The patient was operated by me for right cavernous meningioma with leaving a small tiny remnant in the ICA and the wall of the cavernous sinus through pterional approach 11-May-2003 for epilepsy.

The patient disappeared and came to the clinic 26-June-2008 with recurrent attacks of epilepsy with MRI of the brain performed 24-June-2008 confirming the recurrence of the meningioma, involving the right cavernous sinus and all the right parasellar region with involvement of the tentorium and subtentorial and clival extension with the carotid artery hanging in the middle of the mass.

The patient was admitted 3 days before surgery due to bad condition. He was covered with Depakine I/V and follow up demonstrated surges of high fever exceeding 41 degrees Celsius.  Septic workup was negative and and the only explanation to such event was hypothalamic irritation in reaction to the rich vascularity of the tumor.

The old incision was refreshed and extended more inferiorly and backward. IOM ISIS Highline with neuroexplorer 4.2 was used during all steps of the operation.

Trans-zygomatic approach was performed with drilling of the tumorous bony base of the skull. The drilling was extended back to the cochlea and medially to the V3 division and the horizontal segment of ICA and anteriorly to the V2 division.

The tumorous dura was resected with tumor abutting the V1 emergence. Peace-meal resection of the tumor was done with cleaning of the tentorium. The intracavernous part of the right ICA was exposed and pinpoint tear was repaired with nylon 6 zero.  The subtentorial compartment was reached and removed. The right oculomotor nerve was pushed anteriorly and medially and was anatomically preserved. The basilar artery and right posterior communicating arteries were preserved.

It was felt that further resection could lead to catastrophic events, taking into consideration, that the tumor was rubbery and stuck to all vitally important structures.

It was impossible to reach the sphenoidal compartment from this approach safely.

The dural defect was covered with Tacocele and one stitch was applied to the lateral edge of the V1 emergence.

Routine closure of the wound and ready-vac drain was inserted under the skin.

The operation took 12 hours and 4 units of blood and 6 units of FFP was give.

Smooth postoperative recovery and the patient right hearing is preserved and the abducens was functioning . Lagophthalm of the right eye and paresis of the right oculomotor nerve was noted. 

the patient came to the clinic 11-July-2008 with clean wound with normal oculomotor functions with hypalgesia right V2 division with no motor deficit. He is in Depakine Chrono 500 mg twice daily.

The patient then came 12-October-2009 after radiotherapy  54 Gy in 27 fractions. MRI performed 04-August-2009 showing residual of the tumor in the sella and right side of the tentorium and right cavernous sinus. The right ICA is not compressed. There is numbness of the right V3 division with preservation of sensation.

The patient then came 02-February-2012 with stable condition and MRI done 01-February-2012 showing some shrinkage of the tumor. The last epi-attack was in 2008.

The patient has cavernous meningioma which was subtotally resected 5 years ago.

The recurrence took an aggressive surgical dilemma, which was limiting the percentage of removal.

Radiotherapy could be an acceptable option after the surgery to slow down the speed of regrowth.

For detailed information about meningiomas please refer to meningiomas.info and meningiomas.org.