Abstract
Background:Meningiomas involving both intradural and extradural structures are rare tumors. We report the complete resection of a massive complex transosseous meningioma that had invaded the torcula, superior sagittal sinus, occipital bone, and scalp.Case Description:A 48-year-old male presented after 3 days of worsening headaches and blurry vision. Preoperative imaging demonstrated an 11 × 5-cm extra-axial mass that avidly enhanced with gadolinium in the region of the torcula. Angiography demonstrated occlusion of the involved portions of the superior sagittal sinus, torcula, and proximal left transverse sinus. Cortical drainage occurred via the veins of Labbι and deep drainage via an occipital sinus. Using image-guided stereotaxy, a wide-excision scalp resection and craniectomy with sinus exploration was planned for complete tumor removal. Parasitized cortical veins were preserved. Occluded portions of the superior sagittal sinus and left transverse sinus were resected along with the invaded parts of the falx and tentorium. The walls of the straight sinus, torcula, and right transverse sinus were repaired primarily to facilitate deep drainage. A latissimus dorsi free flap was used to reconstruct the scalp defect. Routine follow-up magnetic resonance imaging (MRI) at 18 months demonstrated no evidence of recurrence or regrowth.Conclusions:This case illustrates the importance of identifying aberrant venous drainage pathways when considering ligation and resection of major sinuses and discusses the management of calvarial and scalp invasion.
Highlights
ConclusionsThis case illustrates the importance of identifying aberrant venous drainage pathways when considering ligation and resection of major sinuses and discusses the management of calvarial and scalp invasion
Meningiomas involving both intradural and extradural structures are rare tumors
Meningiomas arise from arachnoid cap cells in arachnoid granulations, which are abundant near the dural venous sinuses and give rise to intradural tumors involving the superior sagittal sinus, torcula, and transverse sinuses.[5]
Summary
This case illustrates the importance of identifying aberrant venous drainage pathways when considering ligation and resection of major sinuses and discusses the management of calvarial and scalp invasion. Magnetic resonance imaging and magnetic resonance angiography (MRI/MRA) of his brain demonstrated an 11 × 5‐cm mass that extended both supra‐ and infratentorially and into the bilateral parietal and occipital lobes, the superior sagittal sinus, the torcula, and the proximal transverse sinuses [Figure 1]. Cerebral angiography revealed lack of flow through portions of the superior sagittal sinus, torcula, and proximal transverse sinuses [Figure 2]. The http://www.surgicalneurologyint.com/content/6/1/40 tumor was hypervascular, with its major arterial supply from meningeal branches of the external carotid arteries (ECAs) and the posterior inferior cerebellar arteries [Figure 4]. The halo vest was continued for 6 weeks At his 6‐month follow‐up appointment, the patient was able to read a newspaper with reading glasses, but his a Figure 4: Pre (a)- and post (b)-embolization images of the left external carotid artery injection. Main arterial feeders include branches of the occipital (black arrows) and middle meningeal arteries (white arrows), which were successfully embolized.Arterial feeders were embolized from similar branches of the right external carotid artery (not shown). (c) Right vertebral artery injection depicting a posterior meningeal artery branch arising from the posterior inferior cerebellar artery and feeding the meningioma.This branch was not embolized http://www.surgicalneurologyint.com/content/6/1/40 a d e f
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