Resection of a Sphenoid Wing Meningioma

Hello my name is Marcus Czebanka. Today we are going to resect a left side sphenoid wing meningioma. You can see the images over here. It's a 43-year old patient that actually complained about short episodes of speech arrest as well as of oral-like symptoms that have been going on for almost 4 weeks because of this reason the patient received an MRI and the results you can see over there.

In order to resect this kind of tumor you need five steps. The first step of this os the approach and the craniotomy in order to reach this tumor we are going use a terioma approach. The second step would be identification of the tumor and devascularization of the tumor. The third step is preparation of the tumor margins and separation of the tumor margins from the surrounding brain and especially from the internal carotid artery that's very closely associated in this case. The fourth step then is removal of the tumor and the fifth step will be closing.

CHAPTER 1

So the first step now is skin incision for pataro craniotomy. We always use a combined skin muscle fat for this kind of approach. So we are not going to separate the muscle from a large area over the skin. Okay now let’s place the burr hole. So we always place it underneath the temporal we just use one burr hole. Okay now we’ve done the cuts for the craniotomy and we just have a remaining part on the sphenoid bone underneath and this we are going to drill. Now we are gonna flip the flap. Flip the flap, that’s a good way of saying it. Now we are going to flip the flap…

CHAPTER 2

Now we have finished the craniotomy we have the extension to the temporal bone and we also did resect part of the sphenoid vein. So now we are ready to go. And I think after draping we can switch to the microscope. Did you get the video last time? Yes. See I’m annoyed that it’s always oozing from down here. So there’s always some bleeding from down here. So I have to get rid of this.

So now we open the dura after we get hemostasis. So when we incise the dura we always watch the tip of the scissors so we make sure we don’t run into the brain. There we go. There’s the tumor already. Here you can see it. So what we’re going to do now is we’re going to try to get some CSF. The optic nerve is down here. So we drained CSF now to get some space. For this purpose, I am opening the optic cistern.

Okay, so down here is the optic nerve, this gives you good control of the medial aspect of the tumor. So now we are going to devascularize the tumor. There you go. So at the moment I am having trouble getting a clear border between the tumor and the brain. Now I’ve found the, now I’ve finally found the clear tumor border. Down here you can see the carotid artery. That’s the large brain supplying the artery.

Now we’ve made some progress. See, I wasn’t able to find a good entry zone into, for the border of the tumor and the brain. Now since we’ve found it, it’s getting much easier. Okay this we’ll take care of later. See now I’m approaching the circumferential preparation of the tumor borders. So once we have this posterior part I think we should be all set to take it out. Here the tumor is still sticking to the drill, so I’m trying to go through here and then we should be able to remove it on block. The most safe part to remove is definitely the temporal polar part of the tumor. So that’s what I chose as the first part I’m going to resect. So this is going to be the second part. So that’s the blood supply of the dura. This should coagulate. So that was, that was basically it.

Okay just to show, here again, we have the optic nerve and right next to it we have the internal carotid artery and down here you can see the oculomotor nerve. But everything’s okay. We have some arachnoid on it so there should not be a problem with these structures. Just to make sure we don’t have any remnants of the tumor. That would be a pity. Okay here you can see where the tumor was originating from. This we cannot resect. Therefore we coagulated, if I ever find the, to get a simpson grade 2 resection. So now we start closing the dura. We hope that it will close sufficiently. Sometimes the dura shrinks during surgery. Then we have trouble closing it.

CHAPTER 3

This we could do. That would be perfect. To discuss this surgery with a resident. Yea let’s do this. So this procedure overall went very well. We could resect the tumor without any problems. The surgery was quick and it was without any complications. In the beginning of the surgery when I tried to do step number three, which is separation of the tumor margins from the surrounding brain, I had some difficulties because the tumor was very much attached to the surrounding brain, but finally we did get a good plane to really dissect the tumor from the brain and therefore the surgery overall went quite quickly without any problems.