Technical nuances in the management of tuberculum sellae and diaphragma sellae meningiomas

Nanda, Anil; Ambekar, Sudheer; Javalkar, Vijayakumar; Sharma, Mayur

doi:10.3171/2013.10.focus13350

Cited by 32 publications

(20 citation statements)

References 43 publications

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“…Transcranial (TC) microsurgical resection has been the standard of care and has a proven track record of good outcomes, with the majority of patients having improvement in visual function postoperatively. 8,9,13,19,21,23,24,30 The TC approaches commonly used include the extended bifrontal, tailored bifrontal, 26 interhemispheric, orbitozygomatic, pterional, and subfrontal eyebrow 30 approaches. However, with advances in endoscopy 7 and the subsequent development of the expanded endonasal approach, 14 there has been significant debate among practitioners in the neurosurgical community as to whether TSMs should be approached transcranially ("from above") or endonasally and/or transsphenoidally ("from below").…”

mentioning

confidence: 99%

Tuberculum sellae meningiomas: grading scale to assess surgical outcomes using the transcranial versus transsphenoidal approach

Magill

Morshed

Lucas

et al. 2018

Neurosurgical Focus

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OBJECTIVETuberculum sellae meningiomas (TSMs) are surgically challenging tumors that can severely impair vision. Debate exists regarding whether the transcranial (TC) or endoscopic transsphenoidal (TS) approach is best for resecting these tumors, and there are few large series comparing these approaches.METHODSA retrospective chart review was performed at 2 academic centers comparing TC and TS approaches with respect to vision, extent of resection, recurrence, and complications. The authors report surgical outcomes and propose a simple preoperative tumor grading scale that scores tumor size (1–2), optic canal invasion (0–2), and arterial encasement (0–2). The authors performed univariate, multivariate, and recursive partitioning analysis (RPA) to evaluate outcomes.RESULTSThe TSMs were resected in 139 patients. The median follow-up was 29 months. Ninety-five (68%) cases were resected via a TC and 44 (32%) via a TS approach. Tumors treated via a TC approach had a higher tumor (p = 0.0007), artery (p < 0.0001), and total score (p = 0.0012) on the grading scale. Preoperative visual deficits were present in 87% of patients. Vision improved in 47%, stayed the same in 35%, declined in 10%, and was not recorded in 8%. The extent of resection was 65% gross-total resection, 23% near-total resection (95%–99% resection), and 12% subtotal resection (< 95%). A lower tumor score was significantly associated with better or stable vision postoperatively (p = 0.0052). The RPA confirmed low tumor score as the key predictor of postoperative visual improvement or stability. Multivariate analysis and RPA demonstrate that lower canal score (p < 0.0001) and TC approach (p = 0.0019) are associated with gross-total resection. Complications occurred in 20 (14%) patients, including CSF leak (5%) and infection (4%). There was no difference in overall complication rates between TC and TS approaches; however, the TS approach had more CSF leaks (OR 5.96, 95% CI 1.10–32.04). The observed recurrence rate was 10%, and there was no difference between the TC and TS approaches.CONCLUSIONSTuberculum sellae meningiomas can be resected using either a TC or TS approach, with low morbidity and good visual outcomes in appropriately selected patients. The simple proposed grading scale provides a standard preoperative method to evaluate TSMs and can serve as a starting point for selection of the surgical approach. Higher scores were associated with worsened visual outcomes and subtotal resection, regardless of approach. The authors plan a multicenter review of this grading scale to further evaluate its utility.

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confidence: 99%

Tuberculum sellae meningiomas: grading scale to assess surgical outcomes using the transcranial versus transsphenoidal approach

Magill

Morshed

Lucas

et al. 2018

Neurosurgical Focus

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“…The more anterior site of origin of PS tumors leads to posterior and inferior displacement of the ONs and chiasm and the anterior cerebral arteries complex; this can be seen on preoperative imaging. 2,6 Two PS meningiomas, resected endoscopically during the period of study, were excluded from our analysis. Their main tumor volume was anterior to the CS.…”

Section: Discussionmentioning

confidence: 99%

“…[1][2][3][4] They are traditionally grouped together with other suprasellar meningiomas including the more anterior planum sphenoidale (PS) meningiomas. [4][5][6] Even though TS and DS meningiomas have different sites of origin that can be distinguished anatomically, they are often grouped together as TS meningiomas. [3][4][5]7 The differentiation between these two types is confounded by similarity in clinical presentation and anatomical adjacency.…”

Section: Introductionmentioning

confidence: 99%

Meningiomas of the Tuberculum and Diaphragma Sellae

et al. 2014

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Introduction?Although tuberculum sellae (TS) and diaphragma sellae (DS) meningiomas have different anatomical origins, they are frequently discussed as a single entity. Here we review the radiologic and intraoperative findings of TS and DS meningiomas and propose a radiologic classification. Methods?We retrospectively reviewed 10 consecutive TS and DS meningiomas. Data regarding clinical presentation, preoperative imaging, and intraoperative findings were analyzed. Three sellar dimensions were measured on magnetic resonance imaging (MRI): the tuberculum-sellar floor interval (TSFI), the planum-tuberculum interval (PTI), and the total height. Results?Three distinct anatomical patterns were recognized: exclusively tubercular meningiomas (type A) were accompanied by elongation of the TSFI and, more significantly, of the PTI; combined TS and DS meningiomas (type B) were associated with relative elongation of both the PTI and TSFI; and the sole exclusively DS meningioma (type C) was associated with elongation of neither PTI nor TSFI. Conclusion?Suprasellar meningiomas can be classified as tubercular, combined, or diaphragmatic based on preoperative MRI. Exclusively tubercular meningiomas (type A) require only a supradiaphragmatic approach. Tumor involvement of the sellar diaphragm (type B or C) requires resection of the diaphragm and thus a combined infra- and supradiaphragmatic approach.

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“…We searched for data on case series published in PubMed from the year 2000 to 2014. Regarding study design, 32 articles were under transcranial group [5][6][7][8][9]11,[13][14][15][16][18][19][20][21][23][24][25][26][27][28][29][30][31][32][33][34][35][36][37][38][39][40] and 16 articles were under endoscopic group. [19][20][21][22][41][42][43][44][45][46][47][48][49][50][51][52] The following search terms: meningioma, tuberculum sellae, diaphragm sellae, planum sphenoidale, transcranial, resection, and outcomes were used either singly or in combination.…”

Section: Search Methodologymentioning

confidence: 99%

“…2,10 MSMs exhibit complex symptoms such as adhering to vascular walls or completely engulfing them, however, they typically do not invade blood vessels. In view of the delicate anatomic location and proximity of MSMs to neurovascular structures (internal carotid artery and its branches, mainly anterior cerebral artery and anterior communicating artery, optic apparatus) and the pituitary gland, 11 they represent a major problem for surgical removal by neurosurgeons. In most cases, visual disturbances secondary to displaced optic apparatus is the main clinical presentation.…”

Section: Introductionmentioning

confidence: 99%

Transcranial Approach versus Endoscopic Transsphenoidal Approach during Midline Suprasellar Meningioma Resection—A Complication and Outcome-Based Study: A Meta-Analysis

Karki

Yadav

Zhao

2016

IJNS

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Background and Purpose?The choice of surgical approach for the removal of midline suprasellar meningiomas (MSM) has long remained inconclusive among neurosurgeons. While some neurosurgeons prefer transcranial approach (TCA), others favor the use of endoscopic transsphenoidal approach (ETSA). Retrospectively, we assessed the effectiveness of TCA and ETSA on the basis of postoperative outcome and complications to inform future clinical decision making on MSMs. Materials and Methods?A retrospective systematic review and meta-analysis was performed on published case series in PubMed from the year 2000 to 2014. Demographic data, clinical variables, and outcome measures of patients who had their MSMs surgically removed via TCA or ETSA were subjected to rigorous statistical analysis. Results?There were 48 studies with 1,466 patients who underwent TCA (32 studies) and ETSA (16 studies). TCA had a statistically significant rate of tumor recurrence (p?=?0.02; odds ratio [OR], 1.8; 95% confidence interval [CI], 1.1?6.39) while ETSA had a high rate of CSF leakage (p?=?0.04; OR, 25; 95% CI, 1.78?11.56). Both TCA and ETSA did not improve visual recovery and gross total resection, but only minimally influenced total clinical outcome. Conclusion?Put together, ETSA and TCA did not improve CSF leakage rate and tumor recurrence respectively, but in the absence of a surgical approach that could maximize the advantages of both TCA and ETSA, it is advisable that neurosurgeons take an informed clinical decision reflective of patient peculiar clinical presentations as well as risk/benefit profile of surgical technique.

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Technical nuances in the management of tuberculum sellae and diaphragma sellae meningiomas

Cited by 32 publications

References 43 publications

Tuberculum sellae meningiomas: grading scale to assess surgical outcomes using the transcranial versus transsphenoidal approach

Tuberculum sellae meningiomas: grading scale to assess surgical outcomes using the transcranial versus transsphenoidal approach

Meningiomas of the Tuberculum and Diaphragma Sellae

Transcranial Approach versus Endoscopic Transsphenoidal Approach during Midline Suprasellar Meningioma Resection—A Complication and Outcome-Based Study: A Meta-Analysis

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