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Most of the site will reflect the ongoing surgical activity of Prof. Munir Elias MD., PhD. with brief slides and weekly activity. For reference to the academic and theoretical part, you are welcome to visit  neurosurgery.tv

 

 

14-OCTOBER-2006  ABDEL-KAREEM UBEID AL-RUBAYEE  63 YEARS  GIANT TENTORIO-FALCINE MENINGIOMA WITH  LEFT INTRAVENTRICULAR EXTENSION.

The patient came to the clinic 10-October-2006 complaining of right Bell's palsy for 6 days, decreased hearing right ear since childhood. He started to complain of headache and ataxia for 1 year, disturbed memory  and dyslexia for 3 months. He is a known hypertensive for 12 years.

CT-scan done 4-October-2006 showed left occipital meningioma and suspected right CPA lesion. On examination: the patient has Bell's palsy, not related to the mass, otherwise the patient was neurologically free, except for the above mentioned.

MRI of the brain and MRV were performed and showed a giant meningioma having matrix in the tentorium and falx cerebri posterior third  and invading the posterior horn of the left lateral ventricle.

The patient in concord position with the face slightly rotated to the left, a bone flap was performed so as to expose most of the left occipital lobe and the torcula Herophili and left transverse sinus. U-shaped dural incision was done parallel to the transverse sinus , up to the far point of the superior sagittal sinus and reflected to the right.

Despite several method to decrees the swelling of the bulged brain, it was impossible to attack the lesion interhemispherically  and attempts to go supratentorially was difficult without causing harm to neural tissues. It was decided to attack the lesion transcortically  through 2 cm incision.

The tumor was rubbery and violet in color and very vascular with multi feeders. Most of the tumor was so rubbery, that it was difficult to cut it with scissors and No 11 blade. Piece-meal removal was performed and the matrix of the tumor to the falx cerebri was bisected and coagulated. The intraventricular part  had it's own feeders and draining veins, which were coagulated and bisected. The matrix of the tentorium and the tentorial edge was also coagulated and cleaned meticulously. The last small piece which was stuck to the junction of the falcino-tentorial junction was sharply bisected and a 7 mm draining vein was identified, which was draining to the left deep cerebral vein, was removed after coagulating this vein and bisection. Radical removal of the tumor was achieved and the brain regained relaxed appearance  and after that, it was possible to explore the intrhemispheric region and the supratentorial region. The rectus vein was clean of the tumor and the tentorial edge was was free with intact arachnoid and the vein of Labbe was running free.

Routine water-tight closure and smooth postoperative recovery. The patient blood group was B+ and he received 3 units of blood and 6 units of FFP. The operation took 14 hours.

The next day the patient was doing well and no neurological deficit escalated. He spoke with all medical personnel and ate and walked. He was an inelegant one and repeated poems in Arabic. After 30 min of second ambulation, got sudden onset of cardiac arrest, which did not respond to resuscitation  during 90 min with asystole remained during this time, and his clinical death was fixed at 2.00 pm. The cause of death was acute massive thrombotic embolism. For more details about this topic, click here!

Comments:

1. Setting position was not adequate for this operation, because the occipital lobe will be damaged by gravity during work.

2. Concord position is the best option, but the area must be above the level of the heart to prevent venous congestion, and this make the position of surgeon very bad and as in this case the surgeon needs resuscitation in case of more than 12 hour work such in this case.

3. It is hard to tell which type of meningioma is this one, since it had matrix in the falx and tentorium and the left lateral ventricle. When the meningioma reach giant dimensions, it regain  a matrix where it stuck to the dural sleeves and regain pathologic feeders and draining vein when it invade the ventricle.

3. This operation was the most difficult in my life, since it include all the factors, making its resection difficult ( rubbery consistency, highly vascular, multilobulated, has multiple matrices and stuck to major vessels and veins and important sinuses. Patience, time, clean surgery, microscopic facility, sharp dissection and the ability to choose the appropriate exposure  are the key to achieve success in performing such surgery.

4. Old age and hypertension are risk factors for mortality, even for minor surgeries and this factor increases with major surgeries.

5. Prevention of PE in such highly vascular intracranial operation remains a dilemma, which needs solution, since anticoagulants are forbidden during this scenario and despite the fact, that early mobilization of the patient was taken into consideration with this patient to prevent such event.

6. The patient progressed the fatal events within seconds and asystole persisted for 90 min despite the various methods of resuscitation. Nothing can be done more in this situation at the present time and only the future can give the answer for the best practice how to resolve such an event.

 

 

Immediate postoperative check CT-scan
Check CT-scan 15-October-2006 confirming the radical resection of the tumor.


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[2006] [CNS CLINIC - NEUROSURGERY - JORDAN]. All rights reserved