Surgical Management of Medial Tentorial Meningioma: Falcotentorial and Torcular

Falcotentorial meningiomas (FTM) stand out for their rarity, inconsistent definition, and surgical complexity. It is appropriate to deal with them in the context of medial tentorial meningiomas (TMs). Clinical and radiologic characteristics of medial TMs, comprising the typical features of FTM and TM, along with surgical management and short-term and long-term outcomes, are reported. FTM (n = 16) were typically supratentorial, large, edematous tumors that caused mainly headache and hemianopia; TM (n = 12) were infratentorial, smaller not edematous tumors that caused mainly headache and gait ataxia. The most frequent venous pattern was straight sinus infiltration in one third of cases of FTM and occlusion in one half of cases of TM. Total removal (Simpson grade I–II) was obtained in 46.4% of cases and subtotal removal (Simpson grade III–IV) in 53.6%. Suprainfratentorial extension in FTM and incomplete venous invasion in TM were the factors most likely opposing complete removal. The overall acute complications rate was 32.1% (higher for FTM), transient for most cases. Patients with supratentorial meningiomas performed significantly worse preoperatively (Karnofsky Performance Status ≤70 in 75% of cases); patients with infratentorial symptoms/signs recovered worse postoperatively. Stereotactic radiosurgery with subtotal removal was used as adjuvant treatment in 8 cases. Only 2 recurrences, both atypical tumors, occurred at 57.6 months (mean) follow-up. As a general rule, careful venous management, tailored surgical approach for FTM, and cautious tumor removal for TM can yield good and stable results. Total removal accounts for half the cases in both groups, whereas FTM was associated with worse postoperative complications. •We present a series with large tumors and a high clinical burden.•Falcotentorial must be differentiated from posteromedial incisural and torcular.•Sinus reconstruction is not advised for straight and torcular sinuses.•Collateral venous flow may be not evident inside the tentorium and the falx.•Tailored approach and multiple trajectories are surgical priorities.