Interhemispheric Precuneus Retrosplenial Transfalcine Approach for Falcotentorial Meningiomas: Anatomic Study and Clinical Series

Background: Falcotentorial meningiomas are surgically challenging. Currently accepted approaches include occipital interhemispheric and supracerebellar infratentorial approaches, which have documented drawbacks.

Objective: To propose an alternative approach to the posterior tentorial incisural space, the interhemispheric precuneus retrosplenial transfalcine approach (IPRTA).

Methods: A total of 6 colored-silicone-injected adult cadaveric heads were dissected. We measured the interval between bridging veins and studied computed tomography venography scans of 20 subjects to confirm the feasibility of the IPRTA. Bony landmarks, the region's bridging veins, and the anterior and posterior borders of the approach were identified. The surgical corridor widths (veins' interval) and lengths were compared between alternative midline approaches. We also reviewed 4 consecutive clinical cases using this approach.

Results: The IPRTA provides the shortest distance to the anterior and posterior limits of the posterior tentorial incisura. Moreover, it is the only approach that provides direct visualization of the anterior and posterior limits of falcotentorial junction meningiomas. In all specimens and patients, a minimum 30-mm interval between the anterior and posterior parietal veins was found in at least one of the hemispheres. Tumor removal was successful in all 4 patients but resulted in mild paresthesia in the lower extremities of 2 patients and temporary foot drop in 1 patient.

Conclusion: The IPRTA offers the shortest and most direct corridor for falcotentorial meningiomas and provides excellent visualization of most of the critical structures in the region. Detailed preoperative evaluation of the deep and superficial venous structures is recommended.