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01-JULY-2008  AHMAD ALI AL-WALEED  39 YEARS  RECURRENT RIGHT CAVERNOUS SINUS MENINGIOMA WITH MASSIVE RIGHT PARASELLAR AND CLIVAL EXTENSION.

Anamnesis:

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The patient was operated by me for right cavernous meningioma with leaving a small tiny remnant in the ICA and the wall of the cavernous sinus through pterional approach 11-May-2003 for epilepsy.

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The patient disappeared and came to the clinic 26-June-2008 with recurrent attacks of epilepsy with MRI of the brain performed 24-June-2008 confirming the recurrence of the meningioma, involving the right cavernous sinus and all the right parasellar region with involvement of the tentorium and subtentorial and clival extension with the carotid artery hanging in the middle of the mass.

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The patient was admitted 3 days before surgery due to bad condition. He was covered with Depakine I/V and follow up demonstrated surges of high fever exceeding 41 degrees Celsius.  Septic workup was negative and and the only explanation to such event was hypothalamic irritation in reaction to the rich vascularity of the tumor.

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The old incision was refreshed and extended more inferiorly and backward. IOM ISIS Highline with neuroexplorer 4.2 was used during all steps of the operation.

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Trans-zygomatic approach was performed with drilling of the tumorous bony base of the skull. The drilling was extended back to the cochlea and medially to the V3 division and the horizontal segment of ICA and anteriorly to the V2 division.

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The tumorous dura was resected with tumor abutting the V1 emergence. Peace-meal resection of the tumor was done with cleaning of the tentorium. The intracavernous part of the right ICA was exposed and pinpoint tear was repaired with nylon 6 zero.  The subtentorial compartment was reached and removed. The right oculomotor nerve was pushed anteriorly and medially and was anatomically preserved. The basilar artery and right posterior communicating arteries were preserved.

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It was felt that further resection could lead to catastrophic events, taking into consideration, that the tumor was rubbery and stuck to all vitally important structures.

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It was impossible to reach the sphenoidal compartment from this approach safely.

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The dural defect was covered with Tacocele and one stitch was applied to the lateral edge of the V1 emergence.

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Routine closure of the wound and ready-vac drain was inserted under the skin.

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The operation took 12 hours and 4 units of blood and 6 units of FFP was give.

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Smooth postoperative recovery and the patient right hearing is preserved and the abducens was functioning . Lagophthalm of the right eye and paresis of the right oculomotor nerve was noted. 

Comments

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The patient has cavernous meningioma which was subtotally resected 5 years ago.

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The recurrence took an aggressive surgical dilemma, which was limiting the percentage of removal.

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Radiotherapy could be an acceptable option after the surgery to slow down the speed of regrowth.

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For detailed information about meningiomas please refer to meningiomas.info and meningiomas.org.

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Notice: Not all operative activities can be recorded due to lack of time.
Notice: Head injuries and very urgent surgeries are also escaped from the plan .

     

  

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