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Neurosurgery
Surgical Assessment and Management of Tentorial Meningioma
Built from Feldman — Neurosurgical Operative Atlas: Neuro-Oncology
What’s inside
11 sections · 69 slides
Overview
- What this deck teaches
The tumor and its terrain
What these tumors are and how we classify them
- First, what is a meningioma?
- What is the tentorium?
- Rare, and defined by their seat
- The Yasargil classification: three rings
- Two more descriptors that shape the approach
- Ring-based classification of the tumor
- Tentorial vs petroclival: a critical distinction
- Parapineal tumor displacing the midbrain
How they present
Reading symptoms back to the tumor's seat
- Who gets them, and the general picture
- Inner-ring tumors irritate nerves and brainstem
- Extension up, down, and into the sinuses
Preoperative evaluation
Imaging that must precede the operation
- MRI in all three planes, with contrast
- Studying the blood vessels
- Enlarged tentorial feeding artery
- Tailored extra tests
- Torcular, occipital-tentorial tumor on MRI
The management decision
Why surgery remains the mainstay
- Surgery versus the alternatives
- When total removal is not possible
Choosing the approach
Two principles that select the corridor
- Individualize, then apply two rules
- Which location maps to which operation
T1: extended middle fossa approach
Anterior inner-ring tumors
- Why this approach for T1
- Extended middle fossa skin incision
- The incision, protecting the facial nerve
- Pterional incision, facial-nerve landmarks
- Freeing and reflecting the bone and muscle
- Zygomatic osteotomy
- The temporal craniotomy
- Temporal craniotomy
- Peeling the dura off the middle fossa floor
- The safe drilling zone: Kawase quadrilateral
- Petrous apex drilling
- Opening the dura and dividing the tentorium
T2 and T7: the petrosal approach
Lateral and outer-ring tumors
- Why the petrosal approach
- Positioning and incision
- The muscle and fascia layers
- Four burr holes across the sinuses
- Mastoidectomy and skeletonizing the sigmoid
- Opening the dura and cutting the tentorium
- Closure of the petrosal approach
T3-T6: combined occipital craniotomy
Posterior and pineal tumors
- What T3-T6 covers, and the flexible route
- Positioning to let gravity help
- Incision and the inferiorly based flap
- Burr holes and the single craniotomy flap
- Opening the dura and reaching the tumor
Tumor resection, ring by ring
Where the plane and the veins govern removal
- The protective arachnoid layers (T1-T3)
- Anterior and lateral inner ring (T1, T2)
- Pineal-region tumors (T3): mind the veins
- Intermediate ring (T4): the easiest class
- Straight sinus and outer ring (T5-T7)
- Feeder mapping of a midline tumor
- When the sinus is already blocked
Complications and takeaways
What keeps the patient safe
- Reducing the risks
- The operation in three ideas
- Key takeaways
- References (1/2)
- References (2/2)
- Neurosurgical Operative Atlas: Neuro-Oncology