TUBERCULUM SELLAE MENINGIOMAS

Neurosurgery ◽  
2008 ◽  
Vol 62 (3) ◽  
pp. 556-563 ◽  
Author(s):  
Enrico de Divitiis ◽  
Felice Esposito ◽  
Paolo Cappabianca ◽  
Luigi M. Cavallo ◽  
Oreste de Divitiis
Keyword(s):  
Visual Outcome ◽  
Transsphenoidal Approach ◽  
Cerebrospinal Fluid Leakage ◽  
Total Removal ◽  
Extended Transsphenoidal Approach ◽  
Significant Difference ◽  
Major Vessel ◽  
Transcranial Approach ◽  
Tuberculum Sellae ◽  
Postoperative Improvement

Abstract OBJECTIVE Tuberculum sellae meningiomas represent 5 to 10% of all intracranial meningiomas. Such lesions are classically removed through a variety of well-standardized transcranial approaches. The extended endonasal transsphenoidal route, under either microscopic or endoscopic visualization, has only recently been proposed as a viable surgical technique for the management of such tumors. MATERIAL AND METHODS A total of 51 consecutive patients with tuberculum sellae meningiomas were treated at our institution during a 21-year period. Forty-four patients had transcranial surgery, and the last seven were treated via the extended endoscopic transsphenoidal approach. We also compared our data with those reported in the pertinent literature related to the surgical, ophthalmological, and endocrinological outcome. RESULTS The significant difference among the transcranial and transsphenoidal series, both in our experience and in the reviewed literature, did not allow us to draw statistically significant results but rather a reporting of the outcomes. In the transcranial group, 86.4% had a gross total removal of the lesion, whereas the percentage was 83.3% in the transsphenoidal group. Concerning the visual outcome, we experienced postoperative improvement in 61.4% of the transcranial patients and a worsening of 13.6%, whereas improvement was reported in 71.4% of the patients in the transsphenoidal group; in the last group, we did not observe any postoperative worsening. The main drawback of the transsphenoidal approach still remains the difficulty in reconstructing the cranial base dural and bone defects, which expose patients to a greater risk of postoperative cerebrospinal fluid leakage (28.6% in our series) and related complications. CONCLUSION When treating a patient with a diagnosis of tuberculum sellae meningioma, a neurosurgeon should know that, aside from the classical transcranial approach, the possibility of an extended transsphenoidal approach exists. Although it is still not a standardized procedure, in carefully selected cases (i.e., small midline lesions, without major vessel encasement, or parasellar extension) and in experienced hands, it could be considered a viable alternative, especially in overcoming the reconstruction-related problems.

The extended direct endonasal transsphenoidal approach for nonadenomatous suprasellar tumors

2005 ◽  
Vol 102 (5) ◽  
pp. 832-841 ◽  
Author(s):  
Joshua R. Dusick ◽  
Felice Esposito ◽  
Daniel F. Kelly ◽  
Pejman Cohan ◽  
Antonio DeSalles ◽  
...  
Keyword(s):  
Residual Tumor ◽  
Transsphenoidal Approach ◽  
Total Removal ◽  
Content Type ◽  
Patients Âgés ◽  
Extended Transsphenoidal Approach ◽  
Planum Sphenoidale ◽  
Dural Defects ◽  
Fine Print ◽  
Csf Leaks

Object. The extended transsphenoidal approach, which requires a bone and dural opening through the tuberculum sellae and posterior planum sphenoidale, is increasingly used for the treatment of nonadenomatous suprasellar tumors. The authors present their experiences in using the direct endonasal approach in patients with nonadenomatous suprasellar tumors. Methods. Surgery was performed with the aid of an operating microscope and angled endoscopes were used to assess the completeness of resection. Bone and dural defects were repaired using abdominal fat, collagen sponge, titanium mesh, and, in most cases, lumbar drainage of cerebrospinal fluid (CSF). Twenty-six procedures for tumor removal were performed in 24 patients (ages 9–79 years), including two repeated operations for residual tumor. Gross-total removal could be accomplished in only 46% of patients, with near-gross-total removal or better in 74% of 23 patients (five of eight with craniopharyngiomas, six of seven with meningiomas, five of six with Rathke cleft cysts, and one of two with a dermoid or epidermoid cyst); a patient with a lymphoma only underwent biopsy. Of 13 patients with tumor-related visual loss, 85% improved postoperatively. The complications that occurred included five patients (21%) with postoperative CSF leaks, one patient (4%) with bacterial meningitis; five patients (21%) with new endocrinopathy; and two patients (8%) who needed to undergo repeated operations to downsize suprasellar fat grafts. The only permanent neurological deficit was anosmia in one patient; there were no intracranial vascular injuries. Conclusions. The direct endonasal skull-base approach provides an effective minimally invasive means for resecting or debulking nonadenomatous suprasellar tumors that have traditionally been approached through a sublabial or transcranial route. Procedures in the supraglandular space can be performed effectively with excellent visualization of the optic apparatus while preserving pituitary function in most cases. The major challenge remains developing consistently effective techniques to prevent postoperative CSF leaks.

Extended Transsphenoidal Approach to Anterior Communicating Artery Aneurysm: Aneurysm Incidentally Identified During Macroadenoma Resection: Technical Case Report

2007 ◽  
Vol 61 (suppl_5) ◽  
pp. ONSE299-ONSE300 ◽  
Author(s):  
Masahiko Kitano ◽  
Mamoru Taneda
Keyword(s):  
Artery Aneurysm ◽  
Transsphenoidal Approach ◽  
Cerebrospinal Fluid Leakage ◽  
Anterior Communicating Artery ◽  
Posterior Portion ◽  
Invasive Approach ◽  
Extended Transsphenoidal Approach ◽  
Surgical History ◽  
Planum Sphenoidale ◽  
Brain Retraction

Abstract Objective: Full exposure of an aneurysm and surrounding structures with minimal brain retraction is important to eliminate the aneurysm safely and accurately. We describe an extended transsphenoidal approach for clipping an anterior communicating artery (ACoA) aneurysm. Clinical Presentation: A 58-year-old woman had a surgical history significant for subtotal removal of a macroadenoma via the posterior portion of the planum sphenoidale using an extended transsphenoidal approach. Intervention: During the tumor removal, a small unruptured ACoA aneurysm was incidentally found. The aneurysm was eliminated through the same operative route under a direct and wide view. The dural window was patched with abdominal fascia and sutured with 5-0 nylon in a watertight fashion. Conclusion: The extended transsphenoidal approach could expose an ACoA complex and aneurysm without substantial brain retraction. If the major limitations of this approach (e.g., postoperative cerebrospinal fluid leakage and meningitis) can be overcome using technical advances, this technique will offer a minimally invasive approach to the ACoA complex.

Endoscopic endonasal versus transcranial approach to tuberculum sellae and planum sphenoidale meningiomas in a similar cohort of patients

2018 ◽  
Vol 128 (1) ◽  
pp. 40-48 ◽  
Author(s):  
Evan D. Bander ◽  
Harminder Singh ◽  
Colin B. Ogilvie ◽  
Ryan C. Cusic ◽  
David J. Pisapia ◽  
...  
Keyword(s):  
Tumor Size ◽  
Visual Outcome ◽  
Optic Chiasm ◽  
Extent Of Resection ◽  
Surgical Removal ◽  
Endoscopic Endonasal ◽  
Csf Leakage ◽  
Transcranial Approach ◽  
Tuberculum Sellae ◽  
Planum Sphenoidale

OBJECTIVEPlanum sphenoidale (PS) and tuberculum sellae (TS) meningiomas cause visual symptoms due to compression of the optic chiasm. The treatment of choice is surgical removal with the goal of improving vision and achieving complete tumor removal. Two options exist to remove these tumors: the transcranial approach (TCA) and the endonasal endoscopic approach (EEA). Significant controversy exists regarding which approach provides the best results and whether there is a subset of patients for whom an EEA may be more suitable. Comparisons using a similar cohort of patients, namely, those suitable for gross-total resection with EEA, are lacking from the literature.METHODSThe authors reviewed all cases of PS and TS meningiomas that were surgically removed at Weill Cornell Medical College between 2000 and 2015 (TCA) and 2008 and 2015 (EEA). All cases were shown to a panel of 3 neurosurgeons to find only those tumors that could be removed equally well either through an EEA or TCA to standardize both groups. Volumetric measurements of preoperative and postoperative tumor size, FLAIR images, and apparent diffusion coefficient maps were assessed by 2 independent reviewers and compared to assess extent of resection and trauma to the surrounding brain. Visual outcome and complications were also compared.RESULTSThirty-two patients were identified who underwent either EEA (n = 17) or TCA (n = 15). The preoperative tumor size was comparable (mean 5.58 ± 3.42 vs 5.04 ± 3.38 cm3 [± SD], p = 0.661). The average extent of resection achieved was not significantly different between the 2 groups (98.80% ± 3.32% vs 95.13% ± 11.69%, p = 0.206). Postoperatively, the TCA group demonstrated a significant increase in the FLAIR/edema signal compared with EEA patients (4.15 ± 7.10 vs −0.69 ± 2.73 cm3, p = 0.014). In addition, the postoperative diffusion-weighted imaging signal of cytotoxic ischemic damage was significantly higher in the TCA group than in the EEA group (1.88 ± 1.96 vs 0.40 ± 0.55 cm3, p =0.008). Overall, significantly more EEA patients experienced improved or stable visual outcomes compared with TCA patients (93% vs 56%, p = 0.049). Visual deterioration was greater after TCA than EEA (44% vs 0%, p = 0.012). While more patients experienced postoperative seizures after TCA than after EEA (27% vs 0%, p = 0.038), there was a trend toward more CSF leakage and anosmia after EEA than after TCA (11.8% vs 0%, p = 0.486 and 11.8% vs 0%, p = 0.118, respectively).CONCLUSIONSIn this small single-institution study of similarly sized and located PS and TS meningiomas, EEA provided equivalent rates of resection with better visual results, less trauma to the brain, and fewer seizures. These preliminary results merit further investigation in a larger multiinstitutional study and may support EEA resection by experienced surgeons in a subset of carefully selected PS and TS meningiomas.

scholarly journals Selection of endoscopic or transcranial surgery for tuberculum sellae meningiomas according to specific anatomical features: a retrospective multicenter analysis (KOSEN-002)

2019 ◽  
Vol 130 (3) ◽  
pp. 838-847 ◽  
Author(s):  
Doo-Sik Kong ◽  
Chang-Ki Hong ◽  
Sang Duk Hong ◽  
Do-Hyun Nam ◽  
Jung-Il Lee ◽  
...  
Keyword(s):  
Visual Outcome ◽  
Visual Disturbance ◽  
Optic Canal ◽  
Surgical Approaches ◽  
Anterior Clinoid Process ◽  
Endoscopic Endonasal ◽  
Anatomical Features ◽  
Significant Difference ◽  
Stable Vision ◽  
Tuberculum Sellae

OBJECTIVEThe endoscopic endonasal approach (EEA) and the transcranial approach (TCA) are good options for the treatment of tuberculum sellae (TS) meningiomas. The objective of this study was to identify the key anatomical features in TS meningiomas and compare the two surgical approaches.METHODSThe authors retrospectively reviewed clinical data in 178 patients with TS meningiomas treated at 3 institutions between January 2010 and July 2016. Patients with tumors encasing the internal carotid artery or anterior cerebral artery or involving the anterior clinoid process or cavernous sinus were excluded. Tumors were classified as high-lying or low-lying based on their location, and involvement of the optic canal was evaluated. The surgical outcomes of EEA and TCA were analyzed according to the relevant anatomical features.RESULTSDuring the study period, 84 patients underwent EEA and 94 patients underwent TCA. Based on preoperative MR images, 43 (24.2%) meningiomas were classified as high-lying tumors, 126 (70.8%) as low-lying, and 9 (5.0%) as nonspecific. Gross-total resection (GTR) was performed in 145 patients (81.5%); the GTR rate did not differ significantly between the EEA and TCA groups. Of 157 patients with preoperative visual disturbance, 140 had improved or stable vision postoperatively. However, 17 patients (9.6%) experienced some visual deterioration after surgery. The TCA group had a worse visual outcome than the EEA group in patients with preoperative optic canal involvement (77.6% vs 93.2%, p = 0.019), whereas there was no significant difference in visual outcome based on whether tumors were high-lying or low-lying.CONCLUSIONSThe results of this study support EEA over TCA, at least with respect to visual improvement with acceptable complications, although TCA is still an effective approach for TS meningioma.

Microsurgical Transcranial Approach of 112 Paraoptic Meningiomas: A Single-Center Case Series

2020 ◽  
Author(s):  
Etienne Lefevre ◽  
Louis-Marie Terrier ◽  
Olivier Bekaert ◽  
Adrien Simonneau ◽  
Alister Rogers ◽  
...  
Keyword(s):  
Strong Predictor ◽  
Case Series ◽  
Visual Outcome ◽  
Compressive Optic Neuropathy ◽  
Visual Outcomes ◽  
Poor Visual Outcome ◽  
Visual Deficit ◽  
Transcranial Approach ◽  
Tuberculum Sellae ◽  
A Prospective Study

Abstract BACKGROUND Predictors of visual outcomes after optic nerve decompression are controversial. OBJECTIVE To identify the predictors of poor visual outcomes after surgery of meningiomas responsible of a compressive optic neuropathy. METHODS We focused on paraoptic meningiomas (POMs), which gathered tuberculum sellae meningiomas (TSMs) and anterior clinoid meningiomas (ACMs) responsible for visual impairment or threatening visual function, that underwent surgery at our institution between January 2009 and December 2015 and analyzed the clinical and radiological findings of our patients. RESULTS Among 112 patients who underwent surgery for a POM, a preoperative visual deficit was present in 108 patients (96.4%). Six months after surgery, 79 patients (70.5%) had a visual improvement, 15 patients (13.4%) had an unchanged vision, and 18 patients (16.1%) had deteriorated vision. A preoperative visual deficit of 6 mo or more was a strong predictor of poor visual outcome after surgery (P = .034). Poor visual outcome after surgery was not significantly related to the size of the tumor (P = .057), the age of the patient (P = .94), or the tumor extension into the optic canal (P = .47). CONCLUSION The duration of preoperative visual deficit was found to be a strong predictor of poor visual outcomes after surgery in POMs Other predictors of poor visual outcomes are still needed and are currently under evaluation in a prospective study at our institution.

Extended transsphenoidal approach with submucosal posterior ethmoidectomy for parasellar tumors

2001 ◽  
Vol 94 (6) ◽  
pp. 999-1004 ◽  
Author(s):  
Masahiko Kitano ◽  
Mamoru Taneda
Keyword(s):  
Cavernous Sinus ◽  
Lateral Wall ◽  
Arterial Injury ◽  
Transsphenoidal Approach ◽  
Content Type ◽  
Superior Turbinate ◽  
Extended Transsphenoidal Approach ◽  
Suprasellar Region ◽  
Surgical Methods ◽  
Tuberculum Sellae

✓ The authors have developed an extended transsphenoidal approach with submucosal posterior ethmoidectomy for resection of tumors located in the cavernous sinus or the suprasellar region that are difficult to remove via the conventional transsphenoidal approach. Surgery was performed using this approach in 14 patients with large pituitary adenomas, three patients with craniopharyngiomas, and one patient with a meningioma of the tuberculum sellae. The submucosal dissection of the nasal septum used in the conventional transsphenoidal approach was extended to the superior lateral wall of the nasal cavity to expose the bony surface of the superior turbinate lying under the nasal mucosa. Submucosal posterior ethmoidectomy widened the area visualized through the conventional transsphenoidal approach both superiorly and laterally. This provided a safer and less invasive access to lesions in the cavernous sinus or the suprasellar region through the sphenoid sinus. Using this approach the authors encountered no postoperative complications, such as olfactory disturbance, cranial nerve palsy, or arterial injury. In this article the authors present the surgical methods used in this approach.

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

2011 ◽  
Vol 30 (5) ◽  
pp. E2 ◽  
Author(s):  
James K. Liu ◽  
Lana D. Christiano ◽  
Smruti K. Patel ◽  
R. Shane Tubbs ◽  
Jean Anderson Eloy
Keyword(s):  
Tumor Resection ◽  
Visual Outcome ◽  
Optic Canal ◽  
Endoscopic Endonasal ◽  
Simpson Grade ◽  
Extended Transsphenoidal Approach ◽  
Suprasellar Region ◽  
Csf Leakage ◽  
Dural Attachment ◽  
Tuberculum Sellae

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.

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