Preparation for Surgery on Supratentorial Meningiomas in Children

Indications for Surgery

• Symptomatic: Surgery is indicated if the patient have symptoms of elevated ICP (headache, vomiting, and papilledema), seizures, or focal neurological deficit.

Preoperative Orders

Preoperative orders should generally include (depending on tumor location) steroids and anticonvulsants.

• IV hydration: IVF rate before surgery should be adjusted to avoid over-hydration, especially since many of these tumors may be large, with a roughly 30% association with peritumoral edema. Normal saline or lactated Ringers solution are good choices.
• Steroids: Steroids should be started prior to surgery when there is significant mass effect or edema.  Otherwise it is given at induction of anesthesia.
• Antibiotics: Antibiotics are administered 30-60 minutes before surgery.  An option, which the authors use, is to continue them for 24 hours, unless a drain is present. 
• Drains: CSF drains generally are not required but may be used when the tumor is intraventricular.
• Prep: Surgical site scrub is per the routine of the institution.

Anesthetic Considerations

• Possible significant blood loss: There is potential for transfusion, so the team should be ready with blood.
• Possible elevation in ICP: Mannitol, hyperventilattion, elevation of the HOB and other measures may be required to manage elevated ICP. 
• Possible seizures during surgery: Anticonvulsants for seizure prophylaxis must be available during surgery.

Devices

• Bone fixation device: Depending on the age of the child, absorbable or titanium miniplates are appropriate choices, but other skull fixation techniques such as suture or wire are appropriate depending on the resources of the institution. Other devices and material may be needed to repair dural and bone defects.
• Dural substitutes may include synthetics, such as collagen matrix materials, or cadaveric products such as skin or pericardium.
• Skull reconstruction can be done with synthetics such as hydroxyapatite cement or plastic glues, or with autologous bone from another region of the skull or body. Shunts are rarely necessary.

Specialized Equipment

Ancillary or specialized equipment required for surgery will generally be related to the requirements of intraoperative imaging, as well as consideration of specialized devices to remove the tumor.

• Equipment to consider: Microscope and image guidance may be helpful, especially for tumors adjacent to critical structures. Depending on the tumor and its location, one may also want to use intraoperative ultrasound, ultrasonic aspirator, loop monopolar, nonstick or irrigating bipolar cautery forceps, and/or a laser.