Meningioma Explained

Meningiomas are explained as generally slow growing benign tumors that originate in the meninges. The meninges are the membranes that cover and surround the brain. Meningiomas are located outside the brain. But as the tumor grows it can press on the underlying brain and adjacent nerves. Sometimes it can cause neurological symptoms and a disability. They can be located anywhere in the intracranial compartment and are often associated with brain swelling or edema. They can be superficial originating at the convexity or deeper. Some tumors are hidden under the brain when located at the skull base.

Meningiomas are generally diagnosed in the fifth to the seventh decade of the patient’s life. Meningiomas are more common in women than men.

The size of a meningioma varies from very small tumors to formidable size tumors. Around 80% of meningiomas are grade 1, the remaining 20% are called atypical or grade 2. Grade 2 has an increased risk of recurrence after treatment.  Malignant variety of meningioma is a rare occurrence.

The signs and symptoms associated with meningiomas tumor are generally gradual, progressive and directly related to their location.  Along with which part of the brain or nerves the tumor is pressing on.

Common signs of a meningioma can include:

• Headache – New onset of headache which can be localized to the site of the tumor. Or it could be generalized and related to increased intracranial pressure.
• Vision difficulties – Blurriness, double vision or loss of peripheral vision
• Seizures
• Hearing loss, dizziness or balance difficulties
• Arm and / or leg weakness
• Loss of sensation
• Speech difficulties
• Behavioral changes
• Memory loss
• Loss of smell
• Swallowing difficulties
• Dysphonia (voice changes)
• Facial numbness or pain
• Facial paralysis or weakness (droop face)

Meningiomas are diagnosed with brain magnetic resonance (MRI) and head computerized tomography  (CT). A brain MRI allows precise localization of the tumor and definition of the anatomy of the tumor. It also helps your surgeon know its relation to other brain structures. A head CT is less precise but it gives better details of the bone changes and bone in relation to the tumor. Occasionally, a cerebral  angiogram is necessary for further understanding of the vascular relations of the tumor.

Management of your meningioma is individualized for you. It is  based on age, size, symptoms and location of the tumor. It may include:

surgical resection
radiation therapy
observation with surveillance MRI
Or a combination of the above options

Maximal removal of the tumor increases the chances of tumor recurrence.

Meningioma Types – Classification

Meningiomas can be located anywhere in the intracranial compartment. They can be superficial when originating at the convexity or deeper and hidden under the brain when located at he skull base. They are often classified or named according to their location or site of origin.

Convexity Meningiomas

Frontal convexity meningioma

Temporal convexity meningioma

Parietal convexity meningioma

Occipital convexity meningioma

Parasagital meningioma (Paramedian Meningioma)

Falcine meningioma

Skull Base Meningiomas

Olfactory Groove Meningioma

Anterior fossa meningioma

Planum Sphenoidalis Meningioma

Tuberculum Sella Meningioma

Diaframma Sella Meningioma

Sphenoidal Wing Meningioma

Spheno-Orbital Meningioma

Anterior clinoid Meningioma

Posterior Fossa  Meningioma

Petrous Meningioma

Petro-Clival meningioma / Tentorial incisura

Tentorial meningioma

Foramen Magnum Meningioma

Jugular Foramen Meningioma

Other Locations

Lateral ventricle Meningioma

Pineal region meningioma

FIND YOUR TUMOR

If you or a family member have been diagnosed with a meningioma tumor, we encourage you to learn more about your tumor in our Meningioma Center site. Your MRI  radiology report  will generally  describe the location of your tumor. You can search and find a meningioma of the same  kind and location of yours in the “ FIND YOUR TUMOR” in our site. You will  learn more about the nature of your type of meningioma, our experience with meningiomas similar to yours and how tumors of the same type and location of yours is commonly managed in the Center for Meningioma Surgery. For your convenience, feel free to send us your MRI report and we will let you know the precise type and location of your tumor prior to any commitment to a consultation.

Tuberculum Sellae Meningioma

Overview

Tuberculum sellae meningioma is a tumor located deep in the center part of the skull base. The tumor is tucked in under the back part of the frontal lobes of the brain. It arises from the meninges of a bone protuberance between both optic nerves, the so called tubeculum sellae. As it grows it causes pressure to the optic nerves and the crossing of the optic nerves fibers called optic chiasma. The tumor has close relation to important brain arteries such as the carotid arteries and its branches.

Presentation

Tuberculum sellae meningioma presents initially  with unilateral loss of vision acuity and loss of temporal field of vision on the side of the most affected eye. This initial symptoms  can progress with bilateral vision loss and or bilateral visual file loss.

Management

Management of tuberculum sellae meningioma generally requires surgery if the patient presents with vision loss or significant optic nerve compression. Elderly patients with small tumors and minimal symptoms can be treated conservatively with surveillance MRIs. Radiation is generally not recommended because of the proximity to the optic nerves.

Surgical Challenges

Deep location under the brain

Close elation to optic nerves

Close relation to optic chiasma

Close relation to carotid arteries and its branches

SURGICAL MANAGEMENT AT THE CENTER FOR MENINGIOMA SURGERY

Option # 1

At the MENINGIOMA CENTER we conceptualized the focal orbital approach which can be used for removal of tuberculum sellae  meningiomas. This approach associated with the extradural navigation concept and microsurgical technique allows access to this deep tumors without hazardous exposure, direct manipulation or retraction of the brain. In selected cases the focal orbital approach  can be done through a small eyebrow incision. The approach allows for early identification and full decompression of the optic nerves  which maximize chances of visual recovery.  Early identification of the carotid arteries decreases chance of unwanted arterial lesion with possible devastating consequences. Moreover, this minimal  surgical approach enhances the potential for complete resection of the tumor including its meningeal root at the tubercular sellae.

 

Option # 2

 

At the CENTER FOR MENINGIOMA SURGERY the endoscopic transnasal approaches is an option for selected cases of tuberculum sellae meningioma. This approach allows access to the root of the tumor through the nostrils with an endoscopic without any manipulation of the the brain. This approach uses a multidisciplinary team with the participation of our ENT endoscopic nasal surgery specialist and neurosurgeon.

 

PROGNOSIS

 

Adequate surgical management of tuberculum sellae meningiomas using the focal orbital approach or the endoscopic nasal approach can allow full or partial recovery of visual difficulties. Moreover, patients have the potential for returning to the pre-morbid life style and job occupation. Maximal removal of the tumor and its meningeal root maximizes the chances of cure  without tumor recurrence.

 

Complications

 

Surgical complications are directly related to the  challenges and anatomical relations inherent to tuberculum sellae meningiomas. They can include but are not necessarily limited to:

Loss of vision

Brain swelling

Brain damage

Seizure

Stroke

CSK leak

Infection

Tumor recurrence

 

 

Complications and unfavorable outcome can not be always completely avoided when treating these complexes tumors. With this in mind, at the CENTER FOR MENINGIOMA SURGERY,  our surgical approaches and management of tuberculum sellae meningioma have been carefully designed to address and prioritize the prevention of  each of the above listed complications in each and every one  of our patients. The application of these principles when treating tuberculum sellae meningioma have maximized successful outcome to our patients.

 

 

 

CASE EXAMPLES

 

TESTIMONIALS

 

SURGICAL VIDEOS

 

 

OLFACTORY GROOVE MENINGIOMA

ANTERIOR FOSSA MENINGIOMA

 

OVERVIEW

 

Olfactory grove meningioma is a tumor that originates in front part of the skull base or the anterior fossa skull base. The tumor arises from the meninges over the area where the small olfaction fibers pass from the nose to the brain. These tumors have often close relation to the olfactory nerves and to important cerebral arteries (anterior cerebral artery). The tumor is tucked under the anterior aspect of the frontal lobes . Olfactory groove meningioma can grow to formidable size causing significant pressure and swelling or edema to both frontal lobes brain before come to medical attention.

 

PRESENTATION

 

Olfactory groove meningiomas present with insidious and progressive, headache, cognitive and behavioral changes. Patients tend to develop emotional flatness, aggressiveness  or incoherent behavior.  Patient often become  careless about personal affairs and personal care. Other common complain is loss of smell and taste related to olfactory nerve compression. With tumor progression patients can develop seizures and blurred vision.

 

MANAGEMENT

 

 

 

In view of the size of olfactory groove meningioma, often associated with cognitive dysfunction, the management of this tumors generally requires surgical intervention. Other forms of treatment such as radiation or observation are commonly not possible or advisable to large tumors  as primary treatment

 

SURGICAL DIFFICULTIES

 

Tumor size

Swelled frontal lobes covering the tumor.

Close relation to important brain arteries ( Anterior cerebral arteries)

 

 

 

 

SURGICAL  MANAGEMENT AT THE CENTER FOR MENINGIOMA SURGERY

 

At the CENTER FOR MENINGIOMA SURGERY we conceptualized the trans-frontal sinus approach for resection of olfactory grove meningiomas. This approach  associated with microsurgical technique allows access to this large tumors through a small bone window avoiding the traditional large bi-frontal craniotomy with its inherent complications. The focused approach allows safe dissection of the tumor capsule away from brain arteries. Moreover, it enhances for complete resection of these large tumors with minimal brain retraction or manipulation  permitting maximal preservation and restoration of  invaluable brain function.

 

PROGNOSIS

 

Full recovery of cognitive  and behavioral dysfunction is possible with adequate surgical management of olfactory groove meningioma using the trans-frontal sinus approach conceptualized at the Center for Meningioma Surgery. Patients have the potential for returning to pre-morbid  life style and job occupation.  Maximal removal of the tumor and its meningeal root maximizes cure of the tumor without tumor recurrence.

 

CASE EXAMPLES

 

TESTIOMIALS

 

 

PLANUM SPHENOIDALE MENINGIOMA

ANTERIOR FOSSA MENINGIOMA

 

OVERVIEW

 

Planum sphenoidale meningioma is a tumor that  originates in the front part of the skull base or the anterior fossa skull base. The tumor arises from the meninges in the bone plateau (planum sphenoidal) just in front of the optic nerves in the skull base. These tumors are hindered  deep under the middle part of the frontal lobes of the brain and has the potential to grow to formidable size before coming to medical attention. Planum sphenoidale meningiomas have often close relation to the olfactory nerves, optic nerves  and to important cerebral arteries (carotid arteries arteries and anterior cerebral arteries). They can cause significant pressure and swelling or edema of the frontal lobes of the brain leading to disabling cognitive dysfunction.

 

PRESENTATION

 

Planum sphenoidale meningioma can present acutely with seizures or more insidiously with headache, progressive cognitive and behavioral changes. Patients can develop emotional flatness or aggressive incoherent behavior. Other common complain is loss of smell and taste related to olfactory nerve compression. In additional, as the tumor progresses, it can compress the optic nerves causing visual difficulties.

 

MANAGEMENT

 

In view of the large size of Planum sphenoidale meningiomas, often associated with visual difficulties, the management of this tumors generally requires surgical intervention. Other forms of treatment such as radiation or observation are commonly not possible or advisable to large tumors  as primary treatment.

 

SURGICAL DIFFICULTIES

 

Tumor size

Swelled frontal lobes covering the tumor.

Proximity to important brain arteries(Carotid arteries and anterior cerebral arteries)

Proximity to optic nerves

Deep location under the brain

 

 

 

 

SURGICAL  MANAGEMENT AT THE CENTER FOR MENINGIOMA SURGERY

 

Option # 1

 

At the CENTER FOR MENINGIOMA SURGERY we conceptualized the focal orbital approachwhic can be used for removal of planum sphenoidale meningiomas. This approach associated with microsurgical technique and the extradural navigation concept allows access to this deep and large tumors without hazardous exposure, direct manipulation or retraction of the brain which permits maximal functional recovery. In selected cases the focal orbital approach  can be done through a small eyebrow incision. The approach allows for early identification and full decompression of the optic nerves  which maximize chances of visual recovery. Early identification of the carotid arteries decreases chance of unwanted arterial lesion with possible devastating consequences. Moreover, this minimal  surgical approach enhances the potential for complete resection of the tumor including its meningeal root at the planum sphenoidale.

 

Option # 2

 

At the CENTER FOR MENINGIOMA SURGERY the endoscopic transnasal approaches is an option for selected cases of  small planum sphenoidale meningiomas. This approach allows access to the root of the tumor through the nostrils with an endoscopic without any manipulation of the the brain. This approach uses a multidisciplinary team with the participation of our ENT endoscopic nasal surgery specialist and neurosurgeon.

 

PROGNOSIS

 

Full or partial recovery of visual difficulties and cognitive  and behavioral dysfunction is possible with adequate surgical management of planum sphenoidale meningioma using the focal orbital approach or the endoscopic nasal approach. The patients have the potential for returning to pre-morbid life style and job occupation. Maximal removal of the tumor and its meningeal root maximizes the chances of cure  without tumor recurrence.

 

CASES EXAMPLES

 

TESTIMONIALS

 

VIDEOS

 

 

ANTERIOR CLINOID MENINGIOMA

 

Overview

 

Anterior clinoid meningioma is a tumor that arises from the  meninges covering the small bone process named anterior clinoid next to the optic nerve in the skull base. From the anterior clinoid the tumor grows deep under the brain between the frontal lobe and temporal lobe. It can cause pressure and displacement of the optic nerve. It often encases the internal carotid artery and its main branches (middle cerebral artery and anterior cerebral artery). In some cases the tumor can grow to formidable size before diagnosis.

 

Presentation

 

Anterior clinoid meningioma can present with unilateral vision loss and headache. With progression of the tumor it compresses the frontal lobe and temporal lobe of the brain   and can cause disabling seizures and cognitive dysfunction. Speech difficulties  can occur when the tumor is in the dominant side of the brain.

 

Management

 

Management of anterior clinoid meningioma requires surgery when the patient is symptomatic with vision loss, cognitive dysfunction or seizures. Elderly patients with small tumors and minimal symptoms can be treated conservatively with surveillance MRIs. Radiation is generally not recommended in these tumors as a primary treatment because of the proximity to the optic nerve.

 

Surgical Difficulties

 

Deep location of under the brain

Close relation to important major brain arteries

Close relation to optic nerve

Size of the tumor

 

 

SURGICAL  MANAGEMENT AT THE CENTER FOR MENINGIOMA SURGERY

 

At the CENTER FOR MENINGIOMA SURGERY we conceptualized the focal orbital approach which can be used for removal of anterior clinoid meningiomas. This approach associated with microsurgical technique and  the extradural navigation concept allows access to this deep tumor without hazardous exposure and only minimal direct manipulation or retraction of the brain. In selected cases the focal orbital approach  can be done through a small eyebrow incision. The approach allows for early identification and full decompression of the optic nerves  which maximize chances of visual recovery. Early identification of the carotid artery decreases chance of unwanted arterial lesion with possible devastating consequences. Moreover, this minimal  surgical approach enhances the potential for complete resection of the tumor including its meningeal root at the anterior clinoid.

 

Prognosis

 

Full or partial recovery of visual difficulties, cognitive dysfunction  and speech difficulties is possible with adequate surgical management of anterior clinoid meningioma using the focal orbital approach conceptualized at the Center for Meningioma Surgery. The patients have the potential for returning to pre-morbid life style and job occupation. Maximal removal of the tumor and its meningeal root maximizes the chances of cure  without tumor recurrence.

 

CASE EXAMPLES

 

TESTIMONIALS

 

VIDEOS

 

 

SPHENOID WING MENINGIOMA

 

Overview

 

Sphenoid wing meningioma is a tumor that arises on the meninges covering the the bone on the side of the skull base. From the sphenoid wine the tumor grows towards the temporal lobe causing significant temporal lobe brain compression and swelling or edema of the brain. The tumor tend to encase an important brain artery (middle cerebral artery)  which is a major branches of the carotid artery bringing blood supply to the brain. The tumor has the potential to grow to formidable size causing significant temporal lobe dysfunction before coming to medical attention.

 

PRESENTATION

 

Sphenoid wing meningioma presents with headache or disabling temporal lobe dysfunction. Temporal lobe dysfunction may include partial seizures, generalized seizure, memory changes, and personality changes. Speech difficulties can occur when the tumor is located in the dominant brain side.

 

MANAGEMENT

 

Management of sphenoid wing meningioma requires surgery when the tumor is large or  the patient is symptomatic with temporal lobe dysfunction or seizures. Elderly patients with small tumors and minimal symptoms can be treated conservatively with surveillance MRIs. Radiation is generally not recommended to large tumors as a primary treatment to avoid unnecessary radiation to the temporal lobe brain.

 

SURGICAL DIFFICULTIES

 

Size of the tumor

Close relation to major brain artery

Swelled temporal lobe covering the tumor.

Deep location covered by brain

 

 

SURGICAL  MANAGEMENT AT THE CENTER FOR MENINGIOMA SURGERY

 

At the CENTER FOR MENINGIOMA SURGERY we conceptualized the focal orbital approach for removal of sphenoid wing meningiomas. This approach associated with the extradural navigation concept allows access to the tumor without hazardous exposure of the brain and only minimal direct manipulation or retraction of it. In selected cases the focal orbital approach  can be done through a small eyebrow incision. The approach allows for early control of the blood supply to the tumor and full and early identification for safe control of the carotid artery and its main branches.  The approach offers maximal potential for complete resection of the tumor including its meningeal roots

 

Prognosis

 

Full or partial recovery of serious temporal lobe dysfunction is possible with adequate surgical management of sphenoid wing meningioma using the focal orbital approach conceptualized at the Center for meningioma Surgery. Moreover the patients have the potential for returning to pre-morbid life style and job occupation. Maximal removal of the tumor and its meningeal root maximizes the chances of cure without tumor recurrence.

 

Case example

 

Testimonials

 

Videos ?

 

 

DIAPHRAGMA SELLAE MENINGIOMA

 

Overview

 

Diaphragma sellae meningioma is a rare and challenging deep tumor located in the central part of the skull base  and tucked under the brain. It arises from a meningeal fold called the diaphragma sellae which is located over the pituitary gland and behind the optic nerves . As the tumor grows it compresses the optic nerves and optic chiasma, the the central part of the brain (hypothalamus) and engulfs the major arteries supplying blood to the brain.

 

Presentation

 

Diaphragma sellae meningioma presents with severe unilateral or bilateral visual difficulties. At times visual changes are associated with pituitary gland and hormonal imbalance or hypothalamic dysfunction with memory loss and drowsiness

 

Management

 

Management of Diaphragma sellae meningioma generally requires surgery if the patient presents with vision loss or hormonal dysfunction. Elderly patients with small tumors and minimal symptoms can be treated conservatively with surveillance MRIs. Radiation is generally not recommended because of the proximity to the optic nerves and central parts of the brain.

 

Surgical Difficulties

 

Deep location under the brain

Close relation to optic nerves and optic chiasma

Close relation to all major brain arteries

Close relation to pituitary gland structures

Close relation to the hypothalamus

 

SURGICAL  MANAGEMENT AT THE CENTER FOR MENINGIOMA SURGERY

 

Option # 1

 

 

At the CENTER FOR MENINGIOMA SURGERY we conceptualized the focal orbital approach which can be used for removal of diaphragma sellae meningiomas. This approach associated with microsurgical technique and the extradural navigation concept allows access to this deep tumors without hazardous exposure of the brain and only minimal direct manipulation or retraction of it. In selected cases the focal orbital approach  can be done through a small eyebrow incision. The approach allows for early identification and full decompression of the optic nerves  which maximize chances of visual recovery. Early identification of the carotid arteries decreases chance of unwanted arterial lesion with possible devastating consequences. Moreover, this minimal  surgical approach enhances the potential for complete resection of the tumor including its meningeal root at the diaphragma sellae.

 

Option # 2

 

At the CENTER FOR MENINGIOMA SURGERY the endoscopic transnasal approaches is an option for selected cases of small diaphragma sellae meningioma. This approach allows access to the root of the tumor through the nostrils with an endoscopic without any manipulation of the the brain. This approach uses a multidisciplinary team with the participation of our ENT endoscopic nasal surgery specialist and neurosurgeon.

 

Prognosis

 

Adequate surgical management of diaphragma sellae meningiomas using the focal orbital approach or the endoscopic nasal approach can allow full or partial recovery of visual difficulties and hypothalamic dysfunction. Moreover, patients have the potential for returning to the pre-morbid life style and job occupation. Patients may need hormonal replacement depending how much the pituitary gland function had been affected by the tumor. Maximal removal of the tumor and its meningeal root maximizes the chances of cure  without tumor recurrence.

 

CASES

 

TESTIMONIALS

 

 

 

 

SPHENO-ORBITAL MENINGIOMAS

 

Overview

 

Sphene-Orbital meningiomas are tumors with broad base meningeal origin arising from the sphenoid wing in the lateral skull base.The tumor tends to invade the bone of the sphenoid wing and the bone of the orbit or eye socket. It tends to invade the orbit causing compression and eye bulging. The extension to the  intracranial compartment commonly have a thin carpet like configuration against the temporal lobe without significant brain compression or swelling.

 

Presentation

 

Sphene-Orbital meningiomas tend to present with proptosis or eye bulging, vision loss and pain behind the eye.

 

Management

 

Sphene-Orbital meningiomas management generally requires surgical intervention for correction of the proptosis and visual difficulties. Radiation as a primary treatment is not recommended because of the extension of the tumor and proximity to the optic nerve. At the the Center for Meningioma surgery this tumor are managed by a neurosurgeon and an oculoplastic ophthalmologist. This multidisciplinary approach has maximized chances of favorable outcome.

 

Surgical Difficulties

 

Multicompartimental extension of the tumor in the skull base

Extended bone invasion

Orbital invasion

Need for complex bone reconstruction

Proximity to optic nerve

 

 

 

 

SURGICAL  MANAGEMENT AT THE CENTER FOR MENINGIOMA SURGERY

 

At the CENTER FOR MENINGIOMA SURGERY we conceptualized the focal orbital approach which can be adapted for removal of spheno-orbital meningiomas. This approach associated with microsurgical technique and the extradural navigation concept allows access to the tumor without hazardous exposure of the brain and only minimal direct manipulation or retraction of it. The approach allows for early identification and decompression of the optic nerves for best chance of visual recovery. Adequate resection of this tumor requires removal of the intracranial, bone and orbital components of the tumor. Reconstruction of the removed bone in the orbit and skull is necessary for optimal cosmetic outcome and correction of eye bulging.

 

Prognosis

 

Adequate surgical management of spheno-orbital meningiomas using the focal orbital approach and bone reconstruction can allow full or partial recovery of vision and correction of proptosis with optimal cosmetic. Patients may experience temporary double vision or difficulties opening the eye because of manipulation the eye muscles during surgery. Maximal removal of the tumor including the involved bone and meningeal broad origin of the tumor maximizes the chances of cure  without tumor recurrence. Hard to reach tumor in the central orbit may not be possible to remove without unacceptable visual and cosmetic deficits. In these cases, post operative Proton Bean Radiation Therapy may be needed.

 

CASES

 

TESTIMONIALS

 

VIDEOS

 

POSTERIOR FOSSA MENINGIOMA

PETROUS MENINGIOMA

 

Overview

 

Posterior fossa meningiomas are located in the back of the head. In this session we will  discuss the posterior fossa meningiomas located at the front part of the petrous bone (anterior petrous meningioma), in the back part of the petrous bone ( posterior petrous meningioma) or in back surface of the cerebellum (posterior fossa convexity meningioma). Petrous meningioma  arises from the dura lining petrous bone which is the bone structure in the head related to the hearing mechanism. Posterior fossa  convexity meningiomas arises from the meninges covering the back part of the cerebellum.  These tumors can grow to large size and they can cause compression of the brainstem, cranial nerves  or obstruction of the CSF flow and hydrocephalus.

 

Presentation

 

Posterior fossa convexity meningiomas and petrous bone meningiomas can present with headache localized in the back of the head, dizziness, hearing loss, facial numbness,  facial pain,  blurred vision or double vision, balance and gait difficulties. Less commonly patients can experience swallow difficulties or voice changes.  Patient with associated hydrocephalus can develop cognitive dysfunction or acute mental status change. Patients with hydrocephalus may need emergency intervention to alleviate intracranial pressure prior to tumor resection.

 

 

Management

 

Symptomatic tumors generally require surgical intervention. Older patients with small tumors can be candidate to CiberKnife Radiation Therapy or Proton Bean radiation Therapy. Small asymptomatic tumors can be followed with surveillance MRIs

 

Surgical difficulties

 

Possible proximity to multiple cranial nerves

Size of the tumor

Deep location covered by cerebellum

 

 

SURGICAL  MANAGEMENT AT THE CENTER FOR MENINGIOMA SURGERY

 

Option #1

 

Posterior petrous meningioma, small anterior petrous meningioma and and posterior fossa convexity meningioma are approached through craniotomies in the back of the head. At the Center for Meningioma Surgery we have refined a modified focused posterior fossa craniotomy approach which allows accessing these meningiomas using a small focused anatomic approach which has mostly eliminated the post-operative chronic occipital headache associated with the more traditional approaches. This approach is used for superficial tumors in the posterior fossa and small deeper tumors.

 

 

Option # 2

 

At the CENTER FOR MENINGIOMA SURGERY we conceptualized the focal transpetrosal approach which can be used for removal of large anterior petrous meningiomas with brainstem compression. This approach when associated with microsurgical technique and the extradural navigation concept allows for direct access to this deep tumors without hazardous exposure of the brain and only minimal direct manipulation or retraction of the brain tissue. At times, partial resection of the inner ear maybe needed to facilitate unobstructed visualization and dissection  of all tumor parts. The approach allows for early identification of involved cranial nerves enhancing function preservation of these important nerves. Moreover, the approach offers maximal potential for complete resection of the tumor. At the the Center for Meningioma surgery this approach uses a neurosurgeon and an Ear, Nose and Throat specialist. This multidisciplinary approach has maximized chances of favorable outcome.

 

 

 

 

 

Prognosis

 

Treatment of posterior fossa meningiomas and petrous meningiomas using the focused posterior fossa craniotomies or focused transpetrosal approach enhances greatest  tumor removal and  maximizes the chances of cure  without tumor recurrence. Patients have the potential for returning to the pre-morbid life style and job occupation. Small tumor parts at unfavorable hazardous position may not be resected during surgery to avoid  disabling neurological defects. Post-operative residual tumor can be treated with CiberKnife  Radiation Therapy or Proton Bean Radiation Therapy.

Multidisciplinary approach at the Center for meningioma Surgery maximizes the potential for cure or control  of these complex tumors without  recurrence and with preservation or recovery of function.

 

 

 

PETRO-CLIVAL MENINGIOMA

 

Overview

 

Petro-clival meningioma are complex challenging tumors located deep in the back of the head (posterior fossa). As the tumor progresses it causes compression of the brainstem, engulfs major brain arteries (basilar artery), and displaces multiple cranial nerves. These tumors can cause obstruction of the CSF flow and hydrocephalus

 

Presentation

 

Petro-clival meningioma can present with contralateral motor weakness, swallow difficulties, voice changes, blurred vision, double vision, headache, facial numbness, facial pain, facial droop, hearing loss, dizziness, balance and gait difficulties  and hearing loss. Patient with associated hydrocephalus can develop cognitive dysfunction  or acute mental status change. Patients with hydrocephalus may need emergency intervention to alleviate intracranial pressure prior to tumor resection.

 

Management

 

Large symptomatic petro-clival meningiomas in general need surgical intervention. Smaller tumors may be treated only with CiberKnife radiation therapy or Proton bean Radiation Therapy. Incidental tumors in elderly patients maybe managed with observation with surveillance MRIs.

 

Surgical Difficulties

 

Deep location covered by cerebellum

Close relation to the brainstem

Proximity to multiple cranial nerves

Close relation to major brain arteries ( basilar artery)

 

 

 

SURGICAL MANAGEMENT AT THE CENTER FOR MENINGIOMA SURGERY

 

At the CENTER FOR MENINGIOMA SURGERY we conceptualized the focal transpetrosal approach which can be used for removal of complex petr o-clival meningiomas. This approach when associated with microsurgical technique and the extradural navigation concept allows for direct access to this deep tumors without hazardous exposure of the brain and only minimal direct manipulation or retraction of the brain tissue. At times partial resection of the inner ear maybe needed to facilitate visualization of all tumor parts. The focal transpetrosal approach permits direct unobstructed access and dissection of all tumor parts including critical tumor removal away from the brainstem and major arteries. It also allows for early identification of involved cranial nerves enhancing important preservation of function and maximal potential for complete resection of the tumor.

Our team of Ear, Nose and Throat otologist specialists are directed involved in transpetrosal surgeries and management of this patients.

Small tumor parts at unfavorable hazardous position may not be resected to avoid  disabling neurological deficits. Postoperatively residual tumor can be treated with CiberKnife  Radiation Therapy or Proton Bean Radiation Therapy

 

Prognosis

 

Treatment of deep petro-clival meningiomas through focused transpetrosal approach enhances greatest tumor removal, tumor cure and the potential for recovery from preoperative deficits on patients with these complex tumors. Moreover, patients have the potential for returning to the pre-morbid life style and job occupation. Small tumor parts at unfavorable hazardous position may not be resected during surgery. Post-operative residual tumor can be treated with CiberKnife Radiation Therapy or Proton Bean Radiation Therapy. Multidisciplinary approach at the Center for meningioma Surgery maximizes the potential for cure or control  of petro-clival meningiomas without  recurrence and with preservation or recovery of function.

 

 

TENTORIAL MENINGIOMA

 

Overview

 

Tentorial meningiomas are tumor that arise from large dural fold called tentorium. The tentorium separates the brain into infra and supra tentorial compartments. The infratentorial compartment contains the cerebellum and the supratentorial compartment contains the brain. Tentorial meningioma can grow towards the infratentorial or supratentorial compartment with respective compression of the cerebellum or brain. Tentorial meningioma can grow to formidable size causing significant pressure and swelling or edema to the cerebellum or brain before coming to medical attention. These tumors can cause obstruction of the CSF flow and hydrocephalus

 

 

Presentation

 

Tentorial meningiomas can present with headache localized in the back of the head, seizures, dizziness, balance or gait difficulties, blurred vision or double vision. Speech difficulties can occur  when the tumor is associated with compression of the dominant temporal lobe brain. Less commonly patients can experience swallow difficulties or voice changes.Patient with associated hydrocephalus can develop cognitive dysfunction  or acute mental status change. Patients with hydrocephalus may need emergency intervention to alleviate intracranial pressure.

 

Management

 

Large symptomatic tentorial meningiomas in general need surgical intervention. Smaller tumors may be treated primarily with CiberKnife radiation therapy or Proton bean Radiation Therapy. Incidental tumors in elderly patients maybe managed with observation with surveillance MRIs.

 

Surgical Difficulties

 

Deep location covered by brain and cerebellum

Involvement of the supra and infra tentorial compartments

Extension of meningeal origin of the tumor

 

 

SURGICAL  MANAGEMENT AT THE CENTER FOR MENINGIOMA SURGERY

 

Tentorial meningioma are approached through craniotomies in the back of the head. At the Center for Meningioma Surgery we have refined a modified focused posterior fossa craniotomy approach which allows accessing these meningiomas using a small focused approach. This focused approach has mostly eliminated the post-operative chronic occipital headache associated with the more traditional approaches. The approach allows direct access to the parts of the tumor above and below the tentorium. Moreover, it offers potential for complete resection of the tumor including the tentorial meningeal root of the tumor.

 

Prognosis

 

Treatment of tentorial meningiomas through focused posterior fossa craniotomy enhances greatest tumor removal, tumor cure and the possibility for recovery from preoperative deficits. Moreover, patients have the potential for returning to pre-morbid life style and job occupation.

 

FORAMEN MAGNUM MENINGIOMA

 

Overview

 

The foramen magnum is the opening in the skull that communicates the intracranial compartment to the cervical spine compartment. The brainstem passes through the foramen magnum to become the upper most spinal cord in the spinal canal. Meningiomas arising at the foramen magnum compress the brainstem and upper cervical spinal cord. They often engulf the vertebral artery which provides blood supply to the parts of the brain in the back of the head.

 

Presentation

 

Foramen magnum meningiomas tend to present initially with headache in the back of the head. As the tumor progresses, it compresses the brainstem and the spinal cord and it can cause motor weakness. The weakness  can be unilateral or bilateral involving the upper and lower etremities or to involve only both upper extremities. Patient can also develop numbness in the upper and lower extremities. With further progression the patient can become bedridden with quadriplegia and  swallowing difficulties.

 

Management

 

Symptomatic foramen magnum meningiomas in general need surgical intervention. Smaller tumors may be treated primarily with CiberKnife radiation therapy or Proton bean Radiation Therapy. Incidental tumors in elderly patients maybe managed with observation with surveillance MRIs.

 

Surgical Difficulties

 

Deep location of the tumor

Close relation to the brainstem and spinal cord

Close relation to the major brain arteries (vertebral artery)

 

SURGICAL  MANAGEMENT AT THE CENTER FOR MENINGIOMA SURGERY

 

Foramen magnum meningioma are approached through a unilateral craniotomy around the foramen magnum and a unilateral laminectomy of the first vertebra to access the confined area of the foramen magnum. We use visual magnification with the surgical microscope throughout the the approach and tumor dissection. At the Center for Meningioma Surgery we refined a focused approach  to the foramen magnum using a lazy S incision in the back of the head. This focused cranio-cervical approach allows extradural access to the origin of tumor without retraction or manipulation of the brainstem, spinal cord or cerebellum. It allows for the  vertebral artery to be  identified prior to any removal of the tumor enhancing safe tumor dissection without injury to  this main artery to the brain and its branches. The approach offers potential for complete resection of the tumor including the meningeal root of the tumor.

 

Prognosis

 

Treatment of foramen magnum meningiomas through focused combined cervico-foramen magnum approach enhances chances of total  tumor removal, tumor cure and the possibility for recovery from preoperative deficits. Patients have the potential for returning to pre-morbid life style and job occupation.  Maximal removal of the tumor and its meningeal root maximizes the chances of patients to progress without tumor recurrence.

 

 

JUGULAR FORAMEN MENINGIOMA

 

Overview

 

Jugular foramen meningiomas are complex tumors extending from the foramen magnum to the jugular foramen. The foramen magnum is the opening in the skull that communicates the intracranial compartment to the cervical spine compartment. When the brainstem passes through the foramen magnum it becomes the upper most spinal cord. The jugular  foramen is an opening at the skull base where the cranial nerves responsible for swallowing and voice passes from the intracranial compartment to the neck before traveling to the larynx and pharynx.

Meningiomas arising from the meninges around the jugular foramen and foramen magnum compress the brainstem and upper cervical spinal cord and engulfs or displaces the swallowing, the tongue  and vocal cord cranial nerves. Those are the cranial nerves IX, X, XI and XII. In addition, the tumor can engulfs the vertebral artery  and the basilar which provide blood supply to the parts of the brain in the back of the head.

 

Presentation

 

Foramen jugular meningiomas tend to present initially with headache in the back of the head. As the tumor progress the patient may develop swallowing difficulties and voice changes. With further progression and associated compression of the brainstem and the spinal cord it can cause mild to severe motor weakness. The weakness  can be unilateral or bilateral involving the upper and lower exterminates. The patient can also develop numbness in the upper and lower extremities. With further progression the patient can become bedridden with quadriplegia associated with swallowing difficulties and weak voice.

 

Management

 

Symptomatic foramen magnum meningiomas in general need surgical intervention. Smaller tumors may be treated primarily with CiberKnife radiation therapy or Proton bean Radiation Therapy. Incidental tumors in elderly patients maybe managed with observation with surveillance MRIs.

 

Surgical Difficulties

 

Deep location of the tumor covered by cerebellum

Close relation to the brainstem and spinal cord

Close relation to the major brain arteries (vertebral and basilar arteries)

Close relation cranial nerves related to swallow and voice

 

 

 

 

SURGICAL  MANAGEMENT AT THE CENTER FOR MENINGIOMA SURGERY

 

Jugular foramen meningioma are approached through a unilateral craniotomy around the foramen magnum which extends sideways towards the jugular foramen. A unilateral laminectomy of the first vertebra is added and access is gained to the confined area of the jugular foramen and foramen magnum. We use visual magnification with the surgical microscope throughout the  approach and tumor dissection. At the Center for Meningioma Surgery we refined a focused approach through a lazy S incision in the back of the head. The approach allows extradural access to the origin of tumor without retraction or.manipulation of the brainstem, spinal cord or cerebellum. The approach allows for the  vertebral artery to be  identified prior to any removal of the tumor enhancing safe tumor dissection without injury to this major artery to the brain. Early identification of the involved cranial nerves enhances important preservation of swallow and voice function. The approach offers potential for maximal resection of the tumor with the least loss of function.

Small tumor parts at unfavorable hazardous position in the foramen jugular may not be resected to avoid injury to the cranial nerves with disabling post-operative swallowing and vocal cord neurological deficits. Postoperatively residual tumor can be treated with CiberKnife  Radiation Therapy or Proton Bean Radiation Therapy

 

Prognosis

 

Treatment of foramen jugular  meningiomas through focused combined cervico-foramen magnum approach enhances chances of maximal tumor removal with function preservation or recovery of function. Moreover, patients have the potential for returning to pre-morbid life style and job occupation. Small tumor parts at unfavorable hazardous position in the jugular foramen are unlikely to be resected during surgery. Patients with swallowing difficulties are treated with temporary feeding tube. Post-operative residual tumor can be treated with CiberKnife Radiation Therapy or Proton Bean Radiation Therapy. Multidisciplinary approach at the Center for meningioma Surgery maximizes the potential for favorable functional outcome and cure or control of jugular foramen meningiomas without  recurrence

 

PINEAL REGION MENINGIOMA

 

Overview

 

Pineal region meningioma is a deep tumor tucked in between the infra-tentorial and supra-tentorial compartments in the intracranial space. The tumor is behind the pineal gland, in the back side of the upper part of the brainstem, called quadrigeminal plate, which control eye coordination.It is also can be close to important deep centers of the brain (thalamus). It tends to press upon the this part of brainstem causing obstruction of the cerebral-spinal fluid (CSF) and enlargement of the CSF brain chambers (hydrocephalus).

 

Presentation

 

Patients with pineal region meningiomas present with headache, balance or gait difficulties and  vision changes. Patient with associated hydrocephalus can develop cognitive dysfunction  or acute mental status change. Patients with hydrocephalus may need emergency intervention to alleviate intracranial pressure before tumor resection.

 

Management

 

Symptomatic pineal region meningiomas in general need surgical intervention. Smaller tumors may be treated primarily with CiberKnife radiation therapy or Proton bean Radiation Therapy. Incidental tumors in elderly patients maybe managed with observation with surveillance MRIs.

 

Surgical Difficulties

 

Deep location of the tumor covered by cerebellum

Close relation to brainstem

Close relation to thalamus

Close relation to cerebellum

 

SURGICAL  MANAGEMENT AT THE CENTER FOR MENINGIOMA SURGERY

 

Pineal region meningiomas are approached through a  focused small midline or para-midline craniotomy in the back of the head. This focused approach allows navigation over the cerebellum and resection of parts the tentorium for direct accessing the tumor in the infra and supra tentorial compartments. This approach avoids exposure and retraction or manipulation of the occipital lobe of the brain which is responsible for perception of vision. We use visual magnification with the surgical microscope throughout the approach and tumor dissection. Furthermore, this focused approach enhances the  potential for maximal resection of the tumor with function preservation.

 

Prognosis

 

Treatment of pineal region meningiomas through focused combined sub-occipital craniotomy approach improves chances of maximal tumor removal with function preservation or recovery of function, including, pre-operative visual difficulties, cognitive dysfunction and gait/balance problems. Adequate management of pineal region meningiomas enhance the potential for patients  returning to pre-morbid life style and job occupation.  Maximal removal of the tumor and its meningeal root maximizes the chances of patients to progress without tumor recurrence.

LATERAL VENTRICLE MENINGIOMAS

Overview

Lateral ventricle meningiomas are rare tumors located in the cerebral-spinal fluid (CSF) brain chambers, called brain ventricles. They are generally located deep in the brain, in the lateral ventricle between the occipital, the temporal and parietal lobes of the brain. These tumors can grow to formidable size and can have close relation to important deep centers of the brain (thalamus). Brain swelling or edema is often present around the tumor site. Obstruction of the CFS flow in the ventricular system can cause enlargement of the ventricles ( hydrocephalus)

Presentation

Patient with meningioma of the lateral ventricle can present with headache, increased intracranial pressure, cognitive dysfunction, loss of peripheral vision and motor weakness. Tumors in the dominant side of the brain can cause speech dysfunction. Patients with hydrocephalus may need emergency intervention to alleviate intracranial pressure before tumor resection.

Management

Symptomatic lateral ventricle meningiomas with increases intracranial pressure  in general need surgical intervention. Small incidental tumors can be treated with observation and surveillance MRIs. Radiation is generally avoided in these tumors because of the tumor size and its deep location close to eloquent areas of the brain.

Surgical Difficulties

Deep location covered by brain tissue

Close relation to eloquent brain areas

Close relation to thalamus and other deep brain structures

SURGICAL  MANAGEMENT AT THE CENTER FOR MENINGIOMA SURGERY

Lateral ventricle meningioma are approached through a focused superior parietal craniotomy in the convexity of the head. The deep tumor is accessed and removed using a small (16 mm) tubular brain port which is passed from the surface of the brain to the deep site of the tumor. The tumor is removed in a piecemeal fashion through the port after breaking of the tumor with an ultrasonic device which decreases the tumor pressure and facilitates its dissection from the surrounding brain tissue. Tumor removal is carried out using magnification with the surgical microscope. This approach allow accessing deep tumors in the brain with minimal retraction manipulation or the brain parenchyma. The brain port focused approach enhances the  potential for maximal resection of the tumor with function preservation.

Prognosis

Treatment of lateral ventricle meningiomas through focused brain port approach improves chances of maximal tumor removal with function preservation or recovery of function, including, pre-operative visual difficulties, cognitive dysfunction and motor weakness.  Adequate management of lateral ventricle meningiomas enhance the potential for patients  returning to pre-morbid life style and job occupation.  Maximal removal of the tumor and its root in the choroidal plexus maximizes the chances of patients to progress without tumor recurrence.

CONVEXITY MENINGIOMAS

Frontal meningioma

Parietal meningioma

Temporal meningioma

Occipital meningioma

Overview

Convexity meningiomas are superficial tumors arising from the meninges covering the surface of the brain. These tumors  are primarily located outside the brain. As the tumor grows it can presses on the underlying brain and cause brain swelling or edema and  neurological symptoms and disability. Occasionally the overlying cranial bone is invaded by tumor and a lump can be felt under the scalp.

Convexity meningiomas are classified according to their  topographic location and relation to the underlying brain into: frontal meningioma, parietal meningioma, occipital meningioma or temporal  meningioma

Presentation

The location of the tumor determines the possible symptoms and deficits associated with it.

-Headache – New onset of headache which can be localized to the location of the tumor or generalized  when  related to increased intracranial pressure.

-Seizure -.Convexity meningiomas in all location can cause generalized seizures and focal or partial seizures. The type of partial seizure is related to the part of the brain affected by the tumor. Seizure can be the first presentation of meningiomas before diagnosis

-Vision difficulties – Blurriness or loss of peripheral vision

• Balance/gait difficulties
• Arm and and / or leg weakness (contralateral to the side of the tumor)
• Loss of sensation ( contralateral to the side of the tumor)
• Speech difficulties
• Cognitive changes -Behavioral changes

– Memory loss

Management

Convexity meningiomas causing symptoms, either related to the affected underlying brain parenchyma or to increased intracranial pressure, are generally treated  with  surgery. Small to medium size incidental tumors without  associated brain edema can be treated with observation and surveillance MRIs. Elderly patients with small to medium size tumors associated with mild symptoms and without significant mass effect can be treated primarily with CyberKnife or Proton Bean radiation therapy.

Surgical Difficulties

Localization of the tumor

Close relation to swelled brain

Tumor size

Close relation to eloquent brain areas

Close relation to brain feeding arteries

SURGICAL  MANAGEMENT AT THE MENINGIOMA CENTER

Convexity meningiomas are superficial and easily accessed by surgery. In the Center for Meningioma  Suergey these tumors are treated with the smallest  possible incision and bone opening in the skull (craniotomy) tailored to the location and size of the tumor. The size of the craniotomy  and localization of the tumor are guided by a computer assisted device which can pinpoint the site and anatomy of the tumor (Stealth Station or BrainLab Station).

Tumor resection is carried out with magnification with the surgical microscope to allow elevation of the tumor away from the underlying brain following natural anatomical planes of dissection. This strategy avoids unnecessary trauma or damage to the brain tissue. Tumor is removed and dissected in a piecemeal fashion after breaking of the tumor with an ultrasonic device which decreases the tumor pressure and facilitates its dissection. Resection of the meningeal origin of the tumor is necessary to allow complete removal of the tumor. When there is invasion of the overlying cranial bone the involved bone is removed and the cranial defect is repaired with a cranioplasty.

After tumor removal the meningeal defect is repaired and bone flap is placed on its original position and secured with small titanium plates and screws.  The scalp is closed by layers with staples to the more superficial.

Prognosis

Treatment of convexity meningioma in all locations  through focused small craniotomies and microsurgical technique improves chances of maximal tumor removal with function preservation or recovery of function, including, pre-operative motor deficits, visual difficulties, speech difficulties and cognitive dysfunction. Pre-operative seizures are often well controlled with or without medication after atraumatic tumor resection.

Small surgical openings or craniotomies decrease duration of surgery,  soft tissue trauma and swelling, post-operative pain and  hospital stay.

Adequate management of convexity meningiomas enhance the potential for patients  returning to pre-morbid life style and job occupation.  Maximal removal of the tumor and its meningeal origin maximizes the chances of patients to progress without tumor recurrence.

PARASAGITAL MENINGIOMA

PARAMEDIAN  MENINGIOMA

Overview

Parasagiatal or paramedian meningiomas are superficial tumors  located next to the midline in the skull convexity. These tumors are closely related to the superior sagittal sinus. This sinus is a large venous channel located  in the midline between both brain hemispheres. It collects most of the blood from the veins draining blood from the brain. Parasagital meningiomas may partially invade or fully obstruct the superior sagittal sinus.

Parasagital meningiomas can grow to formidable size and ongoing pressure to the underlying brain parenchyma can cause brain swelling or edema. Occasionally the overlying cranial bone is invaded by tumor and a lump can be felt under the scalp.

Parasagital meningiomas can be located can be located in the frontal, parietal or occipital region next to the midline and along the superior sagittal sinus.

Presentation

The location of the parasagittal meningioma along the midline determines the possible symptoms and deficits associated with it.

-Headache – New onset of headache which can be localized to the location of the tumor or generalized  when  related to increased intracranial pressure.

-Seizures -Frontal tumors tend to cause focal motor or sensory seizures in the contralateral side of the tumor. It can be associated with speech arrest when the tumor is on the dominant brain hemisphere. Seizure can be partial or generalized. It is often the first presentation of meningiomas before diagnosis

-Occipital parasagittal meningiomas can cause loss of  peripheral vision are

-Frontal parasagittal meningiomas can cause contralateral leg and foot weakness

• Frontal parasagittal meningiomas can cause contralateral leg and foot numbness

Management

Symptomatic parasagital meningiomas are generally treated  with  surgery. Small to medium size incidental tumors without  associated brain edema can be treated with observation and surveillance MRIs. Elderly patients with small to medium size tumors associated with mild symptoms and without significant mass effect can be treated primarily with CyberKnife or Proton Bean radiation therapy.

Surgical Difficulties

Localization of the tumor

Close relation to superior sagital sinus

Close relation to swelled brain

Tumor size

Close relation to eloquent brain areas

Close relation to brain feeding arteries

Close relation to brain draining veins

SURGICAL  MANAGEMENT AT THE CENTER FOR MENINGIOMA SURGERY

Parasagital meningiomas are superficial and easily accessed by surgery. At the Meningioma Center these tumors are treated with the smallest  possible incision and bone opening in the skull (craniotomy) next to midline. The craniotomy is tailored to the location and size of the tumor. The size of the craniotomy  and localization of the tumor  are guided by a computer assisted device which can pinpoint the site and anatomy of the tumor (Stealth Station or BrainLab Station).

Tumor resection is carried out with magnification with the surgical microscope to allow elevation of the tumor away from the underlying brain following natural anatomical planes of dissection. This strategy avoids unnecessary trauma or damage to the brain tissue. Tumor is removed and dissected in a piecemeal fashion after breaking of the tumor with an ultrasonic device which decreases the tumor pressure and facilitates its dissection.

Opening of the superior sagittal sinus is necessary  for  removal of tumor invading the sinus. This is followed by  repair of the sinus. Resection of the whole sinus is carried out when the sinus is complete obstructed pre-operatively.

When there is invasion of the overlying cranial bone the involved bone is removed and the cranial defect is repaired with a cranioplasty.

Resection of the meningeal origin of the tumor is necessary to allow complete removal of the tumor.

Prognosis

Treatment of parasagittal meningiomas meningioma through focused small craniotomies and microsurgical technique improves chances of maximal tumor removal with function preservation or recovery of function, including, pre-operative motor deficits, visual difficulties, speech difficulties and cognitive dysfunction. Pre-operative seizures are often well controlled with or without medication after atraumatic tumor resection.

Small surgical openings or craniotomies decrease duration of surgery,  soft tissue trauma and swelling, post-operative pain and  hospital stay.

Adequate management of parasagittal meningiomas enhance the potential for patients  returning to pre-morbid life style and job occupation.  Maximal removal of the tumor including the superior sagittal invasion, bone invasion  and  meningeal origin of the tumor maximizes the chances of patients to progress without tumor recurrence.

FALCINE MENINGIOMA

FALX MENINGIOMA

Overview

Falcine or falx meningiomas are deep midline tumor arising from the falx cerebri. The falx is this large  midline meningeal fold between both cerebral hemisphere. As the tumor grows it can presses on the adjacent brain on the inner aspect of either cerebral hemisphere. Tumor growth can cause swelling or edema of the adjacent brain and  lead to neurological symptoms and disability.

Falcine meningiomas can be located can be located in the frontal, parietal or occipital region along the falx in the midline.

Presentation

Frontal falcine meningioma at the mid part of the falx can present with focal motor or sensory seizure on the contralateral side of the tumor.  Patients can also develop progressive  foot and leg weakness or sensory loss.

Occipital falcine meningioma located in the back part of the falx can present with loss of peripheral vision in the contralateral side of the tumor.

Management

Symptomatic falx meningiomas are generally treated  with  surgery. Small to medium size incidental tumors without  associated brain edema can be treated with observation and surveillance MRIs. Elderly patients with small to medium size tumors associated with mild symptoms and without significant mass effect can be treated primarily with CyberKnife or Proton Bean radiation therapy.

Surgical Difficulties

Localization of the tumor

Deep location

Close relation to swelled brain

Tumor size

Close relation to eloquent brain areas

Close relation to brain feeding arteries

SURGICAL  MANAGEMENT AT THE MENINGIOMA CENTER

Falcine meningioma are treated with the smallest  possible incision and bone opening in the skull (craniotomy) next to midline. The craniotomy is tailored to the location and size of the tumor. The size of the craniotomy and localization of the tumor are guided by a computer assisted device which can pinpoint the site and anatomy of the tumor (Stealth Station or BrainLab Station). Occasionally we use an approach contralateral to the side of the bigger part of the tumor to avoid manipulation of swelled and compromised brain around the tumor.

Tumor resection is carried out with magnification with the surgical microscope to allow elevation of the tumor away from the underlying brain following natural anatomical planes of dissection. This strategy avoids unnecessary trauma or damage to the brain tissue. Tumor is removed and dissected in a piecemeal fashion after breaking of the tumor with an ultrasonic device which decreases the tumor pressure and facilitates its dissection.

The origin of the tumor in the falx is routinely removed. Any tumor in the contralateral side of the flax is dissected away from the adjacent brain and removed. This strategy maximizes complete resection of the tumor

Prognosis

Treatment of falcine m meningiomas meningioma through focused small craniotomies and microsurgical technique improves chances of maximal tumor removal with function preservation or recovery of motor function. Pre-operative seizures are often well controlled with or without medication after atraumatic tumor resection.

Small surgical openings or craniotomies decrease duration of surgery,  soft tissue trauma and swelling, post-operative pain and  hospital stay.

Adequate management of falcine meningiomas enhance the potential for patients  returning to pre-morbid life style and job occupation. Maximal removal of the tumor including the falx meningeal origin of the tumor maximizes the chances of patients to progress without tumor recurrence.