2021, 3(2):23-28 e-ISSN: 2674-7103

DOI: 10.37085/jmmv3.n2.2021.pp.23-28

Jornal Memorial

Medicina

Case Report

Falcotentorial meningiomas: Optimal surgical planning and

intraoperative challenges – case report

Otávio da Cunha Ferreira Neto

, Pedro Lukas do Rêgo Aquino

, Marcelo Diniz de Menezes

Nilson Batista Lemos

, Bianca Domiciano Vieira Costa Cabral

, João Ricardo Caldas Pinheiro Pessôa

Andrey Maia Silva Diniz

, Artêmio José Araruna Dias

, Luís Felipe Gonçalves de Lima

Luiz Euripedes Almondes Santana Lemos

, Luiz Severo Bem Junior

4,6

, Nivaldo Sena de Almeida

Hildo Rocha Cirne Azevedo Filho

Catholic University of Pernambuco (UNICAP), Recife, PE, Brasil

University of Pernambuco (UPE), Recife, PE, Brasil

Faculdade Pernambucana de Saúde (FPS), Recife, PE, Brasil

College of Medical Sciences, Unifacisa University Center (UNIFACISA), Campina grande, PB, Brasil

Federal University of Paraíba (UFPB), João Pessoa, PB, Brasil

Department of Neurosurgery, Hospital da Restauração, Recife, PE, Brasil

Abstract

Meningiomas arising from the falcotentorial junction are rare, and selecting the optimal surgical

approach is essential. We report a 41-year-old man presented with progressive left paresis in

the lower limbs. A magnetic resonance image showed a solid mass inside the third ventricle

in contact with the falcotentorial dural junction. The tumor was removed by the transtentorial/

transfalcine occipital approach, performed with the patient in the three-quarter prone position.

The tumor was devascularized from the tentorium, then debulked and nally dissected. The

affected falx and tentorium were resected, but all of the patent dural venous sinuses were pre-

served. The tumor was a subtotal resect. Choosing the surgical approach is essential for the

safe and effective removal of an falcotentorial meningiomaand preoperative imaging analysis

should identify the tumor’s anatomical relations and guide toward the least disruptive route

that preserves the neurovascular structures. This article aims to report a successfully treated a

falcotentorial meningioma.

Otávio da Cunha Ferreira Neto

otaviocferreiraneto@gmail.com

Editado por

Juliana Ramos Andrade

Keywords:

Falcotentorial meningioma

Occipital transtentorial approach

Pineal region meningioma

Third Ventricle

Received: December 10, 2021

Accepted: December 29, 2021

ASAA

Ferreira Neto OCF, Aquino PLR, Menezes MD, Lemos NB, Cabral BDVC, Pessôa JRCP, Diniz AMS, Dias AJA, Lima LFG, Lemos LEAS, Bem Junior LS, Almeida

NS, Azevedo Filho RC

Falcotentorial meningiomas: Optimal surgical planning and intraoperative challenges – case report

Introduction

mong pineal region tumors, meningiomas are a rare

entity, corresponding to 2-8% of pineal tumors and 1%

of all intracranial meningiomas.

1-3

Guttmann described the

rst pineal meningioma in 1930.

These tumors originate

from the posterior portion of the

velum interpositum

or fal-

cotentorial union.

Falcotentorial meningiomas (FTM), as with other pineal

region tumors, are prevalent more in females.

These tumors

can present a different relationship with vital neuroanato-

mical structures; therefore, it is essential to decide the ideal

surgical approach. It is often difcult to discriminate betwe-

en FTM and

velum interpositum

meningiomas, even after

signicant advances in neuroimaging.

However, arterial

irrigation is the main difference between these two groups

of tumors. The tentorial branches of the meningohypo-

physeal trunk usually supply FTMs, while branches of the

posterior choroidal arteries irrigate velum interpositum

meningiomas.

3-6

The surgical treatment of these tumors is

not well established in literature since there are two main

controversial issues. Firstly, concerning validating criteria

for selecting the optimal surgical approach, and secondly,

whether the main inltrated venous structures can be sacri-

ced to obtain a radical resection of the tumor or whether

they should be preserved.

We report an FTM case approached by occipito-trans-

tentorial access and subtotal tumor resection presenting a

satisfactory clinical outcome.

Case Report

A 41-year-old man, with no signicant medical history, was

admitted with progressive paresis in the left lower limb, whi-

ch started one year earlier and deteriorated in the nal 3

months and no other neurological alterations were found. A

computed tomography (CT) scan revealed a solid mass in the

pineal region, causing hydrocephalus. A ventricle-peritoneal

shunt was performed as a primary hydrocephalus treatment.

Posteriorly, brain magnetic resonance imaging (MRI) showed

a solid mass inside the third ventricle in contact with the

falcotentorial dural junction, 42 x 43 x 38 mm in diameter,

hypointense in T1 and slight hyperintense in T2 sequences,

with diffusion restriction and enhancement post gadolinium

(Figure 1). It was minimally lateralized to the right side, with

inferior displacement of the deep venous complex of Galen.

Figura 1. Preoperative axial T1 (A), sagittal T2 (B) and coronal

43 x 38 mm in diameter, hypointense in T1 and hyperintense in

T2 sequences, with the deep venous system displaced inferiorly.