Resection of Aggressive Recurrent Cavernous Sinus Meningioma-Stage 1, IMAX-RAG-MCA Bypass: 2-Dimensional Operative Video

A 56-year-old woman underwent initial resection of a left spheno-caverno-clinoidal meningioma using an orbital zygomatic craniotomy. Residual tumor was left within the left ambient cistern because of adherence to the brainstem and in the cavernous sinus. This was an atypical meningioma (World Health Organization grade 2). The patient received fractionated radiotherapy to the residual disease. The residual tumor within the ambient cistern remained stable; however, the cavernous sinus disease was progressing both radiographically and clinically, causing cavernous sinus syndrome. In addition, the supraclinoid internal carotid artery (ICA) was narrowed and completely encased by the cavernous portion of the tumor. Because of the aggressive nature of atypical meningioma,1-3 surgical resection was planned, with the goals of better disease control and decompressing the optic chiasm. The patient consented to the procedures. The patient passed a balloon test occlusion of the left carotid artery but only through an atretic left A1. Anticipating resection of the cavernous sinus component of the residual tumor including ICA, we decided to proceed with an internal maxillary artery to radial artery graft to middle cerebral artery bypass4 to replace the hemodynamic demand, given the long-term risk of ischemia with an atretic A1. The supraclinoid ICA was permanently occluded immediately distal to the origin of the ophthalmic artery with a surgical clip after the completion of the bypass. Postoperative computed tomography angiography showed patency of the graft. Tumor resection was planned 6 weeks later to allow the maturation of the bypass. The patient tolerated the bypass surgery well.