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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

 

26-AUGUST-2006  AYMAN MUHAMED AMEEN   32 YEARS RECALCITRANT INVASIVE LEFT PTERIONAL MENINGIOMA WITH MASSIVE WIDESPREAD INTRAOSSAL INVASION  

The patient came 22-August-2006 complaining of severe exophthalmus left eye with blind left eye and light sensation on the right eye.  The patient was operated 4 times for meningioma elsewhere 08-July-2003, 17-November-2003, 08-April-2004 and 15-April-2006. Loss of vision left eye for three years. Deterioration of vision right eye the last 20 days. MRI performed 15-August-2006 showed wide spread intraossal pterional meningioma with invasion of the tuberculum sellae and left retrobulbar extension and ethmoidal growth with involvement of both cavernous sinuses and reaching the tenorium both sides. 

On examination: the patient is practically blind, but with some light perception on the right eye. All oculomotor nerves were disturbed both sides with dilated both pupils. Olfaction was preserved. Hearing loss left ear and right  facial central paresis with right hemiparesis.

Considering that the vision on the right eye is rapidly deteriorating with the presence of chiasmal compression and unacceptable exophthalmus, it was decided to operate him. The patient was admitted 3 days prior to surgery and anemia and hypoalbuminemea were corrected and diabetes incipidus was noted and corrected.

Bifrontal  craniotomy was performed, using the old incision, which was extended by using the old bony flap and the nasion with part of the anterior part of the left orbital roof were skeletonized and the involved by the tumor were exposed to high temperature  in autoclave for 10 min  to kill the tumor cells. The left tumorous huge pterion was drilled completely, exposing during that the neurovascular bundle of the left superior orbital fissure. All the lateral wall of the left orbit was drilled off and drilling was extended down until the infratemporal fossa was seen. All the accessible bony elements in that area were drilled off, including the posterior half of the orbit and the lesser wing. This part was extradural.

The dura was opened parallel to the anterior edge of the bony defect at the level of the crista Galli and the falx was bisected. The left olfactory bulb was scarified and the other was preserved. The dura in the planum sphenoidale was sharply dissected and drilling of the planum and tuberculum sellae was achieved, removing during that the ethmoidal extension of the tumor. During this part massive arterial bleeding came from the left superior ethmoidal artery, which was controlled in several stages of removal.

That part of the tumor originating from the tuberculum sellae was removed, after what it was possible to see the right optic nerve hanging free and the supraclinoid ICA freely running underneath. From this point, the left side of the chiasm was identified and the scarous tumor was removed, leaving small remnants stuck to it and the adhere to it the A1 segment.

After removal of the left part of the tumor prechasmatically,  it was possible to see the left optic nerve, The postero-medial part of the orbital roof was drilled off to remove the retroorbital extension of the tumor.

Inspection of the right lesser wing for tumor presence was negative. The arachnoid separating the pituitary gland was kept intact. The extradural left optic nerve was seen pushed downward and the periorbita was incised down to the annulus of Zinn. Part of the periorbita was involved with tumor , which was resected.

A huge muscle graft was harvested from the left quadriceps muscle. Several pieces were inserted snuggly to fill the cavity at the resected part of the ethmoidal sinus. Another parts were inserted to fill all the spaces created after drilling the very huge left pterion.

The bone flaps were gathered and fixed by several means to reconstruct the frontal part of the face and anterior half of the left orbital roof. Routine closure. The operation took 12 hours duration. Smooth postoperative recovery.

27-August-2006: The patient can smell odors and the vision of the right eye the same, but to my surprise and out of expectation, he regained light perception of the left eye. I had a similar case with complete blindness for 9 years in one eye , which regained function later. This happened 15 years ago and I remember the name of the patient, but there were no video-documentations to prove that.

Comments:

1. One can ask: why to do such major surgery in this case? The answer is to improve the vision in the right eye and resolve the unacceptable exophthalmus. Time will give the answer.

2. For more theoretical data concerning meningiomas please visit meningiomas.org, or meningiomas.org.


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