Surgical Treatment of Parasagittal Meningiomas

Surgery of parasagittal meningiomas may represent a real challenge when the superior sagittal sinus (SSS) is involved. The surgeon is often faced with bridging veins, which must be preserved to prevent massive postoperative neurological deficit. Today, magnetic resonance imaging (MRI) is the examination of choice. Magnetic resonance angiography (MRA) allows a precise study of the venous circulation. Indeed, surgery of parasagittal meningioma consists mainly of surgery and dissection of all the veins that surround the tumor, including bridging and parasagittal veins, SSS, and collateral channels. MRA shows whether or not the SSS is patent, demonstrates the direction of venous flow, and helps in planning surgical technique.The goal is complete removal of the tumor, but quality of life issues must be considered. In the past 10 years, a less aggressive attitude toward SSS reconstruction has evolved. When more than one wall is invaded, we favor resection of the tumor outside the SSS and yearly MRI follow-up. When residual tumor grows, we treat with radiosurgery. When the SSS is occluded, we may remove it without grafting, preserving all the collateral venous channels, which have been carefully analyzed by MRA.