Tuberculum sellae meningiomas: surgical considerations

We report our experience on the treatment of tuberculum sellae meningiomas (TSMs) regarding the involvement of the optic canal and clinical outcomes. We reviewed 23 patients who were operated on between January 1997 and December 2008. The surgical approach was unilateral subfrontal supraorbital osteotomy in one piece. Attempts were made to improve visual function via extra/intradural unroofing of the optic canal, which released the optic nerve. Visual symptoms were present preoperatively in 21 patients, and two patients were asymptomatic. Visual acuity remained intact in 6 patients, improved in 10, was unchanged in 5 patients, and worsened in 2 patients. The postoperative visual field was normal or improved in 17 patients, unchanged in four patients, and worsened in two patients. The optic canal and clinoid were drilled extradurally in eight patients and intradurally in nine patients. Total resection of TSMs was achieved in 19 patients. Incomplete resection occurred in two patients. Decompression of the optic canal seemed to increase the visual outcome.

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The value of endoscope assistance during transcranial surgery for tuberculum sellae meningiomas

Journal of Neurosurgery ◽

10.3171/2016.11.jns16713 ◽

2018 ◽

Vol 128 (1) ◽

pp. 32-39 ◽

Cited By ~ 9

Author(s):

Sascha Marx ◽

Stefan Clemens ◽

Henry W. S. Schroeder

Keyword(s):

Visual Acuity ◽

Visual Field ◽

Incidental Finding ◽

Visual Outcome ◽

Assistive Device ◽

Ophthalmological Examination ◽

Total Resection ◽

University Medicine ◽

Visual Field Deficits ◽

Tuberculum Sellae

OBJECTIVEIn tuberculum sellae meningioma (TSM) surgery, endonasal approaches are claimed to have a superior visual outcome compared with transcranial approaches. The authors question whether this is always true and analyze their series of cases of endoscope-assisted transcranial TSM surgery with special regard to the postoperative visual outcome in order to explore this issue.METHODSAll surgical procedures for TSM performed between 2003 and 2015 in the Department of Neurosurgery, University Medicine Greifswald, were retrospectively analyzed. Special attention was paid to the postoperative visual outcome.RESULTSDuring the study period, 15 patients (12 female and 3 male) underwent surgery for TSM. Gross-total resection was achieved in 14 cases (93.3%) and near-total resection in 1. One patient suffered from a major stroke during surgery and had to be excluded from further analyses. No other complications occurred. Preoperatively, visual acuity was disturbed in 12 patients (80%) and visual field deficits were present in 11 patients (73.3%). In 3 patients (20%), the TSM was an incidental finding. Postoperatively, ophthalmological examination revealed an improvement of visual acuity in 10 (90.9%) of 11 patients and improvement of visual field deficits in 9 (90%) of 10 patients; no deterioration of visual acuity or visual field was seen in any patient. Visual acuity and visual field improvement was observed in all patients who had surgery within 3 years after the onset of visual disturbances. No tumor recurrence was observed during follow-up (mean 32 months, range 3–134 months). TSMs were approached via a frontolateral craniotomy in 7 patients and via a supraorbital craniotomy in 8. The use of the endoscope as an assistive device led to improved tumor visualization and consequent removal in areas that were hidden in the microscopic view in 6 patients (40%).CONCLUSIONSThe present series confirms a favorable visual outcome after TSM surgery via supraorbital or frontolateral endoscope-assisted approaches. With endoscopic visualization, major manipulation of the optic apparatus could be avoided, perhaps affecting the favorable visual outcome.

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Visual Outcome of Tuberculum Sellae Meningiomas after Extradural Optic Nerve Decompression

Neurosurgery ◽

10.1227/01.neu.0000228683.79123.f9 ◽

2006 ◽

Vol 59 (3) ◽

pp. 570-576 ◽

Cited By ~ 90

Author(s):

Tiit Mathiesen ◽

Lars Kihlström

Keyword(s):

Cerebrospinal Fluid ◽

Optic Nerve ◽

Diabetes Insipidus ◽

Visual Outcome ◽

Optic Canal ◽

Visual Deterioration ◽

Nerve Decompression ◽

Visual Outcomes ◽

Tuberculum Sellae

Abstract OBJECTIVE: Meningiomas of the tuberculum sellae have a close relationship with the optic apparatus. Even modern series show a 10 to 20% risk of visual deterioration after surgery. We have attempted to improve visual outcome by extradural decompression of the optic canal and anterior clinoid process, followed by intradural release of the optic nerve; this study provides an analysis of visual outcomes with this approach. METHODS: Treatment, histopathology, and follow-up data of 29 consecutive patients undergoing surgery for tuberculum sellae meningiomas with initial release of the optic nerve were prospectively collected. RESULTS: Radical tumor removal was possible in all 23 patients with primary tumors and in three out of six patients with recurrent tumors. All patients but two of the worst affected with preoperative visual compromise improved from surgery; there were no instances of visual deterioration. Five patients with normal preoperative vision remained intact and visual improvement was 22 (91%) out of 24 patients in the remaining patients. In total, 13 patients (42%) had completely normal vision at follow-up. Mainly patients younger than 60 years experienced complete normalization after surgery. Two patients underwent transsphenoidal surgery for cerebrospinal fluid leaks. Postoperative endocrinological symptoms were temporary diabetes insipidus in one patient and permanent diabetes insipidus in another patient undergoing elective sectioning of the pituitary stalk because of a recurrent tumor with invasive growth into the stalk. CONCLUSION: Adding early optic nerve decompression by extradural clinoidectomy and optic canal unroofing to a frontopterional approach seemed to improve visual outcomes because there were no instances of visual deterioration. Simpson Grade 1 to 2 removal was possible in all patients with primary surgery, whereas recurrent cases could only be treated with lower grades of radicality. Radical removal, however, required readiness to reoperate for cerebrospinal fluid leakage at the site of the drilled tumor origin in bone.

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Resection of an Optic Canal Meningioma through a Contralateral Subfrontal Approach with Endoscopic Assistance: A 2D Operative Video

Journal of Neurological Surgery Part B Skull Base ◽

10.1055/s-0037-1620253 ◽

2018 ◽

Vol 79 (S 02) ◽

pp. S229-S230

Author(s):

Moujahed Labidi ◽

Kentaro Watanabe ◽

Anne-Laure Bernat ◽

Shunya Hanakita ◽

Sébastien Froelich

Keyword(s):

Optic Nerve ◽

Optic Canal ◽

Direct Visualization ◽

Medial Aspect ◽

Total Resection ◽

Medial Side ◽

Endoscopic Assistance ◽

Tuberculum Sellae ◽

Surgical Field ◽

Subfrontal Approach

Objective To review the use of the contralateral subfrontal approach for the resection of an optic canal meningioma. Design Operative video. Results A meningioma, located in the inferomedial side of the optic canal (Fig. 1), was found to cause significant visual deterioration. The subfrontal route was preferred to expose the tumor without mobilization of the optic nerve. Drilling of the anterior limb of the chiasmatic sulcus (limbus sphenoidale) provided adequate exposure of the medial aspect of the optic canal. Gross total resection (Simpson II) of the tumor was accomplished, and endoscopic assistance allowed identification and coagulation of an infiltrated dura mater in the chiasmatic sulcus and tuberculum sellae. Conclusion The subfrontal approach grants an optimal surgical trajectory to the contralateral chiasmatic sulcus and optic nerve. When the medial side of the optic canal is drilled, tumors extending into the optic canal can be safely resected, under direct visualization of the inferomedial side of the optic nerve. Breach into the sphenoid sinus can occur during drilling of the anterior limb of the chiasmatic sulcus. Endoscopic assistance can provide a better view on blind areas of the surgical field, including the depth of the optic canal (Fig. 2).The link to the video can be found at: https://youtu.be/fS2udUCPH1g.

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Optic nerve appearance as a predictor of visual outcome in patients with idiopathic intracranial hypertension

British Journal of Ophthalmology ◽

10.1136/bjophthalmol-2018-313329 ◽

2018 ◽

Vol 103 (10) ◽

pp. 1429-1435 ◽

Cited By ~ 6

Author(s):

Jonathan A Micieli ◽

Beau B Bruce ◽

Caroline Vasseneix ◽

Richard J Blanch ◽

Damian E Berezovsky ◽

...

Keyword(s):

Visual Acuity ◽

Visual Field ◽

Intracranial Hypertension ◽

Optic Disc ◽

Visual Function ◽

Idiopathic Intracranial Hypertension ◽

Visual Outcome ◽

Mean Deviation ◽

Cotton Wool Spots

Background/aimsIt remains unclear whether the presence of optic disc haemorrhages (ODH) or cotton wool spots (CWS) at presentation in patients with papilloedema from idiopathic intracranial hypertension (IIH) has prognostic value. The aim of this study was to determine if optic disc appearance at presentation predicts visual outcome in patients with IIH.MethodsRetrospective study of 708 eyes of 360 consecutive patients with IIH who had baseline optic disc photographs before or within 30 days of their diagnostic lumbar puncture and initiation of medical treatment. Optic disc photographs were independently graded by three ophthalmologists in a standardised manner. Visual function was assessed using Snellen converted to logMAR visual acuity, Humphrey mean deviation and visual field grade.ResultsAt least one ODH was found in 201 (28.4%) eyes, at least one CWS was found in 101 (14.3%) eyes and 88 eyes had both ODH and CWS (12.4%). At presentation, Frisén grade was associated with the presence and severity of ODH and CWS (p<0.001). ODH were associated with a worse visual acuity and CWS were associated with a worse visual field grade and mean deviation at presentation (p<0.05). Frisén grade was associated with worse visual function at presentation and final follow-up (p<0.001). Neither ODH nor CWS at presentation were associated with visual function at final follow-up when controlling for the Frisén grade.Conclusions and relevanceODH and CWS at baseline are not independent predictors of final visual function in IIH when controlling for the severity of papilloedema.

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Retrospective analysis of fractionated intensity-modulated radiotherapy (IMRT) in the interdisciplinary management of primary optic nerve sheath meningiomas

Radiation Oncology ◽

10.1186/s13014-019-1438-2 ◽

2019 ◽

Vol 14 (1) ◽

Cited By ~ 2

Author(s):

Franziska Eckert ◽

Kerstin Clasen ◽

Carina Kelbsch ◽

Felix Tonagel ◽

Benjamin Bender ◽

...

Keyword(s):

Visual Acuity ◽

Optic Nerve ◽

Visual Field ◽

Patient Selection ◽

Visual Function ◽

Radiation Treatment ◽

Treatment Decision ◽

Interdisciplinary Treatment ◽

Nerve Sheath

Abstract Background As optic nerve sheath meningiomas (ONSM) are rare, there are no prospective studies. Our retrospective analysis focusses on a cohort of patients with uniform disease characteristics all treated with the same radiotherapy regimen. We describe treatment decision making, radiotherapy planning and detailed neuro-ophthalmological outcome of the patients. Methods 26 patients with unilateral ONSM extending only to the orbit and the optic canal were evaluated for neuro-ophthalmological outcome. Radiation treatment was planned in a simultaneous integrated boost approach to gross tumor volume (GTV) + 2 mm / 5 mm to 54 Gy / 51 Gy in 1.8 Gy / 1.7 Gy fractions. Follow-up was done by specialized neuro-ophthalmologists. Visual acuity and visual field defects were evaluated after therapy as well as during follow-up. Results Interdisciplinary treatment decision for patients with ONSM follows a rather complex decision tree. Radiation treatment planning (equivalent uniform dose (EUD), maximum dose to the optic nerve) improved with experience over time. With this patient selection visual acuity as well as visual field improved significantly at first follow-up after treatment. For visual acuity this also applied to patients with severe defects before treatment. Long term evaluation showed 16 patients with improved visual function, 6 were stable, in 4 patients visual function declined. Interdisciplinary case discussion rated the visual decline as radiation-associated in two patients. Conclusions With stringent patient selection radiotherapy for unilateral primary ONSM to 51 Gy / 54 Gy is safe and leads to significantly improved visual function. Interdisciplinary treatment decision and experience of the radiation oncology team play a major role.

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Ultrasonic bone curettage for optic canal unroofing and anterior clinoidectomy

Journal of Neurosurgery ◽

10.3171/jns.2006.104.4.621 ◽

2006 ◽

Vol 104 (4) ◽

pp. 621-624 ◽

Cited By ~ 38

Author(s):

Han Soo Chang ◽

Masahiro Joko ◽

Joon Suk Song ◽

Kiyoshi Ito ◽

Tatsushi Inoue ◽

...

Keyword(s):

Optic Nerve ◽

Visual Outcome ◽

Optic Canal ◽

Internal Auditory Meatus ◽

Major Morbidity ◽

Anterior Clinoidectomy ◽

Optic Nerve Damage ◽

Bone Removal ◽

Visual Status ◽

Optic Canal Unroofing

✓Extradural unroofing of the optic canal and subsequent mobilization of the optic nerve is a useful technique in the surgical treatment of parasellar tumors; however, the drilling procedure itself is associated with the risk of optic nerve damage. A safer technique would certainly be beneficial. The ultrasonic bone curette is a device developed in Japan for safer bone removal. Its use in intradural anterior clinoidectomy and opening of the internal auditory meatus has been reported before. In this article the authors describe their experience in using this device for extradural unroofing of the optic canal in patients with parasellar tumors. Between March 2002 and November 2004, the aforementioned technique was used in the treatment of eight patients with parasellar tumors. After undertaking a frontotemporal craniotomy and orbital osteotomy, an ultrasonic bone curette was used to unroof the optic canal via an epidural approach; in five cases anterior clinoidectomy was added subsequently. Using an ultrasonic bone curette, unroofing of the optic canal was completed safely and required much less expertise than that required for standard drilling. The mortality and major morbidity rates were 0%. The visual function outcome was satisfactory, with the overall visual status improving in all seven patients in whom this symptom was present preoperatively. The ultrasonic bone curette makes the unroofing of the optic canal safer and easier, possibly improving the visual outcome of patients undergoing surgery for parasellar tumors.

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Suprasellar meningiomas: the effect of tumor location on postoperative visual outcome

Journal of Neurosurgery ◽

10.3171/jns.1988.69.4.0523 ◽

1988 ◽

Vol 69 (4) ◽

pp. 523-528 ◽

Cited By ~ 120

Author(s):

Brian T. Andrews ◽

Charles B. Wilson

Keyword(s):

Visual Loss ◽

Visual Outcome ◽

Tumor Location ◽

Postoperative Recovery ◽

Optic Canal ◽

Visual Disability ◽

Content Type ◽

Tuberculum Sellae ◽

Diaphragma Sellae ◽

Planum Sphenoidale

✓ The authors reviewed 38 cases of suprasellar meningioma to determine the correlation between tumor site and postoperative visual outcome. Progressive visual loss, the most frequent initial complaint (94.7%), occurred over a mean of 24½ months, was most often unilateral (18 patients) or bilateral but asymmetrical (14 patients), and was severe (20/200 vision or worse) in 23 patients; 24 patients had visual field abnormalities. Computerized tomography or magnetic resonance studies clearly delineated the lesions but did not appear to permit earlier diagnosis. Eleven patients had tumors limited to the tuberculum sellae; the tumor extended from the tuberculum sellae onto the planum sphenoidale in nine patients, into one optic canal in eight, onto the diaphragma sellae in seven, and onto the medial sphenoid wing in three. Patients with tumors affecting the optic canal had severe unilateral visual loss more often than those with tumors at other sites. Tumors limited to the tuberculum sellae were most often completely resected; postoperative recovery of vision was also most frequent in patients with tumors at this site. Tumors involving the diaphragma sellae or the medial sphenoid wing were least often completely removed and most likely to be associated with postoperative visual deterioration. Overall, 42% of patients had improved vision postoperatively, 30% remained unchanged, and 28% were worse. After a mean follow-up period of 38 months, 24 patients are doing well, four have significant visual disability, and three are blind or doing poorly. Two patients died of causes unrelated to their tumor. Three patients have had tumor recurrence.

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Arteriovenous malformations in the optic apparatus: systematic literature review and report of four cases

Journal of Neurosurgery ◽

10.3171/2021.1.jns204162 ◽

2021 ◽

pp. 1-11

Author(s):

Visish M. Srinivasan ◽

Phiroz E. Tarapore ◽

Stefan W. Koester ◽

Joshua S. Catapano ◽

Caleb Rutledge ◽

...

Keyword(s):

Visual Acuity ◽

Visual Field ◽

Visual Function ◽

Arteriovenous Malformations ◽

Vascular Malformations ◽

Visual Fields ◽

Optic Tract ◽

Visual Disturbance ◽

Visual Field Defects ◽

Subtotal Resection

OBJECTIVE Rare arteriovenous malformations (AVMs) of the optic apparatus account for < 1% of all AVMs. The authors conducted a systematic review of the literature for cases of optic apparatus AVMs and present 4 cases from their institution. The literature is summarized to describe preoperative characteristics, surgical technique, and treatment outcomes for these lesions. METHODS A comprehensive search of the English-language literature was performed in accordance with established Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to identify all published cases of AVM in the optic apparatus in the PubMed, Web of Science, and Cochrane databases. The authors also searched their prospective institutional database of vascular malformations for such cases. Data regarding the clinical and radiological presentation, visual acuity, visual fields, extent of resection, and postoperative outcomes were gathered. RESULTS Nine patients in the literature and 4 patients in the authors’ single-surgeon series who fit the inclusion criteria were identified. The median age at presentation was 29 years (range 8–39 years). Among these patients, 11 presented with visual disturbance, 9 with headache, and 1 with multiple prior subarachnoid hemorrhages; the AVM in 1 case was found incidentally. Four patients described prior symptoms of headache or visual disturbance consistent with sentinel events. Visual acuity was decreased from baseline in 10 patients, and 11 patients had visual field defects on formal visual field testing. The most common visual field defect was temporal hemianopia, found in one or both eyes in 7 patients. The optic chiasm was affected in 10 patients, the hypothalamus in 2 patients, the optic nerve (unilaterally) in 8 patients, and the optic tract in 2 patients. Six patients underwent gross-total resection; 6 patients underwent subtotal resection; and 1 patient underwent craniotomy, but no resection was attempted. Postoperatively, 9 of the patients had improved visual function, 1 had no change, and 3 had worse visual acuity. Eight patients demonstrated improved visual fields, 1 had no change, and 4 had narrowed fields. CONCLUSIONS AVMs of the optic apparatus are rare lesions. Although they reside in a highly eloquent region, surgical outcomes are generally good; the majority of patients will see improvement in their visual function postoperatively. Microsurgical technique is critical to the successful removal of these lesions, and preservation of function sometimes requires subtotal resection of the lesion.

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Prognostic factors for postoperative visual outcome in surgically treated suprasellar meningiomas

Medicinski pregled ◽

10.2298/mpns1606146g ◽

2016 ◽

Vol 69 (5-6) ◽

pp. 146-152 ◽

Cited By ~ 2

Author(s):

Desanka Grkovic ◽

Sofija Davidovic

Keyword(s):

Visual Acuity ◽

Tumor Size ◽

Visual Function ◽

Tumor Resection ◽

Visual Outcome ◽

Duration Of Symptoms ◽

Postoperative Visual Acuity ◽

Preoperative Visual Acuity ◽

History Of ◽

Meningioma Surgery

Introduction. The prognosis of postoperative visual acuity in patients with surgically treated suprasellar meningiomas is influenced not only by the size and precise localization of meningiomas in the optochiasmatic region and their compressive effect, but also by certain parameters, such as the age of patient, duration of symptoms, and preoperative visual acuity. The purpose of this study was to analyze the influence of these factors on postoperative visual acuity in the patients with surgically treated optochiasmatic meningioma as well as to determine their prognostic value in the recovery of visual function after surgery. Material and Methods. The study sample consisted of 43 patients operated for suprasellar meningioma. All tumors were diagnosed by computed tomography or nuclear magnetic resonance scans. Visual acuity was analyzed both before surgery and six months after surgery. The effects of age, preoperative visual loss, duration of visual symptoms and tumor size on visual outcome were analyzed. Results. Postoperative improvement of visual acuity was observed in 50% of eyes (68.4% of patients). Visual outcome was better in the younger patients. The patients with better preoperative visual acuity had better postoperative visual acuity outcome. Chances of achieving better postoperative visual function and favorable tumor resection outcome were inversely proportional to the increased length of history of disease and tumor size. Conclusion. Postoperative visual acuity prognosis in suprasellar meningioma surgery was favorably affected by the mean duration of symptoms of less than 24 months, tumor size less than 30 mm, and preoperative visual acuity loss below 0.1.

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Twenty-year outcomes in patients with newly diagnosed glaucoma: mortality and visual function

British Journal of Ophthalmology ◽

10.1136/bjophthalmol-2017-311595 ◽

2018 ◽

Vol 102 (12) ◽

pp. 1663-1666

Author(s):

Christopher King ◽

Justin C Sherwin ◽

Gokulan Ratnarajan ◽

John F Salmon

Keyword(s):

Visual Acuity ◽

Visual Field ◽

Open Angle Glaucoma ◽

Survival Curve ◽

Visual Outcome ◽

Field Analysis ◽

Time To Death ◽

Kaplan Meier ◽

Two Stages

Background/aimsTo determine the mortality within 20 years of diagnosis of chronic open-angle glaucoma (COAG) and visual acuity and visual field progression of a cohort followed for 20 years.MethodsTwenty years following the diagnosis of COAG in 68 of 436 (16%) patients seen in a glaucoma case-finding clinic, visual and mortality outcomes were audited from medical records. Causes of death were obtained from general practitioner records and death certificates. Probability of death was calculated using a Kaplan-Meier survival curve. The visual field of each eye of survivors was graded using a nine-stage severity scale. Visual outcome was analysed at the 20-year follow-up visit.ResultsFrom 68, 14 (21%) were lost to follow-up. In the remaining 54, 20 (37%) were alive 20 years after diagnosis. Of 63% who died, mean age of death was 84 years, most commonly due to vascular disease. Mean age at presentation of those who died was 73.7 years versus 63.2 years for survivors (P=0.001). The median time to death was 16 years. On visual field analysis, nearly half (48.9%) of eyes did not deteriorate, but 28.3% eyes deteriorated by more than two stages. Those who died had worse final visual acuity than survivors (P<0.001). Three who died were registered severely visually impaired mainly from macular disease, but no survivors were registered (P<0.001).ConclusionIn this cohort, approximately two-thirds of patients with glaucoma died within 20 years of diagnosis. In most older patients with glaucoma, the overall goal of preventing visual handicap and blindness is achievable 20 years after diagnosis.

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