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Yoshinori Maki1, Yu Abekura2, Toshinari Kawasaki2, Tamaki Kobayashi2, Yoshihiko Ioroi2, Motohiro Takayama2
  1. Department of Neurosurgery, Hikone Chuo Hospital, Hikone,
  2. Department of Neurosurgery, Otsu City Hospital, Otsu, Shiga, Japan.

Correspondence Address:
Motohiro Takayama, Department of Neurosurgery, Otsu City Hospital, Otsu, Shiga, Japan.

DOI:10.25259/SNI_300_2022

Copyright: © 2022 Surgical Neurology International This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-Share Alike 4.0 License, which allows others to remix, transform, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.

How to cite this article: Yoshinori Maki1, Yu Abekura2, Toshinari Kawasaki2, Tamaki Kobayashi2, Yoshihiko Ioroi2, Motohiro Takayama2. Embolization of a vertebral artery encased in a regrowth cervical meningioma before resection. 29-Apr-2022;13:180

How to cite this URL: Yoshinori Maki1, Yu Abekura2, Toshinari Kawasaki2, Tamaki Kobayashi2, Yoshihiko Ioroi2, Motohiro Takayama2. Embolization of a vertebral artery encased in a regrowth cervical meningioma before resection. 29-Apr-2022;13:180. Available from: https://surgicalneurologyint.com/surgicalint-articles/11564/

Date of Submission
31-Mar-2022

Date of Acceptance
14-Apr-2022

Date of Web Publication
29-Apr-2022

Abstract

Background: Managing intraoperative bleeding may be challenging when a cervical tumor encases the vertebral artery (VA). Here, a patient with a recurrent cervical meningioma between the C1/2 and C3/4 levels and encasement of the right VA injury developed intraoperative bleeding that was endovascularly embolized postoperatively.

Case Description: A 30-year-old female presented with a progressive quadriparesis, most markedly involving the right upper extremity. Six years ago, she had a cervical meningioma resected at the C2/3 level. The new MR revealed regrowth of intraspinal tumor between the C1/2 to C4/5 levels accompanied by extradural encasement of the right VA within the C2/3 and C3/4 foramina. Before the first surgery, the right VA was embolized (i.e., after a balloon occlusion test proved negative). During the attempted resection of the intradural/extradural tumor, bleeding from the right VA was encountered; it was temporarily controlled. After complete occlusion of the right VA was angiographically confirmed, a second-stage procedure to fully resect the extradural remanent of the tumor was undertaken.

Conclusion: Endovascular embolization of the right VA before the attempted resection of a recurrent intraspinal/extraspinal cervical meningioma failed to occlude the vessel entirely. The VA bleeding encountered intraoperatively was temporarily controlled. Delayed total VA occlusion was angiographically observed before full tumor resection could be completed.

Keywords: Cervical meningioma, Endovascular embolization, Recurrence, Surgical treatment, Vertebral artery

INTRODUCTION

Extradural spinal meningiomas are rare and comprise just 2.5–3.5% of all spinal meningiomas.[ 1 ] They can be located at the spinal level.[ 1 , 6 ] Although gross total surgical resection is the gold standard, extradural cervical meningiomas extending into the foramina may encase the vertebral artery (VA), making complete excision more challenging.[ 2 ] To avoid injuring the VA during anterior or lateral approaches, preoperative endovascular embolization/occlusion is often recommended.[ 2 , 4 , 6 , 7 ] Here, a case of a 30-year-old woman who developed intraoperative bleeding from the still patent VA during the initial attempt at recurrent tumor resection is presented. The first procedure was aborted following temporary VA occlusion. Postoperative additional endovascular right VA embolization was unnecessary as we confirmed that the VA was completely embolized with cerebral digital angiography. The second stage successfully resulted in gross total tumor resection.

CASE PRESENTATION

A 30-year-old woman presented with a 2-month history of progressive quadriparesis, most markedly involving the right upper extremity. She had undergone resection of a cervical meningioma 6 years before [ Figure 1 ]. Now, the cervical MR showed a recurrent tumor on the right side between the C1/2 to C4/5 levels, with extradural extension into the right C2/3 and C3/4 foramina where it encased the right VA [ Figures 2a - g ].


Figure 1:

First Surgery: MR and pathological findings. Preoperative T2-weighted MR shows a mass at C2/C3 with cord compression (a: Sagittal and b: Axial). Postoperative T2-weighted MR shows a tumor in the spinal canal that was removed, but there is a residual C2/3 foraminal tumor (white arrow heads) (c: Sagittal and d: Axial). Transitional meningioma (Grade 1) was diagnosed with an aggregation of meningothelial cells with pink cytoplasm, short spindle-shaped cells, and psammoma bodies. Mib-1 index was less than 2% (e-g).

 

Figure 2:

Six years later, preoperative MR and angiography of the recurrent tumor encasing the right VA. A T2-weighted MR shows the recurrent meningioma from C1 to C4 (a). The T1-weighted enhanced MR shows the recurrent tumor in the spinal canal extending through the right-sided foramina of C1/C2 and C3/C4 (b-g). Right vertebral angiography shows the tumor is fed by radicular arteries (h and i). The pedicle screws were placed at the bilateral C2, right C3, and bilateral C4 levels. The right vertebral artery was embolized (j and k).

 

First procedure

Endovascular occlusion of the right VA from C3-C5 was performed before the replacement of pedicle screws at the level of bilateral C2, left C3, and bilateral C4 [ Figure 2h - k ].

First surgery of tumor resection

The intracanalicular meningioma was circumferentially detached and removed. This required drilling/excision of the right lateral masses of C2, C3, and C4 [ Figure 3 ]. During this dissection, however, bleeding was encountered from the right VA. The bleeding was controlled and not persistent. The procedure was immediately aborted because continuing the removal procedure could result in bleeding complications [ Figure 4 ].


Figure 3:

Surgery Part 1: Resection of the intradural recurrent tumor between the C1-C5 levels. The intradural meningioma was laterally detached from the dura (a and b). The caudal margin of the tumor involving the C5 nerve root (c). The tumor was then medially detached from the spinal cord (d). The right C2 nerve root was the cranial margin of the meningioma (e). The intradural meningioma was then removed (f). Ca: Caudal, Cr: Cranial, Rt: Right.

 

Figure 4:

Surgery Part 2: Removal of the extradural recurrent tumor. The lateral masse of C2/C3 and C3/C4 were drilled, allowing for exposure of the extradural meningioma in the C3 nerve sheath (a). Removal of the extradural meningioma was initiated (b). The embolized VA was identified (c). The extradural meningioma lateral to the foramen of C3 was removed along the VA (d and e). However, bleeding occurred around the VA when the extradural tumor was removed at the C4 level (black arrows) (f). Ca, Caudal; Cr, Cranial; Rt, Right; VA, Vertebral artery.

 

Angiographic findings after first surgery of tumor resection

The digital cerebral angiography, performed 9 days later, newly documented complete embolization/occlusion of the right VA. Therefore, additional endovascular embolization of the right VA was not performed.

Second surgery of tumor resection

During the second surgery, the residual extradural meningioma located between the C2 to C4 levels was removed [ Figure 5 ]. The postoperative course was uneventful and the patient remained neurologically intact. Ten months later, the postoperative MR documented no tumor regrowth [ Figure 6 ].


Figure 5:

Surgery Part 3; final removal of the extradural recurrent tumor. Residual meningioma at the C2 (a) and C4 levels were removed (b and c). The residual meningioma in the foramen of C4 was curetted (d). The extradural meningioma was then grossly and totally removed, following which a duraplasty was performed (e and f). Ca: Caudal, Cr: Cranial, Rt: Right.

 

Figure 6:

Postoperative MR images. Postoperative T2-weighted magnetic resonance images reveal gross total removal of the regrowth meningioma (a: Sagittal and b-g: Axial).

 

Pathology

The pathology was consistent with a benign meningioma similar to that removed 6 years earlier; there was no evidence of malignancy.

DISCUSSION

Only 2.5–3.5% of spinal meningiomas are extradural, and in these cases, unilateral encasement of VA must be anticipated.[ 1 ] Various preoperative and intraoperative methods for controlling bleeding from the VA compressed/ encased by cervical tumors have been proposed, although the VA can be retracted if necessary. Preoperative embolization of these VA is safer and more effective [ Table 1 ].[ 1 - 7 ] Here, preoperative endovascular embolization of the encased right VA within the recurrent cervical meningioma was first unsuccessful as there was intraoperative bleeding from the still patent right VA. After delayed complete occlusion of the right VA was confirmed angiographically, gross total tumor removal was secondarily achieved.


Table 1:

Past cases of cervical tumor encasing a vertebral artery.

 

CONCLUSION

Endovascular embolization of a unilateral encased VA (i.e., after unilateral balloon occlusion produces no deficits) is often considered to prevent intraoperative hemorrhage, particularly during the resection of recurrent cervical meningiomas.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

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2. Küçük A, Şahin A, Çiftçi M, Ulutabanca H, Koç RK. Vertebral Artery Mobilization and Cervical Tumor Resection. World Neurosurg. 2021. 148: e600-8

3. Ogungbemi A, Elwell V, Choi D, Robertson F. Permanent endovascular balloon occlusion of the vertebral artery as an adjunct to the surgical resection of selected cervical spine tumors: A single center experience. Interv Neuroradiol. 2015. 21: 532-7

4. Ryu SM, Kim SK, Park JH, Lee SH, Eoh W, Kim ES. Subtotal resection of cervical dumbbell schwannomas: Radiographic predictors for surgical considerations. World Neurosurg. 2019. 121: e661-9

5. Schroeder GD, Hsu WK. Vertebral artery injuries in cervical spine surgery. Surg Neurol Int. 2013. 4: S362-7

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