Parasagittal meningiomas without sinus invasion

Introduction

Meningiomas are among the most common primary brain tumor in adults, and the most common locations are parasagittal/parafalcine lesions, which account for 25% of meningiomas. These meningiomas arise from the arachnoid in or next to the falx, and therefore involve critical cortical draining veins and the sagittal sinus. Surgical resection of these lesions, especially when they involve the middle and/or posterior third of the sagittal sinus, can be associated with significant morbidity. The morbidity ranges from 10% to 30%, and mortality rates range from 5% to 15% in several series, and is significantly higher with sinus invasion. In this chapter, we present a case of a patient with a parasagittal meningioma without sinus invasion.

Example case

Chief complaint: left leg weakness

History of present illness

A 55-year-old, right-handed woman with no significant past medical history who presented with left leg weakness. She stated that over the past several months, she had developed increasing difficult with strength in her left leg, but more specifically her left foot. A spine magnetic resonance imaging (MRI) scan was done and was negative for pathology to explain left foot weakness. She saw a neurologist who ordered a brain MRI ( Fig. 45.1 ).

Medications : None.
Allergies : No known drug allergies.
Past medical and surgical history : None.
Family history : No history of intracranial malignancies.
Social history : Homemaker, no smoking or alcohol.
Physical examination : Awake, alert, oriented to person, place, and time; Cranial nerves II to XII intact; No drift, moves all extremities with full strength, except left dorsiflexion/plantar-flexion 3/5.
Magnetic resonance venography : No sagittal sinus narrowing or obstruction.

	Henry Brem, MD, Johns Hopkins University, Baltimore, MD, United States	Ricardo Díez Valle, MD, PhD, Fundación Jimenez Diaz University Clinic, Madrid, Spain	Jacques J. Morcos, MD, University of Miami, Miami, FL, United States	Tetsuro Sameshima, MD, PhD, Hamamatsu University, Shizuoka, Japan
Preoperative
Additional tests requested	MR angiography and venography	None	None	ASL MRI CT Cerebral angiogram
Surgical approach selected	Bifrontoparietal craniotomy	Bifrontoparietal craniotomy	Modified bicoronal craniotomy	Right frontal craniotomy
Anatomic corridor	Right interhemispheric	Right interhemispheric with falx excision	Right interhemispheric with falx excision	Right interhemispheric
Goal of surgery	Simpson grade I	Simpson grade I, likely grade II, without resection of the wall of the sagittal sinus	Simpson grade I, including SSS reconstruction	Simpson grade II
Perioperative
Positioning	Supine neutral	Supine neutral	Left supine with 30-degree right rotation (SSS horizontal)	Supine neutral
Surgical equipment	Surgical navigation IOM (MEP/SSEP/EEG) Surgical microscope Ultrasonic aspirator Ultrasound Vascular clips	Surgical navigation Surgical microscope Ultrasonic aspirator	Surgical navigation Lumbar drain Surgical microscope Ultrasonic aspirator Vascular clips 5-0 Prolene to repair SSS	Surgical navigation Surgical microscope Ultrasonic aspirator
Medications	Steroids Mannitol Antiepileptics	Steroids	Steroids Mannitol Antiepileptics	None
Anatomic considerations	SSS, cortical veins, ACA/MCA branches	SSS, cortical veins, distal ACA, supplementary motor cortex	SSS, ACA and branches, premotor cortex, bridging veins	Bridging veins
Complications feared with approach chosen	Cerebral edema, SSS injury	SSS injury, retraction injury	Retraction injury	Venous infarct
Intraoperative
Anesthesia	General	General	General	General
Skin incision	Linear bicoronal	Linear bicoronal	Linear bicoronal eccentric to the right	Inverted U incision
Bone opening	Bifrontal eccentric to right (burr holes off the sinus)	Bifrontal eccentric to right (burr holes over the sinus)	Bifrontal eccentric to right (burr holes off the sinus)	Right frontal craniotomy exposing superior sagittal sinus
Brain exposure	Right frontal	Right frontal	Bifrontal	Right frontal
Method of resection	Bifrontal craniotomy eccentric to the right but extending at least 3 cm to the left, tenting sutures, dural opening at tumor-brain interface so only tumor pushes outward, U-shaped dural opening on right based on sagittal sinus, bipolar surface of tumor, internally debulk and remove, dissect capsule and preserve all host arteries and collateral veins, open dura on left and inspect for tumor involvement, remove falx from right side to visualize left side and confirm GTR, inspect SSS under microscopic visualization and attempt to remove remaining tumor if not adherent, leave small residual if tumor adherent to SSS, duraplasty, rinse bone flap in Betadine, subgaleal drain placement	Bifrontal craniotomy eccentric to the right with burr holes over sinus at the anterior and posterior limits, hemostasis over SSS with compression, coagulation of arterial meningeal branches, dural opening on right, dissection of arachnoid plane over the tumor, debulking with ultrasonic aspirator if hard, leave dissection of ACA branches until the end, leave superior medial border of SSS for end, attempt at resecting all without compromising SSS, for deeper part of the tumor care with pericallosal arteries, cross falx and dissect remaining deep tumor from contralateral brain, removal of dura and falx but not from SSS, closure with dural substitute	Bifrontal craniotomy eccentric to the right, U-shaped dural opening on right avoiding bridging veins and modify dural opening as necessary, drain 30 cc of CSF from lumbar drain, interhemispheric approach anterior to tumor and devascularize falx and proceed posteriorly, debulk tumor with ultrasonic aspirator and bipolar, identify ACA and branches before deepest portion of tumor removed, leave small portion on SSS for last part of surgery, remove from SSS with or without reconstruction with native dura, watertight dural closure, avoid use of retractors	Right frontal craniotomy with superior sagittal sinus exposure, dural incision to expose interhemispheric fissure with preservation of bridging veins, detachment of tumor from sagittal sinus and falx and internal tumor debulking, separate tumor from brain surface for gross total removal, remove convexity dura and dural reconstruction with periosteum
Complication avoidance	Control of SSS with bifrontal opening, open dura only tumor, leave SSS for last, leave component adherent to SSS alone	Control of SSS with right frontal opening, dissect in arachnoid plane, no retraction needed, decompress tumor from inside, leave SSS for last, remove dura from falx but leave dura along superior sagittal sinus	Right hemisphere down, devascularize early from falx, save SSS for last, avoid fixed retractors with positioning and lumbar drain, separate ACAs meticulously	Expose SSS, limit craniotomy to one side, spare bridging veins, separate from sagittal sinus, remove dural origin
Sinus reconstruction if necessary	Compression, muscle or fascia compression, primary closure, patch graft	Compression, suture, or synthetic patch	Compression and repair with native dura	Suture close or dural patch
Postoperative
Admission	ICU	ICU	ICU	ICU
Postoperative complications feared	Cerebral edema, sinus thrombosis, venous infarct	Cerebral edema due to venous infarct, injury to arterial branches, SSS injury, left lower extremity weakness	SSS occlusion, bridging vein thrombosis, seizures, CSF leak, SMA syndrome, DVT	SSS thrombosis, cerebral venous occlusion
Follow-up testing	MRI/MRV within 24 hours after surgery	MRI within 24 hours after surgery	MRI within 48 hours after surgery 5% albumin for 3 days Physical and occupational therapy	CT immediately after and 1 day after surgery MRI within 7 days after surgery
Follow-up visits	14 days after surgery 3 months, then every 6 months after surgery	7 days after surgery	10 days after surgery 6 weeks after surgery	3 months after surgery
Adjuvant therapies recommended for WHO grade	Grade I–observation Grade II–observation Grade III–observation for GTR, radiation if STR or recurs	Grade I–observation Grade II–radiation Grade III–radiation	Grade I–observation Grade II–radiation Grade III–radiation	Grade I–observation Grade II–observation Grade III–radiation