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nnDATE OF OPERATION: 11/12/2018nnNEUROSURGERY OPERATIVE REPORTnnPREOPERATIVE DIAGNOSIS: Right frontotemporal dural-based tumor with skull base and orbital invasion.nnPOSTOPERATIVE DIAGNOSIS: Right frontotemporal dural-based tumor with skull base and orbital invasion, probable meningioma with atypical features.nnPROCEDURES: Right frontotemporal craniotomy, resection of dural based tumor, suture of bovine pericardial dural graft, Synthes facet bone putty, subtemporal drain, titanium mesh cranioplasty, intraoperative microscope, ICG fluorescence visualization, lateral orbitotomy, and extradural clinoidectomy.nnCO-SURGEONS: Dr. Z, who performed the right frontotemporal craniotomy, resection of dural based tumor, sutured bovine pericardial dural graft, Synthes facet bone putty, subtemporal drain, titanium mesh cranioplasty, intraoperative microscope, and ICG fluorescence visualization.nnCO-SURGEON: L. M., M.D., who performed lateral orbitotomy and extradural clinoidectomy.nnASSISTANT SURGEONS: Dr. M was the assistant surgeon for Dr. Z’s portion of the surgerynnSECOND ASSISTANTS: A. P., MD and C. B., PAnnINDICATIONS: The patient is a 55-year-old left-handed female, with a positive history of left handedness, who presented with a complex past medical history including hypertension and uncontrolled diabetes, with problems of headache, nausea, vomiting, and vertigo. She had a proximally 6 month history of diabetic retinopathy with blood in her eye and was followed closely by her eye doctors for vision changes. She subsequently developed proptotic changes and blurring of the right vision like a film such that her visual acuity was finger counting in the right eye, with the ability to read with retain on the left. Imaging studies were initially performed that demonstrated a complex skull base meningioma with orbital invasion, particularly at the lateral orbital region. She was initially scheduled for surgery, however, because of uncontrolled diabetes, anesthesia colleagues wanted her under better control prior to the procedure. Thus, she was admitted to the medical service for optimization of glucose control and surgery was performed 72 hours later. The patient and her family underwent detailed informed consent, which is documented elsewhere in the electronic health record.nnPROCEDURE DESCRIPTION: Following the attainment of general anesthesia, all performance measures were and had been accomplished including a preoperative time-out, the administration of antibiotics and approved shave and Betadine preparation. The patient’s head was secured in Mayfield-Kees pin fixation and the stealth was registered. The patient’s head was positioned supine with a bump in a vertex down 30 degree facing to the left approach so that the zygoma was at the highest point in the presentation. A modified Yasargil designed flap to include more temporal and frontal lobe exposure was fashioned entirely behind the hairline with the preservation of the anterior hair in a rubber band for cosmesis. After the stealth registration and the designing of the skin incision to the zygoma, a Betadine preparation was performed and local anesthetic was infiltrated in the subcutaneous tissue. The 10 blade knife was utilized to incise the skin and Raney clips were used to secure the drape. The Bovie was used to reflect the pericranium in the anterior portion of the incision and Metzenbaums were used to dissect inferiorly. The fascia was reflected forward using sharp dissection, and the temporalis muscle was reflected inferiorly down to the level of the zygoma with a superb sphenoid wing exposure. The bone flap was designed with the understanding that the tumor in the sphenoid wing region preoperatively was seen to erode through the bone with hyperostosis and direct bony invasion as there was evidence of tumor in contrast-enhanced regions inferior to the temporalis muscle on the outside of the bone. It was also recognized that there was tumor that had transcended the bone of the lateral orbit and was impacting the lateral rectus muscle. Given that, the bone flap was fashioned in a conservative way outside the area of obvious invasion, first using the Codman perforator and the Midas Rex drill. After this, the pineapple bur was used to primarily remove the region of the sphenoid and lateral orbit involved directly with tumor. A specimen of tumor underneath the temporalis and involving the pericranium was removed, and dissection was performed at that level to minimize the amount of observed tumor. With that, multiple specimens were obtained. Hemostasis was obtained by coagulating the dura primarily. The extradural clinoidectomy was performed expertly by Dr. M., who provided his special training in skull base to address the lateral clinoidectomy and the lateral orbitotomy. The dura was gently mobilized and reflected in order to accomplish both of these procedures safely. The dura was then opened until the tumor was identified and a Sonopet was used to remove portions of the tumor. IC-Green was used under the operating microscope to identify the middle cerebral vessels and identify, which vessels were emphasized and which vessels were going directly to the tumor. This technique worked expertly and was useful in safe dissection. The lateral wall of the orbit was removed and the dura was left intact. Some of the superior orbital roof was also reflected. Every aspect of the dura that was clearly involved with tumor was then removed in an en bloc fashion after the tumor had been safely reflected from the sylvian fissure and sylvian vessels. There was a question of brain invasion at the right frontal lobe, which was very limited. Otherwise, there was intact pia over the temporal and frontal lobes abutting the tumor. Once the dura was resected and the bone areas of tumor removed, as well as some of the infratemporal tumor, a bovine pericardial dural graft was then fashioned and secured using 3 mm MRI compatible Synthes screws as well as Tisseel as a tissue glue to prevent drainage through the inlay dural graft. The superior aspects of the graft were closed primarily with running and interrupted 3-0 Nurolon sutures. The bone that was not involved with tumor was replated using Synthes plates and screws, and a mesh was secured over the area of the lateral sphenoid that had been primarily drilled and resected due to involvement with tumor over that. A fast setting bone putty was used for cosmesis with a superb closure and cosmetic result. The wound was irrigated copiously at many stages through the procedure with antibiotic solution including through the dura prior to the placement of the Tisseel. A subgaleal drain was used and remained in place for a prolonged period of time with the tip underneath the temporalis muscle and curvature underneath the galea, so that there were holes picking up any subgaleal fluid and also CSF to serve as a CSF diversion, successfully allowing the dura to close over for a period of several days postoperatively. The alternative would have been to place an external ventricular drain or a lumbar drain; however, this subgaleal drain placed under the temporalis worked superbly as a diversion for CSF to allow excellent healing. The temporalis muscle was secured using 2-0 Vicryl pop-offs. The fascia was secured using 2-0 Vicryl pop- offs. The galea was closed using 2-0 and 3-0 Vicryl interrupted sutures, and the skin was closed with staples with a 3-0 Prolene stitch at the drain exit site, and a Vicryl buddy stitch at the drain exit site. Sterile dressings and a full head wrap were placed. Sponge, needle, and cottonoid counts were correct at the conclusion of the case.nnFINDINGS: The pathology was consistent with meningioma and given the erosion through structures, the final results were consistent with atypical or grade 2 features as expected from the preoperative imaging studies and the findings intraoperatively. The unplug tumor was biopsied and there were also areas of focal probable brain invasion along the right anterior and inferior frontal lobe. There was confirmed involvement of the pericranial aspect of the temporalis muscle with extradural invasion of the lateral orbit and presumed positive bone.nnSPECIMENS: Multiple frozen and permanent section specimens were sent.nESTIMATED BLOOD LOSS: Between 500 and 700 mL.nANESTHESIA: Performed expertly by general endotracheal intubation with Dr. T., Dr. B., and Dr. W.; all contributing to the patient’s care.nnCULTURES: None.nnDRAINS: One 10-French subtemporal subgaleal drain was placed.nnBLOOD REPLACEMENT: Two units of packed cells were placed for intraoperative hematocrit of 24, as I recall.nnThe patient has continued to do well with preserved vision in her right eye and an excellent postoperative resection with no evidence of stroke and no evidence of new deficit.nnDr. Z. was the surgeon for the right frontotemporal craniotomy, resection of dural based tumor, sutured bovine pericardial dural graft, Synthes facet bone putty cranioplasty, subtemporal drain, titanium mesh cranioplasty, intraoperative use of microscope, ICG fluorescent visualization. Dr. M. was the surgeon for the lateral orbitotomy and extradural clinoidectomy. The 2nd surgeon was required due to his particular expertise in training in skull base approaches, which was not otherwise available at our facility.
