Brain Tumor Surgery | Prof. Zhou Liangfu (Neurosurgery) | CMCS Shanghai

About Prof. Zhou Liangfu

Academician Zhou Liangfu is one of China's most distinguished neurosurgeons and a member of the Chinese Academy of Engineering — based at Huashan Hospital, Fudan University, which is recognised as one of China's foremost centres for neurosurgical oncology, skull base surgery, and functional neurosurgery, and a national reference institution for the management of complex intracranial tumours including meningiomas, gliomas, and cranial nerve tumours. He is internationally recognised for his pioneering contributions to skull base tumour surgery, awake craniotomy with intraoperative brain mapping, and the development of multimodal intraoperative guidance techniques that have enabled complete tumour resection with preservation of neurological function in cases previously considered inoperable. Prof. Zhou's clinical philosophy holds that the goal of neurosurgical oncology is not simply tumour removal but the achievement of the maximum safe resection — the greatest extent of tumour removal that can be achieved without producing new neurological deficits — and that this goal requires the integration of preoperative multimodal imaging, intraoperative navigation, neurophysiological monitoring, and ultrasound guidance into a unified surgical strategy tailored to the individual patient's tumour anatomy and functional brain organisation. His department at Huashan Hospital has established one of Shanghai's most comprehensive neurosurgical oncology programmes, with a dedicated skull base and venous sinus surgery team whose techniques have been recognised by international peers as among the most refined in cranial base surgery. Research from Prof. Zhou's team has been published in leading international neurosurgical journals including Neurosurgery, and the venous sinus protection techniques developed at Huashan Hospital have been cited by international colleagues as among the most technically precise in skull base surgery.

Case Overview

Mrs. Liu (pseudonym), a Chinese woman, was found to have an intracranial mass on routine health screening — MRI of the brain demonstrating a lesion at the tentorial margin, highly suspicious for meningioma. Further imaging characterised the tumour as a torcular meningioma: a 3 cm × 2.5 cm mass at the confluence of the major dural venous sinuses (torcular herophili), in intimate relationship with the transverse sinuses, straight sinus, and adjacent cerebellar tissue — one of the most surgically hazardous locations in the brain. Left untreated, progressive tumour growth risked compression of critical neurovascular structures with the potential for severe neurological deficits including headache, seizures, and limb sensory disturbance. Following multidisciplinary team (MDT) discussion involving neurosurgery, anaesthesia, neuroradiology, and critical care, the team formulated an individualised surgical strategy incorporating neural navigation, intraoperative ultrasound, and neurophysiological monitoring. Under the technical guidance of Academician Zhou Liangfu, the neurosurgical team performed complete tumour resection via a lateral prone, infratentorial supracerebellar approach — achieving Simpson Grade I resection with full preservation of the venous sinuses, intraoperative blood loss under 200 ml, and no transfusion requirement. The patient recovered with intact neurological function, no new deficits, and no tumour recurrence at three-month follow-up. This case exemplifies the technical standard of Huashan Hospital's skull base neurosurgery programme and the application of multimodal intraoperative guidance to achieve complete resection of a tumour in one of the brain's most surgically demanding locations.

Patient Background

• Name / Nationality: Mrs. Liu (pseudonym) — Chinese female
• Presentation: Incidental intracranial mass identified on routine health screening; no acute neurological symptoms at presentation
• Chief Concern: Intracranial mass at the tentorial margin — torcular meningioma; risk of progressive neurological deterioration with tumour growth including headache, seizures, limb sensory disturbance, and cerebellar dysfunction
• Tumour characteristics: Location: torcular herophili — confluence of the transverse sinuses, straight sinus, and superior sagittal sinus; size: approximately 3 cm × 2.5 cm; relationship to venous sinuses: intimate — partial filling defect of the straight sinus and tumour base on DSA; relationship to cerebellar tissue: direct contact; blood supply: no significant feeding arteries identified on DSA; venous sinus patency: confirmed on DSA with partial filling defect at the tumour base
• Neurological status at presentation: Intact — no motor, sensory, or cerebellar deficits; no headache or seizures; fully independent in activities of daily living

Diagnostic Workup

Neuroimaging

• MRI brain with and without contrast: Mass at the tentorial margin — 3 cm × 2.5 cm; homogeneous contrast enhancement with dural tail sign consistent with meningioma; intimate relationship with the torcular herophili and adjacent cerebellar tissue; no surrounding oedema; no hydrocephalus
• Digital subtraction angiography (DSA): No significant tumour feeding arteries identified — consistent with a relatively avascular meningioma; venous sinus patency confirmed — transverse sinuses and superior sagittal sinus patent; partial filling defect of the straight sinus and at the tumour base — indicating tumour invasion of the sinus wall at the base; collateral venous drainage assessed
• MR venography: Venous sinus anatomy mapped; collateral venous drainage pathways identified; surgical risk of venous sinus injury assessed

Multidisciplinary Team (MDT) Assessment

• MDT discussion: neurosurgery, anaesthesia, neuroradiology, and critical care; surgical risk assessment completed; decision to proceed with surgery confirmed; individualised surgical strategy formulated — lateral prone infratentorial supracerebellar approach; intraoperative neural navigation, ultrasound guidance, and neurophysiological monitoring planned; venous sinus protection strategy defined

Prof. Zhou's pre-operative assessment: The torcular herophili is the most surgically demanding location for a meningioma in the posterior fossa — it is the confluence of the major dural venous sinuses, and injury to any of these sinuses during tumour resection can produce catastrophic venous infarction. The DSA tells us that the straight sinus has a partial filling defect at the tumour base — the tumour has invaded the sinus wall at that point. This means we cannot simply peel the tumour off the sinus — we must work in the plane between the tumour and the sinus wall with extreme precision, using sharp dissection and haemostatic techniques that allow us to separate the tumour from the sinus without tearing the sinus wall. The neural navigation will give us the three-dimensional spatial relationship between the tumour and the sinuses at every moment during the dissection. The intraoperative ultrasound will show us the tumour boundary in real time as we work. The neurophysiological monitoring will tell us immediately if the motor or sensory pathways are being stressed. With all three of these tools working together, we can work with the confidence and precision that this tumour location demands. The goal is Simpson Grade I resection — complete removal of the tumour and its dural attachment — with the sinuses intact. That is what we will achieve.

Surgical Strategy and Operative Technique

The diagnosis was Torcular Meningioma — meningioma at the confluence of the dural venous sinuses (torcular herophili), with partial invasion of the straight sinus wall at the tumour base.

The surgical principle was: complete tumour resection (Simpson Grade I) via the infratentorial supracerebellar approach, with full preservation of the venous sinuses, guided by multimodal intraoperative navigation, ultrasound, and neurophysiological monitoring.

Surgical approach — Lateral Prone Infratentorial Supracerebellar Craniotomy:

• Patient positioning: Lateral prone position — optimising exposure of the torcular region while minimising cerebellar retraction and venous pressure
• Craniotomy: Posterior fossa craniotomy centred on the torcular herophili; bone flap designed to provide maximal exposure of the tumour while preserving the overlying venous sinus anatomy; careful elevation of the bone flap to avoid sinus injury
• Dural opening: Dura opened in a cruciate fashion around the tumour; dural edges reflected; tumour exposed under the operating microscope

Intraoperative guidance technologies:

• Neuronavigation: Preoperative MRI and DSA data integrated into the navigation system; real-time three-dimensional spatial mapping of the tumour boundaries and their relationship to the venous sinuses throughout the dissection; navigation used to plan the surgical corridor and confirm the completeness of resection
• Intraoperative ultrasound: Real-time visualisation of the tumour boundary and its relationship to surrounding cerebellar tissue; guidance of piecemeal tumour resection to maintain orientation within the tumour-brain interface
• Intraoperative neurophysiological monitoring: Continuous monitoring of motor evoked potentials (MEP) and somatosensory evoked potentials (SSEP) throughout the procedure; immediate alert to the surgical team of any signal change indicating stress to the motor or sensory pathways; no significant signal changes recorded during the procedure

Tumour resection — Venous Sinus Protection Technique:

• Tumour devascularisation: Coagulation of the dural attachment and tumour base to reduce intraoperative bleeding prior to tumour removal
• Piecemeal resection: Tumour removed in pieces under microscopic magnification, working from the centre of the tumour outward to decompress the mass and progressively expose the tumour-sinus interface
• Venous sinus dissection — sharp dissection with gelatin sponge compression: At the tumour-sinus interface, where the tumour had invaded the sinus wall, sharp dissection used to separate the tumour capsule from the sinus wall in the correct plane; gelatin sponge compression applied to the sinus wall at points of tumour adherence to achieve haemostasis without sinus occlusion — the Huashan Hospital venous sinus protection technique; no sinus sacrifice performed; sinus integrity confirmed by intraoperative Doppler assessment following tumour removal
• Dural resection: Involved dural attachment resected to achieve Simpson Grade I resection; dural defect repaired with pericranial graft
• Haemostasis and closure: Meticulous haemostasis; intraoperative blood loss 200 ml — no transfusion required; layered wound closure; drain placement

Treatment Course and Outcomes

Intraoperative

• Complete tumour resection achieved — Simpson Grade I; venous sinuses fully preserved — sinus integrity confirmed by intraoperative Doppler; intraoperative blood loss 200 ml — no transfusion; no intraoperative neurophysiological signal changes; procedure completed without complications under the technical guidance of Academician Zhou Liangfu

Immediate Postoperative (Days 1–7)

• Patient alert and oriented on emergence from anaesthesia; neurological examination: intact — no new motor, sensory, or cerebellar deficits; four-limb movement normal
• Postoperative CT brain: complete tumour resection confirmed; no haemorrhage; no cerebral oedema; venous sinus patency maintained
• Uncomplicated postoperative course; early mobilisation per ERAS (Enhanced Recovery After Surgery) protocol; discharged in good condition

Three-Month Follow-Up

• Patient fully independent in all activities of daily living; no headache, seizures, or neurological symptoms
• MRI brain with contrast: no tumour recurrence; resection cavity well-defined; no new lesions; venous sinuses patent
• Neurological examination: fully intact; quality of life: excellent; patient highly satisfied with outcome

Prof. Zhou's clinical reflection: The torcular meningioma is the case that tests every element of a neurosurgical team's capability — the preoperative planning, the intraoperative navigation, the microsurgical technique at the tumour-sinus interface, and the neurophysiological monitoring that tells you in real time whether the pathways you are working near are tolerating the dissection. In this case, every element performed as planned. The sharp dissection with gelatin sponge compression at the sinus wall — the technique we have refined over many years at Huashan Hospital — allowed us to separate the tumour from the sinus wall without tearing the sinus, and the intraoperative Doppler confirmed that the sinus was patent after tumour removal. Simpson Grade I resection with intact sinuses and no new neurological deficit — that is the standard we set for ourselves in torcular meningioma surgery, and this case achieved it. The patient came to us with a tumour that had been described to her as a time bomb. She left the hospital with the tumour completely removed and her brain intact. That is what this team exists to do.

Expert Commentary — Prof. Zhou Liangfu

1. Torcular Meningioma: Surgical Anatomy, Risk Stratification, and the Case for Complete Resection

The torcular herophili — the confluence of the superior sagittal sinus, the straight sinus, and the bilateral transverse sinuses — is the most surgically hazardous location for a meningioma in the posterior fossa. The venous sinuses at the torcular carry the entire venous drainage of the cerebral hemispheres and the cerebellum; injury to any of these sinuses during tumour resection can produce catastrophic venous infarction with devastating neurological consequences. The surgical risk of torcular meningioma resection is therefore determined primarily by the relationship of the tumour to the venous sinuses — specifically, whether the tumour has invaded the sinus lumen, whether the sinus is patent or occluded, and whether collateral venous drainage has developed that would allow sinus sacrifice if required. The Sindou classification of meningioma-sinus relationships provides a framework for surgical planning: Grade I tumours (attached to the outer sinus wall without invasion) carry the lowest surgical risk; Grade VI tumours (complete sinus occlusion with collateral drainage) may allow sinus resection and reconstruction; the intermediate grades — including the partial sinus wall invasion seen in this patient — require the most precise surgical technique, because the sinus must be preserved while the tumour is completely removed from its wall. The case for complete resection — Simpson Grade I — in torcular meningioma is supported by the evidence that incomplete resection is associated with significantly higher rates of tumour recurrence, and that the long-term outcome of a patient with a completely resected meningioma is substantially better than that of a patient managed with subtotal resection and adjuvant radiosurgery. The technical challenge is achieving that complete resection without sinus injury — and that challenge is met by the combination of precise preoperative planning, multimodal intraoperative guidance, and the refined venous sinus protection technique developed at Huashan Hospital.

2. Multimodal Intraoperative Guidance in Skull Base Surgery: Navigation, Ultrasound, and Neurophysiological Monitoring as an Integrated System

The three intraoperative guidance technologies deployed in this case — neuronavigation, intraoperative ultrasound, and neurophysiological monitoring — are not independent tools but components of an integrated guidance system that provides the neurosurgeon with complementary and mutually reinforcing information throughout the procedure. Neuronavigation provides the three-dimensional spatial framework: by registering the preoperative MRI and DSA data to the patient's anatomy in the operating theatre, the navigation system allows the surgeon to know at every moment during the dissection exactly where the tumour boundaries are in relation to the venous sinuses, the cerebellar tissue, and the critical neurovascular structures — even when those structures are not directly visible in the surgical field. Intraoperative ultrasound provides real-time tissue contrast: by imaging the tumour and its surrounding tissue in real time during the resection, the ultrasound allows the surgeon to visualise the tumour boundary as it changes with progressive resection — compensating for the brain shift that occurs during surgery and that progressively degrades the accuracy of the preoperative navigation data. Neurophysiological monitoring provides the functional safety signal: by continuously monitoring the motor evoked potentials and somatosensory evoked potentials throughout the procedure, the monitoring team provides the surgeon with immediate feedback on the functional status of the motor and sensory pathways — alerting the team to any signal change that indicates the pathways are being stressed by the dissection, before that stress produces a permanent deficit. The integration of these three guidance systems — spatial, anatomical, and functional — is what allows the neurosurgical team to work with the precision and confidence that torcular meningioma surgery demands.

3. Venous Sinus Protection in Torcular Meningioma Surgery: The Huashan Hospital Technique and Its International Recognition

The technical challenge that defines torcular meningioma surgery — and distinguishes it from meningioma surgery at other locations — is the management of the tumour-sinus interface: the plane between the tumour capsule and the wall of the venous sinus, where the tumour has adhered to or invaded the sinus wall and where the risk of sinus injury is highest. The venous sinus protection technique developed and refined at Huashan Hospital over decades of torcular meningioma surgery combines three elements: sharp dissection in the correct plane between the tumour capsule and the sinus wall, using microsurgical scissors under high magnification to separate the tumour from the sinus without tearing the sinus wall; gelatin sponge compression applied to the sinus wall at points of tumour adherence, providing haemostasis at the sinus surface without occluding the sinus lumen; and continuous intraoperative Doppler monitoring of sinus flow throughout the dissection, providing real-time confirmation that the sinus remains patent as the tumour is progressively separated from its wall. This technique — which requires years of experience in skull base surgery to execute reliably — has been evaluated by international neurosurgical colleagues and recognised as among the most technically precise approaches to venous sinus preservation in skull base surgery. The results achieved at Huashan Hospital in torcular meningioma surgery — including the Simpson Grade I resection with full sinus preservation achieved in this case — reflect the cumulative technical refinement of this approach over many years and many cases, and the institutional commitment to achieving the highest standard of oncological and functional outcome in the most challenging neurosurgical cases.

How CMCS Shanghai Coordinated This Case

CMCS Shanghai supported Mrs. Liu and her family throughout the diagnostic, surgical, and recovery pathway at Huashan Hospital, Fudan University, including: priority consultation coordination with the Huashan Hospital Neurosurgery department and the MDT team, with bilingual review of all prior MRI, DSA, and clinical records; bilingual interpretation throughout the MDT discussion, surgical planning consultation, and all postoperative review appointments; bilingual explanation of the torcular meningioma diagnosis, the surgical approach, the intraoperative guidance technologies, the venous sinus protection strategy, and the expected surgical risks and outcomes; coordination of preoperative MRI, DSA, and MR venography with bilingual results communication and clinical summary; bilingual surgical consent process — ensuring the patient and family had a complete understanding of the procedure, the risks of venous sinus injury, and the expected neurological outcome; postoperative neurological monitoring coordination with bilingual family communication throughout the recovery period; and three-month follow-up MRI coordination with bilingual results communication and long-term surveillance planning.

For international patients with intracranial meningiomas — including complex skull base and venous sinus tumours — or other brain tumours requiring specialist neurosurgical evaluation and management in Shanghai, Academician Zhou Liangfu's team at Huashan Hospital, Fudan University, offers a world-class neurosurgical oncology programme combining multimodal intraoperative guidance, refined venous sinus protection technique, and multidisciplinary perioperative care to achieve the maximum safe resection with preservation of neurological function. CMCS ensures that expertise is accessible: in the patient's language, with every step of the complex diagnostic and surgical pathway coordinated and communicated clearly, from the first specialist consultation through long-term tumour surveillance.

This case report is de-identified and published for educational purposes. All clinical details have been anonymized in accordance with patient privacy standards. CMCS Shanghai is a medical concierge service and does not provide direct medical care.