Surgical management of tuberculum sellae meningiomas: involvement of the optic canal and visual outcome

Abstract

To present a large series of surgically treated tuberculum sellae meningiomas with particular regard to involvement of the optic canal and visual outcome. Methods: A retrospective analysis was done on 53 patients (40 female) with meningiomas originating from the tuberculum sellae who underwent surgery between 1991 and 2002. The standard surgical approach consisted of pterional craniotomy. Sixteen meningiomas extended posteriorly onto the diaphragma sella, 29 anteriorly to the planum sphenoidale, and 19 to the anterior clinoid process. Thirty seven tumours involved the optic canal, three bilaterally. Follow up ranged from 6 to 108 months (mean 29.9 months). Results: Total macroscopic resection was achieved in 48 patients. Median tumour size was 2.6 cm. Postoperatively, visual acuity improved in 20 patients and deteriorated in seven. Preoperative and postoperative visual acuity worsened with increasing duration of preoperative symptoms and with increasing age. Extension into the intraconal space was a negative predictor. However, tumour size did not influence visual acuity. Recurrence occurred in two cases (21 and 69 months postoperatively). Two patients died from causes unrelated to the tumour. Conclusions: In the majority of patients with tuberculum sellae meningiomas, total resection may be achieved through a pterional approach with minimal complications.

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

“…Unaddressed residual tumors left within the optic canal after surgery could result in persistent visual loss, visual deterioration, and future tumor recurrence. 56 This has led to several authors in recommending early optic nerve decompression and removal of intracanalicular tumor, which has resulted in favorable visual outcomes. 2,5,14,27,29,43,44,49,51,55,56 Visual improvement has been reported as high as 78%-91% in some series.…”

“…43,55 Access to the optic canals is critical not only for visual outcome, but also for extent of resection, as unaddressed residual tumor in the optic canal can be a source of recurrence or failure of visual improvement. 56 Various transcranial surgical approaches to remove tuberculum sellae meningiomas include unilateral or bilateral subfrontal, bifrontal interhemispheric, supraorbital, eyebrow keyhole supraorbital, frontolateral, frontotemporal/pterional, orbitopterional, and orbitozygomatic approaches. 3,5,11,23,24,29,36,43,[46][47][48][49][50]55 More recently, there has been interest in endonasal extended transsphenoidal approaches (microscopic, microscopic with endoscopic assistance, and purely endoscopic) to remove tuberculum sellae meningiomas.…”

Tuberculum sellae meningiomas: surgical considerations

“…However, the percentage of improvement was significantly higher in patients who presented symptoms for less than six months compared with those whose symptoms had lasted for one year. Schick and Hassler 21 reported on a series of 53 patients with TSMs; 20 patients improved, 25 patients remained unchanged, and seven patients worsened. Statistical analyses allowed these authors to conclude that postoperative recovery of the visual deficit was worst in older patients and in patients in whom the duration of symptoms was longer than six months.…”

“…Together with the removal of the orbital bar and orbital roof, the decompression of the optic nerve via clinoidectomy, the unroofing of the optic canal, and the opening of the falciform ligament have contributed to the significant postoperative improvement of the visual function of these patients 11,17,18,21,[23][24][25] . Ohta et al 10 reported on 21 cases of complete resection of TSMs in a series of 33 patients.…”

“…The main objective of the surgery is to preserve or improve visual function. Improvement of visual function, according to several reports, varies from 32% to 91% 3,5,19,21 . Fahlbusch et al 3 obtained an improvement of 80% in their patients and stated that the best prognoses were found in patients younger than 50 years and in patients who presented symptoms for less than one year.…”