSS, detach tumor from dura to open dura medially, debulk tumor centrally and define brain-tumor interface, detach from midline if bleeding is an issue, confirm margins of closed/open SSS after superior/inferior/anteromedial margins defined with Doppler and navigation, open dural roof of SSS in midpoint and remove tumor within SSS leaving right wall intact, remove lesion until bleeding occurs and sew closed lumen, excise falx where attached to tumor, excise convexity dura and falx, dural closure with pericranium, resect involved inner table of involved bone, fill defects with bone cement and sand down bone, irrigate with Betadine and place vancomycin powder in subgaleal space, closure with subgaleal drain
Complication avoidance	Lumbar drain, precordial Doppler, ipsilateral craniotomy, internal debulking, resect falx, pericranial closure	Craniotomy on both sides, identify draining veins, leave SSS until the end	Craniotomy on both sides, removal of tumor along falx with margin, drilling of calvarium	Two-piece craniotomy crossing midline, central debulking, detach from falx if bleeding, remove tumor from lumen until bleeding in SSS occurs, remove involved bone
Sinus reconstruction if needed	Apply pressure over tear with gelfoam/Surgicel, tension suture gelfoam/Surgicel with adjacent bone, direct repair	Dural patch graft if away from tumor site	Local compression for small defect, pericranium for large defect	Remain calm, expect injury as trying to find proximal and distal ends, assistant to grasp opening closed with nontoothed forceps, primary closure
Postoperative
Admission	ICU	ICU	Floor	ICU
Postoperative complications feared	Air embolus, venous infarct, visual field deficit, seizures, Gerstmann syndrome	Venous hypertension, visual field deficit, calculation and spatial orientation problems	CSF leak, venous infarction	Visual field cut, venous infarct, seizures
Follow-up testing	MRI and MRV within 48 hours after surgery Physical and occupational therapy Ophthalmology evaluation as outpatient	CT immediately after surgery MRI 3 months after surgery	CT within 6–8 hours after surgery MRI 6 weeks after surgery EEG 2 years after surgery Neuropsychological assessment	MRI within 48 hours after surgery
Follow-up visits	2 weeks after surgery	1 month and every 3 months after surgery	6 weeks after surgery	10–14 days after surgery 6–8 weeks after surgery
Adjuvant therapies recommended for WHO grade	Grade I–observation, possible additional resection pending residual Grade II–observation vs. radiation Grade III–radiation	Grade I–observation Grade II–radiation Grade III–radiation	Grade I–observation Grade II–observation Grade III–radiosurgery	Grade I–observation Grade II–radiation Grade III–radiation