2021, 3(2):23-28 e-ISSN: 2674-7103
23
DOI: 10.37085/jmmv3.n2.2021.pp.23-28
Jornal Memorial
da
Medicina
© Copyright 2021
Case Report
Falcotentorial meningiomas: Optimal surgical planning and
intraoperative challenges – case report
Otávio da Cunha Ferreira Neto
1
, Pedro Lukas do Rêgo Aquino
2
, Marcelo Diniz de Menezes
3
,
Nilson Batista Lemos
4
, Bianca Domiciano Vieira Costa Cabral
5
, João Ricardo Caldas Pinheiro Pessôa
1
,
Andrey Maia Silva Diniz
5
, Armio José Araruna Dias
4
, Luís Felipe Gonçalves de Lima
4
,
Luiz Euripedes Almondes Santana Lemos
6
, Luiz Severo Bem Junior
4,6
, Nivaldo Sena de Almeida
6
,
Hildo Rocha Cirne Azevedo Filho
6
1
Catholic University of Pernambuco (UNICAP), Recife, PE, Brasil
2
University of Pernambuco (UPE), Recife, PE, Brasil
3
Faculdade Pernambucana de Saúde (FPS), Recife, PE, Brasil
4
College of Medical Sciences, Unifacisa University Center (UNIFACISA), Campina grande, PB, Brasil
5
Federal University of Paraíba (UFPB), João Pessoa, PB, Brasil
6
Department of Neurosurgery, Hospital da Restauração, Recife, PE, Brasil
Abstract
Meningiomas arising from the falcotentorial junction are rare, and selecting the optimal surgical
approach is essential. We report a 41-year-old man presented with progressive left paresis in
the lower limbs. A magnetic resonance image showed a solid mass inside the third ventricle
in contact with the falcotentorial dural junction. The tumor was removed by the transtentorial/
transfalcine occipital approach, performed with the patient in the three-quarter prone position.
The tumor was devascularized from the tentorium, then debulked and nally dissected. The
affected falx and tentorium were resected, but all of the patent dural venous sinuses were pre-
served. The tumor was a subtotal resect. Choosing the surgical approach is essential for the
safe and effective removal of an falcotentorial meningiomaand preoperative imaging analysis
should identify the tumor’s anatomical relations and guide toward the least disruptive route
that preserves the neurovascular structures. This article aims to report a successfully treated a
falcotentorial meningioma.
Otávio da Cunha Ferreira Neto
otaviocferreiraneto@gmail.com
Editado por
Juliana Ramos Andrade
Keywords:
Falcotentorial meningioma
Occipital transtentorial approach
Pineal region meningioma
Third Ventricle
Received: December 10, 2021
Accepted: December 29, 2021
24
ASAA
Ferreira Neto OCF, Aquino PLR, Menezes MD, Lemos NB, Cabral BDVC, Pessôa JRCP, Diniz AMS, Dias AJA, Lima LFG, Lemos LEAS, Bem Junior LS, Almeida
NS, Azevedo Filho RC
Falcotentorial meningiomas: Optimal surgical planning and intraoperative challenges – case report
Introduction
A
mong pineal region tumors, meningiomas are a rare
entity, corresponding to 2-8% of pineal tumors and 1%
of all intracranial meningiomas.
1-3
Guttmann described the
rst pineal meningioma in 1930.
4
These tumors originate
from the posterior portion of the
velum interpositum
or fal-
cotentorial union.
3
Falcotentorial meningiomas (FTM), as with other pineal
region tumors, are prevalent more in females.
3
These tumors
can present a different relationship with vital neuroanato-
mical structures; therefore, it is essential to decide the ideal
surgical approach. It is often difcult to discriminate betwe-
en FTM and
velum interpositum
meningiomas, even after
signicant advances in neuroimaging.
3
However, arterial
irrigation is the main difference between these two groups
of tumors. The tentorial branches of the meningohypo-
physeal trunk usually supply FTMs, while branches of the
posterior choroidal arteries irrigate velum interpositum
meningiomas.
3-6
The surgical treatment of these tumors is
not well established in literature since there are two main
controversial issues. Firstly, concerning validating criteria
for selecting the optimal surgical approach, and secondly,
whether the main inltrated venous structures can be sacri-
ced to obtain a radical resection of the tumor or whether
they should be preserved.
6
We report an FTM case approached by occipito-trans-
tentorial access and subtotal tumor resection presenting a
satisfactory clinical outcome.
Case Report
A 41-year-old man, with no signicant medical history, was
admitted with progressive paresis in the left lower limb, whi-
ch started one year earlier and deteriorated in the nal 3
months and no other neurological alterations were found. A
computed tomography (CT) scan revealed a solid mass in the
pineal region, causing hydrocephalus. A ventricle-peritoneal
shunt was performed as a primary hydrocephalus treatment.
Posteriorly, brain magnetic resonance imaging (MRI) showed
a solid mass inside the third ventricle in contact with the
falcotentorial dural junction, 42 x 43 x 38 mm in diameter,
hypointense in T1 and slight hyperintense in T2 sequences,
with diffusion restriction and enhancement post gadolinium
(Figure 1). It was minimally lateralized to the right side, with
inferior displacement of the deep venous complex of Galen.
Figura 1. Preoperative axial T1 (A), sagittal T2 (B) and coronal
(C) T2 MR images showing the pineal region meningioma, 42 x
43 x 38 mm in diameter, hypointense in T1 and hyperintense in
T2 sequences, with the deep venous system displaced inferiorly.