2025 Proffered Presentations
S216: SURGERY OF PERITORCULAR MENINGIOMAS WITH CONSERVATION OF THE SINUS ENDOTHELIAL LAYER: A CASE SERIES AND TECHNICAL NOTE
Anil Can, MD; Anna Brettler; Alice Giotta Lucifero; Ossama Al-Mefty; Brigham and Women's Hospital
Introduction: Owing to the potential high risk of perioperative complications, peritorcular meningiomas present a management challenge. Hence, the optimal surgical technique and the extent of resection remains a subject of debate. By recognizing the degree of tumor involvement of the torcular wall, based on the anatomical structure of the torcula, we describe 4 types of tumors which the surgeon could use to design a technique for maximum safe tumor removal. Herein, we present this technique as applied to a series of 12 peritorcular meningiomas of various WHO pathological grades.
Methods: Based on anatomical and pathological studies coupled with intraoperative observation, we describe 4 progressive steps in which meningiomas invade the torcular wall (Fig.1) .
In type I and II, the endothelium layer is not disrupted and the lumen remains intact, where the plane of resection can be carried out in the meningeal fibrous layer (Fig 2).
In type III and IV, the endothelial layer is disrupted and the tumor has penetrated the lumen, and attempt of resection might lead to grave consequences. The patients in this study were operated on by the senior author (OA) according to this paradigm.
Results: There were 12 patients with a torcular meningioma, 7 females and 5 males. The mean age at diagnosis was 51.2 years (range 33.0 – 61.0 years). Mean duration of follow-up was 77.9 months (range 3.0 – 150.0 months). The most common symptoms at presentation were paracentral scotoma (58.3 %), headache (50.0%), ataxia (33.3%) and seizures (25.0%). Gross total resection was obtained in 7 patients (63.6%). All patients who underwent subtotal resection were found to have penetrated the torcular endothelium layer into the lumen, and were also subsequently found to have higher-grade (WHO II and III) meningiomas. Four patients (33.3%) received postoperative radiation therapy for recurrent or residual high grade meningioma, and 3 patients (25.0%) needed underwent repeated surgery for recurrence.(Fig 3.)
Postoperative complications included wound infection in 2 patients with high grade meningioma. There was no surgical mortality, but one patient with an aggressive (grade III) meningioma died 29 months after surgery and radiation treatment due to disease progression.
Conclusions: Surgery plays a fundamental role in the primary treatment of peritorcular meningiomas. Gross total resection is achievable in types I and II, where the tumor has not penetrated the lumen and where the endothelial layer remains intact.