Diaphragma Sellae Meningiomas Research Articles

Suprasellar Meningioma Classification: Endoscopic Transnasal Perspective.

Objectives Midline suprasellar meningiomas include planum sphenoidale, tuberculum sellae, and diaphragma sellae meningiomas. Multiple classifications have been previously documented; however, they come with controversies and limitations, including those with surgical implications. The aim of this study was to classify suprasellar meningiomas based on their behavior toward the underlying bone and neurovascular structures. Methods Patients with newly diagnosed suprasellar meningiomas that underwent extended endoscopic transnasal approach between 2015 and 2021 were included in this study. The following parameters were evaluated: chiasmatic sulcus length, location of the optic chiasm and nerves, optic canal involvement, and vascular displacement. Results We identified 40 cases of midline suprasellar meningiomas, 1 diaphragma sellae meningioma (type A), 10 tuberculum sellae meningiomas (type B), 9 chiasmatic sulcus meningiomas (type C), and 10 planum sphenoidale meningiomas (type D). Asymmetrical visual complaints were most common in chiasmatic sulcus meningiomas, followed by tuberculum sellae meningiomas (66 and 50%, respectively). Chiasmatic sulcus meningiomas showed increased separation between the optic chiasm and the A1/A2 complex (8.9 mm) compared with tuberculum sellae (2.7 mm) and planum sphenoidale (1.9 mm) meningiomas. Compared with other types, increased chiasmatic sulcus length was observed in chiasmatic sulcus meningiomas. Conclusion Preoperative evaluation of bone involvement and tumor relation to neurovascular structures can be used to classify suprasellar meningiomas. Chiasmatic sulcus meningioma is a distinct subtype of suprasellar meningiomas. Its unique behavior toward nearby neurovascular structures could be of surgical value during tumor resection.

Surgery for diaphragma sellae meningioma: how I do it

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.

The extended pterional approach for midline anterior skull base meningiomas

Background: Various surgical approaches for the management of midline anterior skull base meningiomas exist in the literature. The main surgeon target is proper selection the appropriate approach that achieves total removal of the lesion without causing morbidity or mortality and facilitates safe effective removal of the tumour.
 Objectives: To evaluate the role of the extended pterional approach for excision of midline anterior skull base meningiomas as regarding the effectiveness, extent of resection and surgical outcome.
 Patients and methods: This retrospective study involved 23 cases with midline anterior skull base meningiomas resected through the extended pterional approach. Patients' clinical data, operative notes, imaging studies and clinical follow-up data were analyzed and evaluated.
 Results: Tumors studied were 9 olfactory groove meningiomas, 8 tuberculum Sellae meningiomas, 4 planum sphenoidale meningiomas and 2 diaphragma sellae meningiomas. Gross total resection tumour excision in 15 cases (64.5%), subtotal excision in 5 cases (21.5%) and partial excision in 3 cases (14%). Complications were diabetes insipidus (2 cases 8.6%), CSF rhinorrhea (3 cases 12.9%) and visual deterioration (3 cases 12.9%). We had two cases of mortality.
 Conclusion: The extended pterional approach allows safe and effective removal of midline anterior skull base meningiomas. It expands the exposure offered by the classic pterional approach and minimizing the necessity for applying fixed brain retraction with good cosmetic outcome and less approach-related morbidities in comparison with the extensive skull base approaches.

Surgical challenges and outcome of endoscopic endonasal approaches in the management of recurrent pituitary adenomas

Background: Various surgical approaches for the management of midline anterior skull base meningiomas exist in the literature. The main surgeon target is proper selection the appropriate approach that achieves total removal of the lesion without causing morbidity or mortality and facilitates safe effective removal of the tumor.
 Objectives: To evaluate the role of the extended pterional approach for excision of midline anterior skull base meningiomas as regard the effectiveness, extent of resection and surgical outcome.
 Patients and methods: This retrospective study involved 23 cases with midline anterior skull base meningiomas resected through the extended pterional approach. Patients' clinical data, operative notes, imaging studies and clinical follow-up data were analyzed and evaluated.
 Results: Tumors studied were 9 olfactory groove meningiomas, 8 tuberculum Sellae meningiomas, 4 planum sphenoidale meningiomas and 2 diaphragma sellae meningiomas. Gross total resection tumor excision in 15 cases (64.5%), subtotal excision in 5 cases (21.5%) and partial excision in 3 cases (14%). Complications were diabetes insipidus (2 cases 8.6%), CSF rhinorrhea (3 cases 12.9%) and visual deterioration (3 cases 12.9%). We had two cases of mortality.
 Conclusion: The extended pterional approach allows safe and effective removal of midline anterior skull base meningiomas. It expands the exposure offered by the classic pterional approach and minimizing the necessity for applying fixed brain retraction with good cosmetic outcome and less approach related morbidities in comparison with the extensive skull base approaches.

Endoscopic Endonasal Transplanum-Transtuberculum Sellae Approach for the Resection of a Diaphragma Sellae Meningioma.

The endoscopic endonasal approach (EEA) provides a direct access to diaphragma sellae meningiomas. We present a case of a 56-year-old-female with an incidentally diagnosed sellar/suprasellar lesion with no hormonal deficit; thus, she opted for conservative management initially. During her annual follow-up appointment with her ophthalmologist, it was noticed that the patient had right eye peripheral deficit on formal visual field testing. Magnetic resonance imaging (MRI) revealed an enlargement of the sellar/suprasellar mass, causing displacement of the optic chiasm. A transplanum–transtuberculum EEA was performed. Gross-total removal was achieved and closure was done in a multilayer fashion using a collagen matrix, nasoseptal flap. Histopathological examination confirmed a meningioma WHO grade I. There were no intra- or postoperative complications. At 4-year-follow-up, the patient has stable vision and MRI brain showed no recurrence. The link to the video can be found at: https://youtu.be/xY8T9hotlDs .

Meningiomas of the Tuberculum and Diaphragma Sellae

Introduction Although tuberculum sellae (TS) and diaphragma sellae (DS) meningiomas have different anatomical origins, they are frequently discussed as a single entity. Here we review the radiologic and intraoperative findings of TS and DS meningiomas and propose a radiologic classification. Methods We retrospectively reviewed 10 consecutive TS and DS meningiomas. Data regarding clinical presentation, preoperative imaging, and intraoperative findings were analyzed. Three sellar dimensions were measured on magnetic resonance imaging (MRI): the tuberculum-sellar floor interval (TSFI), the planum-tuberculum interval (PTI), and the total height. Results Three distinct anatomical patterns were recognized: exclusively tubercular meningiomas (type A) were accompanied by elongation of the TSFI and, more significantly, of the PTI; combined TS and DS meningiomas (type B) were associated with relative elongation of both the PTI and TSFI; and the sole exclusively DS meningioma (type C) was associated with elongation of neither PTI nor TSFI. Conclusion Suprasellar meningiomas can be classified as tubercular, combined, or diaphragmatic based on preoperative MRI. Exclusively tubercular meningiomas (type A) require only a supradiaphragmatic approach. Tumor involvement of the sellar diaphragm (type B or C) requires resection of the diaphragm and thus a combined infra- and supradiaphragmatic approach.

Planum Sphenoidalis, Tuberculum, and Diaphragma Sellae Meningiomas: A Unique or Three Different Entities?

Objective: Demonstrate within this group the existence of distinct patterns, which could influence the type of treatment. Study Design: Planum sphenoidalis, tuberculum sellae, and diaphragma sellae meningiomas are usually considered as the same entity, known as TSM (tuberculum sellae meningiomas). TSM can origin from dura covering the planum sphenoidalis, limbus sphenoidalis, chiasmatic sulcus, tuberculum sellae, or diaphragma sellae. Methods: In the last 13 years, at our department have been treated 44 TSM. The majority of these cases have been treated by transcranial route. Most of the surgical interventions were performed by pterional approach. Data collection has been based on anatomical characteristics, radiological appearance, and clinical patterns, distinguishing some categories. Results: We suspect that some features could determine the treatment of these lesions: position of nearest vessels (hypophyseal arteries); optic nerves and chiasm position; pituitary stalk displacement; cavernous sinus invasion. Size of lesion is also important for surgical decision-making, including anteroposterior extension and laterolateral diameter. Conclusion: From our analysis, we conclude that some lesions are better approached by transcranial route, respect to diaphragma sellae meningiomas, which could be easily and safely treated by endoscopic approach.

Technical nuances in the management of tuberculum sellae and diaphragma sellae meningiomas

Tuberculum sellae meningiomas (TSMs) and diaphragma sellae meningiomas (DSMs) are challenging lesions to treat due to their proximity to neurovascular structures. The authors reviewed the medical records of patients who underwent surgical excision of TSMs and DSMs from 1990 to 2013. They also describe the technical strategies used to minimize injury to the optic apparatus, vascular structures, and pituitary stalk. Twenty-four patients with TSM and 6 patients with DSM were included in the study. Seventy percent of the tumors were large (≥ 5 cm). The pterional approach was employed in most cases. Optic canal involvement was observed in 4 patients. Twenty-one patients (70%) had visual dysfunction before surgery. At follow-up (median 18 months), visual improvement was noted in 10 (47.6%) of 21 patients. Gross-total excision was achieved in 22 patients (91.6%) with TSM and 5 (83.3%) with DSM. At last follow-up, 28 patients (93.3%) had a Glasgow Outcome Scale score of 5. There were no deaths in this series. Tuberculum and diaphragma sellae meningiomas present a unique subset of tumors due to their location. They can be safely excised with minimal morbidity and mortality using microsurgical techniques. Attention to technical details during surgery leads to greater respectability and superior visual outcome.

Visual Outcome after Frontotemporo-Orbito-Zygomatic Approach Combined with Early Extradural and Intradural Optic Nerve Decompression in Tuberculum and Diaphragma Sellae Meningiomas

Visual Outcome after Frontotemporo-Orbito-Zygomatic Approach Combined with Early Extradural and Intradural Optic Nerve Decompression in Tuberculum and Diaphragma Sellae Meningiomas

Visual outcome after fronto-temporo-orbito-zygomatic approach combined with early extradural and intradural optic nerve decompression in tuberculum and diaphragma sellae meningiomas

ObjectThe surgical challenge of the treatment of tuberculum (TSMs) and diaphragma sellae meningiomas (DSMs) is to preserve or improve the visual function. Extradural and intradural optic nerve decompression should reduce surgical trauma of the nerve achieving a good visual result. MethodsWe reported 37 consecutive TSMs and DSMs operated through fronto-temporo-orbito-zygomatic approach with extradural unroofing of the optical canal and early intradural incision of the dural sheath. Visual data were recorded measuring the visual impairment score (VIS), the visual acuity (VA), the visual field (VF) and the postoperative improvement. ResultsA good visual outcome (VIS improved or unchanged) was obtained in 97.2% of patients (35/36). The evaluation of 72 eyes showed a good outcome (VA and VF unchanged or improved) in 98.6% (71/72 eyes). The degree of preoperative VA and VF impairment was the only factor correlating with the postoperative improvement of VA (P<.001 and P=.018) and VF defect (P<.001). Worsening of visual function occurred in 1/37 patient (2.7%). ConclusionUsing this surgical technique we achieved a high improvement rate of visual defects and a low frequency of worsening.

Extended Transsphenoidal Microsurgical Approach for Diaphragma Sellae and Tuberculum Meningiomas

Diaphragma sellae meningiomas represent a difficult challenge for neurosurgeons; they are generally operated on by a transcranial approach. Some authors reported transsphenoidal surgery in selected cases, but without accurately focusing the surgical technique that should be necessary for removing the typical hard fibrous tissue of the meningioma, that is not aspirable, by this approach. We present the surgical technique and the useful instrumentarium for removing a diaphragma sellae meningioma through an extended microsurgical transsphenoidal approach.

Suprasellar Meningiomas

To the Editor: We read with interest the recent article by Drs. Ciric and Rosenblatt (3) concerning the operative technique used in the surgical excision of suprasellar meningiomas. In our opinion, these authors wrote a clear, step-by-step description of the surgical strategy. Nevertheless, herein we add some observations and ask the authors some questions: The authors presented a series of 24 patients who had undergone surgery between 1971 and 2001. Among these patients, three had meningiomas arising at the level of the anterior clinoid that “also involved the dura of the tuberculum sellae, the diaphragma sellae, or both” (3, p 1372). Why did the authors include these cases in their surgical series? The general consensus is that meningiomas of the clinoid must be distinguished from suprasellar meningiomas because of differences in operative strategy, difficulties encountered, and overall morbidity and mortality (1, 4). Meningiomas of the suprasellar area can be handled safely with the use of a pterional approach. The removal of the orbital rim does not improve a craniotomy cut flush with the roof of the orbit if an adequate extradural resection of the greater and lesser wings of the sphenoid and the opening of the superior orbital fissure have been performed already. We add the extradural removal of the anterior clinoid process if the tumor presents as an extension of the floor of the sella and/or the optic canal, information that is obtained from the MRI scan. In our experience the wide opening of the sylvian fissure with release of cerebrospinal fluid allows to minimize the necessity of brain retraction by means of spatulas, as it appear in the pictures presented through the whole article. We think that the sucker itself can be often used as the only instrument to perform a minimal brain retraction. In the Results, the authors report 7 of 24 patients in whom a subtotal resection of the tumor was achieved and 1 patient in whom partial resection was performed. In such cases, the tumor “straddled (rather than displaced), and in some cases engulfed, the pituitary stalk” (3, p 1377). In our experience, we have found that the main hindrance in performing a radical excision of the tumor is the engulfment of some perforating branches of the anterior communicating artery. The pituitary stalk usually presents its own arachnoidal sheath, which permits a relatively safe microsurgical dissection. Concerning the patient with a “tuberculum clinoid” meningioma infiltrating the optic nerve sheath (3, p 1377), the subtotal resection of the tumor did not result in the regression of a preoperative visual deficit. The same patient showed a “near-complete recovery of vision” (3, p 1377) after radiotherapy focused on the tumor residual. This statement is hard to accept. Radiotherapy in the area of the optic nerve is always a high-risk procedure. Last, we emphasize that the preoperative differential diagnosis between diaphragma sellae meningiomas and nonsecreting pituitary macroadenomas with suprasellar extension may be difficult. This is particularly true in cases of subdiaphragmatic meningiomas—so-called type C meningiomas—according to Kinjo et al. (4). We have collected 42 cases of suprasellar meningiomas from our own surgical series. Among these cases, five patients underwent transsphenoidal surgical exploration because of preoperative misdiagnosis (2). Enrico de Divitiis Giuseppe Mariniello Paolo Cappabianca

Pituitary macroadenoma and diaphragma sellae meningioma: differential diagnosis on MRI.

Diaphragma sellae meningiomas are unusual tumours often not distinguished from pituitary macroadenomas. Preoperative differentiation is essential, because the trans-sphenoidal approach is used for surgical removal of adenomas, while meningiomas are approached via a craniotomy. We reviewed five patients in whom a diaphragma sellae meningioma was initially diagnosed as a nonsecreting pituitary macroadenoma. MRI criteria for differential diagnosis are discussed. The main findings considered are visibility of the pituitary gland, contrast enhancement, the centre of the lesion and sellar enlargement. These criteria, applied to a blind review, allow correct identification of the tumours.