Removal Of Tuberculum Sellae Meningiomas Research Articles

Endoscopic Endonasal and Supraorbital Removal of Tuberculum Sellae Meningiomas: Anatomic Guides and Operative Nuances for Keyhole Approach Selection.

With growing worldwide endoscopy experience, endonasal and supraorbital removal of tuberculum sellae meningiomas (TSM) has increased. To describe anatomic factors for guiding approach selection and outcomes. Retrospective analysis of patients undergoing endonasal or supraorbital TSM resection: approach criteria, clinical outcomes, acute magnetic resonance imaging (MRI) fluid-attenuated inversion-recovery (FLAIR)/T2 changes. From 2008 to 2020, 33 patients (mean age 55±11 yr) were identified: 20 (61%) had endonasal and 13 (39%) supraorbital removal. Comparing endonasal and supraorbital approaches, mean tumor volume (3.7±3.5 cm3 vs 7.7±8.5 cm3, P=.07); percent tumor above planum (42% vs 65%, P=.02), and lateral tumor beyond supraclinoid internal carotid arteries (1.4±2.0 mm vs 4.0±3.2 mm, P=.006) were greater for supraorbital route. Sellar depth was greater for endonasal route tumors (12.2±2.6 mm vs 9.3±2.4 mm, P=.003). Endoscopy, used in 10/13(77%) supraorbital cases, was helpful in additional tumor removal in 4/10(40%). Gross total removal and mean volumetric tumor resection were 16/20(80%) and 97.5% by endonasal, and 5/13(39%) and 96% by supraorbital route. Vision improved in 12/17 (71%) endonasal, 6/8 (75%) supraorbital operations, and worsened in 1 (3%) supraorbital case. Endonasal approach with optic canal decompression increased over study period: 15/20 (75%) endonasal patients vs 1/13(8%) supraorbital (P<.001). Postoperative FLAIR/T2 MRI changes occurred in 2/12 supraorbital and 0/20 endonasal cases. In our experience, both endonasal and supraorbital routes are safe and effective for TSM removal. Greater tumor extension below planum and medial optic canal invasion favor endonasal route, while larger size and lateral extension favor supraorbital route. Given high frequency of TSM growth into optic canals and better access for medial optic canal tumor removal, endonasal route may be preferred for most TSMs.

Transpalpebral Approach for Microsurgical Removal of Tuberculum Sellae Meningiomas.

Background:The evolution of skull base approaches associated with individualization of surgical corridor and minimizing the collateral damage. Achieving the radical removal of tumor and preserving the neurological status of the patient is possible, both with the traditional approaches and keyhole approaches. Our work presents experience using the transpalpebral approach (TPA) for microsurgical removal of tuberculum sellae meningioma (TSM).Materials and Methods:A total of 15 patients with meningiomas underwent microsurgical removal of TSM through TPA. Ten patients were women and five were men. The standard preoperative diagnostic protocol includes magnetic resonance imaging with contrast enhancement, brain computed tomography for neuronavigation. We assess surgical complications, functional and cosmetic outcomes, and surgical parameters, including the time of surgery and intraoperative blood loss.Results:Visual impairment was finding in 100% patients, including slight decrease of vision (46,7%, seven patients), partial vision field loss (six patients, 40%), and serious visual impairment (two patients 13.3%). Visual improvement was noted in ten cases (66.7%), there was no improvement in four cases (26.7%), and one case (6.6%) had transient visual worsening for 4 days and slow improvement in 1 month. Headache disappeared in three patients (50%). There were no cases of cerebrospinal fluid leak. Transient frontal hypoesthesia was noted in all patients (100%) without permanent deficit. Transient palsy of the frontal muscle was noted in four patients for 4–6 months. Histological examination revealed WHO Grade I meningioma in 14 cases and in 1 case WHO Grade II meningioma. No deaths were identified in follow-up at 12 months. The average value of the Modified Rankin Scale was 1.4. The mean length of stay in hospital was 5.Conclusion:TPA is technically difficult and requires some experience to work in deep structures in a small surgical corridor. This technique can be good alternative to traditional fronto-lateral, supraorbital keyhole craniotomies, and endoscopic endonasal approaches.

Lateral Supraorbital Approach Applied to Tuberculum Sellae Meningiomas

Various surgical approaches for the removal of tuberculum sellae meningiomas (TSMs) have previously been described. To assess the reliability and safety of the lateral supraorbital (LSO) approach to remove TSMs. We identified all TSM patients operated on at the Department of Neurosurgery at Helsinki University Central Hospital, Finland, by the senior author (J.H.) using the LSO approach between September 1997 and August 2010. We retrospectively analyzed the clinical data, radiological findings, surgical treatment, histology, and outcome of patients and discuss the operative technique. Apparent complete tumor removal was achieved in 45 patients (87%). Of 42 patients, preexisting visual deficit improved in 22, remained the same in 13, and worsened in 7, and de novo visual deficit occurred in 1 patient. At 3 months post-discharge, 47 patients (90%) had a good recovery, 4 (8%) were moderately disabled, and 1 (2%) died 40 days after surgery of unexplained cardiac arrest. Seven patients (13%) had minimal residual tumors, 2 of which required reoperation. During the median follow-up of 59 months (range, 1-133 months), tumor recurred in 1 of the patients who had undergone a second operation. TSMs of all sizes can be removed via the LSO approach with minimal morbidity and mortality. Low-power or no coagulation is recommended near the optic nerves and the optic chiasm to preserve their vascular support from the internal carotid artery perforators. Our results are comparable to those obtained using more extensive and time-consuming approaches. We recommend the LSO approach to remove TSMs.

Bilateral subfrontal approach for tuberculum sellae meningiomas in long-term postoperative visual outcome

Various surgical approaches, such as uni- and bifrontal, frontolateral, and pterional approaches, have been advocated for tuberculum sellae meningiomas. The authors retrospectively reviewed the effectiveness of a bilateral subfrontal approach for tuberculum sellae meningiomas with special attention to ophthalmological outcomes and complications. Between 1993 and 2009, 34 patients underwent surgery for removal of tuberculum sellae meningiomas at Osaka City University. Tumor size ranged from 14 to 45 mm. Thirty-two of 34 patients presented with visual disturbances before the surgery. The visual functions in all patients were assessed using a visual impairment score (VIS) before and after surgery. Postoperative visual examination was performed 2 weeks after surgery. Long-term follow-up examinations were conducted 1 year after surgery. Radical resection (Simpson Grades I and II) was accomplished in 27 patients, and subtotal or partial resection (Simpson Grades III and IV) was achieved in 7. There was no deterioration in postoperative visual outcome. Twenty-nine (90.6%) of 32 patients showed improved VIS compared with preoperative VIS. The average VIS was 38.1 preoperatively, 23.5 in the short-term postoperative period, and 21.8 in the long-term postoperative period. In the short-term postoperative period, the visual function in 6 patients normalized, and visual problems persisted in the remaining 26. Six (23%) of 26 patients showed further improvement in VIS during the long-term follow-up period, and no patient exhibited a worsened VIS during this time. One patient complained of hyposmia after surgery, but there was no indication of related complications such as CSF leakage or frontal brain contusion. The bilateral subfrontal approach was previously avoided because of the relatively high rate of complications in earlier surgical series of tuberculum sellae meningiomas. However, after developments in microsurgical techniques in recent years, the bilateral subfrontal approach can now provide satisfactory visual outcomes with minimal postoperative complications. Careful preservation of the blood supply to optic apparatus and early unroofing of the optic canal using a bilateral subfrontal approach led to further improvement in long-term postoperative visual outcome.

Surgical nuances for removal of tuberculum sellae meningiomas with optic canal involvement using the endoscopic endonasal extended transsphenoidal transplanum transtuberculum approach

Tuberculum sellae meningiomas frequently extend into the optic canals. Radical tumor resection including the involved dural attachment, underlying hyperostotic bone, and intracanalicular tumor in the optic canal offers the best chance of a Simpson Grade I resection to minimize recurrence. Decompression of the optic canal with removal of the intracanalicular tumor also improves visual outcome since this portion of the tumor is usually the cause of asymmetrical visual loss. The purely endoscopic endonasal extended transsphenoidal approach offers a direct midline trajectory and immediate access to tuberculum sellae meningiomas without brain retraction and manipulation of neurovascular structures. Although the endoscopic approach has been previously criticized for its inability to remove tumor within the optic canals, complete Simpson Grade I tumor removal including intracanalicular tumor, dural attachment, and involved hyperostotic bone can be achieved in properly selected patients. Excellent visualization of the suprasellar region and the inferomedial aspects of both optic canals allows for extracapsular, extraarachnoid dissection of the tumor from the critical structures using bimanual microsurgical dissection. In this report, the authors describe the operative nuances for removal of tuberculum sellae meningiomas with optic canal involvement using a purely endoscopic endonasal extended transsphenoidal (transplanum transtuberculum) approach. They specifically highlight the technique for endonasal bilateral optic nerve decompression and removal of intracanalicular tumor to improve postoperative visual function, as demonstrated in 2 illustrative cases. Special attention is also given to cranial base reconstruction to prevent CSF leakage using the vascularized pedicled nasoseptal flap.

Exclusive Endoscopic Removal of a Planum Sphenoidale Meningioma: A Case Report

Midline suprasellar meningiomas have traditionally been removed through transcranial approaches. Endoscopic endonasal approaches have already been described for the removal of tuberculum sellae meningiomas (Cook), but their exclusive use for planum sphenoidale meningiomas has never been reported. A case report of a planum sphenoidale meningioma removed through a transnasal endoscopic approach is presented: the goal of this technique is tumor control with minimal morbidity. The anterior skull base defect has been reconstructed with a pedicled mucosa flap from nasal septum (Hadad-Bassagasteguy flap). The postoperative course was uneventful, and no sign of recurrence was noticed at the MRI control performed after 3 months.

Microsurgery of tuberculum sellae meningiomas

In this retrospective study, clinical–ophthalmological investigations of all patients operated on at our institution for a tuberculum sellae meningioma from 1991 to 2001 were analyzed. Twenty patients were operated on. There were 16 women and 4 men (average age 50 years). The primary symptom was progressive asymmetrical visual loss in 85%. In 15% the tumor was an incidental finding. All tumors were removed via a pterional approach. The right side was preferred (85%) unless the tumor extended mainly unilateral and below the right optic nerve and sparing the left. There was no mortality. Visual function improved in 77% of patients with affected vision. The degree of visual improvement was better in patients below the age of 60 years and with duration of symptoms less than 12 months. Patients without visual symptoms had no morbidity. The rate of moderate complications was 9%. In a follow-up of 1–11 years, no recurrence was observed. Improvement of visual function after surgical removal of tuberculum sellae meningiomas can be expected in most cases. Patients below 60 years and with symptoms less than 12 months have a better prognosis. Surgical removal should be attempted as soon as visual disturbances occur.

Treatment of tuberculum sellae meningiomas:a long-term follow-up study

Surgical techniques and their results for tuberculum sellae meningiomas were studied. Thirty-three cases, the first of which was operated in 1980, were analysed. There were 4 men and 29 women with an average age of 46.7 years. Eight cases underwent reop erations. The mean follow-up was 10.7 years. Approaches were pterional for 15 patients, FOZ/FO for 10, bilateral subfrontal for 6, and others for 2. Simpson's grade (I, II, III, IV) were 12, 9, 0, and 12 cases respectively. Recurrence rate was 0% for gra de I and 58.3% for grade IV. The FOZ/FO approach resulted in a lower Simpson's grade (P=0.05), but other factors were not related to Simpson's grade (P=0.05). The postoperative visual outcome did not depend on total (grade I and II) or subtotal (grade III and IV) removal (P=0.01). We conclude that radical removal of the tumours may result in lower recurrence rate without increasing surgical complications. Furthermore, skull base approaches can improve the rate of radical removal of tuberculum sellae meningiomas.