Combined supracerebellar infratentorial and right occipital interhemispheric approach to falcotentorial junction meningioma: A case report

Abstract

Background: Falcotentorial meningioma is a rare tumor of pineal region, arising from the dural folds where the tentorium and falx meet. Due to the deep location and near closeness to significant neurovascular structures, gross-total tumor resection in this area can be complicated. Pineal meningiomas can be resected using a variety of approaches; however, all these approaches are associated with a significant risk of postoperative complications.

Case description: A 50-year-old female patient who presented with several headaches and visual field defect and diagnosed with pineal region tumor is discussed in the case report. Patient was successfully managed surgically by combined supracerebellar infratentorial and right occipital interhemispheric approach. Cerebrospinal fluid circulation was restored after surgery and neurological defects were regressed.

Conclusion: Our case shows that it is possible to completely remove giant falcotentorial meningiomas with minimal brain retraction, preserve the straight sinus and vein of Galen, and prevent neurological impairments by combining two approaches.

Keywords: Case report; Combined approach; Falcotentorial meningioma; Occipital interhemispheric approach; Pineal region; Supracerebellar infratentorial approach.

Figure 1:

Brain magnetic resonance imaging (MRI). Preoperative axial (a), sagittal (b), and frontal (c) contrast T1-weighted image and axial (d), sagittal (e), and frontal (f) T2-weighted images demonstrates a large (43 × 36 × 35 mm) and homogenously enhancing tumor in the pineal region, occluding the aqueduct, and results in the hydrocephalus.

Figure 2:

(a) Patient positioning in the operating room. (b) CT 3D reconstruction of the patient’s head with a black arrow indicating the midline occipital incision (dashed line). (c) Postoperative CT 3D reconstruction demonstrating craniotomy extension (dashed black arrow).

Figure 3:

Intraoperative view. (a) Surgical corridor via supracerebellar infratentorial approach. (b and c) The pineal region tumor visualization. (d) Identifying the Vein of Galen. (e) Surgical corridor via right occipital interhemispheric approach. (f) visualization of the superior part of the tumor. (OPMI PENTERO 900 ×6).

Figure 4:

A histological specimen from the tumor resection demonstrates transitional meningioma, WHO Grade 1, ICD-O code 9537/0. Hematoxylin and eosin (×200). A pathological examination was carried out using an Axioskop 40 microscope by Carl Zeiss (Germany) and a panoramic MIDI scanning microscope, with a total magnification of ×200. The hematoxylin and eosin stained slides demonstrated meningothelial cells with bundles of elongated cells that form collagen and reticulin fibers. The nuclei are oval, round, spindle-shaped, and monomorphic.

Figure 5:

Postoperative axial contrast T1-weighted (a), sagittal T2-weighted (b), and CE-FLAIR coronal (c) MRI scans showing tumor removal through a combined supracerebellar infratentorial and occipital interhemispheric approach and the surgical corridor.