2021, 3(2):23-28 e-ISSN: 2674-7103

DOI: 10.37085/jmmv3.n2.2021.pp.23-28

Jornal Memorial

Medicina

Case Report

Falcotentorial meningiomas: Optimal surgical planning and

intraoperative challenges – case report

Otávio da Cunha Ferreira Neto

, Pedro Lukas do Rêgo Aquino

, Marcelo Diniz de Menezes

Nilson Batista Lemos

, Bianca Domiciano Vieira Costa Cabral

, João Ricardo Caldas Pinheiro Pessôa

Andrey Maia Silva Diniz

, Artêmio José Araruna Dias

, Luís Felipe Gonçalves de Lima

Luiz Euripedes Almondes Santana Lemos

, Luiz Severo Bem Junior

4,6

, Nivaldo Sena de Almeida

Hildo Rocha Cirne Azevedo Filho

Catholic University of Pernambuco (UNICAP), Recife, PE, Brasil

University of Pernambuco (UPE), Recife, PE, Brasil

Faculdade Pernambucana de Saúde (FPS), Recife, PE, Brasil

College of Medical Sciences, Unifacisa University Center (UNIFACISA), Campina grande, PB, Brasil

Federal University of Paraíba (UFPB), João Pessoa, PB, Brasil

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

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

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.

These tumors originate

from the posterior portion of the

velum interpositum

or fal-

cotentorial union.

Falcotentorial meningiomas (FTM), as with other pineal

region tumors, are prevalent more in females.

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.

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.

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

43 x 38 mm in diameter, hypointense in T1 and hyperintense in

T2 sequences, with the deep venous system displaced inferiorly.

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

The patient underwent a transtentorial/transfalcine occipital

surgical approach in a three-quarter prone position. The pa-

tient’s head was slightly elevated to 15 degrees in relation to

the oor and turned 60 degrees toward the oor (Figure 2).

The tumor was larger on the right side, and that side was

chosen for a surgical approach. Firstly, the tumor was de-

vascularized from the tentorium, then debulked and nally

dissected. The affected falx and tentorium were resected,

but all the patent dural venous sinuses were preserved. The

tumor underwent a subtotal resection (Figure 3).

Figura 2. Transtentorial/transfalcine occipital surgical approach in three/quarter prone position and the patient head xed in Mayeld.

Figura 3. A. Opening of the interhemispheric ssure through the right transtentorial/transfalcine occipital approach; B. Interhemis-

pheric retraction reveals the tumor in a posterior incisural space; C-D. Tumor devascularization from the tentorium and resection; and

E. Operative cavity. (Continued on next page)

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

The patient presented superior temporal homonymous qua-

drantanopia in the immediate postoperative period and

after permanently. The post-surgery CT revealed hypoin-

tense imaging in occipital-parietal artery supply region,

suggesting ischemia and a small pneumocephalus (Figure

4). The patient is under ambulatory follow-up in the last

three months, without other neurological symptoms. After,

an anatomopathologic study demonstrated a WHO grade

I meningothelial meningioma.

Figura 4. The post-surgery computed tomography revealing surgical

complications.

Discussion

FTMs occurs mostly in patients between 42-56 years old as

well as the posterior fossa meningiomas.

Previously studies

revealed headaches as the most common symptom in pineal

region meningiomas (60 to 100% of the cases), followed by

ataxia (43 to 62%), personality changes and bradypsychia

(37 to 46%) with homonymous hemianopia (20 to 46%).

Ataxia is the most frequent late symptom in type I and II

tumors. Personality changes and bradypsychia were mostly

associated on obstructive hydrocephalus cases.

Neverthe-

less, bilateral visual acuity deterioration due to progressive

papilledema and the following atrophy of the optic nerve

is extremely rare.

In 2008, Bassiouni et al. classied FMTs tumors according

to tumor base location and included four types.

In our

case, the FTM originated from the posterior cerebral falx

and displaced the venous system inferiorly, type I by the

Boussioni classication.

Regarding surgical treatment, comprehending the rela-

tionship between meningiomas of the pineal region and

the deep venous system is decisive for better results. Invasive

tumor degree or the permeability of the vein of Galen and

the straight sinus and the displacement of these vessels are

relevant points in view of the tumor’s mass effect.

7,9

The vein of Galen and straight sinus occlusion and invasion

were described in preoperative angiographic studies; con-

sequently, the development of a secondary collateral venous

drainage is frequently found.

7-9

It can be explained because

the posterior half of the vein of Galen and the anterior half of

the straight sinus is mostly the rst vessels affected by menin-

giomas and are not related to the tumor’s growth direction.

Identifying vessel occlusion and the secondary collateral

venous drainage is essential to evaluate the optimal FTMs

surgical planning.

7,8

Many authors have proposed that the

displacement of the deep venous system due to tumor growth

direction is the most important characteristic when deci-

ding the surgical approach.

1,2,4,6

Therefore, Type I of FTMs

displace the venous complex inferiorly, type II superiorly,

type III medially (supero-/inferomedial), and type IV to the

contralateral side of the meningioma.

FTMs surgical objective is to achieve a macroscopically

complete resection of the lesion, to relieve or solve the neu

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

rologic/clinical symptoms, and to acquire a tissue sample

for a denitive diagnosis. Therefore, the recommendation to

perform an intraoperative biopsy is established, paving the

way to obtaining a differential diagnosis from other pineal

tumors (e.g., germinoma) for which the management may be

different toward a partial resection after adjuvant therapy.

Classically, for preoperative artery embolization is an im-

portant adjuvant treatment for meningioma. However, most

FTMs present short artery caliber, which can difcult preo-

perative artery embolization.

The anatomical relation between the tumor and the deep

venous complex of Galen is the most important factor when

choosing the surgical approach. Some surgical approaches

are described for these tumors: transtenrotial/transfalcine

occipital approach, supracerebellar infratentorial approach,

occipital bitranstentorial/falcine approach and anterior

interhemispheric transsplenial approach.

Transtentorial/Transfalcine Occipital Approach. It was used

in our case, and it is the most frequently used for pineal

meningiomas. This approach is more specically advised

in type I and IV FTMs, which originate from posterior falx

immediately above the vein of Galen and straight sinus junc-

tion. In this location, the tumor’s growth displaces posterior

and inferiorly the deep venous complex.

This approach is used to reach tumors with a mostly su-

pratentorial and a smaller infratentorial extension. The

occipital lobe is also gravity-dependent positioned bearing

the largest component of the tumor. In this present case, we

consider this information to be an important feature in our

surgical approach choice. However, this surgical approach

has some disadvantages such as an increased risk of visual

cortex damage (due to cortex retraction), possible trochlear

nerve damage at the tentorial opening and a limitation of

the contralateral view of the tumor margin.

Conclusion

The selection of an optimal surgical approach is essential

for the safe and effective removal of an FTM. Preoperative

imaging analysis should identify the tumor’s anatomical

relations and guide the least disruptive route that preserves

the neurovascular structures. This article aims to report a

successfully treated FTM at our service and to serve as a

literary review. Subtotal resections appear to reduce severe

neurological decit rates, thus, being benecial in most

cases such as ours.

Otávio da Cunha Ferreira Neto

https://orcid.org/0000-0003-0517-0212

Pedro Lukas do Rêgo Aquino

https://orcid.org/0000-0002-1244-8641

Marcelo Diniz de Menezes

https://orcid.org/

Nilson Batista Lemos

https://orcid.org/0000-0002-2331-6871

Bianca Domiciano Vieira Costa Cabral

https://orcid.org/0000-0001-7725-0524

João Ricardo Caldas Pinheiro Pessôa

https://orcid.org/0000-0002-0612-6478

Andrey Maia Silva Diniz

https://orcid.org/0000-0002-5572-7018

Artêmio José Araruna Dias

https://orcid.org/0000-0002-3565-0586

Luís Felipe Gonçalves de Lima

https://orcid.org/0000-0002-0130-0625

Luiz Euripedes Almondes Santana Lemos

https://orcid.org/0000-0001-5334-004X

Luiz Severo Bem Junior

https://orcid.org/0000-0002-0835-5995

Nivaldo Sena de Almeida

https://orcid.org/

Hildo Rocha Cirne Azevedo Filho

https://orcid.org/0000-0002-1555-3578

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