Surgical considerations in the management of falcotentorial meningiomas: Advantages of the bilateral occipital transtentorial/transfalcine craniotomy for large tumors

OBJECTIVE: Meningiomas arising from the falcotentorial junction are relatively rare, and the description of the surgical nuances in approaching these tumors is limited. We describe our surgical management of these lesions in detail. METHODS: From 2001 to 2005, 9 patients underwent operation for meningiomas arising from the falcotentorial junction, with some extending to and/or invading the torcula. All patients were assessed preoperatively with magnetic resonance neuroimaging and cerebral angiography. Furthermore, preoperative embolization was attempted in all cases. A supratentorial/ infratentorial torcular craniotomy technique was used in all but 1 of these cases. RESULTS: The average dimensions of the falcotentorial meningiomas were 5.1 X 4.4 X 4.2 cm. The angiograms revealed that these tumors were fed by branches of the internal carotid artery, choroidal arteries, branches of the meningohypophyseal trunk, and branches of the posterior cerebral artery. Preoperative embolization was achieved in only 2 patients. Five patients had gross total resection (Simpson grade 1), and 4 had subtotal resection (Simpson grade 4). Two of the tumors (22%) recurred during a mean follow- up period of 49 months (range, 17-88 months). The most common complication after surgery was cortical blindness, but all postoperative visual deficits had fully recovered at the last follow- up evaluation within several months. CONCLUSION: An excellent outcome can be expected with detailed preoperative neuroimaging and knowledge of the nuances of the surgical technique that we describe in detail in this article.