A Superimposition-Based Cephalometric Method to Quantitate Craniofacial Changes

To assess the craniofacial changes related to growth and/or to orthodontic and orthognathic treatments, it is necessary to superimpose serial radiographs on stable structures. However, conventional superimposition provides only a graphical illustration of these changes. To increase the precision of growth and treatment evaluations, it is desirable to quantitate these craniofacial changes. The aims of this study were to (1) evaluate a superimposition-based cephalometric method to process numerical data for craniofacial growth changes and (2) identify a valid, reliable, and feasible method for superimposition. Forty pairs of cephalograms were analyzed at T1 and T2 (mean age 9.9 and 15.0 years, respectively). The superimposition-based cephalometric method involved relating the sagittal and vertical measurements on the T2 radiographs to the nasion and sella landmarks on the T1 radiographs. Validity and reliability were evaluated for three superimposition methods: the sella-nasion (SN); the tuberculum sella-wing (TW); and Björk’s structural. Superimposition-based cephalometrics can be used to quantify craniofacial changes digitally. The numerical data from the superimposition-based cephalometrics reflected a graphical illustration of superimposition and differed significantly from the data acquired through conventional cephalometrics. Superimposition using the TW method is recommended as it is valid, reliable, and feasible.

Simpson Grade I Removal of Tuberculum Sella Meningioma Through the Supraorbital Approach: 2-Dimensional Operative Video

As described by Cushing1 in the chiasmatic syndrome, tuberculum sellae meningiomas induce progressive asymmetrical, incongruous visual loss, which would lead to blindness. The surgical removal of these lesions has been rewarding in regard to visual preservation, or recovery, and has passed the test of time. Optic canal extension, in one or both canals, is a consistent feature of these tumors, and removing the tumor from the optic canals is paramount in the treatment of these lesions.2 Despite the small target volume, radiosurgery is not applicable because of the lack of safe distance from the optic pathways. Tuberculum sella meningioma has been distinguished with good surgical outcomes and low recurrence rates; thus, Simpson grade I removal (tumor, dura, and bone invasion) confers a prospect of cure. Safe and successful resection of tuberculum meningiomas is achieved through the skull base supraorbital approach3 with several critical objectives: (1) visualization of the tumor without brain retraction; (2) 270° opening of the optic canal proximally and distally for safe tumor removal; (3) preservation of the vascular supply to the optic pathways and pituitary; (4) microsurgical dissection under high magnification on a short working distance to the encased carotid and anterior cerebral arteries; (5) complete resection of involved dura and bone at the skull base, particularly laterally; and (6) a robust skull base reconstruction with a vascularized pericranial flap.4 We present the case of a 45-yr-old female with a tuberculum sella meningioma who underwent Simpson grade I removal with an uneventful outcome. The patient consented for surgery. Image at 2:59 reprinted with permission from Al-Mefty O, Operative Atlas of Meningiomas. Vol 1, © LWW, 1998; Image at 9:33 public domain.4

Meningiomas of the Planum Sphenoidale and Tuberculum Sella

Patients with meningiomas of the planum sphenoidale and tuberculum sella often present with insidious vision loss in one or both eyes as the only sign or symptom of their disease, although other sensory, oculomotor, and even endocrine abnormalities may be seen in a minority of cases. Incidentally discovered tumors also are common, as patients may undergo neuroimaging for unrelated symptoms or events. Depending on the size and orientation of the tumor, central vision loss from optic nerve compression may be a later sign, and loss of peripheral vision in one or both eyes may not be recognized until it has progressed to areas closer to fixation. A thorough neuroophthalmologic assessment including visual field testing will help to define the extent of optic pathway involvement. Both fundus examination and optical coherence tomography of the retinal nerve fiber layer and macular ganglion cell complex will aid in determining prognosis after treatment of the tumor. Orbital surgery rarely is indicated as primary therapy for meningiomas in this location, and surgical resection or debulking is usually pursued before consideration is given to radiation therapy. Because of the long-term risk of residual tumor growth or recurrence, neuroophthalmic surveillance along with serial neuroimaging is required for years after tumor resection and/or radiation therapy.

Olfactory Outcomes after Resection of Tuberculum Sella and Planum Sphenoidale Meningiomas via a Transcranial Approach

Objectives Controversy exists surrounding the optimal approaches to tuberculum sella meningioma (TSM) and planum meningioma (PM). Olfaction is infrequently considered within this context but is nonetheless an important quality of life measure. The evolution of olfactory outcomes following contemporary transcranial surgery remains unclear. This study reviews olfactory outcomes after supraorbital craniotomy for TSM or PM and defines temporal trends in its recovery. Study Design A prospective study of a patients who underwent a minimally invasive supraorbital craniotomy for TSM or PM was conducted at a single neurosurgical center. Participants & Main Outcome Measures All patients were questioned about olfaction at presentation 3 months postoperatively, 12 months postoperatively, and annually thereafter (median follow-up = 37 months). The olfactory status of patients was categorized as normosmia, anosmia, hyposmia, parosmia, (altered perception of odours), or phantosmia, (olfactory hallucinations). Results Twenty-two patients were included in the study analysis, (range = 27–76). Precisely, 3 months after surgery, seven patients had normal olfaction (32%). Six patients were anosmic, (27%) four hyposmic, (18%), three parosmic, (14%), and two were phantosmic (9%). At 1-year follow-up, almost half of patients (10; 48%) were normosmic, while two patients (9.5%) were anosmic. There were no further improvements in olfaction between 1 year and long-term follow-up. Conclusion Subfrontal transcranial approaches for TSM or PM appear to be associated with changes in olfaction that can improve with time; these improvements occur within the first year after surgery. Impacts upon olfaction should be considered when selecting a surgical approach and patients counseled appropriately.

Endoscopic endonasal resection of a large tuberculum sella meningioma

Over the past three decades, endoscopic endonasal surgery has unlocked new corridors to treat a wide spectrum of ventral skull base lesions. Tuberculum sella meningiomas represent one of the most ideal pathologies for ventral skull base access. Traditionally, these lesions were approached primarily through various subfrontal and frontal-lateral transcranial approaches that have unfortunately been shown to be associated with worsening visual decline postoperatively. The endoscopic endonasal approach is now being attempted by more surgeons and leverages an infrachiasmatic trajectory that provides direct access to the tuberculum sella where most of the vascular supply for these lesions can be taken early, facilitating more efficient surgical resection and mitigating the risk of optic nerve injury. Here we review a challenging case of a large (∼3 cm) tuberculum sella meningioma, encasing critical vessels off the circle of Willis and resected via an endoscopic endonasal approach. We discuss the technical nuances and relevant surgical anatomy of this approach and highlight important considerations in the safe and successful removal of these meningiomas. We show that certain tumors that appear to encase the supraclinoidal carotid artery can be fully resected via an endonasal approach with precise surgical technique and adequate exposure. Furthermore, this case illustrates the risk of injuring a key perforating vessel from the anterior communicating artery complex, called the subcallosal artery. Injury to this vessel is highly associated with tumors like the one presented here that extend into the suprachiasmatic space between the optic chiasm and the anterior communicating complex. Meticulous surgical dissection is required to preserve this perforating vessel as well as branches from the superior hypophyseal artery. Finally, we review our current closure techniques for these challenging approaches and discuss the use of a lumbar drain for 3 days to lower CSF leak rates.The video can be found here: https://youtu.be/mafyXi5B0MA.

Association between Sella Turcica Bridging and Hypodontia - A Radiographic Study

Background: The bridging of sella turcica and dental anomalies have common embryonic origins and underlying genetic basis. Many studies have linked sella turcica bridging to developmental syndromes affecting the craniofacial region, and local dental anomalies. The purpose of this study was to determine the association between the bridging of the sella turcica and hypodontia. Methods: The clinical records along with lateral cephalograms and orthopantamograms of 40 hypodontic patients as study sample (12 males and 28 females; mean age 13.9±2.5 years) and of 120 non-hypodontic patients as control groups (58 males and 62 females; mean age 14.1±1.8 years) matched for age and gender to the study sample who came for orthodontic treatment, were collected from orthodontic clinics. Panoramic radiographs were evaluated for hypodontia. In order to quantify the extent of a sella turcica bridge on lateral cephalogram, the contour of the pituitary fossa from the tip of the dorsum sellae to the tuberculum sella was traced and extent of bridging was categorized by standardize scoring scale using the comparative measurement of sella length and diameter. Results: The presence of complete bridging (17.5%) and partial bridging (55%) in patients with hypodontia were more than complete bridging (5%) and partial bridging (37.5%) in patients without hypodontia (controls). The association between the degree of bridging and hypodontia was statistically significant according to chi-square statistics (p=0.001). There were no statistical differences between the degree of calcification and gender (p=0.616). Conclusions: The prevalence of sella turcica bridging inpatient with hypodontia was more and showed a significant association between sella turcica bridging and hypodontia. There is no dependence between the degree of calcification and gender. As the sella turcica bridge appears early in life, it should alert clinicians as a useful diagnostic predictor to the possible development of tooth anomalies later in life.