Resection of Peritorcular Meningioma With Sinus Intimal Layer Preservation: 2-Dimensional Operative Video

The torcula being the most vital site of cerebral venous drainage, meningiomas involving the torcula have been fromthe time of H Cushing(1) to our days, themost formidable tumors to resect. When the torcula is completely occluded, radical resection is possible because the safety and efforts go to the preservation of the venous collaterals.(1,2) Preservation of the venous outflow is absolutely crucial and will condition radical tumor removal and accepting subtotal removal.(2,3) Before penetrating and growing inside the lumen, themeningioma grows in thewall of the sinus, invading the fibrous dural outer layer while compressing the endothelial venous intimal layer, thus allowing in these cases, under high magnification, to shave the meningioma off the intimal wall while maintaining flow by preserving the integrity of the inner venous wall and avoiding entry into the vascular lumen proper. Equally important, when the torcular is partially involved, is to recognize all the surrounding venous anatomy, tributary, or early collateral through a careful preoperative evaluation.(2-5)We demonstrate this concept through a case of a 61-year-oldwoman presenting with balance difficulties leading to the diagnosis of a large torcular meningioma invading and occluding the left transverse sinus and extending into the medial wall of the torcular. The patient consented to the surgical intervention. Images and video, (c) Al-Mefty and Aboud from 0:48-1:13 used with permission. All rights reserved.