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DOI: 10.1055/s-0039-1685181
Parieto-Occipital Interhemispheric Transfalcine, Trans-Bitentorial Approach for Radical Resection of Falcotentorial Meningiomas
Publikationsverlauf
25. September 2017
20. Februar 2018
Publikationsdatum:
15. April 2020 (online)
![](https://www.thieme-connect.de/media/jnlsa/202004/lookinside/thumbnails/10-1055-s-0039-1685181_171978tn-1.jpg)
Abstract
Objective Falcotentorial meningioma occurs close to the falcotentorial edges and the confluence of the vein of Galen. The posterosuperior approach conventionally used to reach this site does not allow direct visualization of the tumor matrix, making detachment difficult. Meningiomas at this location are therefore among those that are not well amenable to radical resection. We devised an alternative anterolateral approach that, when used in addition to the posterosuperior approach, provides an operating field which allows to overview large, bilaterally extending tumors. We report this parieto-occipital interhemispheric transfalcine, trans-bitentorial approach, together with associated procedural modifications.
Methods We used the approach in four patients with falcotentorial meningioma between February 2008 and July 2017. We began by extending a parieto-occipital craniotomy slightly beyond the midline, to pass across the most caudal bridging vein on the rostral side. We then created a fan-shaped fenestration as large as possible in the falx, between the superior sagittal sinus and the inferior sagittal and straight sinuses (window 1). We further performed wedge-shaped resections of both tentorial edges to the left and right of window 1 (windows 2 and 3). Tumor debulking was then carried out via these three windows (the triple-window method). Finally, we detached the tumor in the area of the falcotentorial edges and the confluence of the vein of Galen. To obtain a superorostral operating field as wide as possible from laterally, thereby exposing the potential blind spots, the operating surgeon used both hands while retracting the precuneus, and the assistant surgeon used both hands to turn over the falcotentorial edges (twosome four-hand retractorless microsurgery).
Results The wide operating field provided by this parieto-occipital interhemispheric transfalcine, trans-bitentorial approach and twosome four-hand retractorless microsurgery provides a direct view of delicate structures at the falcotentorial edges and the confluence of the vein of Galen, a site that is most likely to be a blind spot in conventional approaches. Retraction of the precuneus on the nondominant side enabled radical resection with no neurologic deficit in any of the patients.
Conclusions The parieto-occipital interhemispheric transfalcine, trans-bitentorial approach with the triple-window method opens an anterolateral operating field in addition to a posterosuperior operating field in large tumors located in the falcotentorial and pineal region, extending anteroposteriorly and bilaterally. The twosome four-hand retractorless technique via this approach enables visualization of the tumor matrix at sites, which are barely visible with the conventional approach. Thus, the tumor can be removed more radically and safely.
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References
- 1 Fukushima T. Fukushima Manual of Skull Base Dissection. 3rd ed. Yokohama, Japan: AF-Neuro Video; 2011: 378-386
- 2 Iwami K, Fujii M, Saito K. Occipital transtentorial/falcine approach, a “cross-court” trajectory to accessing contralateral posterior thalamic lesions: case report. J Neurosurg 2017; 127 (01) 165-170
- 3 Kawashima M, Rhoton Jr AL, Matsushima T. Comparison of posterior approaches to the posterior incisural space: microsurgical anatomy and proposal of a new method, the occipital bi-transtentorial/falcine approach. Neurosurgery 2008; 62 (06) (Suppl. 03) 1136-1149
- 4 Quiñones-Hinojosa A, Chang EF, Chaichana KL, McDermott MW. Surgical considerations in the management of falcotentorial meningiomas: advantages of the bilateral occipital transtentorial/transfalcine craniotomy for large tumors. Neurosurgery 2009; 64 (05) (Suppl. 02) 260-268 ; discussion 268
- 5 Sekhar LN, Goel A. Combined supratentorial and infratentorial approach to large pineal-region meningioma. Surg Neurol 1992; 37 (03) 197-201
- 6 Ziyal IM, Sekhar LN, Salas E, Olan WJ. Combined supra/infratentorial-transsinus approach to large pineal region tumors. J Neurosurg 1998; 88 (06) 1050-1057
- 7 Asari S, Maeshiro T, Tomita S. , et al. Meningiomas arising from the falcotentorial junction. Clinical features, neuroimaging studies, and surgical treatment. J Neurosurg 1995; 82 (05) 726-738
- 8 Jittapiromsak P, Deshmukh P, Nakaji P, Spetzler RF, Preul MC. Comparative analysis of posterior approaches to the medial temporal region: supracerebellar transtentorial versus occipital transtentorial. Neurosurgery 2009; 64 (3, Suppl): ons35-ons42 ; discussion ons42–ons43
- 9 Konovalov AN, Spallone A, Pitzkhelauri DI. Meningioma of the pineal region: a surgical series of 10 cases. J Neurosurg 1996; 85 (04) 586-590
- 10 Lozier AP, Bruce JN. Meningiomas of the velum interpositum: surgical considerations. Neurosurg Focus 2003; 15 (01) E11
- 11 Okami N, Kawamata T, Hori T, Takakura K. Surgical treatment of falcotentorial meningioma. J Clin Neurosci 2001; 8 (Suppl. 01) 15-18
- 12 Rey-Dios R, Cohen-Gadol AA. A surgical technique to expand the operative corridor for supracerebellar infratentorial approaches: technical note. Acta Neurochir (Wien) 2013; 155 (10) 1895-1900
- 13 Samii M, Carvalho GA, Tatagiba M, Matthies C, Vorkapic P. Meningiomas of the tentorial notch: surgical anatomy and management. J Neurosurg 1996; 84 (03) 375-381
- 14 Tanaka R. Surgery of pineal region tumors: key points of occipital transtentorial approach [in Japanese]. Jpn J Neurosurg 1999; 8 (03) 151-155
- 15 Cavanna AE, Trimble MR. The precuneus: a review of its functional anatomy and behavioural correlates. Brain 2006; 129 (Pt 3(: 564-583
- 16 Kouider S, de Gardelle V, Dehaene S, Dupoux E, Pallier C. Cerebral bases of subliminal speech priming. Neuroimage 2010; 49 (01) 922-929
- 17 Binder JR, Desai RH, Graves WW, Conant LL. Where is the semantic system? A critical review and meta-analysis of 120 functional neuroimaging studies. Cereb Cortex 2009; 19 (12) 2767-2796
- 18 Yasargil MG. Microneurosurgery. Vol. IVB. Stuttgart, Germany: Thieme; 1996: 526
- 19 Erbaş G, Oner AY, Akpek S, Tokgoz N. Corpus callosum hematoma secondary to isolated inferior sagittal sinus thrombosis. Acta Radiol 2006; 47 (10) 1085-1088
- 20 Tatarli N, Ceylan D, Canaz H. , et al. Falcine venous plexus within the falx cerebri: anatomical and scanning electron microscopic findings and clinical significance. Acta Neurochir (Wien) 2013; 155 (11) 2183-2189 ; discussion 2189
- 21 Tubbs RS, Loukas M, Louis Jr RG. , et al. Anatomy of the falcine venous plexus. J Neurosurg 2007; 107 (01) 155-157
- 22 Goto T, Ohata K, Morino M. , et al. Falcotentorial meningioma: surgical outcome in 14 patients. J Neurosurg 2006; 104 (01) 47-53
- 23 Kaku S, Fujitsu K, Okada T. , et al. Practical and educational significance of twosome four-hand retractorless microsurgery in Yokohama Medical Center [in Japanese]. Iryo 2010; 64 (10) 689-692
- 24 Hongo K, Kobayashi S, Yokoh A, Sugita K. Monitoring retraction pressure on the brain. An experimental and clinical study. J Neurosurg 1987; 66 (02) 270-275
- 25 Spetzler RF, Sanai N. The quiet revolution: retractorless surgery for complex vascular and skull base lesions. J Neurosurg 2012; 116 (02) 291-300