Resection of Giant Invasive Parasagittal Atypical Meningioma With a Venous Graft Reconstruction of the Sagittal Sinus: 2-Dimensional Operative Video

Abstract

Parasagittal meningioma becomes challenging when it involves the sagittal sinus and frequently invades the skull1; hence, resection of the invasive bone and management of the involved sinus are the two crucial issues in these tumors; notwithstanding the practice of conservative surgical resection coupled with irradiation (radiosurgery or stereotactic radiotherapy),2 radical surgical removal, including the invaded bone and sinus (Simpson grade I), alleviates recurrences. It is more valuable and particularly recommended in grade II meningiomas,3 since radical surgery is the principal factor in a long control of grade II meningioma4 and radiation effectiveness is directly related to gross total removal.5 On the other hand, removal of tumor involving the sinus and sinus reconstruction has been recommended and practiced for years.6-10 When the sinus is occluded, preservation of the collateral venous drainage becomes paramount.11 If the collateral venous drainage included cutaneous and dural channels, as in this patient, reconstructing of the sinus would become preventative of a major venous complication. Sindou et al8 even advocate the routine reconstruction of occluded sinus to minimize morbidity. The patient is 39 yr old with a giant parasagittal meningioma that invaded the skull, occluded the sinus at the mid-third, and had venous collateral through the dura and cutaneous veins. He underwent radical resection with reconstruction of the sinus by saphenous vein graft. Patient consented for the operation and publication of images. Illustrations at 1:51 and 2:15 from Al-Mefty O, Operative Atlas of Meningiomas, © LWW, 1997, with permission.