Tuberculum sellae meningioma: Is there an ideal approach?

Abstract

BACKGROUND:Tuberculum sellae meningiomas is a serious challenge for neurosurgeons. It accounts for up to 10% of all intracranial meningiomas. The difficulty in surgically excising a Tuberculum sellae meningioma comes from its anatomical relationship to the optic nerves and chiasm and to the anterior cerebral and internal carotid arteries and their perforators. The authors discuss the main approaches and the complications based on their experience in comparison to previously reported data. METHODS: We report our personal case series of 38 patients with Tuberculum sellae meningiomas; 36 patients under went craniotomy for tumor resection (12 bifrontal, 12 pterional, 6 supraciliary, 4 unilateral frontals, and 2fronto-orbito-zygomatic); in two patients, the excision was performed through an endoscopic endonasal approach. The Simpson grade of meningioma resection as well as the non-visual morbidity and the mortality rates were analyzed. RESULTS: Thirty-one patients had Simpson grades 1 and 2 excisions, while seven had Simpson grade 4 excisions. The overall rate of non-visual morbidity was 13.15% (5 of 38 patients) and mortality was 5.3% (2 of 38). CONCLUSION: The primary symptom leading to the diagnosis of a Tuberculum sellae meningioma is visual compromise and the main goal of surgery is to achieve improvement of vision. Favorable outcomes were achieved with appropriate selection of surgical approach. More studies are necessary to define the prognostic factors for patients in this scenario.

Tuberculum Sellae Meningiomas: Outcome of Twenty-eight Cases after Surgery

“…To correctly select the surgical approach, it is necessary to understand the advantages and disadvantages of each procedure and some factors must be considered by the neurosurgeon in making the right decision. To correctly select the surgical approach, it is necessary to understand the advantages and disadvantages of each procedure and some factors must be considered by the neurosurgeon in making the right decision 9 . According to Goel et al Younger patients tolerated the surgical procedure better than older patients.…”

“…However during resection of the meningioma, small vessels observed in the stretched arachnoid layer should not be coagulated. By preserving these vessels, there is a better chance for visual function improvement 9 . According to Gadget et al in cases of TSM with a significant level of optic nerve compromise and with limited lateral extension, endoscopic endonasal resection is an excellent option but if there are medial optic canal invasion transcranial surgery is must 9,14 .…”

“…Vital structures and important anatomic landmarks bound the tuberculum sellae are laterally clinoid processes (fig:1), the internal carotid and the posterior communicating arteries; posteriorly the pituitary stalk, infundibulum, and the Lillequist membrane; superior boundary form by the optic chiasm, the lamina terminalis, and the anterior cerebral artery complex. Which make the space is quite small, (mean length 8mm, mean width 11mm) 9 . Compromise of the optic apparatus is an important feature for decision making 9,10 .…”

“…Which make the space is quite small, (mean length 8mm, mean width 11mm) 9 . Compromise of the optic apparatus is an important feature for decision making 9,10 . The aim of surgery is to relieve the mass effect upon the optic apparatus.…”

“…The aim of surgery is to relieve the mass effect upon the optic apparatus. Several surgical approaches such as subfrontal, bifrontal, unilateral frontal, supraorbital keyhole, pterional have been proposed for the resection of TSM, and more recently in different article neurosurgical endoscopic techniques have been introduced as an option during removal of skull base tumors both transcranially and endonasally 9,11 .…”