Parasagittal meningioma surgery [Neurosurgery Wiki]

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====== Parasagittal meningioma surgery ======

The radical resection of [[parasagittal meningioma]]s without [[complication]]s and [[recurrence]]s is the goal of the neurosurgeon. Nowadays, different managements are proposed
((Hua L, Wang D, Zhu H, Deng J, Luan S, Chen H, Sun S, Tang H, Xie Q, Wakimoto
H, Gong Y. Long-term outcomes of multimodality management for parasagittal
meningiomas. J Neurooncol. 2020 Feb 22. doi: 10.1007/s11060-020-03440-9. [Epub
ahead of print] PubMed PMID: 32088814.
)).


===== Technique =====

==== Craniotomy ====

Surgical removal of [[falcine meningioma]] and [[parasagittal meningioma]]s, particularly during a unilateral approach, requires adequate exposure of the midline to avoid undue retraction of the medial ipsilateral cerebral hemisphere. Key technical considerations include avoidance of injury to the [[superior sagittal sinus]] (SSS) and management of [[frontal sinus transgression]] when approaching very anterior extra-axial masses.
----
Frequently warrants an increased exposure of the sagittal sinus and the falx cerebri to facilitate more relaxed retraction of the frontal lobe and improve the safety and manipulation of the tumor resection. Achieving this exposure necessitates craniotomy and frontal bone removal over the SSS; Rutkowski et al. call it a “two-part parasagittal craniotomy” to help with the safe dissection of the midline dura crossing the SSS to the opposite side with diploic bone channel drilling to create a thin lip of the inner table that can be removed piecemeal for safe dissection of the dura crossing the midline in a two-part parasagittal craniotomy. This technique may be utilized in a safe, consistent, and efficacious manner to avoid injury to the superior sagittal sinus when access around the same is warranted, for instance, in cases of falcine and parasagittal tumors.
((Rutkowski M, Ozair A, Niehaus B, McDermott MW. Diploic Bone Channel Drilling Facilitates Dissection of the Midline Dura and Protects the Superior Sagittal Sinus in Hyperostosis Frontalis Interna. Cureus. 2023 Mar 2;15(3):e35704. doi: 10.7759/cureus.35704. PMID: 36895519; PMCID: PMC9988441.)).

Yu et al showed the Gravity-Assisted Ipsilateral Paramedian Approach for Parafalcine Meningioma Resection was safe and advantageous because it does not result in contralateral brain impingement and does not require brain retraction
((Yu G, Wang X, Zhang X, Quan K, Hua W, Yang Z, Li P, Liu P, Song J, Zhu W. Gravity-Assisted Ipsilateral Paramedian Approach for Parafalcine Meningioma Resection. World Neurosurg. 2020 Mar;135:234-240. doi: 10.1016/j.wneu.2019.12.067. Epub 2019 Dec 19. PMID: 31863889.)).



 Preserving the venous outflow is the key point, but this may preclude radical resection. Different surgical strategies have been proposed. 

Once tumor is exposed a partial internal debulking is performed. Then the point of attachment is peeled away using bipolar cautery to divide feeding vessels. Then the main portion of the tumor may be separated from the brain, with the tumor being avascular once the vascular pedicle has been transected.
----


Ricci et al. considered the preservation of the [[cortical vein]]s to be important, and, when possible, they recommended the [[reconstruction]] of the anterior third of the [[superior sagittal sinus]] (SSS). There experience has led them to believe that until now surgery is a winning choice if practiced by expert hands
((Ricci A, Di Vitantonio H, De Paulis D, Del Maestro M, Gallieni M, Dechcordi
SR, Marzi S, Galzio RJ. Parasagittal meningiomas: Our surgical experience and the
reconstruction technique of the superior sagittal sinus. Surg Neurol Int. 2017
Jan 19;8:1. doi: 10.4103/2152-7806.198728. eCollection 2017. PubMed PMID:
28217380; PubMed Central PMCID: PMC5288983.
)).

To contribute to the debate on the optimal strategy for treating these tumors, a single-institutional, single-surgeon series of patients with parasagittal meningiomas was analyzed and the available literature reviewed.
Analysis of the data obtained in the 67 patients confirmed good outcome and long-term tumor control following a surgical strategy aimed to preserve venous outflow. These findings and the results of the authors' analysis of the literature emphasize that the goal of radical tumor resection should be balanced by an awareness of the increased surgical risk attendant on aggressive management of the SSS and bridging veins
((Tomasello F, Conti A, Cardali S, Angileri FF. Venous preservation-guided
resection: a changing paradigm in parasagittal meningioma surgery. J Neurosurg.
2013 Jul;119(1):74-81. doi: 10.3171/2012.11.JNS112011. Epub 2013 Jan 18. PubMed
PMID: 23330997.)).

In surgical planning of the parasagittal meningioma, invasion and occlusion of the superior sagittal sinus are important factors. When tumor is located within anterior 1/3, or when angiographic finding shows total occlusion of superior sagittal sinus, it is regarded that the ligation of superior sagittal sinus is safe. 
A case of parasagittal meningioma in 59-year-old male patient with complete occlusion of superior sagittal sinus which was confirmed by preoperative angiography, who developed temporary neurologic deterioration after superior sagittal sinus ligation and resection
((Oh IH, Park BJ, Choi SK, Lim YJ. Transient neurologic deterioration after
total removal of parasagittal meningioma including completely occluding superior 
sagittal sinus. J Korean Neurosurg Soc. 2009 Jul;46(1):71-3. doi:
10.3340/jkns.2009.46.1.71. Epub 2009 Jul 31. PubMed PMID: 19707499; PubMed
Central PMCID: PMC2729830.))


[[Indocyanine green videoangiography]] (ICGVA) can assist the different stages of parasagittal meningiomas surgery, guiding the vein management and tumor resection strategies with a favorable final clinical outcome. However, Della Puppa et al., experience that the use of other complementary tools was mandatory in selected cases to preserve functional areas. Further studies are needed to confirm that the application of ICGVA in parasagittal meningioma surgery may improve the morbidity rate, as reported
((Della Puppa A, Rustemi O, Gioffrè G, Rolma G, Grandis M, Munari M, Scienza R. Application of indocyanine green video angiography in parasagittal meningioma surgery. Neurosurg Focus. 2014 Feb;36(2):E13. doi: 10.3171/2013.12.FOCUS13385. PubMed PMID: 24484251.)).

===Endoscopy===
For treating a patient with multiple falcine and parasagittal lesions, Yamaguchi et al. believe that it is beneficial to resect the maximum possible number of lesions during one operation, even if some lesions are asymptomatic. This practice can potentially reduce the total number of operations during a patient's lifetime
((Yamaguchi J, Watanabe T, Nagatani T. Endoscopic approach via the
interhemispheric fissure: the role of an endoscope in a surgical case of multiple
falcine lesions. Acta Neurochir (Wien). 2017 Jul;159(7):1243-1246. doi:
10.1007/s00701-017-3129-9. Epub 2017 Mar 11. PubMed PMID: 28283869.
)).

Spektor et al. describe the purely endoscopic removal of an atypical parasagittal meningioma in a patient who could not undergo standard craniotomy due to severe scalp atrophy following childhood irradiation for tinea capitis.

A 68-year-old man in good general health presented with a parasagittal meningioma that recurred following subtotal removal and adjuvant fractionated stereotactic radiosurgery (FSR). The scalp above the tumor location was very diseased and precluded a regular craniotomy for tumor removal. A 4-cm craniotomy was made in the midline forehead, where the skin was normal. A rigid endoscope was advanced under neuronavigation through the interhemispheric fissure, which provided good access with limited retraction, until the tumor was encountered at a depth of 7-8 cm. Two surgeons performed the surgery using a "four-hands technique". The tumor was removed and the insertion area was resected and coagulated.

The surgery was uneventful, with no coagulation or transection of major veins. A subtotal resection was achieved, and the patient recovered with no neurological deficit.

Safe resection of parasagittal meningiomas with a purely endoscopic technique is feasible. This option needs further exploration as an alternative strategy in patients with severely atrophic scalp skin that greatly increases the risk of significant healing complications with calvarian craniotomy
((Spektor S, Margolin E, Eliashar R, Moscovici S. Purely endoscopic removal of a
parasagittal/falx meningioma. Acta Neurochir (Wien). 2016 Mar;158(3):451-6. doi: 
10.1007/s00701-015-2689-9. Epub 2016 Jan 8. PubMed PMID: 26746827.)).

===Cortical vein end-to-end anastomosis===
This technique, which consists of the insertion of a [[Venflon]] tube in the vein during anastomosis, results in easier handling and proper apposition of the vein, resulting in an improved quality of the anastomosis. The technique was successfully applied in a patient after parasagittal meningioma resection, and the patency of the cortical vein was confirmed postoperatively on magnetic resonance venography
((Menovsky T, De Vries J. Cortical vein end-to-end anastomosis after removal of 
a parasagittal meningioma. Microsurgery. 2002;22(1):27-9. PubMed PMID: 11891872.
)).

It has been reported a combination of endovascular stent placement and radiotherapy
((Ganesan D, Higgins JN, Harrower T, Burnet NG, Sarkies NJ, Manford M, Pickard
JD. Stent placement for management of a small parasagittal meningioma. Technical 
note. J Neurosurg. 2008 Feb;108(2):377-81. doi: 10.3171/JNS/2008/108/2/0377.
PubMed PMID: 18240939.)).

After radiosurgery peritumoral edema tends to occur in meningiomas with a parasagittal position. Radiation necrosis, infiltration of inflammatory cells, and radiation injury to the vasculature causing hyalinization of blood vessels are suggested as the underlying histopathology
((Chen CH, Shen CC, Sun MH, Ho WL, Huang CF, Kwan PC. Histopathology of
radiation necrosis with severe peritumoral edema after gamma knife radiosurgery
for parasagittal meningioma. A report of two cases. Stereotact Funct Neurosurg.
2007;85(6):292-5. Epub 2007 Aug 17. PubMed PMID: 17709982.)).

===== References =====