Tumor Devascularization

Many meningiomas can be quite vascular. In addition to utilization of pre-operative embolization when appropriate, early operative devascularization of the tumor reduces blood loss and makes surgery easier. In superficial tumors, upon dural exposure prior to opening the dura, extra time should be expended to coagulate all the dural feeding vessels - most commonly the branches or the main trunk of the middle meningeal artery. In olfactory groove meningiomas, bifrontal craniotomy, preferred by many surgeons, provides early access to the main tumor feeders, i.e. ethmoidal arteries, as they enter the medial anterior fossa floor. In large sphenoid wing meningiomas, which receive significant transdural blood supply, utilizing the extradural skull base technique of orbitosphenoid bone removal obliterates many dural feeders prior to dural opening. Similarly, in petroclival meningiomas, the transpetrosal approach allows the exposed petrous dura and tentorium to be aggressively coagulated and may significantly devascularize the tumor. In falcine or tentorial meningiomas, wide exposure and coagulation of the surrounding falx and tentorium reduce tumor vas-cularity. Yasargil advocates initial transtumoral devascularization of basal meningiomas by working through a small "window" created in the tumor to reach the blood supply coming through the base. However, this technique may not be suitable for an inexperienced surgeon as there may be a significant risk of injury to unex-posed neurovascular structures that may be located on the other side of the tumor.

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