Multi-staged approach for safe removal of tentorial meningioma – A case report

Falcotentorial meningiomas are rare and comprise only 0.3-1.1% of all meningiomas. The choice of surgical strategy for such lesions is not straightforward. 46 year old female came to our institute with complaints of gradually intensifying headache since 3 months which had aggravated over a period of 5 days. MRI Brain with contrast was done which showed a large, well circumscribed, lobulated, midline, extra-axial lesion attached to the posterior third of the falx and the anterior lip of the tentorium. The surgical plan was to excise the infra tentorial portion, for which a Steins (supra cerebellar infra tentorial) approach was deployed. Attempts to approach the supratentorial portion by incising the tentorium were unsuccessful as the required trajectory was far too acute. The supra tentorial portion would have to be approached by a more cranial trajectory, and hence it was decided to tackle that portion at a second stage. Some tumors may not be amenable to total excision in a single sitting. This case is being reported to underline the importance of a delayed 2 stage approach to excise this complex genre of Falcotentorial meningiomas which invade the supra and infra tentorial compartments.