Resección de meningioma clinoidal que rodea la arteria carótida: un procedimiento quirúrgico complejo y delicado

Demonstrate surgical techniques for anterior clinoidal meningioma through surgical video.

Video Display.

Two patients with anterior clinoidal meningioma underwent surgery, which went smoothly with satisfactory tumor resection and a good prognosis for the patients.

Surgery for anterior clinoidal meningiomas (CMs) can be daunting, especially encasing the internal carotid artery (ICA)[1]. In particular, the growth and infiltration of the tumor at the skull base with the involvement of optic nerves and the ICA are major impediments to radical tumor resection[2]. For these two patients, we have taken the following measures to ensure the smooth operation. First of all, the preoperative MR showed that there was obvious peritumoral brain edema in 2 cases. Peritumoral edema can come from venous compression or from vascular permeability and inflammation. We administered steroids to these two patients before the operation to reduce the edema caused by vascular permeability, so as to obtain more operative space during the operation. Secondly, we carefully drilled and flattened the sphenoid ridge using a high-speed drill, thereby obtaining a larger operative space. After flattening the sphenoid ridge, we cut the meningo-orbital band and detached the temporal fossa dura from the lateral wall of the cavernous sinus. We then drilled the lesser wing of the sphenoid bone and the roof of the orbital apex to a thin eggshell layer. Finally, we removed the remaining bone piece. The complete extradural drilling of the anterior clinoid process (ACP) was performed. It allows us to process the tumor base at the start of dissection rather than after partial resection. Thirdly, we conducted CTA and CTV examinations before surgery and did not observe abundant blood supply to the tumor. Additionally, studies have shown that CMs are predominantly fed by feeders from the supraclinoid ICA[3]. Embolization is deemed not feasible due to the ICA-dominant supply[4]. Therefore, in order to reduce the damage to patients, we did not perform DSA and preoperative embolization. In order to reduce intraoperative bleeding and clear surgical view. We prioritize dissecting the tumor base to reduce blood supply from dura. However, when preoperative CTA and CTV suggest that the tumor blood supply is abundant and there is external carotid artery (ECA) blood supply, we recommend preoperative DSA and embolization. Finally, the optic nerve, ICA and oculomotor nerve are relatively fixed in the skull base. Early exposure of these structures helps protect them from injury.