Tuberculum Sellae Meningiomas Operated on by Supraorbital Minimal Craniotomy

Abstract

Aim of the Study: The concept of the minimally invasive keyhole approach in neurosurgery has been increasingly used in past years. The approach is different from standard craniotomy because of the smaller size of the skin incision and bone window; distinct microneurosurgical technique; and instrumentation, including endoscopic assistance. It involves a small supraorbital craniotomy of 2.5 cm × 1.5 cm, with the skin incision in the eyebrow. It is most suitable for tumors in the sellar region, especially for tuberculum sellae meningiomas. Patients and Methods: Between 1996 and 2010, we operated on 78 patients with tuberculum sellae meningiomas using this approach. There were 48 (61.5%) women and 30 (38.5 %) men with an age range of 28 to 76 years. Preoperative and postoperative CT scans and MRI were performed, as well as angiography if there were main vessels incorporated in tumor. The tumor sizes were from 1.8 cm to 5.6 cm. The follow-up period was from 6 months to 6 years. Results: In all operations, the keyhole approach was sufficient for complete exposure of the tumor layer. In 69 cases, gross total resection was successfully performed. Five residual tumors were treated by gamma knife radiosurgery. In two cases, gamma knife radiosurgery was not indicated because the tumor was adherent to the optic nerve so reoperation was performed using the existing craniotomy. Two recurrent tumors needed reoperation, both by pterional craniotomy. Postoperative complications were CSF leakage in five cases, visual impairment in eight cases, local infection in five cases, meningitis in four cases, and seven cases of supraorbital nerve palsies. Conclusion: Comparing the keyhole and standard approaches, we believe that the in-depth manipulative space is identical but there is less opportunity in the former to change the angle of approach during the procedure, so good preoperative planning and the use of endoscope is necessary. This approach has practically replaced pterional craniotomy in patients with this kind of tumor. Therefore, it can be considered to have certain advantages over standard craniotomy, particularly in terms of less brain exposure, shorter operation time, faster recovery, shorter hospitalization, and better cosmetic result.