The patient came to the
hospital with history of longstanding ataxia, headache with
decreased hearing left ear and left ophthalmalgia and blurring
vision left eye. Neurologically the patient was intact.
except for nystagmus and decreased hearing left ear and mild facial
paresis left side.
The patient performed MRI, which showed massive
left posterior fossa mass, resembling meningioma. Considering its
giant dimensions with extension down to the caudal group of nerves
left side, it was difficult to establish the histologic diagnosis.
But the patient claim, that she has remnant hearing with this giant
mass and the absence of intracanalicular growth of the mass, made
the diagnosis more favourable to meningioma.
In the setting position with head tilted to look
to the left with moderated extension, a wide osteoplastic craniotomy
was performed over the left cerebellar hemisphere, exposing during
that the left transverse sinus and the sigmoid sinus. The tumor was
attacked subtentorially. The matrix of the meningioma could be seen
starting from the level of the left petrosal vein.
Intracapsular resection started and piecemeal
resection followed with coagulation of the matrix of the tumor which
was reaching the tentorial edge. After debulking of the tumor
without applying any traction, with preservation of the Dendy vein
to control the level traction of the left cerebellum by gravity. The
tumor was stuck to the vestibular nerve, but by sharp dissection it
was anatomically preserved to the end of the operation. The major
portion of the tumor attached to left SCA was removed, except a tiny
remnant engulfing it at the level of the tentorial edge , which was
left intentionally to avoid catastrophic sequelae. The trochlear
nerve was dissected and preserved.
The caudal part of the mass was dissected off the
vertebral artery and one of branches of the accessory nerve. No
attempt was made to violate the facial nerve, so as not to expose it
to surgical trauma. It was hidden under the petrosal and the
preserved vestibular nerve.
The matrix of the tumor was stony hard and it was
decided to remove it. When this action was started, it became clear,
that the bone is under the tentorium and it was removed by
Smith-Kerrison rongeur. That part of the bone parallel to the
superior petrosal sinus was left in place to avoid possible fracture
of the bone with possible bleeding from the superior petrosal sinus,
which could be uncontrollable to stop due bony involvement.
All the neural and vascular structures were
preserved and routine closure of the wound. The bone reflected back
to place and the patient was extubated immediately after the
operation, which took 14 hours. The nystagmus increased after
surgery and there was noticeable left facial paresis.
The next day 16-January-2006, the patient is
fully conscious, ambulating with mild paresis of the left facial
nerve with with preserved hearing and subsiding nystagmus. The left
side of the face is numb with hypalgesia.
CT-scan done showing complete resection of the
tumor with part of the hyperostosis left in place at the anterior
third of the left pyramid.