PMC4392537_01
Axial (a) and coronal (b) contrast-enhanced T1-weighted MRI demonstrates tumor encasing the posterior portion of the superior sagittal sinus extending into the torcula. Abnormal thickening of the posterior scalp is seen. (c) Axial T2-weighted MRI sequence demonstrates abnormal hyperintensity in the white matter of the occipital lobe consistent with vasogenic edema from parenchymal tumor invasion. (d) Sagittal view of contrast-enhanced CT scan, bone window, shows that the occipital bone is both hyperostotic and thickened from tumor infiltration
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F1
Magnetic resonance imaging and magnetic resonance angiography (MRI/MRA) of his brain demonstrated an 11 x 5-cm mass that extended both supra- and infratentorially and into the bilateral parietal and occipital lobes, the superior sagittal sinus, the torcula, and the proximal transverse sinuses [Figure 1].
Lateral view cerebral angiogram after left internal carotid artery injection. The posterior skull/extra-axial tumor invades and occludes 7 cm of the posterior superior sagittal sinus, torcula, and proximal transverse sinus (black arrows). There is reconstitution at the distal transverse sinuses. Deep venous drainage occurs via an occipital sinus that connects the straight sinus to the left jugular bulb (white arrow)
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F2
Cerebral angiography revealed lack of flow through portions of the superior sagittal sinus, torcula, and proximal transverse sinuses [Figure 2]. Deep venous drainage proceeded via an occipital sinus [Figure 2] and cortical venous drainage via enlarged veins of Labbe [Figure 3].
Anteroposterior (a) and lateral projection (b) cerebral angiogram depicting the venous phase of a right internal carotid artery injection. Cortical venous drainage proceeds via a dilated vein of Labbe (black arrows)
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F3
Deep venous drainage proceeded via an occipital sinus [Figure 2] and cortical venous drainage via enlarged veins of Labbe [Figure 3].
Pre (a)- and post (b)-embolization images of the left external carotid artery injection. Main arterial feeders include branches of the occipital (black arrows) and middle meningeal arteries (white arrows), which were successfully embolized. Arterial feeders were also embolized from similar branches of the right external carotid artery (not shown). (c) Right vertebral artery injection depicting a posterior meningeal artery branch arising from the posterior inferior cerebellar artery and feeding the meningioma. This branch was not embolized
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F4
The tumor was hypervascular, with its major arterial supply from meningeal branches of the external carotid arteries (ECAs) and the posterior inferior cerebellar arteries [Figure 4]. Prior to surgery, the ECA tumor feeding vessels were embolized with coils and polyvinyl alcohol particles [Figure 4].
Intraoperative photographs depicting (a) extension of the meningioma from the bone to scalp; (b) use of neuronavigation to identify the margin of venous sinuses for ligation; (c) dissection of tumor that has invaded the pia and into the occipital lobe; (d) gross resection of the tumor and its dural attachment; (e) primary repair of the torcula suture after the intrasinusal tumor portions are removed; (f) duroplasty and overlying titanium mesh cranioplasty prior to placement of latissimus dorsi free flap
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F5
The tumor was dissected from the underlying brain using standard microsurgical technique [Figure 5].
Postoperative radiographs of latissimus dorsi free flap with split-thickness skin graft immediately after surgery (a) and at 3 months (b)
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F6
The muscle was inset over closed suction drains and then covered with a split thickness skin graft [Figure 6].
Coronal contrast-enhanced T1-weighted MRI at 18 months depicts gross-total resection of the transosseous meningioma with no evidence of recurrence or regrowth
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F7
Routine follow-up MRI at 18 months demonstrated no evidence of recurrence or regrowth [Figure 7].