Assessment and Treatment of Peritumoral Cortical Veins in Parasagittal Meningiomas with Application of 3-Dimensional Imaging Fusion Model.

BACKGROUND: Operation of cortical veins is the keystone of parasagittal meningioma (PSM) resection. Little is known about pathologic changes of the veins and proper treatment. We built 3-dimensional (3D) image fusion models by neuronavigation to analyze the features of peritumoral cortical veins for PSMs and explore intraoperative treatment options.

METHODS: We performed a prospective study of 42 consecutive surgically treated PSM patients who underwent preoperative evaluation of peritumoral cortical veins using a 3D venous-tumor fusion model established by a neuronavigation system. We categorized cortical veins into 3 types: single-end anastomosis (type a), tumor-to-end anastomosis (type b), and end-to-end anastomosis (type c). We present surgical strategies to operate these veins.

RESULTS: Preoperative evaluation demonstrated 39 patients with peritumoral cortical veins. The 3D models show 100% of the veins (95 in total), which were confirmed intraoperation. The postoperative complication rates after vein injury were 60% (type a), 16.7% (type c), and 0% (type b). Ten patients (23.8%) had residual tumor because of venous protection (equal to Simpson grade III). After correlation analysis, type b and c cortical veins were positively correlated with tumor volume.

CONCLUSIONS: The anastomoses of cortical veins may provide compensation for venous transaction. There may be a time-evolution relationship between different cortical veins (type a to c to b). Treatment of cortical veins should follow the following principles: single-end veins must be protected, tumor-to-end veins should be transacted directly, and end-to-end veins could be cut selectivity based on the degree of occlusion of the superior sagittal sinus. Detailed preoperative assessment of peritumoral cortical veins is critical for proper treatment.