Meningioma

1. Pre-operative case presentation
Dr. K. M. Zobair Alam
Resident - Phase B
Neurosurgery Dept. BSMMU
07.08.22 Yellow unit

2. Particulars of the patient
 Name : Fatema
 Age : 40 years
 Sex : Female
 Marital status : Married
 Occupation : Housewife
 Address : Narayanganj
 DOA : 26/06/2022
 R/N : 529/02
 Ward : NSER
 Bed : FNP-26
Picture taken with the permission of the patient

3. Chief complaints
Headache for 2 years
Blurring of vision for 3 months.
Behavioral changes for last 3 months.

4. History of presenting illness
According to the statement of the patient, she was reasonably alright 2
years back. Then she experienced occasional headache which was
insidious in onset, gradually progressive, no diurnal variation, localized
in left side of head, moderate to severe in intensity, dull aching in nature ,
aggravated with coughing, sneezing, straining & bending forward,
associated with nausea & vomiting & partially relieved by taking rest &
analgesics.

5. She also notice blurring of vision for last 3 months which is insidious in
onset, gradually progressing more in the left eye.
Patient’s attendant also complains about some changes in the behavior
in the form of increased forgetfulness, prolonged response time to any
command, poor judgment.

6. Her bowel & bladder function are normal.
She does not give any H/O convulsion, vertigo, hearing or swallowing
difficulty.
There is no history of cough, haemoptysis, weight loss, evening rise of
temperature or contact with any TB patient.
With these above complaints she was admitted to BSMMU for specific
management.

7. Associated illness
Disease Duration Drugs
Diabetes - -
Hypertension 2 years -
Bronchial
Asthma
- -
Hypo/hyperthyro
idism
- -
CKD - -

8. Past medical history
 Childhood illness : Nothing contributory.
 History of surgery : Nothing contributory.
 Immunization : BCG mark present on left arm.
 Personal history : She is non-smoker, non-alcoholic, Does not take
betel nut.
 Family history : All of her family members are in good health.
 Socioeconomic status : She belongs to middle class family
 Drug history : Tab. Paracetamol 500mg,Tab.Levetiracetam 500 mg.
Tab Olmesartan 20mg
 Menstrual cycle : Regular. Last menstruation on 25/07/2022
.

9. General Examination
 Appearance : anxious
 Body built : Average
 Co-operative
 Decubitus : on choice
 Weight : 50 kgs
 Anemia : absent
 Cyanosis : absent
 Jaundice : absent

10.  Edema : absent
 Dehydration : absent
 BP : 120/70 mm of Hg
 Pulse : 72 b/min
 Temp : 98 F
 Skin condition : Normal.
 No lymphadenopathy

11. Systemic Examination
• Respiratory System Examination:
Trachea is midline position. Breath sound is vesicular and no added
sound.
• Cardiovascular System Examination:
Apex beat present in left 5th intercostal space.S1-S2 normal and no
murmur.
• Gastrointestinal System Examination:
Abdomen is scaphoid, soft, non tender. No organomegaly or lump on
palpation.

12. Neurological Examination
 Higher psychic function: Oriented to time, place & person
Memory is impaired.
 GCS : 15
 Handedness : Right handed
 Speech : Normal
 Gait : Normal.
 no signs of meningeal irritation.
 No signs of cerebellar dysfunction.

13. Orbitofrontal Syndrome
Disinhibition Absent
Poor Judgment Present
Emotional lability Present
Frontal Convexity Syndrome
Poor Abstract thought Absent
Indifference Present
Apathy Present
Medial Frontal Syndrome
Sparse verbal output Absent
Incontinent Absent
Akienetic Absent
Frontal Lobe Syndromes

14. Parietal Lobe Functions
FUNCTIONS FUNCTIONS
Postural Sensation Normal Geographical Agnosia Absent
Sensation Of Passive
Movement
Normal Constructional Apraxia Absent
Accurate Localization Of
Light Touch
intact Left-right Confusion Absent
Two Point Discrimination Normal Finger Agnosia Absent
Astereognosis absent Dressing Apraxia Absent
Perceptual Rivalry Absent Agraphia Absent
Anosognosia Absent Acalculia Absent
Wernicke’s Dysphasia Absent Visual Field Defect Absent

15. Temporal Lobe Syndromes
FUNCTIONS
Auditory Hallucination Absent
AMUSIA Absent
Memory Short term & long term memory
impaired
Olfactory Hallucination Absent
Aggressive Behavior Absent
Visual Field Defect Absent

16. Cranial Nerve Examination
Olfactory Nerve
Normal
Optic Nerve
 Visual Acuity : 6/6 on both eye
 Visual Field exam (Confrontation testing) : Normal (B/L)
 Color vision : Normal in both eyes.
 Fundoscopy : Papilloedema (B/L).

17. Visual Field Analysis

18. Colour Fundal Photograph

19. Oculomotor, Trochlear & Abducens nerve
Right Left
Pupil
Size 4 mm 4 mm
Shape round round
Direct light reflex Intact Intact
Indirect light reflex Intact Intact
EOM Normal in all gazes Normal in all gazes
Accommodation
reflex
Intact Intact
Nystagmus Absent

20. Trigeminal nerve (V)
 Sensory: Intact.
 Corneal Reflex: Normal (B/L).
 Motor (Muscles of Mastication): Intact (B/L).
 Jaw Jerk: Absent

21. Facial Nerve : Normal
Vestibulo-cochlear nerve
Right Left
Hearing Normal Normal
Rinne Test AC>BC AC>BC
Weber Test Central

22. Glossopharyngeal and Vagus nerve
Voice Normal
Gag reflex Present
Position of uvula Central
Palatal movement Normal

23. Accessory Nerve (XI)
Hypoglossal Nerve (XII)
Right Left
Sternocleidomastoid Intact Intact
Trapezius Intact Intact

24. Upper Limb Examination
Right Left
Inspection Normal Normal
Bulk Normal Normal
Tone increased Normal
Fasciculation Absent Absent
Power Elbow Flexors 4 5
Wrist Extensors 4 5
Elbow Extensors 4 5
Finger Flexors 4 5
Finger Adductors 4 5
Jerks Biceps +++ ++
Triceps +++ ++
Supinator +++ ++
Hoffman Positive Negative

25. Lower Limb Examination
Right Left
Inspection Normal Normal
Bulk Normal Normal
Tone increased Normal
Fasciculation Absent Absent
Power Hip Flexors 4 5
Knee Extensors 4 5
Ankle Dorsiflexors 4 5
Great Toe Extensors 4 5
Ankle Plantar Flexors 4 5
Jerks Knee +++ ++
Ankle +++ ++
Plantar Extensor Flexor

26. SENSORY SYSTEM EXAMINATION
All modalities of sensations are intact in all dermatomal distribution.

27. Provisional Diagnosis
• A case of Raised ICP most possibly due to intracranial Space
Occupying Lesion involving frontal lobe

28. INVESTIGATIONS

29. X-ray Skull A/P & Lateral view

33. T1 weighted MRI of
brain axial sections

34. T2 weighted MRI of
brain axial sections

35. MRI of brain axial
sections contrast:

36. FLAIR

37. DWI

39. MRI of brain coronal
sections Contrast:

40. MRI of brain sagittal
sections contrast:

42. Left sided sphenoid wing meningioma
Radiological Diagnosis

43. Plan
• Left sided Pterional craniotomy and removal of tumor .

44. Position
• The patient is placed in a supine position with the head slightly extended
and rotated toward the right side.
• Head is above heart level to optimise venous return

45. SKIN INCISION
Curvilinear skin incision starting
at the root of the zygomatic arch,
just 5 mm in front of the tragus,
which runs vertically upward.
Once it passes the ear, it is curved
superiorly toward the ipsilateral
frontal region until it reaches the
midline ,always keeping behind
the hairline.

46. Exposing temporalis fascia

47. Inter-Fascial Dissection

48. Subperiosteal dissection of temporalis muscle

49. CRANIOTOMY
A key burr hole is made just behind
the orbital rim.
Another burr hole is made at the
inferior apex of the exposure, just
above the root of the zygoma.
A third burr hale is placed posterior
to the key burr hole, along the
superior temporal line.

50. Extradural Bony Work

51. Durotomy
Depends upon extent of dural involvement
Not involved: curvilinear, base directed towards orbit
Involved: circular fashion following tumor margin to achieve simpson
grade I removal

53. Tumor Removal
• Dedressing
• Devascularization
• Debulking
• Dissection

54. Dedressing

55. Devascularization
Extradural – coagulation of dural branches of middle meningeal artery.
Intradural –during dedressing, feeding vessels originated from MCA

56. Debulking
Done with bipolar
coagulation and suction
& also in piecemeal
fashion.

57. Dissection
Tumor capsule separated
from MCA
Feeders from these vessels
will be cauterized and
divided

58. Closure
• Duraplasty with pericranium- if needed.
• Replacement of bone flap
• Layered closure, leaving a subgaleal drain in situ

59. Per-operative Complication
• Excessive hemorrhage, during craniotomy and tumor removal
• Brain swelling due to excessive retraction of temporal lobe
• Injury to the branches of MCA during dissection of tumor capsule
• Injury to cerebral cortex & cortical vessels
• Injury to the globe & orbital contents

60. Post-operative Complications
• Onset of new neurological deficit
• CSF leakage
• Meningitis
• Wound infection
• Cosmetic deformities
• Convulsion

61. THANK YOU

63. Non- Contrast CT scan of brain

65. Anterior Cliniodectomy

66. Pre-operative Consideration
• MR Preoperative endovascular embolization of highly vascular
meningioma .
• Drainage of 50-60 ml of CSF Preoperatively through lumbar drain in
the OT.