Intraoperative neurovascular considerations for efficient intraventricular meningioma surgery: illustrative case

Abstract

Background: Intraventricular meningiomas (IVMs) are a rare subtype of brain tumors. Typically slow growing, these tumors can occasionally reach a substantial size, causing ventricular obstruction and hydrocephalus. Resection remains the treatment of choice; however, the deep location and proximity to critical neurovascular structures can pose significant challenges. Various surgical strategies and adjuncts have been described. Here, the authors highlight the benefits of early intraoperative tumor devascularization to minimize blood loss and enable safe, efficient removal through a minimally disruptive transsulcal approach.

Observations: A 59-year-old woman presented with symptoms of increased intracranial pressure due to a large atrial IVM causing temporal horn entrapment. The tumor was hypervascular, with prominent arterial feeders. Early intraoperative microsurgical devascularization was favored over preoperative embolization, combined with temporary clipping of adjacent arterial feeders and intraoperative neurophysiological monitoring. This strategy facilitated piecemeal gross-total tumor resection within a relatively short surgical duration, minimizing brain retraction. The patient was neurologically intact after gross-total resection.

Lessons: Early and strategic tumor devascularization is an effective approach to achieve safe and efficient resection of large intraventricular tumors with minimal brain retraction. https://thejns.org/doi/10.3171/CASE2569.

Keywords: intraoperative neuromonitoring; intraventricular tumors; meningioma; microneurosurgery.

FIG. 1.

Preoperative neuroimaging. Gadolinium-enhanced T1-weighted axial (A), coronal (B), and sagittal (C) MR images at the level of the ventricular atrium, demonstrating a large enhancing mass occupying the left ventricle, causing a midline shift and entrapment of the left temporal horn. Axial (D) and coronal (E) CT angiograms revealing a highly vascularized tumor with a prominent arterial pedicle traversing the anterior and lateral surfaces of the tumor (arrows). A 3D reconstruction (F) highlighting the hypervascular blush within the tumor.

FIG. 2.

A: Microscopic view of the tumor exposure through the transsulcal approach. An asterisk marks the tumor. A retractor blade maintained the working corridor open for 35 minutes. Several hypertrophic vessels were observed running on the tumor’s surface. A temporary clip was applied to a large artery around its entry into the tumor (arrows). B: Transcranial MEP recordings from four different muscles on the patient’s left side before (lower recording line in blue) and 5 minutes after (upper recording line in red) temporary clip application, showing no changes. C: Averaged SSEP recordings from the right posterior tibial nerve before (lower recording line in blue) and 5 minutes after (upper recording line in red) temporary clip application, also showing no significant changes.

FIG. 3.

A: Microscopic view of the ventricular ependyma at the conclusion of the procedure, revealing GTR of the tumor. B: Gadolinium-enhanced axial T1-weighted MR image obtained at the 3-month follow-up with no residual tumor. C: Axial FLAIR image with minimal retractor-related changes in the surrounding brain parenchyma.