Surgery for diaphragma sellae meningioma: how I do it

Amani Belouaer,Daniele Starnoni,Roy Thomas Daniel

doi:10.1007/s00701-020-04581-6

Amani Belouaer, Daniele Starnoni + Show 1 more

Open Access

https://doi.org/10.1007/s00701-020-04581-6

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Abstract

BackgroundSurgery for diaphragma sellae meningiomas (DSM) remains challenging due to the intimate neurovascular relationships of the tumor. Excision of DSM along with a decompression of the optic apparatus requires a good knowledge of the skull base anatomy and a precise preoperative evaluation of the tumor extensions.MethodWe describe the key steps of transcranial approach for DSM with a video illustration. The surgical anatomy is described along with the advantages and limitations of this approach.ConclusionsThe transcranial approach allows a safe tumor excision with an early and adequate control of the neurovascular structures, while minimizing postoperative CSF rhinorrhea.

Highlights

Surgery for diaphragma sellae meningiomas (DSM) remains challenging due to the intimate neurovascular relationships of the tumor
At the level of the optic canal (OC), the optic nerves (ON) is covered by the falciform ligament, which extends from the anterior clinoid process (ACP) to the planum sphenoidale (Fig. 1)
The roof of the OC is formed by the medial root of the ACP, and the inferolateral wall is formed by the optic strut, which separates the OC from the superior orbital fissure (SOF)

Summary

Conclusions

The transcranial approach allows a safe tumor excision with an early and adequate control of the neurovascular structures, while minimizing postoperative CSF rhinorrhea. At the level of the optic canal (OC), the ON is covered by the falciform ligament, which extends from the anterior clinoid process (ACP) to the planum sphenoidale (Fig. 1). To achieve an adequate ON decompression and prevent extensive manipulation of the nerve during tumor removal, an extradural clinoidectomy and opening of the OC is performed. Placed between coagulated dural implantation sites and the optic apparatus to allow radiosurgical treatment if necessary. The extradural clinoidectomy allows reaching the suprasellar region through a lateral subfrontal corridor with minimal brain retraction. The dural implantation on the DS is coagulated, and the tumor capsule progressively dissected from the surrounding structures respecting the arachnoidal plane, allowing a complete resection of the DSM (Fig. 4). Surgery is considered as the first-line treatment option

Limitations

Findings

Compliance with ethical standards