Features of convex and skull base plastic surgery defects in intracranial meningioma recurrence and progression

INTRODUCTION. Recurrent meningiomas surgery has its own features and is more difficult in comparison with the removal of initially identified meningiomas; previous repeated interventions and courses of adjuvant treatment irreversibly disrupt the plasticity and trophism of the head soft tissues, causing a high risk of wound liquorrhea. Extracranial spread of basal recurrent meningiomas also causes a high risk of postoperative liquorrhea. These factors certainly lead to the necessity of the convex and skull base plastic surgery.

AIM. To describe the basic principles and features of convex and skull base plastic surgery defects in recurrent meningiomas, to present a clinical case of microsurgical removal of recurrent intra-extracranial meningioma.

MATERIALS AND METHODS. The study was based on patients (105 cases) with recurrence and progression of intracranial meningiomas with Grade 1–3 according to histology, who were treated in the Department of Neurosurgery No. 4 of the Russian Neurosurgical Institute named after professor A. L. Polenov in the period from 2014 to 2022. A petrospective disease history and our own clinical cases analysis with meningioma recurrence and progression was performed. The result of the plastic surgery was assessed according to control imaging and clinical data: the presence/absence of liquorrhea in the early and long-term postoperative periods; assessment of functional and cosmetic outcomes (in cases of cranial convex plastic surgery).

RESULTS. The plastic surgery using a mesh titanium implant was performed in 12 (52.2 %) patients after recurrent convexital meningiomas (n=23) removal in cases of tumor infiltration and destruction of the calvarial bones. After recurrent skull base meningiomas (n=38) removal the plastic material placement on the skull base was performed only in 7 of 12 (31.6 %) patients in case of no dura mater defect; in case of a meningeal defect – in all 16 (42.1 %) patients; in case of a through defect – in 100 % of cases out of 10 (26.3 %) patients. The skull base plastic surgery made it possible to avoid postoperative liquorrhea in 96 % of patients with meningioma recurrence/ progression (p<0.001).

CONCLUSION. During convex plastic surgery after removal of recurrent meningiomas, it is necessary to take into account the high rigidity of the soft tissues of the skull, choose the titanium mesh implants with the largest radius angle, reconstruct the cranioplate yourself intraoperatively, and pay attention to the main principle of cranioplasty is to complete hermetically sealed closure of the cerebrospinal fluid spaces.

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