Falcotentorial Meningiomas: Insights from Surgical Strategies and Clinical Outcomes.

Background: Falcotentorial meningiomas are exceptionally uncommon tumors, presenting a challenge for neurosurgeons due to their close proximity to vital structures. Gross total resection represents the standard of treatment for these tumors. However, care must be taken when surgically approaching these lesions, since damaging neurovascular structures may cause unacceptable morbidity. Selecting the optimal surgical approach for each tumor is of paramount importance when treating these patients. Methods: The authors reviewed medical records to identify all patients with falcotentorial meningiomas who underwent resection at the University Hospital of Freiburg between January 2001 and December 2021. Clinical and imaging data, surgical management, and clinical outcomes were analyzed. Results: Falcotentorial meningiomas occurred in 0.7% (15 of 2124 patients) of patients with intracranial meningiomas. Of these 15 patients, 8 were female and 7 male. The occipital interhemispheric approach was used in nine patients, the supracerebellar infratentorial approach in five patients, and the retrosigmoidal approach in one patient. Three patients developed visual field deficits after surgical resection. Incomplete resection was significantly associated with tumor progression (p < 0.05). Conclusions: Individualized surgical strategies, guided by preoperative imaging and classification systems, play a crucial role in optimizing patient care. Among the available approaches, the occipital interhemispheric and supracerebellar infratentorial approaches are frequently employed and considered among the safest options for these tumors.

Surgical Treatment of Falcotentorial Meningioma: An Illustrative Case Report and Literature Review.

Falcotentorial meningiomas are rare tumors, representing only 2-3% of all intracranial meningiomas. These tumors can grow rapidly, leading to severe neurological complications. They grow at the junction of the tentorium cerebelli and the falx cerebri, in close proximity to the great vein of Galen. The surgical approach depends on several factors, such as the tumor's size, the patency of the straight sinus, and its location, either above or below the tentorium. Complete removal of the tumor in this area is difficult due to its deep location near major neurovascular structures. Various surgical approaches can be employed to remove these tumors, and the decision on which approach to use should be based on its advantages and disadvantages.

Combined supracerebellar infratentorial and right occipital interhemispheric approach to falcotentorial junction meningioma: A case report.

Background: Falcotentorial meningioma is a rare tumor of pineal region, arising from the dural folds where the tentorium and falx meet. Due to the deep location and near closeness to significant neurovascular structures, gross-total tumor resection in this area can be complicated. Pineal meningiomas can be resected using a variety of approaches; however, all these approaches are associated with a significant risk of postoperative complications. Case Description: A 50-year-old female patient who presented with several headaches and visual field defect and diagnosed with pineal region tumor is discussed in the case report. Patient was successfully managed surgically by combined supracerebellar infratentorial and right occipital interhemispheric approach. Cerebrospinal fluid circulation was restored after surgery and neurological defects were regressed. Conclusion: Our case shows that it is possible to completely remove giant falcotentorial meningiomas with minimal brain retraction, preserve the straight sinus and vein of Galen, and prevent neurological impairments by combining two approaches.

3-Dimensional Modeling in Virtual Reality for Resection of a Pineal Region Falcotentorial Meningioma.

We present a parietal interhemispheric approach to resect a pineal region falcotentorial meningioma. Three-dimensional (3D) modeling was used to visualize and plan the surgical approach in virtual reality (Video 1). A 78-year-old woman was incidentally found to have a slow-growing falcotentorial meningioma. The tumor was first treated with stereotactic radiosurgery, but the patient had progressive confusion, memory issues, and bilateral temporal field cuts with interval expansion of the tumor and significantly increased peritumoral vasogenic edema on magnetic resonance imaging. After recommending tumor resection, the patient consented to surgery and underwent resection via a posterior interhemispheric subsplenial approach. Using a 3D model in virtual reality, we discuss the advantages and disadvantages of various classical approaches to the pineal region for resection of this tumor.1-3 Falcotentorial meningiomas often displace the deep veins inferiorly, making an interhemispheric approach more favorable.4-6 Preoperative visualization of critical deep venous structures with the 3D model was a valuable adjunct to magnetic resonance imaging for achieving safe resection. We depict key steps of the surgical planning process using virtual reality and demonstrate how simulation can be used to evaluate risks and benefits of different surgical corridors. A small rim of residual tumor adherent to the deep cerebral veins was intentionally left behind in order to minimize risk of morbidity to the patient.7 At 1-month follow-up, the patient's cognition had returned to baseline and her vision had significantly improved. Ultimately, surgical planning using virtual reality promotes both neurosurgical education and patient safety through clear visualization and understanding of different surgical approaches.

Two-stage endoscopic assisted approach for large pineal region and falcotentorial meningioma: first stage paramedian supracerebellar infratentorial approach, second stage interhemispheric occipital transtentorial approach: surgical cases and anatomical study.

Resection of complex falcotentorial meningiomas, growing along the pineal region (PR), and posterior incisural space (PIS) represents a neurosurgical challenge. Here, we present our strategy for effective resection of large falcotentorial meningiomas applying a paramedian supracerebellar infratentorial and interhemispheric occipital transtentorial approach in staged surgeries. We further systematically compared the effectiveness of midline (MSIA) and paramedian (PSIA) supracerebellar infratentorial, as well as interhemispheric occipital transtentorial approaches (IOTA) to operate along the PR and PIS in 8 cadaveric specimens. The staged PSIA and IOTA enabled successful resection of both falcotentorial meningiomas with an uneventful postoperative course. In our anatomo-morphometrical study, superficial vermian veins at an average depth of 11.38 ± 1.5 mm and the superior vermian vein (SVV) at 54.13 ± 4.12 mm limited the access to the PIS during MSIA. MSIA required sacrifice of these veins and retraction of the vermian culmen of 20.88 ± 2.03 mm to obtain comparable operability indexes to PSIA and IOTA. Cerebellar and occipital lobe retraction averaged 14.31 ± 1.014 mm and 14.81 ± 1.17 mm during PSIA and IOTA respectively, which was significantly lower than during MSIA (p < 0.001). Only few minuscule veins were encountered along the access through PSIA and IOTA. The application of PSIA provided high operability scores around the pineal gland, ipsilateral colliculus and splenium, and acceptable scores on contralateral structures. The main advantage of IOTA was improving surgical maneuvers along the ipsilateral splenium. In summary, IOTA and PSIA may be advantageous in terms of brain retraction, vein sacrifice, and operability along the PR and PIS and can be effective for resection of complex falcotentorial meningiomas.

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

Meningiomas arising from the falcotentorial junction are rare, and the selection of the optimal surgical approach is essential. We report a falcotentorial meningioma (FTM) case approached by occipitotranstentorial resection and subtotal tumor resection presenting a satisfactory clinical outcome. The present review sought to reveal the current knowledge regarding the clinical presentation, radiological imaging, and the microsurgical anatomy of FTMs as a form of improving the surgical approach. The selection of the optimal surgical approach is essential for the safe and effective removal of an FTM. Preoperative imaging analysis should identify the anatomical relations of the tumor and guide toward the least disruptive route that preserves the neurovascular structures.

Laparoscope-Assisted Guidance to the Pineal Region.

Tumors arising in the pineal region present a number of challenges when planning for effective removal. This report describes the successful resection of a falcotentorial meningioma occurring in a 56-year-old female using a supracerebellar infratentorial approach. In order to excise the pineal region mass, a unique combination of instrumentation was used, including a microscope, endoscope, and abdominal laparoscope. This technique afforded us passage to the pineal region, which allowed for enhanced visualization and maneuverability and was more amenable to decreasing the physical stress of the operating surgeon. This article is the first to detail the use of an abdominal laparoscope to remove a pineal tumor of this size for near-total resection. The various surgical approaches and tools traditionally used to remove pineal tumors are discussed, and the particular advantages and disadvantages of our hybrid approach are reviewed.

The Supra/Infra Transtentorial Transfalcine Approach for the Removal of a Falcotentorial Meningioma: 2-Dimensional Video.

Falcotentorial meningiomas originate in the junction of the falx cerebri and the tentorium. Due to its anatomic vicinity, these tumors have a close relationship with important neurovascular structures surrounding the pineal region including the deep venous system. Surgical approaches would normally consider posterior midline corridors, but decision between supra or infratentorial access should be considered by the size, anatomic displacement of structures, and the infiltration of the dural attachment. This surgical video1,2 demonstrates the surgical technique and pearls to achieve a stepwise resection of a complex falcotentorial meningioma. We present a case of a 42-yr-old female patient, neurologically intact at presentation. A semi-sitting position was used. Appropriate management of cerebrospinal fluid was obtained with an external ventricular drainage which is kept closed until the dura is opened. A suprainfratentorial craniotomy was done with adequate exposure of the superior sagittal sinus and torcula. The supracerebellar infratentorial corridor was used for inferior internal debulking and arachnoidal dissection of the tumor while the exposure obtained in the posterior interhemispheric allowed a corridor which exposed widely the tumor with transtentorial transfalcine extension. Adequate management of adjacent structures was done while preserving the straight sinus and vein of Galen. A gross total removal of the tumor was achieved and the patient was discharged without complications. After this surgical video, the viewer will have learned the steps to safely achieve a surgical removal of a falcotentorial meningioma taking care of its relationship with the venous and neural adjacent structures.

Meningiomas Originated at the Falcotentorial Region: Analysis of Topographic and Diagnostic Features Guiding an Optimal Surgical Planning.

BACKGROUND: Meningiomas arising at the pineal region are a rare entity and still represent a great neurosurgical challenge given their deep location and critical neuroanatomic relationships. The optimal surgical approach to treat these lesions is still under debate. Our objective is to review the topographic and diagnostic features of these lesions, which can help to guide an optimal surgical outcome. METHODS: We present 2 clinical cases of falcotentorial meningiomas successfully treated at our institution (2016-2017) with different surgical approaches. A literature review is performed, and a description of the classification, anatomic relationships, clinical features, diagnosis, and different surgical options and outcomes of these lesions is presented. RESULTS: The first patient was treated via a supracerebellar infratentorial approach, and the second patient was treated via a parieto-occipital interhemispheric approach. In both tumors, a gross total resection was achieved with no permanent neurologic deficits. In the literature review, gross total resection rates range from 33% to 100%, with no differences regarding the type of meningioma or the surgical approach performed. Permanent neurologic morbidity varies from 0% to 50%, and mortality rates range from 0% to 23%. The distortion and displacement of the vein of Galen and straight sinus represent the most important feature in the decision of optimal surgical approach. CONCLUSIONS: Pineal region meningiomas represent very infrequent, challenging lesions, and their description in the literature is scarce. The systematic topographic classification of these tumors and evaluation of the neuroanatomic structures involved are crucial to guide a safe and optimal surgical approach and achieve satisfactory outcomes.

Combined bi-occipital suboccipital transsinus transtentorial approach for resection of a pineal region falcotentorial meningioma: operative video and technical nuances.

Large deep-seated meningiomas of the falcotentorial region present a formidable surgical challenge. In this operative video, the author demonstrates the combined bi-occipital suboccipital transsinus transtentorial approach for microsurgical resection of a large falcotentorial meningioma. This approach involves division of the less dominant transverse sinus after assessment of the venous pressure before and after clipping of the sinus with continuous neurophysiologic monitoring. Mild retraction of the occipital lobe and cerebellum results in a wide supra- and infratentorial exposure of extensive pineal region tumors. This video atlas demonstrates the operative technique and surgical nuances, including patient positioning, supra- and infratentorial craniotomy, transsinus transtentorial incision, and tumor removal with preservation of the vein of Galen complex. In summary, the combined bi-occipital suboccipital transsinus transtentorial approach provides a wide supra- and infratentorial surgical corridor for removal of select falcotentorial meningiomas. The video can be found here: https://youtu.be/3aD8h2uwBAo .

Endoscopic-assisted posterior interhemispheric retrocallosal transfalcine approach for microsurgical resection of a pineal region falcotentorial meningioma: operative video and technical nuances.

Falcotentorial meningiomas are rare tumors of the pineal region that arise from the dural folds where the falx and tentorium meet and are often intimately related to the vein of Galen and straight sinus. These lesions often present with signs and symptoms related to hydrocephalus and brainstem compression. Surgical resection of falcotentorial meningiomas remains the definitive treatment, with a variety of surgical approaches used to resect these lesions. The choice of approach depends on several factors, including the size and location of the tumor relative to the vein of Galen complex. Falcotentorial meningiomas can be technically challenging to remove with significant risk of morbidity because of the close proximity to and occasional invasion of the vein of Galen and straight sinus. In this operative video, the authors demonstrate an illustrative step-by-step technique for endoscopic-assisted microsurgical resection of a falcotentorial meningioma using the posterior interhemispheric retrocallosal transfalcine approach for a superiorly positioned falcotentorial meningioma. The surgical nuances are discussed, including the surgical anatomy, gravity-assisted interhemispheric approach in the lateral position, retrocallosal dissection, transfalcine exposure, tumor removal, and preservation of the vein of Galen complex. In summary, the posterior interhemispheric retrocallosal transfalcine approach is a useful surgical strategy for select superiorly positioned falcotentorial meningiomas. The video can be found here: https://youtu.be/d8mdunsRacs .