Parasagittal meningiomas

PARASAGITTAL STUART Assistant

MENINGIOMAS*

N. ROWE,

in Neurosurgery,

Western

PITTSBURGH,

I

REPORTS

CASE I. M. C., white femaIe, aged 59, reported a mass on the top of the head, progressiveIy enIarging over a period of nine years, accompanied by convuIsive seizures during the past seven months. Present Illness. Nine years before admission the patient noticed a smaI1 Iump on the top of her head. Her physician advised her that it was probabIy a cyst of the scaIp which she shouId have removed if it enIarged. When she next consulted him the mass had enIarged to the size of a Iemon and was obviousIy not an ordinary sebaceous cyst. During the seven months prior to admission the patient had had four or five attacks of Jacksonian epiIepsy invoIving the right foot and Ieg. was a rather Examination. The patient obese woman with mild cardiac enIargement,

F.A.C.S.

PennsyIvania

Hospital

PENNSYLVANIA

T is we11 known that the intracranial tumors which arise from the meninges are we11 circumscribed and can be compIeteIy removed. But it is aIso true that such a removal is not aIways accomphshed easiIy. Because of their SIOW growth, meningiomas often attain considerabIe size without symptoms, they are frequentIy quite vascuIar, and in many instances they invade the dura mater and skuI1. With the possibility of a permanent cure of the disease in view, the surgeon has continued to work to overcome these obstacIes and frequently is rewarded by a most satisfactory and Iasting postoperative resuIt. However, the tumors lying aIong the faIx cerebri on either side of the mid-Iine-the so-caIIed parasagitta1 meningiomas-through their very Iocation present particuIarIy difEcuIt probIems in diagnosis and in treatment. It is these probIems which we wish to discuss brieffy here. CASE

M.D.,

a bIood pressure

of 170/80, and a mass measuring 6 X 3 X 1% inches near the vertex of her skuI1. She showed scattered neuroIogic signs, incIuding a sIight weakness of the right extremities, a sIight Ieft-sided ptosis, and a smaI1 Ieft homonymous defect in her visual fieIds. The x-ray (Fig. I) discIosed extensive changes in the vauIt of the skuI1, thought to be due to invasion by a meningioma or a choIesteatoma. Operations. Biopsy showed the tumor to be a meningeal fibrobIastoma. At the first stage operation the invoIved bone and a portion of the underIying tumor were removed by Dr. C. H. Frazier. (Fig. 2.) At the second stage (five months later) a meningea1 fibrobIastoma Iying aIong the Ieft side of the faIx cerebri in the parietal region was extirpated by the author. The patient had considerabIe right-sided weakness for a few weeks after operation. SeveraI months Iater she had a few brief twitchings of the right foot, but was free of symptoms five months postoperativeIy. Comment. The enormous extent of the bone invoIvement in this patient forced the remova of a Iarge bone ffap which left a CorrespondingIy Iarge skuI1 defect. The suspected area was thoroughIy coagulated with the eIectrosurgica1 unit, but it is impossibIe to say whether a11 ceIIs were destroyed. In a woman of 60 it is doubtfu1 whether the skuI1 defect or a possibIe very SIOW recurrence wouId represent any rea1 hazard, but obviousIy, either might be serious in a younger individua1. CASE II. M. P., white, femaIe, 58, had a Ieft occipita1 parasagitta1 meningioma which was removed in 1918, in 1930, and again in 1936. The bone was not invoIved, but invasion of the faIx Ied to an incompIete extirpation on each occasion.

* From the Neurosurgical Service, Landon Surgical Clinic, Western PennsyIvania Hospital, Pittsburgh, vania. Read at a meeting of the AIIegheny County Medical Society, Pittsburgh, PennsyIvania, November

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History. On her first admission in rgr8 (at the age of 40) the patient’s failing vision, headaches, staggering, and right homonymous

FIG. I. hemianopsia Ied to the diagnosis of a Ieft occipita1 brain tumor. A left parasagitta1 meningioma 4 cm. in front of the poIe of the o&pita1 lobe was found and removed by Dr. C. H. Frazier. Symptoms of a recurrence began to appear ten years Iater and in rg3o a tumor measuring 7 X 6.5 X 5.5 cm. was removed by Dr. Frazier. He noted the infiItration of the falx and feared a recurrence. The patient deveIoped weakness of the right extremities, attacks of dizziness, impairment of memory and vision in 1935 (at the age of 58) and was operated upon for the third time in 1936 by the author. Operation. A very Iarge tumor principaIIy on the Ieft side of the faIx but straddIing its Iower edge to extend across the midIine was found, and a considerabIe portion extirpated. Course. The patient’s convaIescence was uneventfu1 after a rather stormy first twentyfour hours. Eight months Iater she was greatIy improved mentaIIy and in the strength of her right side, but was stiI1 sIightIy forgetfu1 and had begun to drag her Ieft leg slightly. Comment. In this case the absence of bone invoIvement enabIed the operators to repIace the bone flap three times without risk, but the invasion of the dura Ied to recurrences in ten and five years respectiveIy. Furthermore, the Iast recurrence was so extensive as to preclude the possibiIity of radica1 remova of the tumor.

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CASE III. W. R., white, maIe, 27 (referred by Dr. WiIIiam Anderson), had had a sIowIy emarging “bump” near the vertex of the skuI1

FIG. 2. for about one year. No neuroIogic findings were noted except earIy papiIIedema. At operation a biIatera1 frontoparieta1 parasagitta1 meningioma was removed with the portion of the faIx and superior IongitudinaI sinus which it invaded. The involved bone was boiIed and repIaced. History. For one year the patient had been aware of a sIowIy enIarging firm sweIIing near the vertex of his skull. (Fig. 3.) One month before admission he began to notice a momentary clouding of his vision when he changed his position quickIy, as in getting up from a chair. Examination. NeuroIogic examination was entireIy negative with the exception of a sweIIing (apparentIy bony) about 2 X 3 inches aIong the midline of the head in the parieta1 regions, and biIatera1 papilledema. X-ray discIosed a thickening of an area in the parieta1 portion of the skuI1, showing a definite vertical striation. Operation. A scaIp flap was reflected around the bony sweIIing with the base to the right and posteriorIy. The invoIved bone was surrounded by burr hoIes and excised. (Fig. 4.) Upon opening the dura it became apparent that the underIying tumor Iay aIong both sides of the faIx and invoIved this structure, the superior IongitudinaI sinus, and the overIying dura. After some consideration the sinus was ligated and cut anterior and posterior to the Iesion and the tumor with a11 of the invoIved dura removed. (Fig. 5.) The bone fIap was

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boiIed for ten minutes wired in pIace. The scaIp Course. The patient recovery and was abIe to

Rowe-Meningiomas

and repIaced, being was cIosed as usua1. made an uneventfu1 resume his duties as

JANUARY,1939

bony swehing had been present for one year and in spite of the fact that the tumor found at operation pressed upon the sensory and motor cortica1 areas biIateraIIy.

FIG. 3.

a teacher when schoo1 after his operation.

opened

two

months Fit.

DISCUSSION

The symptomatoIogy of parasagitta1 meningiomas naturaIIy varies with the position of the Iesion aIong the faIx and in genera1 coincides with the symptom compIex of the Iobe invoIved-fronta1, parieta1, or 0ccipitaI. Two characteristics, however, seem worthy of emphasis. The first is the very earIy bone invasion when the tumor is near the surface; or, stated in another fashion, the frequent association of very extensive invoIvement of the skuI1 with a relativeIy smaI1 intracrania1 tumor. In both Case I and Case III of this report, the operator was surprised at the comparativeIy small size of the tumors found beneath the very large bony swelhngs. A second characteristic which is perhaps in a Iarge measure dependent upon the first, is the Iate appearance of neuroIogic symptoms or signs in case of meningiomas along the falx. In Case III, for exampIe, no neuroIogic changes whatsoever could be detected though the

4.

The remaining features of the symptomatology are essentiaIIy those of meningea1 fibrobIastomas in any Iocation, nameIy: sIow growth, often a history of convuIsive attacks, and the late deveIopment of symptoms or signs of increased intracraniai pressure. These need not be dweIt upon here. The resection of a portion of the superior IongitudinaI sinus is a procedure which may be regarded as at Ieast somewhat hazardous. NevertheIess, a number of reports in the Iiteraturell2*3 attest the fact that it can be carried out without producing any detectable change in the patient. As in the ligation of any Iarge vessel, the sequeIae of tying the Iongitudinai sinus seem to depend IargeIy upon the adequacy of the coIIatera1 circuIation. This in turn depends upon (I) the point at which resection is ,carried out, and (2) the existence of previous thrombosis from tumor invasion. It is generalIy agreed that such thrombosis is usuaIIy present in cases of

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meningioma (ahhough unfortunately there are no avaiIabIe histoIogic studies to prove it) and that in such cases any part of the sinus can be resected with impunity. If no such thrombosis exists, ligation of the anterior third can be done without fatality, but in some cases this has been foIIowed by transient mental changes. Boiling of portions of the skull to kiI1 invading neopIastic ceIIs or organisms was described by Naffziger4 in 1936. He reported the successful use of the procedure in severa cases of meningioma and osteomyeIitis. In Case III this method was empIoyed to avoid creating a Iarge skuI1 defect in a young maIe patient-a defect, moreover, which wouId have exposed a considerable part of both motor areas to possibIe injury.

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era1 inches of the superior IongitudinaI sinus, and a portion of the faIx. The widely invaded overIying bone was resected,

SUMMARY

FIG. 5.

I. Three cases of successfuIIy operated parasaggita1 meningioma are described. Their characteristics, (I) early invoIvement of overlying bone, and (2) the Iate deveIopment or total absence of neuroIogic symptoms, are stressed. 2. In one instance the very extensive bone invoIvement necessitated the creation of a Iarge skuI1 defect. 3. In a second the third recurrence of the tumor was found to be so Iarge that only a partia1 remova couId be effected. 4. In a recent case a compIete extirpation of a biIatera1 parasaggita1 meningioma was carried out successfuIIy by resection of a11 of the invoIved dura-including sev-

boiled, and repIaced. This technique seems to offer a permanent cure without producing a postoperative skuI1 defect. REFERENCES I. TOWNE, E. B. Invasion of the intracranial venous sinuses by meningioma (dural endotheIioma). Ann. hrg., 83: 321-327 (March) 1926. 2. DAVID, M., and BISSERY, BRUN M. Sur un cas de mkningiome de Ia faux opCrk avec succ&s. Absence de troubles paraIytiques apres r§ion du sinus IongitudinaI au niveau de I’abouchement des veines roIandiques. Rev. neural., I : 725-730 (May) 1934. 3. TBNNIS, W. Die ZuILssigkeit der Resektion des tingsbluteiters des Gehirns. Dezrtscbe Ztscbr. f. Nerved., 136: 186-189 (March) 1935. 4. NAFFZIGER, H. C. The restoration of defects in the skul1. Ann. hrg., 104: 321-331 (Sept.) 1936.