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

Abstract

<jats:sec><jats:title>OBJECTIVE</jats:title><jats:p>Tuberculum 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.</jats:p></jats:sec><jats:sec><jats:title>METHODS</jats:title><jats:p>A 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.</jats:p></jats:sec><jats:sec><jats:title>RESULTS</jats:title><jats:p>The 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 &lt; 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 (&lt; 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 &lt; 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.</jats:p></jats:sec><jats:sec><jats:title>CONCLUSIONS</jats:title><jats:p>Tuberculum 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.</jats:p></jats:sec>

An Overview of Managements in Meningiomas

“…The visual function of patients with tuberculum sellae meningioma improved more significantly after endoscopic surgery. However, the incidence of cerebrospinal fluid leakage after endoscopic surgery was higher than transcranial approach, olfactory groove meningiomas (25.1 vs. 10.5%) (25,26) and tuberculum sellae meningiomas (19.3 vs. 5.81%) (17), which is almost three times of that of patients undergoing transcranial surgery. It is clear that further research is needed to determine the recurrence rate of these two methods, and with the development of endoscopy, it may be matched with craniotomy in terms of recurrence risk 1 day.…”

Letter to the Editor. Grading scale for tuberculum sellae meningiomas

“…We read with great interest the article by Magill et al 5 (Magill ST, Morshed RA, Lucas CHG, et al: Tuberculum sellae meningiomas: grading scale to assess surgical outcomes using the transcranial versus transsphenoidal approach. Neurosurg Focus 44 (4):E9, April 2018).…”

Endoscopic surgical resection of tuberculum sellae meningiomas based on decision-making algorithms proposed in the literature

“…The most common clinical symptoms, such as impaired visual acuity and hemianopia, are considered as the primary indication for surgical resection. Radiotherapy is usually reserved for asymptomatic tuberculum sella meningiomas (TSMs) without tumour compression upon the optic apparatus [10].…”

“…Using transcranial or endoscopic transsphenoidal approach for resecting these tumours is still a topic of debate [10], although recent publications and studies propose using decision-making algorithms in choosing the optimal approach for each individual case of TSMs, which constitute around 5-10% of all intracranial meningiomas [11]. The surgeon's experience, tumour location and size, as well as relation with the surrounding neurovascular structures are critical in the selection of the most adequate surgical approach [12].…”

“…The surgeon's experience, tumour location and size, as well as relation with the surrounding neurovascular structures are critical in the selection of the most adequate surgical approach [12]. Here, we used the decision-making algorithm proposed in the literature [13] for using the extended EEA, however sufficient results in large series are still lacking [10,13].…”