J Neurosurg 104:47–53, 2006

Falcotentorial meningioma: surgical outcome in 14 patients

TAKEO GOTO, M.D., KENJI OHATA, M.D., MICHIHARU MORINO, M.D.,
TOSHIHIRO TAKAMI, M.D., NAOHIRO TSUYUGUCHI, M.D., AKIMASA NISHIO, M.D.,
AND MITSUHIRO HARA, M.D.

Department of Neurosurgery, Osaka City University Graduate School of Medicine, Osaka, Japan

Object. The authors evaluated their surgical experience over 20 years with 14 treated falcotentorial meningiomas.
Methods. In the past 20 years, 14 patients with falcotentorial junction meningiomas were surgically treated. There
were seven men and seven women, whose ages ranged from 34 to 79 years. On the basis of neuroimaging studies, the
authors analyzed the influence of the anatomical relationship of the tumor to the vein of Galen, patency of the vein of
Galen, tumor size, and the signal intensities on the magnetic resonance images to determine possible difficulties that
might be encountered during surgery and to prognosticate the outcome of surgery. Depending on the relationship with
the vein of Galen, tumors were labeled as either a superior or an inferior type. All tumors were resected via an occip-
ital transtentorial approach.
The surgical outcome in eight patients was excellent; in the remaining six patients, it was fair. Of the prognostic fac-
tors, tumor location especially seemed to be the most important (p , 0.01, Fisher exact test). The outcome associated
with the inferior type of tumor was significantly less optimal probably due to the relationship to the deep veins and the
brainstem. In this series, the occlusion of deep veins did not significantly influence outcome.
Conclusions. Classification of the tumor location by preoperative neuroimaging studies can be helpful in estimat-
ing the surgical difficulty that might be encountered in treating the falcotentorial junction meningioma.

M
KEY WORDS • meningioma • falcotentorial junction • galenic system

ENINGIOMAS arising from the falcotentorial junction
are relatively rare, and only isolated case reports or
small series related to surgical technique are avail-
able in the literature.1,5,7,8,11–13,16 Because of the lesion’s depth
from the surface and its anatomical proximity with critical
neural and vascular structures, surgical access and tech-
nique are complex issues. A variety of factors influence
surgery and outcome. In this paper, on the basis of our expe-
rience, we analyze a set of factors to determine which prob-
ably influence surgical outcome.
Clinical Material and Methods
Patient Population and Tumor Characteristics
During the years between 1984 and 2004, 14 patients
with falcotentorial junction meningiomas were surgically
treated at our institution by the two senior surgeons (A. Ha-
kuba and K.O.). Pineal region meningiomas that did not
have a dural base in the falcotentorial region were not in-
cluded in this series. There were seven men and seven wom-
en whose ages ranged from 34 to 79 years (mean 57 years;
Table 1). The chief presenting symptoms included severe
headache in five, memory disturbance in five, gait distur-
bance in two, and tinnitus in two patients. All tumors were
exposed via an occipital transtentorial approach. The side of
the surgical approach was dependent on the predominant
side of tumor extension. Four tumors were approached on
the right side and five on the left. In five tumors the ap-
proach was bilateral because the tumor extended widely on
both sides of the midline. Total resection of the tumor was
Abbreviation used in this paper: MR = magnetic resonance.
achieved in 11 patients, and subtotal tumor removal in three.
Among the 11 patients, eight had no postoperative neuro-
logical worsening except for transient hemianopia; the oth-
er three patients experienced postoperative permanent neu-
rological deterioration, including memory disturbance and
hemianopia. Among the three patients who had undergone
a subtotal tumor removal, no neurological deterioration oc-
curred postoperatively. Surgical outcome was graded as sat-
isfactory in eight patients (Cases 1–8) given that the tumors
had been totally removed and there was no permanent neu-
rological deterioration. Outcome was unsatisfactory in six
patients (Cases 9–14) because either the lesions were not to-
tally removed or the patients had permanent functional dete-
rioration following total tumor removal.
Analysis of Prognostic Factors
Preoperative neuroimaging investigations included MR
imaging, MR venography, and angiography. Apart from
evaluating the physical characteristics of the tumor, we
evaluated the relationship of the tumor to the great vein of
Galen, the patency of the vein of Galen, and the straight si-
nus. Depending on the relationship of the tumor to the great
vein of Galen, tumors were classified into two types: tumors
located superior to the vein and compressing it downward
were labeled as the superior type, whereas those displacing
it superiorly were labeled as the inferior type (Fig. 1).
To evaluate prognostic factors, preoperative neuroimag-
ing findings and surgical findings were analyzed in eight
patients (Cases 1–8) with satisfactory outcomes and six
(Cases 9–14) with unsatisfactory outcomes. Neuroimag-
ing findings were statistically compared between these two
groups.

J. Neurosurg. / Volume 104 / January, 2006 47

 T. Goto, et al.

TABLE 1
Summary of characteristics in 14 patients with falcotentorial junction meningiomas
Case Age (yrs), Chief Extent of Follow Up Outcome
No. Sex Symptom Tumor Removal Complications (mos) Group

1 49, F headache total none 238 satisfactory

2 50, F headache total none 221 satisfactory
3 55, F memory disturbance total none 220 satisfactory
4* 54, M memory disturbance total none 217 satisfactory
5 47, M headache total transient hemianopia 187 satisfactory
6 63, M memory disturbance total none 90 satisfactory
7 34, M tinnitus total none 70 satisfactory
8 69, M headache total none 51 satisfactory
9 69, F memory disturbance total deterioration of memory 126 unsatisfactory
& hemianopia
10 49, F headache total hemianopia 72 unsatisfactory
11 62, F gait disturbance total memory disturbance 60 unsatisfactory
12 79, M gait disturbance subtotal none 50 unsatisfactory
13 57, F tinnitus subtotal none 41 unsatisfactory
14 61, M memory disturbance subtotal none 38 unsatisfactory
* The MR imaging unit was not used before surgery in this case.

Results presumed to be due to postoperative dysfunction of the left

Neuroimaging characteristics and surgical results are
summarized in Table 2. In the satisfactory-outcome group
(Cases 1–8), the tumor did not tightly adhere to the straight
sinus, deep veins (great vein of Galen and basal vein), col-
lateral venous channels, or brainstem. Only one patient
(Case 3) required suturing of the injured venous wall at a
single point during surgical procedures. This situation en-
abled the surgeons to remove the tumor totally without sur-
gical complication. On the other hand, in the three cases
(Cases 9–11) in which there was an unsatisfactory outcome,
there was tight adhesion or proximity between the tumor
and collateral venous channels of the deep veins. In all of
these three cases, there was intraoperative injury to the deep
veins or collateral veins during resection of the tumor. All
of these patients suffered postoperative venous infarction
associated with memory disturbance and hemianopia. The
cause of memory disturbance was unclear, although it was
FIG. 1. Ilustration demonstrating the location type of the tumor.
A tumor located over the vein of Galen and compressing it down-
ward was classified as the superior type, and one situated under the
vein of Galen and dislocating it upward was the inferior type.
mesial temporal lobe structures, which was related to com-
promise of the left basal vein of Rosenthal or the left inter-
nal cerebral vein.
Based on the lessons learned from our experience with
the initial three cases, a small amount of the tumor was left
behind to avoid injury to the deep veins, collateral veins,
and brainstem in the subsequent three cases (Cases 12–14).
Tumor Location Related to the Great Vein of Galen
In the satisfactory-outcome group, seven tumors were
classified as the superior type and one tumor as the inferi-
or type. On the other hand, in the unsatisfactory-outcome
group all six tumors were classified as the inferior type. The
location type was significantly different between the two
outcome groups (p , 0.01, Fisher exact test).
Occlusion of the Great Vein of Galen and the
Straight Sinus
In the satisfactory-outcome group, preoperative inves-
tigations suggested occlusion of the great vein of Galen in
one case and of the straight sinus in another case. In the
unsatisfactory-outcome group, there were three cases of ve-
nous occlusion, one of which involved occlusion of the
straight sinus and two of which involved occlusion of both
the great vein and the straight sinus. Preoperative inves-
tigations in all cases with venous occlusion in both out-
come groups demonstrated well-developed collateral ve-
nous channels. Occlusion of the great vein of Galen and the
straight sinus did not significantly influence surgical out-
come (p = 0.34, Fisher exact test).
Tumor Size
Tumor size ranged from 22 to 58 mm (mean 38.6 mm).
In the satisfactory-outcome group, tumor size was signifi-
cantly larger than that in the unsatisfactory-outcome group
(mean 6 standard deviation, 44 6 9.4 mm compared with
31.3 6 6.1 mm; p , 0.05, Welch t-test).
Magnetic Resonance Imaging Intensity of the Tumor
Eleven patients underwent MR imaging studies before

48 J. Neurosurg. / Volume 104 / January, 2006

Falcotentorial meningioma

TABLE 2
Neuroimaging characteristics and surgical findings in 14 patients with falcotentorial junction meningiomas*
Occlusion of Deep Veins Surgical Findings

Vein Tumor MRI Signal Intensity Injuy to Deep Suturing

Outcome Case Tumor of Straight Size or Collateral of Vein
Group No. Location† Galen Sinus (mm)† T1 T2† Veins Wall

satisfactory 1 superior 45 NE NE
satisfactory 2 superior 40 NE NE
2 2 2 2

satisfactory 3 superior 50 NE NE
2 1 2 2

satisfactory 4‡ superior 58 iso high

2 2 1 1

satisfactory 5 superior 32 iso high

2 2 2 2

satisfactory 6 superior 32 iso high

2 2 2 2

satisfactory 7 inferior 42 iso high

2 2 2 2

satisfactory 8 superior 53 iso high

2 2 2 2

unsatisfactory 9 inferior 31 iso low

1 2 2 2

unsatisfactory 10 inferior 27 iso iso

1 1 1 1

unsatisfactory 11 inferior 38 iso low

2 2 1 1

unsatisfactory 12 inferior 40 iso low

2 1 1 1

unsatisfactory 13 inferior 30 iso iso

1 1 2 2

unsatisfactory 14 inferior 30 low high

2 2 2 2
2 2 2 2
* Iso = isointense; NE = not evaluated; 1 = occluded; 2 = patent.
† This prognostic factor significantly influenced surgical outcome.
‡ The MR imaging unit was not used before surgery in this case.

the operation; three patients were treated before the era of
MR imaging. On T1-weighted MR images, all tumors in the
satisfactory-outcome group and five of six tumors in the
unsatisfactory-outcome group appeared isointense. Signal
intensity on T1-weighted images was not significantly dif-
ferent between the two outcome groups (p = 0.68, Mann–
Whitney U-test). On T2-weighted MR images, four tumors
were hyperintense and one was isointense in the satisfacto-
ry-outcome patients. In the unsatisfactory-outcome group,
the tumor was hyperintense in one case, isointense in two
cases, and hypointense in three cases. The T2-weighted sig-
nal was significantly greater in the satisfactory-outcome
group than that in the unsatisfactory-outcome group (p ,
0.05, Mann–Whitney U-test).
Illustrative Cases
Case 8. This 69-year-old man presented with a 3-month
history of gradually progressing severe headache. There
was no neurological deficit at the time of admission.
Magnetic resonance imaging demonstrated a large mass at
the falcotentorial junction. The size of the tumor was 53
mm in its maximal diameter. On an angiogram and a MR
venogram, the tumor was located over the vein of Galen and
dislocated it downward and was classified as the superi-
or type. The vein of Galen was occluded at the point of en-
try into the straight sinus, and the deep venous flow drained
through the collateral venous channels into the petrosal vein
and the transverse sinus. The tumor was excised via an oc-
cipital transtentorial approach. The tumor had a well-de-
fined plane of dissection from the brainstem, vein of Galen,
straight sinus, and collateral veins. The tumor could be to-
tally removed and there was no postoperative complication
(Fig. 2).
Case 13. This 57-year-old woman, who had presented
with a 2-month history of tinnitus, harbored an inferior type
of falcotentorial meningioma. Although the size of the tu-
mor was not very large (22 mm in its maximal diameter), it
was tightly adhered to the great vein of Galen and basal
veins. A small portion of the tumor was left behind around
these veins to avoid venous damage (Fig. 3). Postoperative-
ly, there was no neurological worsening.

FIG. 2. Case 8. a: Preoperative sagittal contrast-enhanced T1-weighted MR image demonstrating a superior type tu-
mor. b: An MR venogram demonstrating the anatomical relationship between the vein of Galen and the tumor. c: Post-
operative sagittal contrast-enhanced T1-weighted MR image showing total removal of the tumor.

J. Neurosurg. / Volume 104 / January, 2006 49

 T. Goto, et al.

FIG. 3. Case 13. a: Preoperative sagittal contrast-enhanced T1-weighted MR image revealing an inferior type tumor.
b: An MR venogram showing the anatomical relationship between the vein of Galen and the tumor. c: Postoperative sag-
ittal contrast-enhanced T1-weighted MR image demonstrating partial removal of the tumor.

Discussion relatively difficult technically. Resection of the tumor in

Our study data suggested that the tumor location in rela-
tion to the great vein of Galen was the most significant
prognostic factor in surgery for the falcotentorial junction
meningioma. Occlusion of the galenic system, however,
was not an indicator of excellent surgical outcome. The size
of the tumor was not necessarily a prognostic factor given
that all of the large tumors in our series were the superior
type, could be totally resected, and were associated with a
satisfactory outcome. Concerning the MR imaging signal
intensity, it is clear that the softer meningiomas can be more
easily removed than the firmer ones.
A review of the literature demonstrates that preexisting
occlusion of the galenic system and the subsequent de-
velopment of collateral venous circulation is an important
factor when considering surgery on pineal region tumors,
including falcotentorial junction meningiomas.1,3,9,10,14 In
such a situation, however, the collateral venous flow must
be preserved.1,7 In the present study in cases of the inferior
type tumor with an occluded galenic system, dissecting the
tumor from surrounding collateral veins and brainstem was
TABLE 3
Relationship between tumor location and surgical
outcome in 38 cases
No. of Patients
Satis-
Authors & Tumor factory
Year Location Outcome
such cases led to damage of the surrounding structures with
additional neurological deficits. It appeared that in cases in
which the galenic venous system was patent, the surgical
procedure was more difficult because the tumor was tightly
adhered to the venous system. To prevent injury to the deep
vein, a small amount of the tumor can be left behind around
the deep veins to avoid their injury in the context of an infe-
rior type tumor. It was observed that in the case of the supe-
rior type tumor, even when the vein of Galen was patent, a
careful surgical technique enabled the surgeon to separate
the tumor from the vein of Galen. As a result, complete sur-
gical removal could be relatively safely performed in the
case of superior type tumors.
Several types of collateral venous channels developed as
a result of occlusions of the galenic system. Based on our
study data, it appears that collateral channels under the thick
arachnoid septum might be the most functionally and sur-
gically important collateral veins in surgery for the infe-
rior type tumor, because the tumor tends to adhere to all of
the galenic system including possible collateral veins in the
same cistern.
To evaluate the importance of tumor location as a prog-
nostic factor, we reviewed the literature on falcotentorial
junction meningiomas from the past 20 years and found 24
cases to which we could apply our classification system of
tumor location on the basis of neuroimages and lesion de-
scriptions (Table 3).1,5,7,8,11–13,16 Of the 38 cases—that is, 14
from the present study and 24 from the literature—18 were
Unsatis- included in the satisfactory-outcome group and the other 20
factory
Outcome

Suzuki, et al., 1984 superior 1 0

inferior 0 0
Odake & Goel, 1992 superior 0 1
inferior 0 1
Sekhar & Goel, 1992 superior 0 0
inferior 0 1
Asari, et al., 1995 superior 2 0
inferior 2 2
Matsuda & Inagawa, superior 1 1
1995 inferior 0 1
Samii, et al., 1996 superior 0 0
inferior 2 4
Ziyal, et al., 1998 superior 1 0
inferior 0 1
Okami, et al., 2001 superior 1 2
inferior 0 0
present study superior 7 0 FIG. 4. Graph showing the relationship between the tumor loca-
inferior 1 6 tion type and surgical outcome. The location of the tumor was sig-
total 18 20 nificantly different between the two outcome groups (p , 0.01).

50 J. Neurosurg. / Volume 104 / January, 2006

Falcotentorial meningioma

FIG. 5. Drawings depicting the growing process of the superior type falcotentorial junction meningioma. a: The supe-
rior type tumor is originally located in the posterior pericallosal cistern. b: As the tumor increases in size, it pushes down
the quadrigeminal cistern, including the vein of the Galen and basal veins. The tumor and deep veins are in different cis-
terns. There is a thick arachnoid membrane between them.

in the unsatisfactory-outcome group. In the satisfactory-out-
come group, 13 tumors were classified as the superior type
and the other five as the inferior type. In the unsatisfactory-
outcome group, four tumors were categorized as the superi-
or type and the other 16 as the inferior type. Based on our
experience with the cases in our study and those reported in
the literature, it appears that there is a significant difference
in surgical outcome between superior and inferior types of
tumor locations (p , 0.01, Fisher exact test; Fig. 4).
The reason for the relative difficulty in surgical removal
and outcome between superior and inferior types of tumors
could be due to the relationship of the arachnoid membrane
to the deep veins, brainstem, and tumor. In the normal anat-
omy, the thick broad arachnoid membrane, extending from
the tentorial ridge to the splenium, clearly separates the pos-
terior pericallosal cistern from the quadrigeminal cistern,
which includes the great vein of Galen, basal veins, and dor-
sal midbrain.2,4,6,15 It is most likely that the superior type tu-
mor, growing inside the posterior pericallosal cistern, might
compress deep veins over the arachnoid membrane. In this
situation, thick arachnoid membrane septum between two
cisterns protects the deep veins from direct tumor invasion,
which enables the surgeon to dissect the lesion from the
deep veins (Fig. 5). On the other hand, the inferior type tu-
mor, growing in the quadrigeminal cistern, might compress
the deep veins and dorsal midbrain in direct contact with

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 T. Goto, et al.

FIG. 6. Drawings depicting the developmental pattern of the inferior type falcotentorial meningioma. a: From its be-
ginning, the inferior type tumor grows upward in the quadrigeminal cistern, which contains the deep veins. b: The larg-
er the tumor grows, the more severe it adheres to the deep veins because it exists in the same cistern with the deep veins
and there is no arachnoid membrane separating these two structures.

them. Accordingly, in many cases of the inferior type, the
tumor tightly adheres to the vein of Galen, basal vein, col-
lateral veins, and midbrain (Fig. 6).
The arachnoid membrane provides a barrier to prevent
injury of adjacent arteries and nerves during removal of the
meningiomas. This principle can be applied to the falcoten-
torial junction meningioma. Certainly, an invasive menin-
gioma, even if it is the superior type, may have adhesions to
the deep veins; in comparison with tumors having the same
pathological features, however, the surgical difficulty asso-
ciated with the inferior type tumor is remarkable. Samii,
et al.,11 who defined our inferior type of meningioma as a

52 J. Neurosurg. / Volume 104 / January, 2006

Falcotentorial meningioma
posteromedial tentorial edge tumor, reported on the surgical
difficulty associated with the inferior type of meningioma
and suggested that a subtotal tumor removal be performed
to prevent unacceptable morbidity. In our study it is clear
that the surgical difficulty involved in removing the falco-
tentorial junction meningioma depends mainly on the ana-
tomical relationship between the tumor and the deep veins.
Considering the surgical risk involved in excising the infe-
rior type of meningioma, a combination of subtotal tumor
resection and stereotactic radiotherapy might be recom-
mended.
As a surgical strategy, there may be some opinion on the
occipital transtentorial approach for inferior type tumors.
With inferior tumors located below the vein of Galen, a
supracerebellar approach might be advantageous because
the vein of Galen would not be directly in harm’s way. Sur-
geons would not have to work through the vein and its trib-
utaries. Hereafter, we must consider a supracerebellar ap-
proach to inferior type tumors.
Conclusions
Classification of tumor location by using preoperative
neuroimaging studies can assist the surgeon in evaluating
the extent of possible surgical difficulties and in predicting
the outcome.
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Manuscript received May 26, 2005.
Accepted in final form September 29, 2005.
Address reprint requests to: Kenji Ohata, M.D., 1-4-3 Asahi-
machi, Abeno-ku, Osaka 545-8586, Japan. email: kohata@med.
osaka-cu.ac.jp.
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