Circular multiple burr hole for surgical removal of an extra and intracranial meningioma (technical note)

Introduction. Intracranial meningiomas are the most common primary central nervous system tumors and are mostly benign, arising from the meninges surrounding the brain, nerves, and vessels. An obstacle to the surgical resection of meningiomas is the risk of injury to the superior sagittal sinus and the resulting compromise to the integrity of the venous drainage. This article describes a circular multiple trepanation technique, which can be used to safely perform resection of extracranial and intracranial meningiomas, aiming to reach the largest possible tumor area, since patient prognosis is directly proportional to tumor resection.

Surgical technique. The first step is to make a horseshoe incision, then drill burr holes, forming a circumference around the bone meningioma. The next step is to connect the orifices, incising the dura mater affected by the tumor along the periphery of the extracranial meningioma. Subsequently, the bone and the dura mater are elevated. Thus, the bone and dural part are separated from the intradural part, which is, in turn, removed later. Results. The circular multiple trepanation technique was performed and a gross total resection of the extracranial and intracranial meningioma (Simpson grade I) was achieved. The postoperative period showed positive results, with an improvement in the patient’s eye disorder and interruption of generalized tonic‑clonic seizures.

Conclusion. The circular multiple trepanation approach for treating extracranial and intracranial meningiomas described in this note is performed safely and effectively, with good patient prognosis. Although it is a recognized option, it has been insufficiently described, and it is therefore important to expand the knowledge and proper use of this technique among neurosurgeons.

1. Bailo M., Gagliardi F., Boari N. et al. The Role of Surgery in Meningiomas. Curr Treat Options Neurol 2019;21(10):51. DOI: 10.1007/s11940-019-0587-9

2. Rockhill J., Mrugala M., Chamberlain M.C. Intracranial meningiomas: an overview of diagnosis and treatment. Neurosurg Focus 2007;23(4):E1. DOI: 10.3171/FOC-07/10/E13.

3. Buerki R.A., Horbinski C.M., Kruser T. et al. An overview of meningiomas. Future Oncol 09 2018;14(21):2161–77. DOI: 10.2217/fon-2018-0006

4. Rushing E.J., Bouffard J.P., McCall S. et al. Primary extracranial meningiomas: an analysis of 146 cases. Head Neck Pathol 2009;3(2):116–30. DOI: 10.1007/s12105-009-0118-1

5. Narayan V., Bir S.C., Mohammed N. et al. Surgical management of giant intracranial meningioma: operative nuances, challenges, and outcome. World Neurosurg 2018;110:e32–41. DOI: 10.1016/j.wneu.2017.09.184

6. Tomasello F., Conti A., Cardali S., Angileri F.F. Venous preservation-guided resection: a changing paradigm in parasagittal meningioma surgery. J Neurosurg 2013;119(1):74–81. DOI: 10.3171/2012.11.JNS112011

7. Mathiesen T. Parasagittal meningiomas. Handb Clin Neurol 2020;170:93–100. DOI: 10.1016/B978-0-12-822198-3.00031-8

8. Cohen-Gadol A.A. Parasagittal Meningioma. In: Neurosurgical Atlas. Available: DOI: 10.18791/nsatlas.v4.ch02.2

9. Ricci A., Di Vitantonio H., De Paulis D. et al. Parasagittal meningiomas: Our surgical experience and the reconstruction technique of the superior sagittal sinus. Surg Neurol Int 2017;8:1. DOI: 10.4103/2152-7806.198728

10. Pires De Aguiar P.H., Paiva W.S., De Santana P.A., Isolan G. Tentorial posterior fossa meningioma: Which is the ideal surgical approach: Supra/infratentorial combined or retrosigmoid? Neurosurg Q 2009;19(1). DOI: 10.1097/WNQ.0b013e31818d0fcb

11. Rai S.K.R., Dandpat S.K., Jadhav D. et al. Optimizing Burr Hole Placement for Craniotomy: A Technical Note. J Neurosci Rural Pract 2019;10(3):413–6. DOI: 10.1055/s-0039-1695699

12. Pires de Aguiar P.H., Aires R., Maldaun M.V. et al. Is sagittal sinus resection in falcine meningiomas a factor of bad surgical outcome? Surg Neurol Int 2010;1:64. DOI: 10.4103/2152-7806.71983

13. Cohen-Gadol A. Parietal Craniotomy. In: Neurosurgical Atlas. Available: DOI: 10.18791/nsatlas.v2.ch03

14. Burke J., Han S.J., Han J.H., McDermott M.W. Two-Part Parasagittal Craniotomy: Technical Note. Cureus 2014. DOI: 10.7759/cureus.193

15. Spektor S., Margolin E., Eliashar R., Moscovici S. Purely endoscopic removal of a parasagittal/falx meningioma. Acta Neurochir (Wien) 2016;158(3):451–6. DOI: 10.1007/s00701-0152689-9