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Falcotentorial Meningiomas: Clinical, Neuroimaging, and Surgical Features in Six Patients

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Falcotentorial Meningiomas: Clinical, Neuroimaging, and Surgical Features in Six Patients Neurosurg Focus 14 (6):Article 11, 2003, Click here to return to Table of Contents Falcotentorial meningiomas: clinical, neuroimaging, and surgical features in six patients ALFREDO QUINONES-HINOJOSA, M.D., EDWARD F. CHANG, B.S., AND MICHAEL W. MCDERMOTT, M.D. Department of Neurological Surgery, The Brain Tumor Research Center, University of California at San Francisco, California Object. Meningiomas arising from the falcotentorial junction are rare. As a result, their clinical presentation and sur- gical management are not well described. During the past 3 years, the authors have treated six patients with falcoten- torial meningiomas. Methods. Most patients presented with symptoms related to raised intracranial pressure, including headaches, papilledema, and visual and gait disturbances. Magnetic resonance imaging revealed a smooth, oval, or round mass, which was typically homogeneously enhancing. Angiography was useful in evaluating arterial supply for emboliza- tion, when possible, and determining the status of venous collateral supply and sinus patency. The authors detail the surgical technique used in all six patients. Postoperatively, patients experienced transient cortical blindness, which in all cases spontaneously resolved during the course of several days to weeks. They provide a comprehensive descrip- tion of the presentation and surgical management of falcotentorial meningiomas. Conclusions. An excellent outcome can be expected when surgery is predicated on detailed preoperative neu- roimaging and knowledge of the nuances of the surgical technique. KEY WORDS • meningioma • surgery • outcome • neurological deficit • radiographic feature Meningiomas arising from the falcotentorial junction ical, neuroimaging, intraoperative, and postoperative fea- are extremely rare. Fewer than 50 cases have been report- tures obtained in six patients with falcotentorial junction ed in the literature1,–3,9,11–21,26,28–31 Because the tumor arises meningiomas as well as a review of the literature. at the junction of dural folds in which the straight sinus and both torcular and arachnoid granulations are found, however, its infrequency in that region is not surprising. CLINICAL MATERIAL AND METHODS Most patients present with symptoms of increased ICP Patient Population and occasionally with visual symptoms related to the tu- mor’s occipital location. Because bilateral occipital re- During the course of 3 years, we performed surgery in traction is required during the operation, transient cortical six patients with meningiomas arising from the falcoten- blindness routinely develops in cases involving larger- torial junction (Figs. 1 and 2). Four were women and two sized tumors. Patients should be informed of this transient were men, with a mean age of 42.5 years (range 38–48 neurological deficit prior to surgery. years). The origin of tumor was confirmed intraoperative- Because these tumors grow slowly, collateral venous ly in all patients, and diagnosis was established by histo- outflow channels for the deep venous system develop via pathological examination. the basal vein of Rosenthal, the petrosal, the precentral ce- Neuroimaging Studies rebellar, and the pontomedullary veins. Preoperative cere- bral angiography is crucial to determine the status of the Lesions in all patients were evaluated using MR im- straight sinus because the lower falx cerebri, lateral tento- aging and cerebral angiography. Patients underwent T1- rium, and upper falx cerebelli are excised with the tumor. weighted, T2-weighted, and Gd-enhanced MR imaging. We have successfully resected six large meningiomas Cerebral angiography included injection of the left sub- arising from the falcotentorial junction. We report the clin- clavian artery, bilateral ICAs, ECAs, and VAs. Operative Approach: “Surgeon’s Perspective” Abbreviations used in this paper: ECA = external carotid artery; ICA = internal carotid artery; ICP = intracranial pressure; MR = Patient Positioning, Intubation, and CSF Diversion. magnetic resonance; PCA = posterior cerebral artery; SCA = supe- Because most of these tumors are quite large at the time rior cerebellar artery; VA = vertebral artery. of diagnosis, preoperative angiography, embolization, and Neurosurg. Focus / Volume 14 / June, 2003 1 Unauthenticated | Downloaded 09/24/21 09:32 PM UTC A. Quinones-Hinojosa, E. F. Chang, and M. W. McDermott Fig. 1. Representative MR images obtained in a 44-year-old Fig. 2. Representative MR images and angiogram obtained in a woman who presented with progressive cognitive impairments and 43-year-old man who presented with recent onset of mild cognitive personality changes during a 3-year period, with recent episodes of impairment, papilledema, and a right homonymous hemianopsia. visual hallucinations and urinary incontinence. Imaging revealed a Magnetic resonance imaging revealed a 6.9 ϫ 6.4 ϫ 5.9–cm mass large (7 ϫ 4.9 ϫ 3.8–cm) mass arising from the falcotentorial junc- attached to the falx anteriorly in the region of the falcotentorial tion. A: Preoperative sagittal T -weighted contrast-enhanced im- 1 junction. A: Preoperative sagittal T1-weighted image demon- age demonstrating homogeneous enhancement. B: Preoperative strating a large isointense round mass. B: Preoperative axial axial T -weighted image without contrast revealing slight hypo- 1 T2-weighted revealing slight hyperintensity. C: Preoperative left intensity. C and D: Postoperative sagittal (C) and axial (D) T1- VA angiogram demonstrating evidence of hypervascularity, with weighted contrast-enhanced images demonstrating a near-total re- predominant vascular supply from medial and lateral choroidal section and small residual enhancement at the vein of Galen. This arteries off the left PCA. Because the vast extent of blood was sup- patient underwent subsequent radiotherapy. plied by pial arteries, not the ECA, embolization was not attempt- ed. D: Postoperative coronal T1-weighted contrast-enhanced im- age demonstrating a gross-total resection. imaging for surgical navigation systems are required. The choice of patient positioning (prone or semisitting) de- pends on the surgeon’s preference and the patient’s body bellar hemispheres necessary for dissection of infratentor- habitus. Most surgeons prefer the prone position because ial tumor. We take the bone flap off over the torcular and it is safe and has a lower risk of air embolism. Obese pa- transverse sinuses in two components. First, the supraten- tients, however, frequently only receive adequate ventila- torial bone flap is removed and then the dura mater over tion in the absence of extreme airway pressures—hence, the torcular and transverse sinuses is dissected under di- elevated transmitted venous pressures in the semisitting rect vision prior to cutting the infratentorial bone flap. position. Patients considered for the semisitting position The dura is opened beyond the lateral margins of the should be evaluated for patent foramen ovale preoper- tumor above and below the tentorium. First on one side atively. and then the other, the tentorium is incised from immedi- We prefer the prone position, the neck extended on the ately in front of the transverse sinus to its free edge ante- chest, and the head flexed on the neck. Armored endotra- riorly at the hiatus. This will eliminate arterial supply via cheal tubes should be used to avoid kinking and obstruc- the tentorial arteries, which cannot usually be embolized tion resulting from positioning or as the operation pro- preoperatively. Next, depending on the angiography-doc- ceeds due to softening of the plastic tube. An external umented status of the torcular and transverse sinuses, ventricular drain is routinely placed via the parietooc- either the tentorium is incised from lateral to medial in cipital trajectory with the aid of the surgical navigation front of the torcular (patent torcular and one or both trans- system. verse sinuses) or the sinuses are ligated using suture at the Surgical Approach. A large U-shaped incision, based lateral margin of the tumor and the posterior fossa dura is inferiorly, is marked to allow for a supra- and infratentor- opened (occluded torcular and transverse sinuses). Fi- ial craniotomy. Depending on the amount of the posterior nally, the falx cerebri over the top of the tumor is incised fossa component, the foramen magnum is included in as far as is practical, and usually the final incision through cases of larger tumors. The foramen magnum may be the free edge anteriorly can only be made with tumor opened at the surgeon’s discretion when there is a signifi- debulking. This step completes the initial circumferential cant infratentorial tumor component. We believe that this dural incisions around the tumor, with the falx cerebelli reduces resistance against inferior retraction of the cere- incised after more extensive tumor debulking superiorly. 2 Neurosurg. Focus / Volume 14 / June, 2003 Unauthenticated | Downloaded 09/24/21 09:32 PM UTC Falcotentorial meningiomas TABLE 1 Demographic and clinical data at presentation* Case Age (yrs), Duration of No. Sex Symptom Sign Symptoms (yrs) 1 38, F headaches, visual disturbances none 1 2 44, F personality changes, hallucinations, incontinence none 3 3 42, F headaches papilledema 4 4 40, F headaches, dizziness none 1 5 48, M headache, diplopia, ataxia, worsened cognition CN III w/ ptosis, rt strabismus, slight rt 0.5 facial droop 6 43, M visual field cut, impaired cognition papilledema, rt homonymous hemianopsia 0.2 *CN = cranial nerve. Frequently the surgeon will
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