Surgical treatment of falcotentorial meningiomas: a retrospective review of a single-institution experience

Abstract

OBJECTIVEMeningiomas at the falcotentorial junction represent a rare subgroup of complex meningiomas. Debate remains regarding the appropriate treatment strategy for and optimal surgical approach to these tumors, and surgical outcomes have not been well described in the literature. The authors reviewed their single-institution experience in the management, approach selection, and outcomes for patients with falcotentorial meningiomas.METHODSFrom the medical records, the authors identified all patients with falcotentorial meningiomas treated with resection at the Barrow Neurological Institute between January 2007 and October 2017. Perioperative clinical, surgical, and radiographic data were retrospectively collected. For patients who underwent the supracerebellar infratentorial approach, the tentorial angle was defined as the angle between the line joining the nasion with the tuberculum sellae and the tentorium in the midsagittal plane.RESULTSFalcotentorial meningiomas occurred in 0.97% (14/1441) of the patients with meningiomas. Most of the patients (13/14) were female, and the mean patient age was 59.8 ± 11.3 years. Of 17 total surgeries (20 procedures), 11 were single-stage primary surgeries, 3 were two-stage primary surgeries (6 procedures), 2 were reoperations for recurrence, and 1 was a reoperation after surgery had been aborted because of brain edema. Hydrocephalus was present in 5 of 17 cases, 4 of which required additional treatment. Various approaches were used, including the supracerebellar infratentorial (4/17), occipital transtentorial/transfalcine (4/17), anterior interhemispheric transsplenial (3/17), parietal transventricular (1/17), torcular (2/17), and staged supracerebellar infratentorial and occipital transtentorial/transfalcine (3/17) approaches. Of the 17 surgeries, 9 resulted in Simpson grade IV resection, and 3, 1, and 4 surgeries resulted in Simpson grades III, II, and I resection, respectively. The tentorial angle in cases with Simpson grade I resection was significantly smaller than in those with an unfavorable resection grade (43.3° ± 4.67° vs 54.0° ± 3.67°, p = 0.04). Complications occurred in 10 of 22 approaches (17 surgeries) and included visual field defects (6 cases, 2 permanent and 4 transient), hemiparesis (2 cases), hemidysesthesia (1 case), and cerebellar hematoma (1 case).CONCLUSIONSFalcotentorial meningiomas are challenging lesions. A steep tentorial angle is an unfavorable preoperative radiographic factor for achieving maximal resection with the supracerebellar infratentorial approach. Collectively, the study findings show that versatility is required to treat patients with falcotentorial meningiomas and that treatment goals and surgical approach must be individualized to obtain optimal surgical results.

Combined Microscopic and Endoscopic Surgery for Pineal Region Meningiomas Using the Occipital-Parietal Transtentorial Approach

“…In contrast, the occipital transtentorial approach (OTA) provides the most extensive exposure of both the supratentorial and infratentorial compartments. It provides direct visualization of the deep venous structure and ipsilateral dorsal and lateral extension of the midbrain (15,18). In this study, an OTA was used in all 12 patients, as we found that this approach has particular advantages for meningiomas in the pineal region.…”

“…Different from many pineal region malignant tumors, pineal region meningioma is a slow-growing benign tumor for which complete resection is the best treatment strategy. Therefore, despite surgical challenges, radical resection remains the primary treatment goal (15). In the present study, we treated 12 consecutive patients with meningiomas in the pineal region.…”

Surgical management of tentorial meningiomas: case series

“…Complications rate is highly dependent on tumor location [15,16]. Hydrocephalus and CSF fistula are the main drawbacks in the natural history of a surgically removed tumor [1,8,17]. Even in meticulous procedures that aimed to preserve neurological function, complications rate ranged between 24 and 33% in these reports.…”

Clip retraction of the tentorium: application of a novel technique for tentorial retraction during supracerebellar transtentorial approaches

“…Because of their advantages over transcortical approaches, SCTT approaches are becoming more common for the treatment of pathologic conditions in the posterior thalamus and medial temporooccipital space. Previous studies have characterized the use of either SCTT or occipital transtentorial approaches for the microsurgical resection of meningiomas, 4,6,16 CMs, 8-10 epidermoid cysts, 17 and other pathologic conditions. 11,12,18,19 Compared with transcortical routes, transtentorial approaches provide excellent anatomical exposure without traversal of eloquent cortex or retraction of parenchyma.…”

“…Recently, supracerebellar transtentorial (SCTT) approaches have become a popular option for treatment of a variety of pathologic conditions in the medial and basal temporal and occipital lobes. [4][5][6] Lesions such as meningiomas, 7 gliomas, cavernous malformations (CMs), [8][9][10] and arteriovenous malformations 11,12 have been removed through posterior approaches through the tentorium, often with the use of the sitting position and gravity retraction of the cerebellum to widen the supracerebellar space and extend the upward reach beyond the tentorium. We and others have found this strategy useful for the treatment of thalamic pathologic entities that abut the posterior-inferior surface of the pulvinar.…”