Surgical treatment of falcotentorial meningiomas: a retrospective review of a single-institution experience

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OBJECTIVE

Meningiomas at the falcotentorial junction represent a rare subgroup of complex meningiomas. Debate remains regarding the appropriate treatment strategy for and optimal surgical approach to these tumors, and surgical outcomes have not been well described in the literature. The authors reviewed their single-institution experience in the management, approach selection, and outcomes for patients with falcotentorial meningiomas.

METHODS

From the medical records, the authors identified all patients with falcotentorial meningiomas treated with resection at the Barrow Neurological Institute between January 2007 and October 2017. Perioperative clinical, surgical, and radiographic data were retrospectively collected. For patients who underwent the supracerebellar infratentorial approach, the tentorial angle was defined as the angle between the line joining the nasion with the tuberculum sellae and the tentorium in the midsagittal plane.

RESULTS

Falcotentorial meningiomas occurred in 0.97% (14/1441) of the patients with meningiomas. Most of the patients (13/14) were female, and the mean patient age was 59.8 ± 11.3 years. Of 17 total surgeries (20 procedures), 11 were single-stage primary surgeries, 3 were two-stage primary surgeries (6 procedures), 2 were reoperations for recurrence, and 1 was a reoperation after surgery had been aborted because of brain edema. Hydrocephalus was present in 5 of 17 cases, 4 of which required additional treatment. Various approaches were used, including the supracerebellar infratentorial (4/17), occipital transtentorial/transfalcine (4/17), anterior interhemispheric transsplenial (3/17), parietal transventricular (1/17), torcular (2/17), and staged supracerebellar infratentorial and occipital transtentorial/transfalcine (3/17) approaches. Of the 17 surgeries, 9 resulted in Simpson grade IV resection, and 3, 1, and 4 surgeries resulted in Simpson grades III, II, and I resection, respectively. The tentorial angle in cases with Simpson grade I resection was significantly smaller than in those with an unfavorable resection grade (43.3° ± 4.67° vs 54.0° ± 3.67°, p = 0.04). Complications occurred in 10 of 22 approaches (17 surgeries) and included visual field defects (6 cases, 2 permanent and 4 transient), hemiparesis (2 cases), hemidysesthesia (1 case), and cerebellar hematoma (1 case).

CONCLUSIONS

Falcotentorial meningiomas are challenging lesions. A steep tentorial angle is an unfavorable preoperative radiographic factor for achieving maximal resection with the supracerebellar infratentorial approach. Collectively, the study findings show that versatility is required to treat patients with falcotentorial meningiomas and that treatment goals and surgical approach must be individualized to obtain optimal surgical results.

ABBREVIATIONS EVD = external ventricular drain; mRS = modified Rankin Scale; VFD = visual field defect.

Article Information

Correspondence Peter Nakaji: c/o Neuroscience Publications, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, AZ. neuropub@barrowneuro.org.

INCLUDE WHEN CITING Published online August 2, 2019; DOI: 10.3171/2019.4.JNS19208.

Disclosures The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    Case 10. A 60-year-old woman presented with a headache. Preoperative MRI revealed a falcotentorial meningioma based on the left tentorium and an additional smaller falcine meningioma on the left side. A left occipital transtentorial/transfalcine approach was used to exploit the natural corridor between the left occipital lobe and the falx. The second smaller falcine meningioma was resected afterward through the interhemispheric trajectory using the same craniotomy during the same operation. The patient had a transient VFD and demonstrated no recurrence on 12-month follow-up MRI. Preoperative T1-weighted MRI: a sagittal image with contrast enhancement (A) showed two lesions, a smaller falcine and a larger falcotentorial meningioma; an axial image (B) showed that the tumor displaced the tributaries of the vein of Galen (arrow) to the right; and a contrast-enhanced coronal image (C) showed the falcine tumor projecting to the left side. Intraoperative view (D) during the first-stage transtentorial/transfalcine approach shows exposure of the tumor (arrowhead) after the left tentorium was cut (arrow). Postoperative contrast-enhanced T1-weighted MRI: the coronal view (E) showed Simpson grade I resection with removal of the tumor base (cut tentorium, arrow), and patency of the galenic venous system is illustrated on the sagittal (F) image as a flow void (arrow). Figure is available in color online only.

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    Case 12. A 77-year-old woman presented with episodes of dizziness. Preoperative sagittal (A) and axial (B) MRI demonstrated an inferior-pointing falcotentorial meningioma. The lesion base was located on the inferior surface of the tentorium on both sides. The diameter was measured as 2.5 cm on the sagittal section. A midline supracerebellar infratentorial approach was planned. A prone position was selected instead of a sitting position because of the patient’s history of patent foramen ovale. A lumbar drain was placed preoperatively to achieve brain relaxation. The cerebellum appeared edematous after tumor resection; therefore, the bone flap was left off. The patient presented with decreased mental status after the operation, with a Glasgow Coma Scale score of 5, and postoperative imaging demonstrated increasing hydrocephalus and swelling cerebellum. A posterior fossa decompression with resection of the infracted cerebellum was performed. The patient was confined to a wheelchair and had an mRS score of 5 at the 24-month follow-up. Postoperative axial CT (C) of the tumor resection cavity showed scattered subarachnoid hemorrhage. Postoperative axial (D) and sagittal (E) MRI demonstrated an edematous cerebellum. Axial CT (F) after posterior fossa decompression showed the large decompressive craniotomy.

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    Case 4. A 31-year-old woman presented with headache and was found to have a falcotentorial meningioma. The lesion base was located on the left tentorium, and the tumor projected superiorly. A stage 1 supracerebellar infratentorial approach was performed first. The superior posterior portion of the tumor projecting into the occipital lobe was left for a second-stage surgery. A stage 2 ipsilateral occipital transtentorial/transfalcine approach was then used to remove the residual tumor. A Simpson grade I resection was achieved, and no complication was encountered postoperatively. The patient had no recurrence on the 42-month follow-up MRI. Preoperative sagittal (A) and axial (B) T1-weighted MRI with contrast enhancement demonstrated a left-sided falcotentorial meningioma projecting superiorly and laterally, while the tentorial angle (C) was measured as 49.0°. Sagittal MRI (D) after stage 1 surgery showed that superior and posterior portions of the tumor required a more upward approach angle (arrow), so a small residual lesion was intentionally left for a second-stage surgery. Sagittal (E) and coronal (F) contrast-enhanced T1-weighted MRI after the second-stage surgery via the occipital transtentorial/transfalcine approach showed a Simpson grade I resection.

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    Case 9. Preoperative coronal (A) and sagittal (B) T1-weighted MRI with contrast enhancement showed the galenic venous system was displaced superiorly (arrow). The postoperative coronal image (C) showed subtotal resection. Case 10. Preoperative coronal (D) and axial (E) T1-weighted MRI with contrast enhancement showed the galenic venous system was displaced contralaterally (arrow). A postoperative coronal image (F) showed that gross-total resection was achieved.

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