Abstract
Optimal vascular control during neurosurgical resection of large sub-frontal meningioma is hindered by limited early access to the ethmoidal arteries. Pre-operative ligation of the ethmoidal arteries 1) induces tumor necrosis simplifying resection and 2) minimizes blood loss and operative time. Early arterial ligation is an advantage of endoscopic approaches to transnasal resection of anterior skull base meningiomas that is not appreciated in open approaches with larger meningioma. Here we present a case of a colossal meningioma where minimally invasive pre-operative ligation of ethmoidal arteries prior to a traditional open surgical approach allowed for improved vascular control and decreased surgical time.
1
Introduction
Meningiomas are the most common benign tumor of the central nervous system, accounting for nearly a third of primary intracranial neoplasms. These are highly vascular tumors arising from the meninges of the central nervous system. As the majority of meningiomas are benign, gross total surgical resection offers definitive disease management .
The currently accepted methods for neurosurgical tumor resection of sub-frontal meningiomas are the frontal craniotomy and transnasal approaches. Transnasal meningioma resection offers a safe and less invasive approach to surgical resection; however, gross total resection with this approach may be limited by tumor size and extent. Larger meningiomas are amenable to frontal craniotomy for gross total resection, yet special consideration of vascular characteristics is necessary. Sub-frontal meningiomas are firm and enjoy ample vascular supply from the anterior and posterior ethmoid arteries. Frontal craniotomies for tumor resection provide limited early neurosurgical access to the ethmoidal arteries, thus significant operative blood loss accumulates throughout the course of a long and tedious operation .
Pre-operative ligation of anterior and posterior ethmoid arteries prior to resection of large sub-frontal meningioma offers a potential solution for management of the bleeding caused by limitations in surgical access to tumor arterial supply. Minimally invasive medial orbital approaches in the management of advance sino-orbital diseases are now well-described, and enable safe access to the ethmoid arteries . Application of a medial transconjunctival approach to pre-operative ligation of the anterior and posterior ethmoid artery prior to tumor resection allows for optimal control of operative bleeding. Here we report the case of a patient who underwent bilateral medial transconjunctival anterior and posterior ethmoid artery ligation prior to surgical resection for a colossal bifrontal meningioma.
2
Case report
2.1
History
A 59 year old female patient with acute onset mental status changes, severe hyperglycemia, hypernatremia, and diabetic ketoacidosis initially presented to the emergency department, where a computed tomography scan revealed a large intracranial sub-frontal extra-axial lesion with calcifications and mass effect causing anterior horn compression of the lateral ventricles. The lesion was radiographically consistent with a meningioma ( Fig. 1 A ). Examination of the patient revealed orientation to name, but not date or place, decreased attention span, and impaired concentration without other focal neurological deficits.
2.2
Operation
Bilateral anterior and posterior ethmoid artery ligation was performed via an endoscopic-assisted transcaruncular approach in anticipation of definitive surgery through a traditional bifrontal craniotomy. Anterior and posterior ethmoid arteries were clearly visualized with the use of the endoscope and ligation of the arteries was achieved with application of microvascular clips and bipolar cautery. Operative time was 1 h and 33 min. Estimated blood loss for this case was 10 mL.
Approximately 36 h later, the patient underwent a bifrontal craniotomy for tumor resection. The mass was noted to be devascularized. Gross total surgical tumor resection was achieved with a minimized operative time of 6 h and 27 min, 500 cc of estimated blood loss, and was without complications.
2.3
Post operative course
Post-operative recovery from bilateral ligation of ethmoid arteries was rapid and without complications, requiring no special care. The patient was post-operatively neurologically intact, without focal or visual deficits. She was able to maintain a normal post-craniotomy hospital course, and her altered mental status gradually improved throughout her hospital course. The patient was discharged home on post-operative day eight. Post-operative MRI of the brain revealed gross total tumor resection ( Fig. 1 B).
2.4
Pathology
Formalin-fixed, paraffin embedded sections showed a meningioma attached to dura without stellate geographic necrosis or brain invasion. Hypercellularity and small cell formation were focally recognized, but no eosinophilic macronucleoli or architectural pattern loss was found. Mitoses reached a maximum of 2 per 10 on high power microscopic fields, also falling below criteria for WHO grade II meningioma. MIB-1 cell cycle labeling performed on two different slides (including areas with hypercellularity) was 4%. Bony spicules adjacent to tumor were noted in several areas. Thus, the tumor did not fulfill criteria for an atypical meningioma, WHO grade II, based on cytoarchitectural features . Despite the preoperative interruption of circulation, no zonal necrosis was identified in the material submitted for pathological examination; consultation with the neurosurgeon divulged that only the more intact tumor was sent for permanent sections.
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