Purely endoscopic removal of a parasagittal/falx meningioma

Background: Endoscopic techniques are an integral part of the neurosurgical armamentarium with a growing list of indications. We describe the purely endoscopic removal of an atypical parasagittal meningioma in a patient who could not undergo standard craniotomy due to severe scalp atrophy following childhood irradiation for tinea capitis. Methods: A 68-year-old man in good general health presented with a parasagittal meningioma that recurred following subtotal removal and adjuvant fractionated stereotactic radiosurgery (FSR). The scalp above the tumor location was very diseased and precluded a regular craniotomy for tumor removal. A 4-cm craniotomy was made in the midline forehead, where the skin was normal. A rigid endoscope was advanced under neuronavigation through the interhemispheric fissure, which provided good access with limited retraction, until the tumor was encountered at a depth of 7–8 cm. Two surgeons performed the surgery using a “four-hands technique”. The tumor was removed and the insertion area was resected and coagulated. Results: The surgery was uneventful, with no coagulation or transection of major veins. A subtotal resection was achieved, and the patient recovered with no neurological deficit. Conclusions: Safe resection of parasagittal meningiomas with a purely endoscopic technique is feasible.