Bilateral olfactory groove meningioma surgery approach [Neurosurgery Wiki]

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====== Bilateral olfactory groove meningioma surgery approach ======

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Surgical removal is often performed through the [[bifrontal]], [[unilateral]] [[subfrontal]] ([[frontolateral]]), or 
[[pterional approach]].
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Bi-[[coronal]] [[subfrontal approach]] appears to be an excellent technique for [[Olfactory groove Meningioma]] removal as practiced by most neurosurgeons. Nevertheless, it is not mandatory to carry out [[orbital osteotomy]] to acquire optimal surgical outcome as is advocated by some authors
((Farooq G, Rehman L, Bokhari I, Rizvi SRH. Modern Microsurgical Resection of Olfactory Groove Meningiomas by Classical Bicoronal Subfrontal Approach without Orbital Osteotomies. Asian J Neurosurg. 2018 Apr-Jun;13(2):258-263. doi: 10.4103/ajns.AJNS_66_16. PMID: 29682018; PMCID: PMC5898089.))
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Approached via a [[bifrontal craniotomy]] (preserving the [[periosteum]] to cover the [[frontal sinus]] and floor of the frontal fossa at the end of the case). Small tumors may be approached via unilateral [[craniotomy]] on the side with the most tumor.

For large tumors, a [[external lumbar cerebrospinal fluid drainage]] will help with brain relaxation and the head is rotated 20° to one side to facilitate dissection of the anterior cerebral arteries and [[optic nerve]] while preserving visualization of both sides of the tumor involvement.

The neck is slightly extended. The dura is opened low, and the [[superior sagittal sinus]] is ligated and divided at this location. Amputation of the frontal pole should be done if necessary to avoid excessive [[retraction]]. Vascular feeding arteries come through the floor of the frontal fossa in the midline. Initially, the anterior tumor [[capsule]] is opened and the tumor debulked from within, heading towards the floor of the frontal fossa to interrupt the blood supply. The posterior capsule of the tumor is dissected carefully as this portion of the tumor may encase branches of the anterior cerebral artery, and/or optic nerves and chiasm. A large tumor with suprasellar extension usually displaces the optic nerve and chiasm inferiorly.

If necessary, the frontopolar branch and other small branches may be sacrificed without a problem.

[[Periosteum]] is laid over the floor of the [[frontal fossa]]. To hold it in place, one may attempt to suture it to the adjacent dura with a couple of retaining sutures, alternatively, a small titanium plate (e.g. “dogbone”) can be placed over the flap, and screws are placed into the bone of the floor of the frontal fossa (both methods are challenging). Post-op risks include CSF leak through the ethmoid sinuses.

===== Disadvantages =====
The neurovascular structures come into view late, after a major part of the tumor has been removed. The superior sagittal
sinus should be divided, compromising venous drainage from the frontal lobes and thus contributing to brain edema 
((Hassler W, Zentner J (1991) Surgical treatment of olfactory
groove meningiomas using the pterional approach. Acta Neurochir Suppl (Wien) 53:14–18))
((Turazzi S, Cristofori L, Gambin R, Bricolo A (1999) The pterional
approach for the microsurgical removal of olfactory groove
meningiomas. Neurosurgery 45:821–826. doi:10.1097/00006123-
199910000-00016)).

===Anterior interhemispheric approach===

[[Anterior interhemispheric approach]]

[[Transsinusal frontal approach]]