The patient OS A Yemini lady came to the clinic 14-November-2015 complaining of blind left eye for 3 years with bifrontal headache for 2 years and almost blind right eye for 8 months.

On examination; the patient is blind in the left eye and can differentiate fingers 10 cm near the right eye. The right eye shift lateral when looking anterior with horizontal nystagmus when looking to the right. 

The patient was sent for investigations and MRI done 14-November-2015 showing a giant meningioma involving the planum sphenoidale and tuberculum sella with massive supra-retrosellar growth more to the left with left optic nerve canal extension and stretching with spasm of the left A1 and edema of the left frontal lobe.

Bifrontal craniotomy with reflection of the bone flap to the right. The frontal sinuses were violated and the mucosa stripped accordingly. The dura was opened parallel to the base of the anterior fossa and both olfactory tracts were dissected of the mediobasl frontal lobes, but the left one was completely destroyed by the tumor and it was not possible to dissect it to the trigone for what it was intentionally bisected to remove the anterior part of the tumor. The tumor was rich in feeders and it was necessary to remove it by piece-meal fashion after coagulation. That part compressing the right optic nerve was removed, but at the junction with the chiasm, the tumor was stuck with optic nerve, for what a tiny layer was lift intentionally to preserve the right optic nerve. That part which was extending to the left optic canal was removed, but a thin layer stuck with left ICA was left to avoid vasospasm. It was coagulated. The tumor was followed posteriorly until the basilar artery was seen with Liliquest membrane has defect due to tumor invasion. Most of the time dissection was carried at the area of the right A1 segment and the tumor was maximally removed. It was possible to expose the chiasm at its medial part, which was pushed posterior. The area of the left A1 segment was not violated and to avoid possible bleeding from this segment, a surgicelle was applied to this area. All the feeders which were many, were coagulated and bisected by microscissors. Strict hemostasis and routine closure of the wound with repair of the frontal sinuses by muscle harvested from the left thigh. The patient was sent MRI to investigate the circulation, since a lot of vascular dissection was carried out, especially the right side. MRI showed severe spasm of the left ICA at the bifurcation from the left CCA. MRI with contrast showed branched of the left M1 and the left A1. This could be due to transitory spasm. The patient then was extubated.

Smooth postoperative recovery. The patient showed at the start right side paresis, which resolved over minutes. She was sent to the ICU for 24 hour observation.

The patient progressed right sided paresis with pronounced spasticity 2 hours after surgery. The next day the right limbs improved and the spasticity gone, but she developed diabetes insipidus for what Minirin was started. She still have total aphasia.

The tumor is very huge with blind left eye for three years. There recovery of the left eye mostly unpredictable, but the improvement of the right is mostly predictable.

Intraoperative MRI not only confirm the radical removal of the tumor, but also detect other events such in this case.

Arterial spasm after release of the stretched arteries must be anticipated and treated accordingly. Nimotop was started the day before surgery.

Intraoperative MRI confirmed the escalation of such event, but surprisingly the spasm got place in the left ICA distal to the junction with CCA. I was afraid of right circulation compromise, but got the opposite site. This can be explained to gross vascular dissection and the exposure of the basilar artery with slippage of clots around it or the surgicelle which was put to the left side to avoid manipulation with the left A1. 

This is the most difficult meningioma I have ever seen. Thousands of feeders and invasion of the arteries and the neural tissues surrounding the area. The operation took 10 hours which is not long to me. Some other operations took 30-40 hours, but here the character of the tumor restricting to go further.

For more detailed information about arterial spasm, please click here!