Parasagittal meningiomas – literature review and a case report

Abstract

Meningiomas are tumors that can develop anywhere along the neuraxis, but with increased concentration in some specific areas. Parasagittal meningiomas have the dural attachment on the external layer of the superior sagittal sinus (SSS) and invade the parasagittal angle displacing brain away from its normal position.Among meningiomas, the parasagittal location is the most common (22%). Taking into account their anatomic insertion along SSS, parasagittal meningiomas can have their dural attachment in the anterior, the middle or the posterior third of the SSS. Most frequently parasagittal meningiomas are located in the middle third of the superior sagittal sinus (between coronal suture and lambdoid suture). The clinical picture of parasagittal meningiomas depends on the tumor location along the SSS and so is the attitude towards ligation and reconstruction of the sinus. Controversial issues regarding surgical management of parasagittal meningiomas concerning leaving a tumor remnant that invades the SSS instead attempting total resection, or the attitude in the case of totally occluded segment of a sinus are summarized in this paper. The special care for the venous system is emphasized. The recurrence matter is also approached underlining the importance of adjuvant radiosurgery for the management of residual tumors. Results described in the main papers of the literature are reviewed.Conclusions are referring to the historical evolution regarding the surgical management of parasagittal meningiomas: aggressiveness of resection, sinus reconstruction, importance of adjuvant techniques: radiosurgery, endovascular surgery and to the importance of microsurgery and careful and meticulous planning of the approach in order to avoid interference with venous collaterals. A suggestive clinical case from the authors experience is presented.Acne conglobata is a rare, severe form of acne vulgaris characterized by the presence of comedones, papules, pustules, nodules and sometimes hematic or meliceric crusts, located on the face, trunk, neck, arms Toma Papacocea et al. 40

Attempted Radical Removal of Parasagittal Meningioma: Risks and Benefits

“…(19,29) Lesions that partially occlude the sinus without collateral pathways are at particular risk for complications suggesting a more conservative treatment aimed at resecting only the extrasinusal portion of the meningioma while preserving major cortical veins, and leaving tumor remnants that significantly involve the sinus and awaiting for sinus occlusion by residual tumor with the hope of promoting the development of collateral venous outflow. (5,7,14,24,30,31) This strategy was agreed and reported by Colli et al in their series, they opted to perform a subtotal resection when the posterior two thirds of the sinus was significantly invaded by a tumor and they never interrupted and reconstructed the sinus. (7) Sughrue et al postulated that the residual small tumor portion which invades SSS will not increase in short period even without adjuvant radiation-based treatments.…”

“…(1) Such tumors may invade partially or completely the superior sagittal sinus. (2)(3)(4)(5) They comprise approximately 19.5 to 45% of all intracranial meningiomas. (6) Parasagittal meningiomas are classified according to which third of the sinus they involve; as anterior third (from the crista galli to the coronal suture), middle third (from the coronal to the lambdoid suture), or posterior third (from the lambdoid suture to the torcular) (1,5,7) .…”

“…(18,19) The advantages of a radical resection should be weighed against the potential additional risks related to the opening of the sinus and its wall resection. (1,(20)(21) Some neurosurgeons consider the invasion of the middle and posterior third parts of the sinus as a contraindication for a complete resection (19)(20) and have proposed alternately more or less aggressive treatment modalities to manage this dilemma by resecting the tumor mass outside the sinus wall(s) and coagulate the remnant (5)(6)14) . Other neurosurgeons consider important to perform tumor excision when the SSS is completely occluded and sufficient collateral venous pathways have been established, (1,14,16,(22)(23)…”