Occipito-transtentorial approach for falcotentorial meningiomas: how I do it

BACKGROUND: Falcotentorial meningiomas are rare tumors that arise at the junction of the dural folds of the tentorium and falx cerebri, at the junction of the vein of Galen with the straight sinus with possible extensions along the course of the straight sinus. Surgery of falcotentorial meningiomas remains challenging due to the intimate neurovascular relationships in the posterior incisural space. METHODS: We describe the key steps of the occipito-transtentorial approach for falcotentorial meningiomas with a video illustration. The surgical anatomy is described along with the advantages and limitations of this approach. CONCLUSION: The occipito-transtentorial approach offers good surgical exposure and outcomes in carefully selected patients harboring falcotentorial meningiomas. Precise understanding of the relationship between the tumor and the internal cerebral veins, basal veins, and vein of Galen should be thoroughly analyzed as these structures may be infiltrated or displaced. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1007/s00701-022-05236-4.