title: Is "en-bloc" excision, an option for select large vascular meningiomas?
abstract: BACKGROUND
  Large highly vascular meningiomas surgically challenging when preoperative embolization is not feasible.
  
  
  METHODS
  We present an illustrative case of 'en bloc' excision of a highly vascular giant lateral sphenoid wing meningioma using the technique of 4 D's. After ruling out neurovascular encasement and significant brain interposition, our technique consisted of devascularization, diminutive dural opening, early detachment, and progressively deeper circumferential dissection. "En bloc" delivery was aided by the underlying brain pulsations and edema with no retraction or manipulation. This was successfully employed in a series of seven more patients with large meningiomas with less blood loss. All the patients recovered well with no clinical or radiological sequelae.
  
  
  CONCLUSIONS
  In select large vascular meningiomas, en bloc excision appears to be a simple, safe, and effective alternative to piecemeal excision, which can be performed in any set-up.
authors.affiliation: Department of Neurosurgery, Post Graduate Institute of Medical Education and Research, Chandigarh, India.
authors.forename: Sivashanmugam
authors.initials: S
authors.lastname: Dhandapani
authors.forename: Karamchand
authors.initials: K
authors.lastname: Sharma
keywords: Meningioma; blood loss; en bloc; excision; piecemeal
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