PMC9063020_01
First Surgery: MR and pathological findings. Preoperative T2-weighted MR shows a mass at C2/C3 with cord compression (a: Sagittal and b: Axial). Postoperative T2-weighted MR shows a tumor in the spinal canal that was removed, but there is a residual C2/3 foraminal tumor (white arrow heads) (c: Sagittal and d: Axial). Transitional meningioma (Grade 1) was diagnosed with an aggregation of meningothelial cells with pink cytoplasm, short spindle-shaped cells, and psammoma bodies. Mib-1 index was less than 2% (e-g).
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F1
She had undergone resection of a cervical meningioma 6 years before [Figure 1].
Six years later, preoperative MR and angiography of the recurrent tumor encasing the right VA. A T2-weighted MR shows the recurrent meningioma from C1 to C4 (a). The T1-weighted enhanced MR shows the recurrent tumor in the spinal canal extending through the right-sided foramina of C1/C2 and C3/C4 (b-g). Right vertebral angiography shows the tumor is fed by radicular arteries (h and i). The pedicle screws were placed at the bilateral C2, right C3, and bilateral C4 levels. The right vertebral artery was embolized (j and k).
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F2
Now, the cervical MR showed a recurrent tumor on the right side between the C1/2 to C4/5 levels, with extradural extension into the right C2/3 and C3/4 foramina where it encased the right VA [Figures 2a-g].
Surgery Part 1: Resection of the intradural recurrent tumor between the C1-C5 levels. The intradural meningioma was laterally detached from the dura (a and b). The caudal margin of the tumor involving the C5 nerve root (c). The tumor was then medially detached from the spinal cord (d). The right C2 nerve root was the cranial margin of the meningioma (e). The intradural meningioma was then removed (f). Ca: Caudal, Cr: Cranial, Rt: Right.
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F3
This required drilling/excision of the right lateral masses of C2, C3, and C4 [Figure 3].
Surgery Part 2: Removal of the extradural recurrent tumor. The lateral masse of C2/C3 and C3/C4 were drilled, allowing for exposure of the extradural meningioma in the C3 nerve sheath (a). Removal of the extradural meningioma was initiated (b). The embolized VA was identified (c). The extradural meningioma lateral to the foramen of C3 was removed along the VA (d and e). However, bleeding occurred around the VA when the extradural tumor was removed at the C4 level (black arrows) (f). Ca, Caudal; Cr, Cranial; Rt, Right; VA, Vertebral artery.
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F4
The procedure was immediately aborted because continuing the removal procedure could result in bleeding complications [Figure 4].
Surgery Part 3; final removal of the extradural recurrent tumor. Residual meningioma at the C2 (a) and C4 levels were removed (b and c). The residual meningioma in the foramen of C4 was curetted (d). The extradural meningioma was then grossly and totally removed, following which a duraplasty was performed (e and f). Ca: Caudal, Cr: Cranial, Rt: Right.
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F5
During the second surgery, the residual extradural meningioma located between the C2 to C4 levels was removed [Figure 5].
Postoperative MR images. Postoperative T2-weighted magnetic resonance images reveal gross total removal of the regrowth meningioma (a: Sagittal and b-g: Axial).
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F6
Ten months later, the postoperative MR documented no tumor regrowth [Figure 6].