Endoscopic endonasal approach for suprasellar meningiomas: introduction of a new scoring system to predict extent of resection and assist in case selection with long-term outcome data

Abstract

OBJECTIVEThe endoscopic endonasal approach (EEA) has gained increasing popularity for the resection of suprasellar meningiomas (SSMs). Appropriate case selection is critical in optimizing patient outcome. Long-term outcome data are lacking. The authors systematically identified preoperative factors associated with extent of resection (EOR) and determined the relationship between EOR and long-term recurrence after EEA for SSMs.METHODSIn this retrospective cohort study, the authors identified preoperative clinical and imaging characteristics associated with EOR and built on the recently published University of California, San Francisco resectability score to propose a score more specific to the EEA. They then examined the relationship between gross-total resection (GTR; 100%), near-total resection (NTR; 95%–99%), and subtotal resection (STR; < 95%) and recurrence or progression with Kaplan-Meier survival analysis.RESULTSA total of 51 patients were identified. Radiographic GTR was achieved in 40 of 47 (85%) patients in whom it was the surgical goal. Significant independent risk factors for incomplete resection were prior surgery (OR 25.94, 95% CI < 2.00 to 336.49, p = 0.013); tumor lateral to the optic nerve (OR 13.41, 95% CI 1.82–98.99, p = 0.011); and complete internal carotid artery (ICA) encasement (OR 15.12, 95% CI 1.17–194.08, p = 0.037). Tumor size and optic canal invasion were not significant risk factors after adjustment for other variables. A resectability score based on the multivariable model successfully predicted the likelihood of GTR; a score of 0 had a positive predictive value of 97% for GTR, whereas a score of 2 had a negative predictive value of 87.5% for incomplete resection. After a mean follow-up of 40.6 ± 32.4 months (mean ± SD), recurrence was 2.7% after GTR (1 patient with atypical histology), 44.4% after NTR, and 80% after STR (p < 0.0001). Vision was stable or improved in 93.5% and improved in 67.4% of patients with a preoperative deficit. There were 5 (9.8%) postoperative CSF leaks, of which 4 were managed with lumbar drains and 1 required a reoperation.CONCLUSIONSThe EEA is a safe and effective approach to SSMs, with favorable visual outcomes in well-selected cases. The combination of postoperative MRI-based EOR with direct endoscopic inspection can be used in lieu of Simpson grade to predict recurrence. GTR dramatically reduces recurrence and can be achieved regardless of tumor size, proximity or encasement of the anterior cerebral artery, or medial optic canal invasion. Risk factors for incomplete resection include prior surgery, tumor lateral to the optic nerve, and complete ICA encasement.

Midline Skull Base Meningiomas: Transcranial and Endonasal Perspectives

“…Since Cushing’s first description, countless reports, series, and classifications arose regarding the so-called suprasellar meningioma, namely lesions arising from sellar and juxtasellar regions, planum sphenoidale, and tuberculum sellae [ 58 , 59 , 60 , 61 , 62 , 63 ]. Recently, Al-Mefty defined specific subsets based on a tumor’s origin, encompassing in the term suprasellar meningiomas those arising from the planum sphenoidale (PS), tuberculum sellae (TS), diaphragma sellae (DS), and anterior clinoid (AC) processes [ 49 , 64 ].…”

“…Moreover, in a limited number of cases with a high degree of pneumatization superolateral decompression can be achieved [ 90 ]. Concerning the removal rates, GTR has been reported in modern series, ranging from 80 to 95% [ 62 , 72 , 87 , 88 ].…”

“…Likewise, the opening of suprasellar and lamina terminalis cisterns via the extended approach exposes a greater amount of CSF leak to be sealed, and in case of repair failure, the risk of pneumocephalus and meningitis increases [ 92 ]. The introduction of multilayer reconstruction techniques accounting for autologous materials (above all, the Hadad–Bassagasteguy flap), along with clinical strategies aimed at counteracting CSF pulsation [ 53 , 93 , 94 ], markedly the reduced rate of complications (from 22% to 4%) [ 44 , 62 , 72 , 87 , 88 , 95 ].…”

Endoscopic endonasal surgery for anterior skull base meningiomas

“…CSF leak rates were significantly higher in the endoscopic cohorts (8.6% vs. 2.1%), although we have recently published a CSF leak grading scale and recommended skull base reconstruction protocol that has resulted in a CSF leak rate of only 2% (1 of 49 patients) of patients with high flow (Grade 3) CSF leaks [31] . A recent meta-analysis has demonstrated a significant decrease in CSF leak rate over time to 4% with the endoscopic endonasal approach, reported in the last 5 years [44] .…”

Minimally Invasive Approaches to Anterior Skull Base Meningiomas

“…The primary goal of this technique in our series was tumor debulking and decompression of the optic apparatus to preserve vision. Complete macroscopic resection TS tumors is challenging, particularly when tumors extend lateral to the optic nerves and carotid arteries 22 ; as such subtotal resection is often the preoperative oncologic goal but still achieving goals of optic apparatus decompression. In our series, these lateral limits set by the orbit and important neurovascular structures including the optic nerves 7 21 dictated choice of approach.…”