PMC9968800_01
Radiological evaluation of the retrosellar lesion preoperatively. (A) Preoperative CT image showing a hyperdense lesion on the right-sided of posterior clinoid process. (B-E) Post-contrast (gadolinium-enhanced) axial (B), sagittal (C), and coronal (D, E) MRI images showing the thick enhancement of the lesion as well as the relative position to surrounding neural structures. (F) Preoperative CT angiography images demonstrating the relative location of tumor to the Willis' circle and the dorsum sellae. The yellow arrows denote the posterior bend of caveronous carotid artery. The red arrow indicates the posterior cerebral artery. The white arrow denotes the up-elevated right optic chiasma. The green arrow indicates the pituitary stalk. The blue arrow indicates the dural detachment of the tumor on the posterior clinoid process.
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The mass grew into the ambient cistern, lying medially close to the medial temporal lobe and displacing the midbrain posteriorly ( Figure 1A ). Magnetic resonance imaging (MRI) examinations showed a homogeneously enhancing tumor centering over the PCP ( Figures 1B-E ). On CT angiography, the tumor was displacing the ICA anteriorly and encasing the right P1 segment of posterior cerebral artery posteriorly ( Figure 1F ). Owing to the mass effect, the right-sided optic chiasma was up-elevated and the pituitary stalk (PS) was slightly displaced to the contralateral side ( Figure 1E ).
Surgical procedure and nuances of the EF-SCITA approach for resection of posterior clinoid meningioma. (A) Endoscopic explorations in the lateral supracerebellar infratentorial space and the exposure of CN IV after opening the arachnoid in the ambient cistern. (B) The exposure of the infratentorial part of the tumor in the ambient cistern after incision of the tentorium cerebelli. (C) The exposure of the supratentorial tumor after up-elevating the tentorium cerebelli. (D) The exposure of the PCA and CN III as well as the supratentorial tumor after debulking of the infratentorial tumor. (E) Dissection of the supratentorial tumor from the ICA and the initial part of BV and the exposure of DS during tumor resection. (F) The exposure of PCP after total tumor removal. BV, basal vein of Rosenthal (the initial part); Cer., cerebellum; CN III, oculomotor nerve; CN IV, trochlear nerve; CN V, trigeminal nerve; DS, dorsum sellae; ICA, internal carotid artery; MTL, medial temporal lobe; PCA, posterior cerebral artery; PCP, posterior clinoid process; Ped., pedunculus cerebri; PS, pituitary stalk; SPV, superior petrosal vein; Tent., tentorium cerebelli. The black asterisks indicate the supratentorial part of the tumor, the white asterisk denotes the infratentorial part of the tumor, and the yellow asterisks indicate the arachnoid in the ambient cistern.
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The surgical position, together with intraoperative drainage, facilitated endoscopic explorations in the lateral superior cerebellar space ( Figure 2A ). The tumor was found to encase and compress the CN IV towards the tentorial incisura ( Figure 2B ). ICA and the initial part of the basal vein (BV) in front, which were carefully dissected from the tumor ( Figure 2E ). Intraoperatively, the tumor was grayish, soft, and moderately vascular. Finally, its dural attachment could be detected at the right PCP and adjacent petrous apex, which was coagulated under direct vision ( Figure 2F ).
Radiological and pathological evaluation of the lesion postoperatively. (A-C) Postoperative post-contrast axial (A), sagittal (B), and coronal (C) MRI scans performed one month after surgery showing total removal of the lesion. (D) Photomicrograph of hematoxylin-eosin staining showing typical features of meningothelial meningioma. (E) Physical examinations at one month follow-up indicating no limitation in eye movements.
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Postoperative MRI demonstrated complete excision of the lesion ( Figures 3A-C ). Histopathological examinations demonstrated findings consistent with a meningioma of meningothelial type ( Figure 3D ). The patient on follow-up at 1 month had improvement in visual acuity (0.8) in right eye, with no restriction of extra-ocular movements observed ( Figure 3E ).