Ospedale Cvile S. Annunzıata, Department of Neurosurgery, Sassari, Italy.
Turk Neurosurg. 2024;34(4):737-744. doi: 10.5137/1019-5149.JTN.43641-23.2.
Intradiploic meningiomas are rare neoplasms, often mistaken for metastases or malignant bone tumors. Surgical management can be challenging, considering their diffusive bony invasion. Two main critical decisions need to be taken: the timing for cranial vault reconstruction and the choice of the adequate material for cranioplasty. We believe that this case underscores the complexity of such lesions, the importance of a prompt devascularization, and the pivotal role of an immediate reconstruction to avoid the additional morbidity of a re-do surgery. Here, we report a case of 68-year-old men who presented with slow growing right parietal bone swelling he noted many years before, but for which he didn't seek medical attentions, associated with mild contralateral hemiparesis. Neuroradiological examinations revealed a giant extradural intradiploic tumor affecting the right temporo-parietal bone and conditioning significant compression of the underlying brain. We planned a surgical strategy to deafferent the tumor and to reduce the intraoperative bleeding. At first, a circumferential craniectomy centered upon the lesion was performed, then it was devascularized by means of surgical ligation of the ipsilateral superficial temporal artery (STA) and middle meningeal artery (MMA); these steps allowed a subsequent en block tumor excision, despite its large size, without significant blood loss and respecting the oncological principles. At the end, a contextual calvarial reconstruction was performed using a precurved titanium mesh. The patient was discharged seven days after surgery with complete recovery of the left-sided motor deficit. Thereafter, he underwent scheduled outpatient evaluations and radiological examinations. At 1-year follow-up, the Modified Rankin Scale (MRS) was 1, with no evidence of recurrent disease. To conclude, surgical complications can be reduced adopting an optimal preoperative work-up and a tailored surgical strategy focused on early tumor deafferentation. Moreover, an immediate cranial vault reconstruction avoids the risks related to a second procedure.
颅板内脑膜瘤是一种罕见的肿瘤，常被误诊为转移瘤或恶性骨肿瘤。由于其广泛的骨侵犯，手术治疗具有挑战性。需要做出两个主要的关键决策：颅骨重建的时机和颅骨修补的合适材料的选择。我们认为，该病例突出了此类病变的复杂性，及时去血管化的重要性，以及即刻重建的关键作用，可避免再次手术带来的额外发病率。在此，我们报告了一例 68 岁男性患者，他多年前出现右顶骨缓慢生长性肿胀，但未寻求医疗关注，伴有轻度对侧偏瘫。神经影像学检查显示，一个巨大的硬膜外颅板内肿瘤影响右颞顶骨，并对下方大脑造成显著压迫。我们计划了一种手术策略，以去神经肿瘤并减少术中出血。首先，围绕病变进行了环形颅骨切除术，然后通过手术结扎同侧颞浅动脉（STA）和脑膜中动脉（MMA）使肿瘤去血管化；尽管肿瘤体积较大，但这些步骤允许随后整块切除肿瘤，而不会大量失血，并遵循肿瘤学原则。最后，使用预弯曲钛网进行了上下文颅骨重建。术后 7 天，患者出院，左侧运动功能障碍完全恢复。此后，他接受了定期的门诊评估和影像学检查。在 1 年的随访中，改良 Rankin 量表（MRS）为 1，无疾病复发证据。总之，通过优化术前检查和针对早期肿瘤去神经化的个体化手术策略，可以减少手术并发症。此外，即刻颅骨重建可避免与二次手术相关的风险。
