Occipital bi-transtentorial/falcine approach for falcotentorial meningioma: case report

Abstract

-Lesions located in the bilateral posterior incisural space are difficult to treat due to limited e x p o s u re. The classical approaches to this area are limited for lesions located bilaterally and especially when the lesion extends also below the tentorium as it may occur with meningiomas. Kawashima et al. re p o rted, in anatomic studies, a new occipital transtentorial approach: the occipital bi-transtentorial/falcine approach, to treat such lesions. We present a patient with a large falcotentorial meningioma, located bilaterally in the posterior incisural space. The occipital bi-transtentorial/falcine approach allowed an excellent surgical exposure and complete tumor removal with an excellent patient outcome.KEY WORDS: occipital bi-transtentorial/falcine approach, posterior incisural space, falcotentorial meningioma.Acesso occipital bitranstentorial-falcino para abordagem de meningioma falco-tentorial: relato de caso RESUMO -Grandes lesões que ocupam bilateralmente o espaço incisural posterior são de difícil abord a g e m c i r ú rgica pelos acessos clássicos. Recentemente, Kawashima et al. descreveram, em peças anatômicas, uma modificação do acesso occipital transtentorial, o acesso occipital bitranstentorial-falcino, para abord a g e m de grandes lesões que ocupam bilateralmente o espaço incisural posterior. Retata-se um caso de grande meningioma falco-tentorial que ocupava o espaço incisural posterior bilateralmente. O acesso occipital bitranstentorial-falcino permitiu exérese completa da lesão sem déficit no pós-operatório. PALAVRAS-CHAVE: acesso occipital bitranstentorial-falcino, espaço incisural posterior, meningioma falcotentorial.The posterior incisural space is located posterior to the midbrain, in the pineal body region 1 . Lesions located in this region include pineal tumors, meningiomas, gliomas, medial occipital lobe and superior c e rebellar arteriovenous malformations. The infratentorial supracerebellar approach and the occipital t r a n stentorial appro a c h 2 -5 a re the main approaches used to reach lesions located in this area. However, these a p p roaches do not allow a good exposure of lesions located bilaterally in the posterior incisural space 1 . Using anatomical specimens, Kawashima et al. 1 describe the occipital bi-transtentorial/falcine approach that provides better exposure of the bilateral posterior incisural space. It is a modification of the occipital transtentorial approach with the division of the falx and the tentorium bilaterally.We re p o rt a case of a large falcotentorial meningioma located bilaterally in the posterior incisural space, in which it was used the occipital bi-transtentorial/falcine approach. CASEOn November 2002, a 58 year-old woman was admitted to our neuro s u rgical unit with headache, torpor, and papilledema. The CT scan revealed a large mass compre s sing the midbrain and causing hydrocephalus. A ventriculoperitoneal shunt was placed on an emergency basis.The patient re c o v e red fully after the shunt, and an MRI (Fig 1) showed a large h...

Multistaged, multidirectional strategy for safe removal of large meningiomas in the pineal region

“…The occipital bitranstentorial/falcine approach via the unilateral occipital interhemispheric space has several advantages for access to the tumor in the contralateral infratentorial space and allows for easier observation of the contralateral basal vein. 5,8 Although this approach has the advantages of both the unilateral OTA and bilateral combined supra-and infratentorial approaches, blind spots remain due to incomplete skeletonization and incomplete mobilization of the straight sinus, and management of the contralateral basal vein after the final stage of the tumor removal carries some risks (Fig. 6).…”

“…15 Multiple compartments formed by the firm dural structures and involvement of the vital deep venous system present difficulties in the removal of these tumors, especially when they are large. The supracerebellar infratentorial approach, 2,11 combined supratentorial and infratentorial approach, 16 combined supra-/infratentorial-transsinus approach, 12,18 unilateral occipital transtentorial approach (OTA) with or without the transfalcine approach, 2,4,12,14,15 and occipital bitranstentorial/falcine approach 5,8 have been advocated to remove this challenging meningeal tumor. Simultaneous multidirectional approaches, such as the combined supra-/infratentorial-transsinus approach and occipital bitranstentorial/falcine approach, may be advantageous in the removal of large pineal region meningiomas during a single operation, but blind spots remain around the skeletonized straight sinus and galenic venous system.…”

Falcotentorial Meningiomas: Optimal Surgical Planning and Intraoperative Challenges - Case Report and a Review

“…42,43 Occipital bitranstentorial/falcine approach:This approach was first described by Sekhar et al in 2002. 15,44 This surgical approach is recommended particularly for large pineal tumors with supra-and infratentorial extension or for those with a significant lateral extension. This technique can be described as a modification of the occipital transtentorial approach, with the division of the falx and the bilateral tentorium.…”