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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.
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