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Multistaged, multidirectional strategy for safe removal of large meningiomas in the pineal region
Abstract:
OBJECTIVE Pineal region meningiomas are rare and tend to be discovered only after they grow. Several simultaneous multidirectional approaches performed as a single operation have been proposed, but the best strategy to remove these deeply situated large meningiomas involving the deep vital venous system remains to be established. The authors advocate a multistaged, multidirectional approach to safely remove these challenging tumors. METHODS Four consecutive cases of meningioma in the pineal region were treated between April 2013 and June 2016. The 3 large (> 40 mm diameter) tumors were removed via multistaged, multidirectional approaches (2 surgeries in 2 patients and 3 surgeries in 1 patient) with gravity retraction of the occipital or parietal lobe. The large occipital skin incision extending bilaterally was used for the next operation from the contralateral side. Combinations of the occipital transtentorial approach with or without the transfalcine approach, occipital bitranstentorial/falcine approach, combined supra-/infratentorial transsinus approach, and contralateral parietal interhemispheric transcallosal approach were used. RESULTS Transient visual field deficits occurred after 2 of the 8 operations, but all tumors were removed grossly or subtotally without permanent surgery-related morbidity. The galenic venous system and straight sinus remained intact in all patients. During the follow-up period (mean 29.5 months [range 13-52 months]), there were no recurrences after the final operation. CONCLUSIONS A multistaged, multidirectional strategy with an intentional large occipital scalp incision and gravity retraction of the occipital lobe is a good choice for the safe removal of large meningiomas in the pineal region.
Insights
A multistaged, multidirectional surgical approach is effective for removing large pineal region meningiomas. This strategy ensures safe tumor removal while preserving vital venous structures, with no recurrences observed during follow-up.
Area of Science:
- Neurosurgery
- Oncology
- Neuropathology
Background:
- Pineal region meningiomas are rare, deeply situated tumors.
- Large meningiomas pose significant surgical challenges due to their location and involvement of vital venous systems.
- Optimal surgical strategies for these complex tumors are still under investigation.
Purpose of the Study:
- To advocate for and evaluate a multistaged, multidirectional surgical approach for large pineal region meningiomas.
- To assess the safety and efficacy of this strategy in achieving gross or subtotal tumor removal.
- To determine the impact on vital venous structures and long-term recurrence rates.
Main Methods:
- Retrospective analysis of four consecutive cases of large pineal region meningiomas treated between April 2013 and June 2016.
- Utilized multistaged, multidirectional surgical approaches, including occipital transtentorial, transfalcine, supra-/infratentorial transsinus, and contralateral parietal interhemispheric transcallosal techniques.
- Employed gravity retraction of the occipital/parietal lobe and a bilateral occipital skin incision for staged contralateral access.
Main Results:
- Gross or subtotal tumor removal was achieved in all cases without permanent surgery-related morbidity.
- Transient visual field deficits occurred postoperatively in two instances, resolving without lasting deficits.
- The galenic venous system and straight sinus remained intact in all patients.
- No tumor recurrences were observed during a mean follow-up of 29.5 months.
Conclusions:
- A multistaged, multidirectional surgical strategy is a safe and effective option for large pineal region meningiomas.
- The technique, incorporating gravity retraction and staged contralateral access, facilitates complete tumor resection while protecting critical neurovascular structures.
- This approach offers a viable solution for managing these challenging intracranial tumors with favorable long-term outcomes.
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