Falcotentorial Meningiomas: Surgical Outcomes and the Importance of Deep Venous Preservation

Introduction: 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 the Galen and straight sinus. Surgical resection of falcotentorial meningiomas remains the definitive treatment, with various surgical approaches used to resect these lesions. This study aimed to describe the operative nuances, clinical presentation, and surgical outcomes for resection of falcotentorial region meningiomas in 9 patients.

Methods: We retrospectively reviewed the records of all patients with falcotentorial region meningiomas treated between March 2010 and May 2023. Tumor characteristics, imaging studies, and patient characteristics were reviewed and analyzed. Surgical factors such as approach selection, tumor classification, brain relaxation techniques, window expansion (transfalcine, transtentorial, transsinus), prior operation, and complications were also collected and analyzed.

Results: Nine patients (2 males, 7 females. underwent microsurgical resection of falcotentorial region meningiomas with the intent of maximal safe resection. The average age was 60.3 (range 42 to 74). The most common presentations were memory loss (75%), headache (62.5%), personality changes (37.5%), blurred vision (37.5%), and impaired cognition (25%). The average tumor size was 37.4 ± 18.1 mm and were mostly (55.6%) superior to the vein of Galen. All patients underwent either gross total resection (55.6%), or near-total (>95% volumetric. resection (44.4%). The primary reason for near-total resection was because of tumor adherence or invasion to the internal cerebral veins, vein of Galen, and/or straight sinus. The most common surgical approach was the parietal interhemispheric precuneal transtentorial transfalcine approach. There were no complications of venous infarction, visual decline, or neurological impairment. One patient had delayed hydrocephalus requiring a shunt and one patient had a postoperative pseudomeningocele that resolved after lumbar drainage.

Conclusion: Falcotentorial meningiomas remain surgically formidable lesions. Maximal safe resection can be achieved with interhemispheric parieto-occipital precuneal approaches in the lateral position with gravity-assistance to avoid brain retraction. Corridors can be expanded with transtentorial and transfalcine incisions and intraoperative CSF drainage. Preservation of the deep venous complex is paramount to avoid postoperative venous complications. Endoscopic-assistance is also a useful adjunct for intraoperative inspection.

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Artikel online veröffentlicht:
05. Februar 2024