Precision in Complexity: A Protocol-Driven Quantitative Anatomic Strategy for Giant Olfactory Groove Meningioma Resection in a High-Risk Geriatric Patient.

Background/Objectives: Managing large midline olfactory groove meningiomas is especially difficult in elderly patients who have limited physiological reserves. Here we describe a unique and dangerous geriatric case where we used new quantifiable anatomical measurements and developed a structured multidisciplinary preoperative and postoperative protocol to assist in all aspects of surgery. Case Presentation: A 68-year-old male with fronto-lobe syndrome and disability (astasia-abasia; Tinetti Balance Score of 4/16 and Gait Score of 0/12) as well as cognitive dysfunction (MoCA score of 12/30) and blindness bilaterally. Imaging prior to surgery demonstrated a very large olfactory groove meningioma which severely compressed both optic pathways at the level of the optic canals (up to 71% reduction in cross-sectional area of the optic nerves) and had complex vascular relationships with the anterior cerebral artery complex (210° contact surface). Due to significant cardiovascular disease and liver disease, his care followed a coordinated optimization protocol for the perioperative period. He underwent bifrontal craniotomy, initial early devascularization and then staged ultrasonic internal decompression (approximately 70% reduction in tumor volume) and finally microsurgical dissection of the tumor under multi-modal monitoring of neurophysiology. Discussion: We analyzed his imaging data prior to surgery using a standardized measurement protocol to provide quantitative measures of the degree of compression of the optic pathways (traction-stretch index = 1.93; optic angulation = 47.3°). These quantitative measures allowed us to make a risk-based evaluation of the anatomy and to guide our choices of corridors through which to dissect and remove the tumor. Following surgery, imaging studies demonstrated complete removal of the tumor with significant relief of the frontal lobe and optic apparatus from compression. His pathology showed that he had a WHO Grade I meningioma with an AKT1(E17K) mutation identified on molecular profiling. Conclusions: This case is intended to demonstrate the feasibility of integrating quantitative anatomical measurements into a multidisciplinary, protocol-based perioperative pathway to maximize the safety and effectiveness of the surgical removal of a complex and high-risk skull-base tumor. While the proposed quantitative indices are experimental and require additional validation, the use of a systematic approach such as this may serve as a useful paradigm for other complex skull-base cases.