Meningiomas

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be considered in this situation include the transoccipital/transtentorial approach with the patient in the prone position, or the infratento-rial/supracerebellar approach with the patient in the modified park-bench (the "Concorde") position (Fig. 12.2).

For superficial tumors (e.g. convexity or parasagittal), the planned scalp flap should contain the tumor in the center, and the patient is positioned so that the tumor is at the highest point. Importantly, the incision must be planned to avoid any visible cosmetic defect or significant compromise to the scalp vascular supply. If a horseshoe-shaped incision is planned, the depth must not exceed the width of the flap. Again, for superficial tumors, the size of the scalp and bone flaps must be sufficiently large so as to allow for maximal exposure of the tumor, the involved bone and dura, as well as the limits of the dural tail as noted on pre-oper-ative MRI scans. With the availability of frame-less stereotactic image-guidance systems, the exact extent of the tumor and the dural tail may be fully delineated before surgery. This aids in optimal positioning and placement of incision and craniotomy.

An optimal approach should provide the shortest and most direct route to the tumor without "sacrificing" any normal brain tissue or creating undue brain damage by retraction. The need for retraction is minimized by taking advantage of gravity. For example, for surgery

Fig. 12.2. Coronal and sagittal gadolinium-enhanced T1-weighted MR images of a 55-year-old female patient who presented with headache and unsteady gait (upper left and upper right). Because of the small posterior fossa and the near-vertical tentorial angle noted on the sagittal MRI (upper right), the tumor was approached via the occipital interhemispheric/transtentorial route with the patient in the prone position. Following total resection (lower left and lower right), her presenting symptoms resolved completely.

Fig. 12.2. Coronal and sagittal gadolinium-enhanced T1-weighted MR images of a 55-year-old female patient who presented with headache and unsteady gait (upper left and upper right). Because of the small posterior fossa and the near-vertical tentorial angle noted on the sagittal MRI (upper right), the tumor was approached via the occipital interhemispheric/transtentorial route with the patient in the prone position. Following total resection (lower left and lower right), her presenting symptoms resolved completely.

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The Prevention and Treatment of Headaches

The Prevention and Treatment of Headaches

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