Doing More with Less: Complex Meningiomas Illustrative Case Series

Abstract

Objective

The present study addresses the challenges of treating complex meningiomas in a low- to middle-income country (L-MIC) with limited access to advanced surgical equipment. The objective is to present innovative low-cost approaches and surgical techniques employed in the absence of a neurosurgical microscope, emphasizing resourcefulness in addressing surgical challenges.

Methods

The senior author conducted surgical interventions on four patients with complex meningiomas in a middle-income country's grade III hospital. Due to resource limitations, surgeries did not utilize a neurosurgical microscope. Instead, the Modified Pure Endoscopic Approach (MAPEnd) technique, intratumoral hydrogen peroxide infiltration, and water dissection were employed for intraoperative vision and magnification support. Thorough preoperative planning was crucial for successful treatment.

Results

The case series includes four illustrative cases ranging from parietal and posterior fossa giant meningiomas to front-parietal and cerebellopontine angle large meningiomas. Despite the limitations, effective tumor resections and favorable patient outcomes were achieved.

Conclusions

In resource-limited settings, where access to advanced neurosurgical equipment is constrained, this study demonstrates the successful treatment of complex meningiomas. The combination of water dissection, intratumoral hydrogen peroxide injection, and the MAPEnd method, along with meticulous preoperative planning, promises favorable surgical outcomes. These techniques contribute to neurosurgical innovation and bridge the gap in providing quality surgical care in L-MICs.

 

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Resumo

Objetivo

O presente estudo aborda os desafios de tratar meningiomas complexos em um país de baixa a média renda (L-MIC) com acesso limitado a equipamentos cirúrgicos avançados. O objetivo é apresentar abordagens inovadoras de baixo custo e técnicas cirúrgicas utilizadas na ausência de um microscópio neurocirúrgico, enfatizando a engenhosidade na resolução de desafios cirúrgicos.

Métodos

O autor sênior realizou intervenções cirúrgicas em quatro pacientes com meningiomas complexos em um hospital de grau III de um país de média renda. Devido às limitações de recursos, as cirurgias não utilizaram um microscópio neurocirúrgico. Em vez disso, foram empregadas a técnica Modified Pure Endoscopic Approach (MAPEnd), infiltração de peróxido de hidrogênio intratumoral e dissecção com água para suporte de visão e ampliação intraoperatória. O planejamento pré-operatório detalhado foi crucial para o tratamento bem-sucedido.

Resultados

A série de casos inclui quatro casos ilustrativos que variam de meningiomas gigantes parietal e fossa posterior a meningiomas grandes frontoparietais e angulares cerebellopontinos. Apesar das limitações, ressecções tumorais eficazes e resultados favoráveis para os pacientes foram alcançados.

Conclusões

Em ambientes com recursos limitados, onde o acesso a equipamentos neurocirúrgicos avançados é restrito, este estudo demonstra o tratamento bem-sucedido de meningiomas complexos. A combinação de dissecção com água, injeção intratumoral de peróxido de hidrogênio e o método MAPEnd, juntamente com um planejamento pré-operatório meticuloso, promete resultados cirúrgicos favoráveis. Essas técnicas contribuem para a inovação neurocirúrgica e preenchem a lacuna na prestação de cuidados cirúrgicos de qualidade em L-MICs.

 

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Keywords

meningioma - global neurosurgery - LMICs - resource-limited settings - low-cost techniques

Palavras-chave

meningioma - neurocirurgia global - LMICs - configurações com recursos limitados - técnicas de baixo custo

Introduction

Meningiomas primarily originate from meningoendothelial cells in the arachnoid meningeal layer and typically exhibit slow growth, often diagnosed at advanced stages.[1] [2] Computed tomography (CT) and magnetic resonance imaging (MRI) play crucial roles in diagnosis and pre-surgical planning.[2] [3] Large meningiomas (LMs) exceed 3 cm, while giant meningiomas (GMs), measuring over 5 cm, present unique challenges due to their rarity, size, elevated intracranial pressure, and proximity to critical structures.[2]

In low- and middle-income countries (L-MIC), limited access to advanced surgical equipment necessitates resourceful approaches - do more with less- by healthcare professionals when addressing such surgical challenges.[4] [5]

This study presents four cases of complex meningiomas treated in an L-MIC hospital, where the absence of equipment like a surgical microscope posed a significant limitation but did not preclude effective neurosurgical treatment.

 

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Methods

In a middle-income country's grade III hospital, the senior author JCHV conducted surgical interventions on four patients with complex meningiomas. Due to limited resources, these surgeries did not employ a neurosurgical microscope. Instead, comprehensive preoperative neuroanatomical planning, intratumoral hydrogen peroxide infiltration, and the utilization of the Modified Pure Endoscopic Approach (MAPEnd) technique provided intraoperative vision and magnification support.[6] [7] This study was reviewed and approved by the institutional ethics committee in accordance with regulations for human subject research. Additionally, measures were taken to ensure participant confidentiality, and all information presented in this manuscript was appropriately anonymized.

Surgical Technique

Thorough preoperative planning is crucial for the successful treatment of complex meningiomas. This planning involves assessing the optimal surgical approach, identifying critical neurovascular structures, recognizing tumor-feeding vessels, and understanding perilesional and draining veins.[8]

The general strategy for complex meningiomas is to remove the whole tumors over 1 or 2 cm in the margins of dural origin. Thus, the craniotomy must ensure a few centimeters of clearance around the entire dural attachment perimeter. Before opening the dura, we lift it to the craniotomy edges using securing sutures, preventing epidural space leakage, and reducing tumor-related bleeding. First, we eliminate a significant portion of the tumor's blood supply that originates from the dural attachment. In the case of convexity meningiomas, this is achieved by making a circular incision in the dura, leaving a few centimeters of margin, and cauterizing the dural edges. In the case of the cerebellar pontine angle meningioma, we proceed to eliminate the blood supply of the tumor originating in the inner dural surface where the tumor is attached. Since this procedure should be performed by magnification, we use the MAPEnd technique to ensure complete dissection and careful bipolar coagulation. Once this stage is achieved, the tumor must be carefully dissected gradually along the separation boundary between the tumor and the cortex. For this, the water dissection technique or “water jet” technique reported by Toth et al. facilitates tumor dissection with the use of saline solution and a syringe. The initial step of this technique involves creating access to the tumor-arachnoid space, simultaneously, coagulation of the tumor matrix is performed to disrupt its vascular supply. The next phase entails the meticulous removal of the tumor from within. The separation of the tumor from the brain's surface is a delicate process accomplished by directing a saline solution into the tumor-arachnoid space while gently manipulating the tumor sheath. This hydrodissection technique effectively detaches the tumor from the arachnoid-covered brain surface. It is imperative to maintain efficient fluid drainage throughout the procedure to prevent undue pressure on the relatively soft brain tissue. The tumor is then extracted piece by piece with meticulous care to preserve the integrity of the brain components.[8] [9] [10]

A cone-shaped tumor is typically removable in a single unit, but a spherical tumor with a small dural connection might need to be removed in sections to avoid excessive disturbance of the neighboring brain tissue. Thus, intratumor hydrogen peroxide is injected to facilitate hemostasis and consequently to perform a less bleeding removal of the tumor.[6] [8] After the entire tumor mass is resected, we should achieve proper hemostasis before closure. At this point, we use the MAPEnd technique for ensuring proper hemostasis in the surgical field. The saline irrigation helps to recognize small bleeding in the surgical field. For the dura replacement, we use occasionally synthetic dura or biological tissue from the epicraneal tissues. For intact or slightly hyperostotic bone, we smooth it and reposition the original bone. In tumor-invaded bones, we perform cranioplasty using artificial materials.[8]

 

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Results

Case 1: Parietal GM

A 47-year-old woman experienced a 6-month history of mild holocranial headaches, accompanied by decreased visual acuity and worsening symptoms with tinnitus, leading to a referral to our healthcare facility. CT and MRI scans revealed a left parietal GM measuring 7 × 5 cm (see [Fig. 1A]).

Fig. 1 (A & B) Left Parietal GM pre-surgical (yellow asterisk) and post-surgical MRI without tumoral mass (yellow arrow), (C) Right Posterior Fossa GM (red asterisk), (D) Right Posterior Fossa GM post-surgical excision, red circle shows residual tumor that is closer to lower cranial nerves.

We performed a single-layer linear incision, followed by a frontal-parietal craniotomy, successfully excising the tumor without any intraoperative complications. Immediate postoperative evaluation showed a favorable recovery. During the recovery period, the patient experienced the accumulation of cerebrospinal fluid in a subdural collection, which was treated with vendage compression. The patient's condition remained stable, and follow-up MRI scans showed no remaining tumor (see [Fig. 1B]).

During the long-term follow-up at 12 months, the patient remained stable, showing no neurological deficits, and there were no tumor remnants.

 

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Case 2: Posterior Fossa GM

A 29-year-old male experienced a three-month illness characterized by severe headaches, right upper limb weakness, nausea, vomiting, fever, and sphincter relaxation. A month later, his condition worsened, leading to altered consciousness, right upper limb paralysis, and intensified headaches. Initially, he sought medical care locally and was subsequently referred to our facility with a Glasgow Coma Scale (GCS) score of 10/15. He exhibited holocranial headaches, reduced tendon reflexes, and diminished strength (3/5) in the right upper limb. CT scans revealed obstructive hydrocephalus caused by a GM in the right posterior fossa, measuring 6 × 4 cm and exerting mass effect (see [Fig. 1.C]). Additionally, the tumor had invaded and eroded the right portion of the occipital bone and a section of the foramen magnum.

The following day, we performed a ventriculoperitoneal shunt to manage hydrocephalus and collected samples for pathological examination. Two weeks later, surgical intervention was recommended for GM resection. We conducted a suboccipital craniotomy with a paramedian incision, successfully achieving a radical tumor excision. A small portion of the tumor, closely associated with the lower cranial nerves, was intentionally left for subsequent evaluation and potential radiosurgery. The procedure proceeded without any intraoperative complications.

The patient's immediate postoperative recovery went smoothly, and his condition remained stable. He was discharged in the two weeks after surgery with improved upper limb motor function. At the 12-month follow-up, the patient remained stable without neurological symptoms, with a small residual tumor observed on MRI scans waiting for a radiosurgery or a microsurgical resection (see [Fig. 1.D] & [1.E]).

 

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Case 3: Front-Parietal GM

A 33-year-old male, previously experiencing significant visual impairment due to physical assault and moderate-intensity headaches for a year, developed weakness in the right upper limb, right facial weakness, and headaches one week after a tonic-clonic seizure. He was referred to our facility with a GCS score of 15/15. CT scans revealed the presence of a right fronto-parietal giant meningioma (see [Fig. 2A]).

Fig. 2 (A & B) Front-Parietal GM pre-surgical MRI (red asterisk) and post-surgical CT scan without tumoral mass (red arrow), (C & D) Cerebellopontine Angle LM pre-surgical (yellow asterisk) and post-surgical (yellor arrow) CT scans.

To achieve complete tumor removal, we performed an S-shaped frontal-parietal incision followed by a right front-parietal craniotomy. In the immediate postoperative period, the patient displayed mild bradypsychia and had a GCS score of 14/15. He could move his limbs with some weakness in the left hand, retaining finger mobility, and exhibited slight left facial weakness. A CT scan indicated a moderate brain edema, which resolved with corticosteroid treatment. The patient's condition improved, and he was discharged in the fifth postoperative week, with no evidence of a tumor lesion on CT scans (see [Fig. 2B]). The eight-month follow-up showed a patient with no neurological deficit and without tumor recurrence.

 

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Case 4: Cerebellopontine Angle LM

A 62-year-old woman presented with a mild headache that persisted for a year, which gradually intensified and led to decreased visual acuity and subsequent vertigo. She was referred to our medical center for evaluation. CT scans revealed obstructive hydrocephalus caused by an LM in the left cerebellopontine angle (see [Fig. 2C]).

We successfully achieved the complete removal of the meningioma using a retrosigmoid approach. The patient's immediate postoperative recovery was favorable, and her condition remained stable. Additionally, the hydrocephalus resolved. She was discharged in the second postoperative week with no evidence of tumor remnants on CT scans (see [Fig. 2D]). The six-month follow-up showed a patient with no neurological deficit and without tumor recurrence.

 

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Discussion

In this report, we present the clinical and surgical outcomes of four complex meningioma patients. Our focus is on the unique surgical challenges posed by these rare tumors, particularly in the context of our hospital, which is classified as a grade III facility in an L-MIC. The successful outcomes we describe result from a combination of extensive neuroanatomical knowledge and appropriate surgical techniques.

Meningiomas are non-brain tumors that elicit symptoms based on their location or by causing increased intracranial pressure.[1] [2] [11] They are typically found in the brain's outer covering, with convexity (20-34%) being a common location, as seen in cases 1 and 3. Meningiomas in the posterior fossa (9-15%) and cerebellopontine angle (2-4%) are much less frequent, as observed in cases 2 and 4, respectively.[12] [13]

The definition of a GM remains contentious in the medical literature, with varying opinions on the maximum tumor diameter, ranging from 4.5 to 7 cm. However, most reports consider meningiomas larger than 5 cm to be classified as GMs.[2] The surgical approach to GMs must be tailored to the tumor's characteristics, aiming for a location that allows for complete visible tumor removal while ensuring the patient's safety.[14] [15] It's important to note that achieving total resection isn't always possible due to the tumor's size, adhesion, or its significant involvement in neurovascular regions.[2] For instance, in our case 2, only a radical resection was achieved due to neurovascular constraints. Given these challenges, the information provided by CT and MRI scans plays a crucial role in facilitating adequate and safe pre-surgical planning.[14]

Micro neurosurgery and conventional neurosurgery differ in their approach, although both are effective for meningioma resection. Micro neurosurgery employs advanced tools like microscopes and precision instruments, providing a broader surgical field view, enhancing surgical accuracy, and minimizing collateral tissue damage. It also enables smaller incisions, particularly valuable for challenging-to-reach meningiomas. On the other hand, conventional neurosurgery relies on standard instruments and offers reduced visualization as it doesn't utilize microscopes. This approach is suitable for easily accessible meningiomas like those located on the brain's convexity.[2] [8]

Due to the absence of specialized micro neurosurgery equipment at our institution, we managed our challenging cases using conventional neurosurgery methods. For complex meningiomas like those situated in the cerebellopontine angle and posterior fossa, we augmented surgical management with the MAPEnd technique, a cost-effective approach utilizing a borescope camera to provide a clear intraoperative view.[7]

In all cases, we employed the intratumoral hydrogen peroxide injection, a method recommended by Lichtenbaum et al. for achieving effective intratumoral hemostasis during surgery, facilitating tumor resection. Following the standard neurosurgical procedure, we exposed the four tumors conventionally. After exposure, we carefully injected hydrogen peroxide directly into the meningioma without causing damage to the surrounding brain tissue or venous invasion.[6] Within seconds of hydrogen peroxide injection, we proceeded with tumor resection, aided by the water dissection technique, which proved effective in facilitating separation between the tumor and the arachnoid, leading to satisfactory intraoperative and postoperative hemostasis.[8] [9] [10]

In L-MICs, the shortage of resources for acquiring advanced neurosurgical equipment not only hampers research efforts but also contributes to increased patient disability and mortality rates.[5] [16] In Peru, the most advanced neurosurgical centers are primarily located in the capital city, Lima. While there is a gradual shift towards change, such as the establishment of the High Complexity Hospital "Virgen de la Puerta" in Trujillo, La Libertad region, there remains an inherent inefficiency in managing complex neurosurgical conditions. Patients from other regions often face the necessity of being referred from their local health systems to hospitals in Lima or must use their resources to travel for treatment. Nevertheless, this process is fraught with numerous obstacles and barriers, including distance, financial constraints, and inherent risks for the patients themselves.[17] Prior to our hospital's initiation of the management of complex lesions, only a few complex neurosurgical procedures had been conducted, primarily focusing on giant meningiomas or similarly complex cases.

Limitations

Although we provide care to complex meningiomas patients within the limited resources of an L-MIC, it's important to acknowledge that the standard neurosurgical treatment demands more specialized equipment. Consequently, the administrative leadership of our institution is actively working towards acquiring essential equipment, including microsurgery sets, upgrading operating rooms, and introducing fluoroscopes to enhance our capabilities.

 

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Conclusions

In L-MICs, accessing surgical care is challenging due to long distances to health centers, financial constraints, and limited resources. Neurosurgical innovation helps bridge these gaps.

We showcase the successful treatment of four complex meningioma cases at our institution, highlighting crucial surgical techniques like water dissection, intratumoral hydrogen peroxide injection, and intraoperative magnification through the MAPEnd method. Combined with meticulous preoperative planning, these techniques promise favorable surgical outcomes. This case series introduces the Cusco region to the realm of Global Neurosurgery.

 

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Conflict of Interest

The authors have no conflict of interest to declare.

Author's Contribution

• Uriel Tagle-Vega: Conceptualization; Data curation; Formal analysis; Investigation; Methodology; Validation; Visualization; Writing-original draft.

• Lucero Vera-Torres: Conceptualization; Data curation; Formal analysis; Investigation; Methodology; Validation; Visualization; Writing-original draft.

• Monserrat Medina-Mendez: Conceptualization; Methodology; Visualization; Writing-original draft.

• Joham Choque-Velasquez: Conceptualization; Data curation; Formal analysis; Investigation; Methodology; Project administration, Resources; Supervision; Visualization; Validation; Writing-review & editing.

Ethical Aspects

The Local Ethics Committee approved this study.

• References

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Publication History

Received: 11 March 2024

Accepted: 20 March 2025

Article published online:
16 July 2025