What best can be offered to him?

Posted by KRISHNAPRASAD KRISHNAPRASAD
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40 YR male from central Africa-operated in 2004 at Baltimore ,USA for meningioma grade2 and had SRT.He came to us in 2010 with recurrence and had surgical total excision with 1cm clearence of the infiltrated bone in 2010.HPE-ATYPICAL MENIGIOMA,Ki67 index-10%-20% with mitotic cells.Now,Dec2011,visited us with GCS-E4V2M6 and right hemiplegia.Refer the images.What best can be offered to him?

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Dr. Thamburaj Dr. Thamburaj
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Re: What best can be offered to him?

Preop 2010 pics are not available.
I am not sure if he has had DXT in 2010.

Presently, I suggest the frontal lesions may be excised and if feasible, thetentorial one as well in a second stage, and WBRT given
Dr. Thamburaj Dr. Thamburaj
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Re: What best can be offered to him?

In reply to this post by KRISHNAPRASAD
 Ketan bulsara (ketan.bulsara@yale.edu) has added thru my mail

This is a very difficult case for an unfortunately young pt. i would go after the symptommatic lesion which is causing midline shift. Then electively would go after left atrial lesion. I suspect the malignant transformation may be sarcomatous and therefore adjunct chemo may be needed
 
vikram vikram
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Re: What best can be offered to him?

In reply to this post by KRISHNAPRASAD
I agree with operating in two stages first the frontal one followed by tentorial one however, atypical ones are notorious and long term is guarded. nice case
Jim Ausman Jim Ausman
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Re: What best can be offered to him?

In reply to this post by KRISHNAPRASAD
This is a very challenging case. As I think about it the symptomatic lesion is the left parietal tumor which extends into the motor strip on the left. That is the tumor mass that needs to be removed first. However the frontal mass is also causing compression of the ventricle and shift. It appears as though all tumors have invaded the saggital sinus so I would expect the venous drainage to be reversed and go thru the skull and inferiorly in many paths. There is also an inferior temporal tumor which does not appear to be symptomatic.

Now the question is what to do. I see a number of choices. First to preserve the scalp blood supply in two craniotomies you could make an incision across the top of the head from right to left posteriorly parallel to the lambdoid suture. Then you could do a craniotomy that would extend go across the saggital sinus and extend to the left. That would allow you to open the dura with the in a half moon manner with the base on the sinus. You should see the tumors immediately and then begin to debunk the posterior tumors. THe tumor extends into the posterior sensory and motor cortex to the atrium. To avoid retracting on the brain you could do the patient in the lateral position. Make sure his right axilla is off the table and not compressed with the arm supported to prevent brachial plexus injury. That may be enough surgery for one day. Leave the tumor that is extending into the right hemisphere when you reach the flax.

Still the frontal tumors will have to be removed as they are causing so much mass effect. To do this a Soutthar incision should be made frontally removing the bone as you did posteriorly. Remove the tumors as you did posteriorly.  

The problem I have with these approaches are the mass effects on the brain. He does not appear to be symptomatic from ICP but I would be concerned. So, another idea is to place the patient supine and do  a huge hemicraniectomy on the left. Then you can open the dura widely to provide decompression. Then you could attack the tumor posteriorly as I outlined above and close. Do not put the bone flap back to allow for swelling which will occur. When the swelling has reduced you can go frontally and remove the frontal tumor without replacing the bone flap to allow for the swelling to reduce. After the patient has stabilized you can replace the bone flap.

I am not sure this is right but they are some ideas on how to handle a difficult case with masses anteriorly and posteriorly and no doubt swelling postopeatively treated as simply as one can with a decompressive craniotomy.

Hope this helps

Dr. Thamburaj Dr. Thamburaj
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Re: What best can be offered to him?

Dear Prof. Ausman,
Thank you for your extensive input.
I have forwarded the same to my collegue, Dr. Krishnaprasad who had put up
the question..

I do appreciate your efforts.