Tag: Tuberculum sellae meningioma

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Contralateral subfrontal approach for tuberculum sellae meningioma

J Neurosurg 138:598–609, 2023

Tuberculum sellae meningiomas (TSMs) present a burdensome surgical challenge because of their adjacency to vital neurovascular structures. The contralateral subfrontal approach provides an outstanding corridor for removing a TSM with an excellent visual outcome and limited complications. The authors present their long-term surgical experience in treating TSMs via the contralateral subfrontal approach and discuss patient selection, surgical techniques, and clinical outcomes.

METHODS Between 2005 and 2021, the authors used the contralateral subfrontal approach in 74 consecutive patients presenting with TSMs. The surgical decision-making process and surgical techniques are described, and the clinical outcomes were retrospectively analyzed.

RESULTS The mean patient age was 54.4 years, with a female predominance (n = 61, 82%). Preoperatively, 61 patients (82%) had vision symptoms and 73 (99%) had optic canal invasion by tumor. Gross-total resection was achieved in almost all patients (n = 70, 95%). The visual function improvement and stabilization rate was 91% (67/74). Eight patients (11%) showed a worsening of visual function on the less-compromised (approach-side) optic nerve. There was no occurrence of cerebrospinal fluid leakage. Four patients (5%) experienced recurrences after the initial operation (mean follow-up duration 63 months). There were no deaths in this study.

CONCLUSIONS The contralateral subfrontal approach provides a high chance of complete tumor removal and visual improvement with limited complications and recurrences, especially when the tumor is in a unilateral or midline location causing unilateral visual symptoms or bilateral asymmetrical visual symptoms, regardless of tumor size or encasement of major vessels. With the appropriate patient selection, surgical technique, and familiarity with surrounding neurovascular structures, this approach is reliable for TSM surgery.

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The endoscope-assisted supraorbital “keyhole” approach for anterior skull base meningiomas: an updated meta-analysis

Acta Neurochirurgica (2021) 163:661–676

The gold-standard treatment for symptomatic anterior skull base meningiomas is surgical resection. The endoscope-assisted supraorbital “keyhole” approach (eSKA) is a promising technique for surgical resection of olfactory groove (OGM) and tuberculum sellae meningioma (TSM) but has yet to be compared with the microscopic transcranial (mTCA) and the expanded endoscopic endonasal approach (EEA) in the context of existing literature.

Methods An updated study-level meta-analysis on surgical outcomes and complications of OGM and TSM operated with the eSKA, mTCA, and EEA was conducted using random-effect models.

Results A total of 2285 articles were screened, yielding 96 studies (2191 TSM and 1510 OGM patients). In terms of effective- ness, gross total resection incidence was highest in mTCA (89.6% TSM, 91.1% OGM), followed by eSKA (85.2% TSM, 84.9% OGM) and EEA (83.9% TSM, 82.8% OGM). Additionally, the EEA group had the highest incidence of visual improvement (81.9% TSM, 54.6% OGM), followed by eSKA (65.9% TSM, 52.9% OGM) and mTCA (63.9% TSM, 45.7% OGM). However, in terms of safety, the EEA possessed the highest cerebrospinal fluid leak incidence (9.2% TSM, 14.5% OGM), compared with eSKA (2.1% TSM, 1.6% OGM) and mTCA (1.6% TSM, 6.5% OGM). Finally, mortality and intraoperative arterial injury were 1% or lower across all subgroups.

Conclusions: In the context of diverse study populations, the eSKA appeared not to be associated with increased adverse outcomes when compared with mTCA and EEA and offered comparable effectiveness. Case-selection is paramount in establishing a role for the eSKA in anterior skull base tumours.

 

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Endoscopic endonasal anatomy of the ophthalmic artery in the optic canal

Endoscopic endonasal anatomy of the ophthalmic artery in the optic canal

Acta Neurochir (2016) 158:1343–1350

The endoscopic endonasal opening of the optic canal has been recently proposed for tumors with medial invasion of this canal, such as tuberculum sellae meningiomas. Injury of the ophthalmic artery represents a dramatic risk during this maneuver. Therefore, the aim of this study was to analyze the endoscopic endonasal anatomy of the precanalicular and canalicular portion of this vessel, discussing its clinical implication.

Methods The course of the ophthalmic artery was analyzed through five endoscopic endonasal dissections, and 40 nonpathological consecutive MRAs were reviewed.

Results The ophthalmic artery arises from the intradural portion of the supraclinoid internal carotid artery, in 93%of cases about 1.9 mm (range: 1–3) posterior to the falciform ligament. At the entrance into the optic canal, the ophthalmic artery is located infero-medially to the optic nerve in 13 % of cases. In 50 % of these cases the artery moves infero-laterally along its course, remaining in a medial position in the others. In cases with an non medial entrance of the ophthalmic artery, it runs infero-lateral to the optic nerve for its entire canalicular portion, with just one exception.

Conclusion The endoscopic endonasal approach gives a direct, extensive and panoramic view of the course of the precanalicular and canalicular portion of the ophthalmic artery. Dedicated high-field neuroimaging studies are of paramount importance in preoperative planning to evaluate the anatomy of the ophthalmic artery, reducing the risk of jeopardizing the vessel, particularly for those uncommon cases with an infero-medial course of the artery.

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Extended endoscopic transsphenoidal approach infrachiasmatic corridor

EE transsphenoidal approach infrachiasmatic corridor

Neurosurg Rev (2015) 38:137–147

An extended endoscopic transsphenoidal approach is required for skull base lesions extending to the suprasellar area. Inferior approach using the infrachiasmatic corridor allows access to the lesions through the tumor growth that is favorable for the extended transsphenoidal approaches. Infrachiasmatic corridor is a safer route for the inferior approaches that is made up by basal arachnoid membrane and Liliequist’s membrane with its leaves (diencephalic and mesencephalic leaf). This area extends from the optic canal and tuberculum sella to the corpus mamillare.

We performed extended endoscopic approach using the infrachiasmatic corridor in 52 cases, including tuberculum sella meningiomas (n:23), craniopharyngiomas (n:16), suprasellar Rathke’s cleft cyst (n:6), pituitary adenoma (n:2), fibrous dysplasia (n:1), infundibular granulosa cell tumor (n:2), and epidermoid tumor (n:2). Total resection was achieved in 17 of 23 (74 %) with tuberculum sellae meningioma using infrachiasmatic approach. Twenty patients presented with visual disorders and 14 of them improved. There were two postoperative cerebrospinal fluid (CSF) leakages and one transient diabetes insipidus and one permanent diabetes insipidus. Sixteen patients were operated on by the infrachiasmatic approach for craniopharyngiomas. Improvement was reached in seven of eight patients presented with visual disorders. Complete tumor resection was performed in 10 of 16 cases and cyst aspiration in 4 cases, and there were remnants in two cases. Postoperative CSF leakage was seen in two patients.

Infrachiasmatic corridor provides an easier and safer inferior route for the removal of middle midline skull base lesions in selected cases.

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Lateral Supraorbital Approach Applied to Tuberculum Sellae Meningiomas

Neurosurgery 70:1504–1519, 2012 DOI: 10.1227/NEU.0b013e31824a36e8

Various surgical approaches for the removal of tuberculum sellae meningiomas (TSMs) have previously been described.

OBJECTIVE: To assess the reliability and safety of the lateral supraorbital (LSO) approach to remove TSMs.

METHODS: We identified all TSM patients operated on at the Department of Neurosurgery at Helsinki University Central Hospital, Finland, by the senior author (J.H.) using the LSO approach between September 1997 and August 2010. We retrospectively analyzed the clinical data, radiological findings, surgical treatment, histology, and outcome of patients and discuss the operative technique.

RESULTS: Apparent complete tumor removal was achieved in 45 patients (87%). Of 42 patients, preexisting visual deficit improved in 22, remained the same in 13, and worsened in 7, and de novo visual deficit occurred in 1 patient. At 3 months postdischarge, 47 patients (90%) had a good recovery, 4 (8%) were moderately disabled, and 1 (2%) died 40 days after surgery of unexplained cardiac arrest. Seven patients (13%) had minimal residual tumors, 2 of which required reoperation. During the median follow-up of 59 months (range, 1-133 months), tumor recurred in 1 of the patients who had undergone a second operation.

CONCLUSION: TSMs of all sizes can be removed via the LSO approach with minimal morbidity and mortality. Low-power or no coagulation is recommended near the optic nerves and the optic chiasm to preserve their vascular support from the internal carotid artery perforators. Our results are comparable to those obtained using more extensive and time-consuming approaches. We recommend the LSO approach to remove TSMs.

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Extended transsphenoidal approach for tuberculum sellae meningioma

Acta Neurochir (2012) 154:621–626. DOI 10.1007/s00701-011-1266-0

Recent advances in minimally invasive surgery have allowed extended transsphenoidal approaches to treat large and complex lesions beyond the sella turcica including basal meningiomas, but the inclusion criteria and limitations of this approach remain unclear.

Methods Retrospective review of 19 consecutive patients (5 males and 14 females aged from 43 to 79 years) with tuberculum sellae meningioma with a maximum diameter of less than 30 mm surgically treated between December 2006 and August 2011 by a single surgeon. Operative outcomes and limitation-based indications were investigated. Findings Total removal was achieved in 15 cases including Simpson’s grade 1 in 2 cases (78.9%). All tumor remnants were located in the lateral portion of the internal carotid artery (ICA), as indicated by preoperative magnetic resonance (MR) imaging. Additional oblique imaging along the longitudinal axis of the C1-2 portion of the ICA revealed a paradoxical presence of tumor in between both sides of the ICA in some patients, even in the case with lateral extension over the ICA on coronal MR imaging. Total removal could be achieved in these patients, and after the introduction of additional preoperative oblique MR imaging, total removal was achieved in all patients. Visual outcomes of eyes showed improvement in 23, remained steady in 11, and showed deterioration in 4, and 89.5% eyes recovered to a good state. Deterioration was caused by injury of a small vein in one patient and previous disruption of the arachnoidal sheath in the remaining three. One patient suffered cerebrospinal fluid leakage and required re-operation. None of the patients developed endocrinological deficits or required prolonged hormonal supplementation.

Conclusions The extended transsphenoidal approach has equivalent potential to transcranial surgery for tuberculum sellae meningiomas with a maximum diameter of less than 30 mm. The tumors with lateral extension over the ICA have fewer chances of total removal. ICA-oriented simulation and surgical planning are important.

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