File 12: FALX MENINGIOMA
| FIG. 17.16. Falx meningioma.
This 45-year-old woman presented with headache and a feeling
of heaviness and progressive loss of function in the right lower
extremity. After total removal there was a temporary increase
in hemiparesis that was followed by recovery with minimal residual
weakness. (A and B) MRI coronal (A) and
sagittal (B) TI images after gadolinium show the left
falx tumor in relation to the cerebral tissues. (C) The MRI
axial T2 image shows the displacement and course of the anterior
cerebral artery and the edema in the adjacent brain areas. (D)
An angiogram is needed to see the position of the cortical
veins in order to plan the operation.
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Meningioma Treatment Homepage
To the Introduction and Contents of Management
of Cranial and Spinal Meningiomas
G. OJEMANN, M.D.
© Congress of Neurological Surgeons
Honored Guest Presentation
Originally Published Clinical Neurosurgery, Volume 40, Chapter
17, Pages 321-383, 1992
Used with permission of the Congress of Neurological Surgeons.
HTML Editor: Stephen
B. Tatter, M.D., Ph.D.
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| FIG. 17.17. Falx meningioma.
This 50-year-old woman presented with a mild frontal lobe syndrome.
Complete removal was followed by a good recovery. (A and
B) MRI axial (A) and coronal (B) T1 images
after gadolinium, showing a large right anterior falx meningioma.
Note the displacement of the anterior cerebral artery to the
(Meningioma Management, File 12)
Meningiomas arising from the falx
can also be classified into anterior, middle, and posterior thirds,
as described for parasagittal meningiomas (20, 35). These tumors
are completely covered by the overlying cortex and tend to grow
predominately into one cerebral hemisphere but are often bilateral.
In some patients the tumor grows into the inferior edge of the sagittal
MRI defines the tumor and may give
information relative to the relationship of the anterior cerebral
artery branches (Fig. 17.16, A-C). However, in patients with tumors
at and posterior to the coronal suture an angiogram is needed to
clarify this relationship as well as the position of the cortical
veins, which is important in planning surgery (Fig. 17.16D).
The indications for treatment are the
same as outlined for parasagittal meningiomas. The details of the
operative procedure have been described (26, 35, 38, 42, 47). Most
of the key considerations are the same as those described for parasagittal
meningioma. Additional considerations include the following.
| FIG. 17.18. Falx meningioma.
Exposure of the tumor between two cortical veins. Only enough
retraction to expose a little more than 1 cm of the tumor capsule
- Exposure of the tumor is planned
in relation to the draining cortical vein for tumors in the middle
and posterior thirds of the falx (Fig. 17.16D). In the anterior
third it is usually possible to take the draining veins and the
sagittal sinus, if necessary, to complete the resection (Fig.
- It is important to avoid excessive
retraction of the cerebral cortex. Only I cm, or at most 2 cm,
of the surface of the tumor needs to be seen (FIG. 17.18).
- The falx is divided around the area
of attachment or the tumor is transsected parallel to the falx
so the bulk of the tumor can be mobilized.
- An extensive internal decompression
is done so the capsule can be gradually drawn into the area of
- The falx attachment is excised.
If tumor extends to the opposite side, it can usually be removed
through the opening in the falx.
| FIG. 17.19. Falx meningioma.
This 90-year-old woman presented with headaches and deteriorating
mental function over several months. She had been living alone
and had normal mental function. Removal was followed by full
recovery. (A-D) CT scans after contrast, showing a right
frontal meningioma with edema. At operation there was a thin
layer of cortex over the tumor.
There were 14 patients, including nine
women and five men ranging in age from 10 to 90 years, with three
over 70 years of age (Table 17. 1 1). Of the 14 patients 13 had
a good outcome and one was better but had residual preoperative
deficits. A total removal was done in 12 patients, one had subtotal
removal because of involvement with the anterior cerebral artery,
and one a radical subtotal removal because of tumor in the inferior
wall of an open sagittal sinus. Three patients had significant temporary
worsening, which recovered over weeks to months. There has been
no evidence of recurrence in any patient, including those with subtotal
removal, over 8 years.
The largest tumor (Fig. 17.17) and
the oldest patient with an intracranial tumor (Fig. 17.19) in this
series involved falx meningiomas. As noted in the introduction,
age by itself has not been a limiting factor in recommending surgical
treatment. This last patient lived alone and had normal mental function
and good medical condition prior to the onset of a frontal lobe
syndrome. Removal of the meningioma was followed by a full recovery
and independent living.
|TABLE 17.11 Falcine
aT, total removal
RST, radical subtotal removal
ST, subtotal removal
bGood, free of major
and able to return to previous activity level
Fair, independent but not able
to return to full activity
because of new neurological deficit or significant
preoperative deficit that did not fully recover
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