Meningioma with holo-sagittal sinus involvement treated successfully with intrinsic sinus surgery: illustrative case

Abstract

Background: This report describes an unusual meningioma with a large left frontal component and extensive growth within the sagittal sinus and its successful treatment with a staged approach: left frontal craniotomy followed by a sagittal craniotomy and intrinsic removal of the tumor from the sagittal sinus.

Observations: A previously healthy 27-year-old presented with 6 months of progressively worsening bilateral headaches, visual changes, and nausea. On examination she had a left cranial nerve VI palsy and severe papilledema. Magnetic resonance imaging revealed a 5.1 × 3.8 × 4.1 cm homogenously enhancing left superior frontal parafalcine extra-axial mass with surrounding vasogenic edema and growth through the sagittal sinus extending just short of the torcula.

Lessons: This case report describes a fast-growing meningioma with a unique pattern of spread, growing through the sagittal sinus as if it were a conduit and resulting in complete occlusion of flow in the sinus. An important recognition in this case was that a robust parasagittal venous plexus had developed on either side of the falx cerebri with drainage to the inferior sagittal sinus. This collateral drainage pattern allowed for an extradural opening of the sagittal sinus from front to back and intrinsic resection of the tumor from the sinus with preservation of the lateral walls of the sinus.

Keywords: case report; meningioma; sagittal sinus; sinus surgery.

FIG. 1.

Noncontrast coronal CT scan (A) obtained 19 months prior to presentation (obtained for evaluation following motor vehicle accident) showing no abnormalities. CT scan (B) 5 months prior to presentation was interpreted as normal, however, the sagittal sinus is enlarged and hyperdense. No left frontal mass is present. CT scan at presentation (C) shows left frontal edema and mass effect from the left frontal component of the tumor and involvement of the sagittal sinus.

FIG. 2.

A: Axial, coronal, and sagittal brain MRI with gadolinium contrast demonstrating contrast enhancing dural growth in the left frontal lobe with extension through the superior sagittal sinus. B: Postoperative coronal and sagittal gadolinium enhanced MRI performed after the first surgery, demonstrating resection of the left frontal mass and continued sagittal sinus involvement.

FIG. 3.

Axial T2-weighted (A) and postcontrast T1-weighted (B) magnetic resonance images demonstrate collateral venous drainage on the lateral (external) walls of the sinus with complete occlusion of sinus with tumor.

FIG. 4.

Intraoperative image demonstrating resection of the meningioma inside the superior sagittal sinus (A). Line drawing (B).

FIG. 5.

Eighteen-month postoperative MRI shows no residual or recurrent tumor. Significant recanalization of the sagittal sinus with persistent deep venous compensation via inferior sagittal sinus and deep venous drainage. Less prominent compared to immediately postoperative MRI.