Is “en-bloc” excision, an option for select large vascular meningiomas?

BACKGROUND: Large highly vascular meningiomas surgically challenging when preoperative embolization is not feasible. CASE DESCRIPTION: We present an illustrative case of ‘en bloc’ excision of a highly vascular giant lateral sphenoid wing meningioma using the technique of 4 D's. After ruling out neurovascular encasement and significant brain interposition, our technique consisted of devascularization, diminutive dural opening, early detachment, and progressively deeper circumferential dissection. “En bloc” delivery was aided by the underlying brain pulsations and edema with no retraction or manipulation. This was successfully employed in a series of seven more patients with large meningiomas with less blood loss. All the patients recovered well with no clinical or radiological sequelae. CONCLUSION: In select large vascular meningiomas, en bloc excision appears to be a simple, safe, and effective alternative to piecemeal excision, which can be performed in any set-up.