- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, 175 N, Medical Drive East, Salt Lake City, Utah 84132, USA
- Department of Plastic and Reconstructive Surgery, University of Utah, 100 N, Medical Drive, Salt Lake City, Utah 84132, USA
Correspondence Address:
William T. Couldwell
Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, 175 N, Medical Drive East, Salt Lake City, Utah 84132, USA
DOI:10.4103/2152-7806.153708
Copyright: © 2015 Mazur MD. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.How to cite this article: Mazur MD, Neil JA, Agarwal C, Jensen RL, Couldwell WT. Surgical management of a transosseous meningioma with invasion of torcula, superior sagittal sinus, transverse sinus, calvaria, and scalp. Surg Neurol Int 20-Mar-2015;6:40
How to cite this URL: Mazur MD, Neil JA, Agarwal C, Jensen RL, Couldwell WT. Surgical management of a transosseous meningioma with invasion of torcula, superior sagittal sinus, transverse sinus, calvaria, and scalp. Surg Neurol Int 20-Mar-2015;6:40. Available from: http://sni.wpengine.com/surgicalint_articles/surgical-management-transosseous-meningioma-invasion-torcula-superior-sagittal-sinus-transverse-sinus-calvaria-scalp/
Abstract
Background:Meningiomas involving both intradural and extradural structures are rare tumors. We report the complete resection of a massive complex transosseous meningioma that had invaded the torcula, superior sagittal sinus, occipital bone, and scalp.
Case Description:A 48-year-old male presented after 3 days of worsening headaches and blurry vision. Preoperative imaging demonstrated an 11 × 5-cm extra-axial mass that avidly enhanced with gadolinium in the region of the torcula. Angiography demonstrated occlusion of the involved portions of the superior sagittal sinus, torcula, and proximal left transverse sinus. Cortical drainage occurred via the veins of Labbι and deep drainage via an occipital sinus. Using image-guided stereotaxy, a wide-excision scalp resection and craniectomy with sinus exploration was planned for complete tumor removal. Parasitized cortical veins were preserved. Occluded portions of the superior sagittal sinus and left transverse sinus were resected along with the invaded parts of the falx and tentorium. The walls of the straight sinus, torcula, and right transverse sinus were repaired primarily to facilitate deep drainage. A latissimus dorsi free flap was used to reconstruct the scalp defect. Routine follow-up magnetic resonance imaging (MRI) at 18 months demonstrated no evidence of recurrence or regrowth.
Conclusions:This case illustrates the importance of identifying aberrant venous drainage pathways when considering ligation and resection of major sinuses and discusses the management of calvarial and scalp invasion.
INTRODUCTION
Meningiomas arise from arachnoid cap cells in arachnoid granulations, which are particularly abundant near the dural venous sinuses and give rise to intradural tumors involving the superior sagittal sinus, torcula, and transverse sinuses.[
CASE REPORT
History and presentation
A 48-year-old male presented to the emergency department after experiencing 3 days of worsening headaches and blurry vision. Physical examination revealed an inferior field hemianopsia and a large firm protuberance in the posterior occiput without any overlying skin abnormality. He was a nonsmoker with no history of cancer, and a screening computed tomography (CT) scan of his chest, abdomen, and pelvis showed no evidence of malignancy. Magnetic resonance imaging and magnetic resonance angiography (MRI/MRA) of his brain demonstrated an 11 × 5-cm mass that extended both supra- and infratentorially and into the bilateral parietal and occipital lobes, the superior sagittal sinus, the torcula, and the proximal transverse sinuses [
Figure 1
Axial (a) and coronal (b) contrast-enhanced T1-weighted MRI demonstrates tumor encasing the posterior portion of the superior sagittal sinus extending into the torcula. Abnormal thickening of the posterior scalp is seen. (c) Axial T2-weighted MRI sequence demonstrates abnormal hyperintensity in the white matter of the occipital lobe consistent with vasogenic edema from parenchymal tumor invasion. (d) Sagittal view of contrast-enhanced CT scan, bone window, shows that the occipital bone is both hyperostotic and thickened from tumor infiltration
Figure 2
Lateral view cerebral angiogram after left internal carotid artery injection. The posterior skull/extra-axial tumor invades and occludes 7 cm of the posterior superior sagittal sinus, torcula, and proximal transverse sinus (black arrows). There is reconstitution at the distal transverse sinuses. Deep venous drainage occurs via an occipital sinus that connects the straight sinus to the left jugular bulb (white arrow)
Figure 4
Pre (a)- and post (b)-embolization images of the left external carotid artery injection. Main arterial feeders include branches of the occipital (black arrows) and middle meningeal arteries (white arrows), which were successfully embolized. Arterial feeders were also embolized from similar branches of the right external carotid artery (not shown). (c) Right vertebral artery injection depicting a posterior meningeal artery branch arising from the posterior inferior cerebellar artery and feeding the meningioma. This branch was not embolized
Surgery
A small open biopsy of the abnormal scalp and involved occipital bone was performed as an initial procedure to obtain a tissue diagnosis. Pathological analysis revealed meningioma, World Health Organization (WHO) Grade I. For definitive treatment, the patient was positioned prone using a Mayfield 3-pin head holder. Using image-guided stereotaxy, we planned a wide-excision scalp resection and craniectomy with sinus exploration to allow for complete tumor removal. The scalp was excised en bloc in a circular fashion with a wide margin, and intraoperative frozen pathological diagnosis confirmed that the scalp margins were free of tumor. The underlying calvaria was grossly abnormal—alternately hyperostotic with areas of soft tumor infiltration. The superior sagittal sinus, torcula, and transverse sinuses were outlined stereotactically, and multiple burr holes were placed along the sinuses and the periphery of the planned bone flap, which encompassed portions of both the supra- and infratentorial compartments. Craniectomy was performed using a high-speed drill with burrs and footplate.
The dura was opened over the bilateral parietal and occipital lobes. The tumor was dissected from the underlying brain using standard microsurgical technique [
Figure 5
Intraoperative photographs depicting (a) extension of the meningioma from the bone to scalp; (b) use of neuronavigation to identify the margin of venous sinuses for ligation; (c) dissection of tumor that has invaded the pia and into the occipital lobe; (d) gross resection of the tumor and its dural attachment; (e) primary repair of the torcula suture after the intrasinusal tumor portions are removed; (f) duroplasty and overlying titanium mesh cranioplasty prior to placement of latissimus dorsi free flap
Postoperative course
Postoperatively, the patient was transferred to the intensive care unit. Initially, he experienced surgery-related visual disturbances with diminished visual acuity, which gradually improved during inpatient rehabilitation. Final pathological diagnosis from the gross total resection was also meningioma, WHO Grade I. The halo vest was continued for 6 weeks. At his 6-month follow-up appointment, the patient was able to read a newspaper with reading glasses, but his preoperative inferior hemianopsia remained stable. A minor revision of scalp reconstruction was performed to remove a lateral dog-ear deformity, but otherwise, he healed without complication. Routine follow-up MRI at 18 months demonstrated no evidence of recurrence or regrowth [
DISCUSSION
Complex meningiomas invading the torcula are uncommon. Published series of meningiomas involving the tentorium or major dural sinuses include only a few cases of tumors with torcular involvement.[
Management of dural venous sinuses
Radical resection of meningiomas invading the dural venous sinuses is controversial. Some authors advocate performing a complete resection to prevent tumor recurrence or regrowth,[
It is generally accepted that patients can tolerate resecting portions of the venous sinuses that are completely occluded. Nonetheless, surgical resection of meningiomas invading the sinuses must be balanced with avoidance of venous outflow obstruction, which could cause neurological complications, such as brain swelling, cerebrospinal fluid obstruction, seizures, hemorrhage, infarction, and death. Some surgeons are in favor of flow restoration with sinus reconstruction or bypass even when the sinus is completely occluded. Because the reconstructed outflow tract allows time for compensatory collateral circulation to form, patients may better tolerate alterations in venous drainage that occur after the meningioma is resected. Delayed complications from cerebral edema have occurred in patients who had meningiomas occluding the sinus who did not undergo venous restoration.[
Sindou and Alvernia[
Because fractionated radiation therapy and stereotactic radiosurgery of small meningiomas can achieve acceptable tumor control rates,[
Ligation of the occluded sections of the venous sinuses was necessary to completely excise the involved sinus walls and resect the extensive intravascular portions of tumor. To minimize risk of venous complications in these cases, many authors, including us, recommend preoperative angiography to verify a widely open contralateral transverse sinus or evidence of sufficient venous collateral formation.[
Patients with meningiomas involving the posterior third of the superior sagittal sinus frequently present with visual disturbances or visual field deficits that impact their quality of life.[
Management of skull and scalp defects
In addition to the removal of the intradural and intravascular portions of this transosseous meningioma, wide excision of the involved calvaria and overlying scalp was required to prevent recurrence. Histological analysis has shown that meningothelial tumor cells infiltrate the Haversian canals of hyperostotic bone.[
CONCLUSIONS
We describe the complete resection of a large transosseous meningioma that invaded the occipital lobes, posterior section of the superior sagittal sinus, torcula, transverse sinus, calvaria, and scalp. Collateral venous drainage of the cortex via the veins of Labbé and deep structures via an occipital sinus allowed for the resection of the involved walls of the venous sinuses without complication. Scalp reconstruction with a latissimus dorsi free flap enabled the complete removal of tumor that had invaded the scalp.
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