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Two-stage endoscopic assisted approach for large pineal region and falcotentorial meningioma: first stage paramedian supracerebellar infratentorial approach, second stage interhemispheric occipital transtentorial approach: surgical cases and anatomical study

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Abstract

Resection of complex falcotentorial meningiomas, growing along the pineal region (PR), and posterior incisural space (PIS) represents a neurosurgical challenge. Here, we present our strategy for effective resection of large falcotentorial meningiomas applying a paramedian supracerebellar infratentorial and interhemispheric occipital transtentorial approach in staged surgeries. We further systematically compared the effectiveness of midline (MSIA) and paramedian (PSIA) supracerebellar infratentorial, as well as interhemispheric occipital transtentorial approaches (IOTA) to operate along the PR and PIS in 8 cadaveric specimens. The staged PSIA and IOTA enabled successful resection of both falcotentorial meningiomas with an uneventful postoperative course. In our anatomo-morphometrical study, superficial vermian veins at an average depth of 11.38 ± 1.5 mm and the superior vermian vein (SVV) at 54.13 ± 4.12 mm limited the access to the PIS during MSIA. MSIA required sacrifice of these veins and retraction of the vermian culmen of 20.88 ± 2.03 mm to obtain comparable operability indexes to PSIA and IOTA. Cerebellar and occipital lobe retraction averaged 14.31 ± 1.014 mm and 14.81 ± 1.17 mm during PSIA and IOTA respectively, which was significantly lower than during MSIA (p < 0.001). Only few minuscule veins were encountered along the access through PSIA and IOTA. The application of PSIA provided high operability scores around the pineal gland, ipsilateral colliculus and splenium, and acceptable scores on contralateral structures. The main advantage of IOTA was improving surgical maneuvers along the ipsilateral splenium. In summary, IOTA and PSIA may be advantageous in terms of brain retraction, vein sacrifice, and operability along the PR and PIS and can be effective for resection of complex falcotentorial meningiomas.

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Data availability

The data that support the findings of this study are available from the corresponding author, L. Serrano Sponton, upon reasonable request.

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Acknowledgements

We thank very much Mr. Thomas Bauer for assistance with drawings for the Figure 4, which greatly improved the message of our manuscript.

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Authors and Affiliations

  1. Department of Neurosurgery, Mainz University Medical Center, Langenbeck Str. 1, 55131, Mainz, Germany

    Lucas Serrano Sponton, Eleftherios Archavlis, Jens Conrad & Sven R. Kantelhardt

  2. Department of Neurosurgery, Hamad Medical Corporation, P.O. Box 3050, Doha, Qatar

    Ahmed Taha Shaaban, Mohammed Alhoobi & Ali Ayyad

  3. Department of Neurosurgery, Charing Cross Hospital, Imperial College Healthcare NHS Trust, Fulham Palace Rd, London, W6 8RF, UK

    Amr Nimer

  4. Department of Neurosurgery, Saarland University Medical Center, Kirrberger Str. 100, 66421, Homburg, Germany

    Ali Ayyad

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  1. Lucas Serrano Sponton
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Contributions

Lucas Serrano Sponton: conceptualization, methodology, performance and formal analysis of the anatomical data, writing the original draft, review and editing, and visualization. Ahmed Taha Shaaban: collecting and editing data and images corresponding to surgical cases, and writing the original draft. Eleftherios Archavlis: supervision and review and editing. Mohammed Alhoobi: collecting and editing data and images corresponding to surgical cases. Amr Nimer: review and editing. Jens Conrad: review and editing. Sven R. Kantelhardt: project administration, supervision, and review and editing. Ali Ayyad: conceptualization, project administration, supervision, and review and editing.

Corresponding author

Correspondence to Lucas Serrano Sponton.

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This article does not contain any experimental studies with human participants or animals performed by any of the authors. Illustrative surgical cases do not contain any identifying information of the patients. The cadaveric study followed all ethical and hygienic procedures ruled by the Hygiene and Health Department of Mainz University and current national and international standards. Ethical committee approval was not required as presented data correspond to cadaveric specimens and anonymized patient’s data, so that there is no risk of identification.

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Consent was not obtained given that the presented illustrative data corresponding to patients are anonymized, and there is no risk of identification.

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Consent was not obtained from patients given that the presented illustrative surgical data are anonymized, and there is no risk of identification.

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Sponton, L.S., Shaaban, A.T., Archavlis, E. et al. Two-stage endoscopic assisted approach for large pineal region and falcotentorial meningioma: first stage paramedian supracerebellar infratentorial approach, second stage interhemispheric occipital transtentorial approach: surgical cases and anatomical study. Neurosurg Rev 45, 1759–1772 (2022). https://doi.org/10.1007/s10143-021-01709-9

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