2026 Poster Presentations
P128: SEQUENTIAL EXTRADURAL AND INTRADURAL DEVASCULARIZATION OF ANTERIOR AND MIDDLE FOSSA MENINGIOMAS - AN ANATOMICAL AND SURGICAL SUCCESSIVE APPROACH BASED ON PREDICTABLE LANDMARKS
Stephen F Shafizadeh, MD, PhD1; Adedamo Adepoju, MD2; 1Arrowhead Regional Medical Center; 2Integris Health Baptisit Medical Center
INTRODUCTION: Anterior and middle fossa meningiomas account for one third of all intracranial meningiomas. Based on the primary site of dural attachment, anterior cranial fossa meningiomas can be further subclassified into; olfactory groove, planum sphenoidale, tuberculum sellae, falcine and parafalcine, and convexity. Similarly, middle fossa meningiomas can be further subclassified into; outer (lateral) and medial sphenoid wing, clinoidal, cavernous sinus, suprasellar, Meckel’s cave, petrous ridge and tentorium, and lateral convexity. A critical step in the planned removal of anterior and middle fossa meningiomas is devascularization. Devascularization can offer decreased blood loss, improved visualization, safer and more extensive resection, and reduced surgical time.
METHODS: There needs to be a clear anatomic and sequential microdissection strategy and understanding of the most common extradural and intradural arterial supplies to these tumors as well as safe surgical corridors to access such supply to optimize devascularization while simultaneously minimizing risk to surrounding parenchyma and cranial nerves. We review the predictable anatomic localization of relevant bony landmarks and cranial nerves [CN I, II, III, IV, V1-V2-V3, AND VI] as contributing reliable surgical markers for the aforementioned arterial supply to these tumors and the surgical sequence of dissection of these structures to maximize devascularization and minimize ischemic and other sequalae. Cadaveric dissections were performed to depict the surgical localization and safe corridors to these structures. These cadaveric dissections were then supported by surgical photos and videos.
RESULTS: The most common arterial supply to anterior cranial fossa meningiomas are; anterior and posterior ethmoidal branches of the ophthalmic artery, anterior falcine branch of anterior ethmoidal artery, meningio-orbital artery, artery of the foramen rotundum, accessory meningeal artery, middle meningeal artery, ascending pharyngeal artery, as well as dural branches of the ICA particularly the inferior lateral trunk. Middle fossa meningiomas are often supplied by meningio-orbital artery, lacrimal branch of the ophthalmic artery, artery of the foramen rotundum, accessory meningeal artery, middle meningeal artery, ascending pharyngeal artery, and the inferior lateral trunk of the ICA .
CONCLUSION: Devascularization of anterior and middle fossa meningiomas is a crucial step in their resection and is more safely performed after anatomic localization of predictable arterial supply through reliable and safe surgical corridors in a sequential manner. This microsurgical progression is presented in a sequential stepwise surgical extension of the traditional pterional and modified orbitozygomatic craniotomy.