Radical resection of meningiomas and arteriovenous fistulas involving critical dural sinus segments: experience with intraoperative sinus pressure monitoring and elective sinus reconstruction in 10 patients.
OBJECTIVE
Radical resection of meningiomas and dural arteriovenous fistulas involving functional major dural sinuses entails the risk of intracranial hypertension and venous infarction. Surgical reconstruction of dural sinuses and bridging veins increases the spectrum of dural sinus conditions that can be treated by complete resection, but indications for venous reconstructions and associated risks are still not well defined. We report our experience with sinus reconstruction based on the intraoperative assessment of collateral venous flow.


METHODS
Radical resection of meningiomas (n = 5) or dural arteriovenous fistulas (n = 5) involving critical segments of dural sinuses was performed in 10 patients. All but two patients were suffering from recurrent disease after incomplete treatment. Tolerance of sinus occlusion was assessed intraoperatively by measuring stump pressure in the superior sagittal sinus during test clamping of the involved sinus segment.


RESULTS
In five patients, the results of pressure monitoring suggested that occlusion of the sinus might not be tolerated. In two other patients, major bridging veins entered the diseased segment. In these patients, the resected sinus segment was reconstructed and bridging veins were reinserted as far as possible. Postoperative graft occlusion occurred in two patients. One patient who was managed without reconstruction sustained a transient postoperative neurological deficit resulting from venous congestion in the vein of Labbé. Postoperative imaging confirmed total elimination of the pathological process in all 10 patients. There was no recurrence of disease during follow-up periods of up to 8 years.


CONCLUSIONS
The monitoring of sinus pressure, together with the possible reconstruction of the diseased sinus, allows complete surgical treatment of dural sinus abnormalities and involves acceptable risk.
Schmid-Elsaesser
R
R
Department of Neurosurgery, Ludwig-Maximilians-Universität, Klinikum Grosshadern, Munich, Germany.
Steiger
H J
HJ
Yousry
T
T
Seelos
K C
KC
Reulen
H J
HJ
D000293:Adolescent; D000328:Adult; D001164:Arteriovenous Fistula / Q000601:surgery*; D002544:Cerebral Infarction / Q000517:prevention & control; D002550:Cerebral Veins / Q000601:surgery; D004388:Dura Mater / Q000098:blood supply* / Q000601:surgery; D005260:Female; D006801:Humans; D002538:Intracranial Arteriovenous Malformations / Q000601:surgery*; D019586:Intracranial Hypertension / Q000517:prevention & control; D007427:Intracranial Pressure; D008297:Male; D008577:Meningeal Neoplasms / Q000601:surgery*; D008579:Meningioma / Q000601:surgery*; D008875:Middle Aged; D016343:Monitoring, Intraoperative; D009493:Neurosurgery / Q000379:methods; D012008:Recurrence; D012307:Risk Factors