After classic pterional exposure of the tumor on the lesser sphenoid wing and in the middle cranial fossa, the optic nerve internal carotid artery were exposed medial to the tumor by °penmg the Sylvian fissure and retracting the anterior pole of the ernporal lobe posteriorly.The tentorium was incised, and the meningioma was progressively exposed from behind along with the trochlear and trigeminal nerves. As expected, both nerves were infiltrated on all sides by tumor, so they could be sacrificed. The tumor in the cavernous sinus was removed piecemeal, sparing the intracavernous portion of the internal carotid artery. Because of the heavy vascularity of the meningtoma, it was necessary to leave behind a thin layer of tumor attachment on the oc-ulomotor nerve; otherwise we would have risked functional loss. Standard wound closure was carried out, and the postoperative course was uneventful.  There was no evidence of functional abnormality of either the optic nerve or the oculomotor nerve.

 

　　Case 16: Recurrent meningioma involving the cavernous sinus

 

　　海绵窦复发性脑膜瘤

 

　　This 51-year-old woman was referred for management of a recurrent meningioma 4 years after an initial operation to remove a middle toss tumor.

 

　　Examination. Trismus, fullness of the right side of the face and the nasopharynx, and diminished sensation in the trigeminal distribution were present. A CT scan revealed a very large tumor involving the petrous bone and clivus, retropharyngeal area? in-fratemporal fossa, sphenoid sinus, middle fossa, cavernous sinus, and tentorial notch area on the right side.Cerebral angiog-raphy revealed that the neoplasm was quite vascular,predominantly supplied by the external carotid artery.  A trial balloon-occlusion was well tolerated by the patient clinically, but cerebral blood flow was significantly reduced.

 

　　Operations. The tumor was resected in two stages. During the first operation, an infratemporal fossa approach was used? with resection of the mandibular condyle and mobilization of the intratemporal facial nerve. The neoplasm was totally removed from the infratemporal fossa, including the invaded muscles, the mandibular,nerve, and a portion of the nasopharyngeal wall. The petrous ICA was encased by tumor involving the petrocltval bone.  The vertical segment of the petrous ICA was identified,  and the entire petrous ICA was dissected free of tumor.The tumor was then removed from the basal cavernous sinus (inferior approach) by dissecting it away from the cavernous ICA and the abducens nerve. The petroclival bone and the sphenoid sinus were also cleared of tumor.At the end of the operation, a vascu-larized rectus abdominis muscle flap was used to fill the infratemporal fossa, the sphenoid sinus, and the defect in the nasopharyngeal wall. Postoperatively, the patient had facial and abducens nerve palsy.

 

　　The second stage of the operation involved a frontotemporal approach to the lesion. Residual tumor was found in the upper cavernous sinus area, the dura overlying the trigemtnal nerve in the middle fossa, the tentorial notch , and the clival area,  through a lateral and superior approach,  the neoplasm was totally removed from the cavernous sinus.  The third,  fourth, and with cranial nerves and the second division of the trigeminal nerve were dissected from the tumor and preserved. Two lacerations of the cavernous ICA were sutured with 8-0 nylon after temporary clipping of the petrous and supraclinoid ICA. The regaining intracranial tumor was also removed.

 

　　Postoperative course. Postoperatively, the patient had a piete third and fourth cranial nerve paralysis in addition to her previous sixth nerve palsy, but otherwise had an uneventful recovery. A postoperative angiogram revealed the ICA to be patent and normal. On follow-up examination 1 year later, the third, fourth and sixth cranial nerve palsies had completely recovered. Radiation therapy was given to the infratemporal fossa region as an adjunct to tumor resection. There is no evidence of tumor recurrence on recent CT scans.