Falcotentorial Meningioma Resection Through the Supracerebellar Infratentorial Approach: 2-Dimensional Operative Video.

Abstract

Meningiomas are a common pineal region tumor in adults.1 They frequently reach large size with pending serious neurological consequences.1 Although they are more common in women, their presence in men might raise concerns about a higher-grade meningioma. Accordingly, their treatment starts with surgical resection. Their origin is the falcotentorial junction involving the midbrain tectum and the vital deep venous system. The torcular, transverse sinuses, cerebellar veins, straight sinus, internal occipital veins, basal veins, and internal cerebral veins are encountered requiring a cautious fine intra-arachnoidal dissection under high magnification.2 Multiple surgical approaches are described for pineal area tumors with the advantages and disadvantages of each guiding the selection of the approach.3 We believe that the main deciding factor is the relationship of the vein of Galen and its tributaries to the tumor, simply choosing the route that encounters the tumor first and the vein last. We demonstrate the surgical nuances of removing a pineal area meningioma that displaced the vein of Galen superiorly, prompting the resection through a lateral infratentorial supracerebellar approach. We currently prefer the 3/4 concord position because it provides a superb direct exposure over one cerebellar hemisphere, with the cerebellum relaxed downward while the bridging veins are not severely stretched with gravity.4 The sitting surgeon with resting arms in an ergonomic position is able to perform fine microsurgical dissection over extended time.5 The patient was a 57-year-old man with a large falcotentorial meningioma. The patient consented to the surgery and publication of his images.