Supracerebellar Transtentorial Approach for Occipital Meningioma to Maximize Visual Preservation: Technical Note

Abstract

BACKGROUND AND IMPORTANCE Surgery for resection of tentorial meningiomas compressing primary visual cortex carries a significant risk of worsening vision. This concern is especially acute in patients with a preexisting visual deficit. Approaches that involve mechanical retraction of the occipital lobe further threaten visual function. The supracerebellar transtentorial (SCTT) approach, which does not carry a risk of occipital retraction injury, should be considered for patients with occipital tentorial meningiomas to maximize functional visual outcomes. CLINICAL PRESENTATION A 54-yr-old woman underwent 2 resections and radiation therapy for a right occipital oligodendroglioma as a teenager. She was left with a complete left homonymous hemianopsia. The patient now presented with progressive vision loss in her remaining right visual field. Imaging revealed a left occipital superiorly projecting tentorial meningioma. To preserve her remaining visual function the SCTT approach was chosen for resection. A Simpson grade 1 removal was achieved without disrupting the occipital lobe pia or requiring mechanical cerebellar retraction. A diagnosis of a WHO grade II meningioma (presumably radiation induced) was made. The patient's vision returned to premorbid baseline 1 wk after surgery. CONCLUSION The SCTT approach should be considered for the surgical management of patients with occipital tentorial meningiomas when visual preservation is at risk. This approach avoids transgression of visual cortex and minimizes the risk of venous infarction or contusions from retraction injury.

Clip retraction of the tentorium: application of a novel technique for tentorial retraction during supracerebellar transtentorial approaches

“…Because of their advantages over transcortical approaches, SCTT approaches are becoming more common for the treatment of pathologic conditions in the posterior thalamus and medial temporooccipital space. Previous studies have characterized the use of either SCTT or occipital transtentorial approaches for the microsurgical resection of meningiomas, 4,6,16 CMs, 8-10 epidermoid cysts, 17 and other pathologic conditions. 11,12,18,19 Compared with transcortical routes, transtentorial approaches provide excellent anatomical exposure without traversal of eloquent cortex or retraction of parenchyma.…”

“…Recently, supracerebellar transtentorial (SCTT) approaches have become a popular option for treatment of a variety of pathologic conditions in the medial and basal temporal and occipital lobes. [4][5][6] Lesions such as meningiomas, 7 gliomas, cavernous malformations (CMs), [8][9][10] and arteriovenous malformations 11,12 have been removed through posterior approaches through the tentorium, often with the use of the sitting position and gravity retraction of the cerebellum to widen the supracerebellar space and extend the upward reach beyond the tentorium. We and others have found this strategy useful for the treatment of thalamic pathologic entities that abut the posterior-inferior surface of the pulvinar.…”

“…8,9,15 Numerous techniques for retraction of the incised tentorium have been described, including sutures, fixed retractors, and electrocautery. 4 However, to our knowledge, no one has adapted the technique described by Hernesniemi et al 3 for obtaining subtemporal exposures to attaining SCTT exposures. In this paper, we describe the novel application of clip retraction of the tentorium to obtain a supracerebellar approach in a case of a right posterior medial temporal lobe CM resection.…”