How I do it: endoscopic endonasal resection of tuberculum sellae meningioma.
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ABSTRACT: Background
Tuberculum sellae meningiomas (TSMs) adherent to neurovascular structures are particularly challenging lesions requiring delicate and precise microneurosurgery. There is an ongoing debate about the optimal surgical approach.Method
We describe technical nuances and challenges in TSM resection using the endoscopic endonasal approach (EEA) in two cases of fibrous tumors with adherence to neurovascular structures. The cases are illustrated with a video (case 1) and figures (cases 1 and 2).Conclusion
A dedicated team approach and precise microsurgical technique facilitate safe resection of complex TSMs through the EEA.
SUBMITTER: Wiedmann M
PROVIDER: S-EPMC8270812 | biostudies-literature | 2021 Aug
REPOSITORIES: biostudies-literature
Publications
How I do it: endoscopic endonasal resection of tuberculum sellae meningioma.
Wiedmann Markus M Lashkarivand Aslan A Berg-Johnsen Jon J Dahlberg Daniel D
Acta neurochirurgica 20210305 8
<h4>Background</h4>Tuberculum sellae meningiomas (TSMs) adherent to neurovascular structures are particularly challenging lesions requiring delicate and precise microneurosurgery. There is an ongoing debate about the optimal surgical approach.<h4>Method</h4>We describe technical nuances and challenges in TSM resection using the endoscopic endonasal approach (EEA) in two cases of fibrous tumors with adherence to neurovascular structures. The cases are illustrated with a video (case 1) and figures ...[more]
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Project description:BackgroundTuberculum sellae meningioma (TSM), a common benign tumor in the sellae region, usually causes neurological deficits, such as vision impairment, by squeezing the peripheral neurovascular structures. Surgical management is recommended as the optimal strategy for TSM treatment and vision restoration. However, it remains challenging to resect TSM in the traditional transcranial approach (TCA). Recently, the endoscopic endonasal approach (EEA) has emerged as an effective option in skull base surgeries. Besides the effectivity, the advantages and limitations of EEA in TSM surgery remain controversial.ObjectWe compared the surgical outcomes and complications between TCA and EEA surgeries to identify the principles in TSM surgical management.MethodsRetrospective analysis was performed on the patients, who underwent TSM surgery in Wuhan Union Hospital between January 2017 and December 2021. The patients were assigned to TCA or EEA group according to the surgery they experienced. All patients were analyzed with the extent of tumor resection, vision outcome, postoperative complications, and follow-up results.ResultsA total of 112 patients were enrolled in this study, including 78 in TCA group and 34 in EEA group. The mean follow-up was 20.5 months (range 3-36 months). There were no statistically significant differences in patient demographic data, preoperative symptoms, and tumor characteristics between TCA and EEA groups. Both TCA and EEA surgeries are effective in TSM resection with relatively high gross total resection rates (85.9% in TCA vs. 91.2% in EEA, p > .05). Meanwhile, EEA surgery has a better outcome in vision restoration or stabilization than TCA surgery (74.6% in TCA vs. 93.1% in EEA, p < .05). Whereas EEA surgery causes more occurrences of cerebrospinal fluid (CSF) leakage than TCA surgery (0% in TCA vs. 11.8% in EEA, p < .05).ConclusionBoth TCA and EEA surgeries are effective in TSM resection. EEA surgery has a better outcome in vision restoration or stabilization than TCA surgery, but induces higher risk of CSF leakage. As each approach has unique advantages and limitations, we must take all aspects into consideration, including approach feathers, tumor characteristics, and clinical requirements, to make the optimal choice in TSM surgical management.
| S-EPMC9470762 | biostudies-literature
Project description:BackgroundTuberculum sellae meningiomas represent approximately 5-10% of intracranial meningiomas.[2] Although benign, they are associated with substantial morbidity, especially visual disturbance. At present, there are three main treatment options for patients with tuberculum sellae meningiomas: observational, with serial imaging follow; microsurgical resection; and stereotactic radiosurgery. The advantages of the supraorbital eyebrow craniotomy are the direct visualization of the anterior cranial fossa, anterior circulation, and the optical apparatus, reducing the extent of brain retraction, and the absence of risks of temporalis muscle hypotrophy and posterior chewing discomfort. Conversely, minor drawbacks are a steeper learning curve related to a narrower surgical corridor than a standard frontotemporal approach and the minimal risk of supraorbital nerve injury.[1,3].Case descriptionThe authors report the case of a 42-year-old female who presented with acute-onset vision loss and only finger counting in her left eye associated with headache. Magnetic resonance imaging (MRI) showed a suprasellar extra-axial T1 enhancing mass with encasement of the left optic nerve and paraclinoid internal carotid artery and mass effect on the optic chiasm. A keyhole supraorbital eyebrow approach assisted with a microinspection tool was performed for tumor resection and optic nerve decompression. A Simpson Grade 2 tumor resection was achieved, and histopathology revealed a WHO Grade-I tuberculum sellae meningioma. The patient's presentation, rationale, key surgical steps, and outcome are discussed, and informed consent for surgery and video recording was obtained.ConclusionThis surgical video illustrates the use of a keyhole supraorbital eyebrow approach assisted with a microinspection endoscopic tool for the resection of a tuberculum sellae meningioma. The tumor size, extension, and preoperative clinical status determine the optimal surgical corridor in tuberculum sellae meningioma. The keyhole supraorbital eyebrow approach allows safe and direct access to anterior cranial fossa lesions.
| S-EPMC8986636 | biostudies-literature
Project description:BackgroundTuberculum sellae meningiomas pose a surgical challenge due to the tumor adhesion to vital structures. In many cases, tumor residue and dural tail sign may contribute to an opportunity for future recurrence.MethodsIn this study, we introduced endoscopic technique in supraorbital keyhole approach to further resected residual tumor and dural attachments that are traditionally difficult to detect under microscopic surgery, and finally achieved Simpson Grade II resection.ConclusionThe use of endoscopy offers enhanced visualization and ensures more reliable Simpson Grade II resection outcomes for tuberculum sellae meningiomas.
| S-EPMC11885384 | biostudies-literature
Project description:Objective Giant tuberculum sellae meningiomas (TSMs) are deeply located in the suprasellar region and extensively compressed or encased in the surrounding neurovascular structures, making gross total resection (GTR) without postoperative visual impairment challenging. The authors presented individualized unilateral subfrontal approach and endoscopic transsphenoidal approach (ETSA) in a series of patients and elaborated on their advantages and indications in resecting giant TSMs. Methods A total of 38 patients with giant TSMs operated by a single surgeon between March 2012 and November 2021 were retrospectively reviewed. Patients underwent unilateral subfrontal approach and ETSA according to preoperative imaging characteristics. Tumor characteristics, surgical details, preoperative symptoms, and neurological outcomes of TSMs patients were collected and analyzed. Results In 31 patients operated with the unilateral subfrontal approach, total resection (Simpson grade I or II) was achieved in 27 patients (87.0%), while 6 patients (85.7%) achieved GTR in 7 patients using ETSA. The postoperative visual improvement was maintained in 22 (81.5%) and 5 patients (83.3%). Recurrence or progression was only observed in 2 (7.4%) patients operated with the unilateral subfrontal approach. There was no mortality in our series. Conclusions Preoperative imaging and visual function are important for surgical approach selection. Maximum tumor resection and optic nerve protection can be achieved concurrently by taking advantage of these surgical approaches. The cerebral artery protection strategies and individualized surgical techniques provide great utility in improving a patient's quality of life.
| S-EPMC9890549 | biostudies-literature
Project description:BackgroundThe fully endoscopic combined endonasal and supraorbital keyhole approach, which integrates the endoscopic endonasal approach (EEA) and the endoscopic supraorbital keyhole approach (eSKA), is effective for complex suprasellar tumors extending beyond the internal carotid artery (ICA). We detail its application for tuberculum sellae meningiomas with lateral extension.MethodTumor resection is performed via the EEA, with support from the eSKA. This allows for careful management of the optic nerve under direct visualization and enables sufficient tumor resection.ConclusionThis combined approach facilitates extensive tumor resection, effective skull base reconstruction, and preservation of surrounding structures.
| S-EPMC11828812 | biostudies-literature
Project description:BackgroundTuberculum sellae meningiomas have an incidence from 5 to 10% of all intracranial meningiomas[2] and tend to be surgically difficult and challenging tumors given their proximity to important structures such as the internal carotid artery (ICA), anterior cerebral artery (ACA), and optic nerves.[3] Typically, their growth is posteriorly and superiorly oriented, thereby displacing the optic nerves and causing visual dysfunction, which is the primary indication for surgical treatment.[1] The main goals of the treatment are the preservation or restoration of visual abilities and a complete tumor resection.[1] Conventionally, surgical approaches to tuberculum meningiomas involve largely invasive extended bifrontal, interhemispheric, orbitozygomatic, pterional, and subfrontal eyebrow approaches. The supraorbital craniotomy, however, is a minimally invasive transcranial approach that offers a similar surgical corridor to conventional transcranial approaches, using a limited craniotomy and minimal brain retraction that can be used for tumoral and vascular pathologies,[4,5] offering added cosmetic outcomes.[1] We present the case of a patient undergoing a supraorbital transciliary craniotomy with a tuberculum sellae meningioma causing bitemporal hemianopsia.Case descriptionA 70-year-old female with chronic headaches and progressive vision loss and visual field deficit for about 1 year. On ophthalmological evaluation, she was able to fixate and follow objects with each eye, light perception was only present in the right eye, and the vision in the left eye was 0.2 decimal units. Her visual fields demonstrated severe campimetric deficits. Her extraocular movements were intact and bilateral pupils were equal, round, and reactive to light. MRI of the brain demonstrated tuberculum sellae meningioma with bilateral optic canal invasion, displacing the chiasm, and extending ≥180° around the medial ICA wall and anterior ACA wall. The patient underwent supraorbital transciliary keyhole approach for total resection of the tumor. Postoperatively, visual acuity and visual field were significantly improved.ConclusionPerforming a supraorbital transciliary keyhole craniotomy for tuberculum sellae meningiomas requires an adequate and meticulous preoperative planning to determine the optimal surgical corridor to the lesion. The use of supraorbital craniotomy is safe with good cosmetic results and potentially lower morbidity allowing for adequate exposure, resection, and release of neurovascular structures.
| S-EPMC7827506 | biostudies-literature
Project description:BackgroundMeningiomas of the optic sheath have been traditionally treated with radiotherapy, among other reasons, because of the poor results in terms of visual preservation of the open surgical approaches.Case descriptionTwo cases of optic nerve meningioma were operated through an endoscopic endonasal expanded approach due to rapidly progressing visual deterioration and doubtful diagnosis. In the first case an exclusively bone decompression was performed. In the second one a partial resection of the intradural portion and complete opening of the dural sheath was undertaken. In both cases visual acuity remained stable without further treatment for the 2 years follow up.ConclusionsEndoscopic endonasal decompression of the optic nerve by removal of the optic canal and opening of the optic sheath is safe. This approach is feasible for optic sheath meningioma. This treatment might be considered as an option in patients with rapidly deteriorating visual acuity.
| S-EPMC9623684 | biostudies-literature
Project description:BackgroundPosterior clinoid process (PCP) meningioma is an exceedingly rare entity. It remains the most challenging skull base lesion for neurosurgeons due to its treacherous location that insinuates amongst critical neurovascular structures. This article will describe the technical notes using the endoscopic endonasal approach that provide the earliest devascularization and detachment of the tumor PCP meningioma.MethodsWe are introducing the surgical implementation of an endoscopic endonasal approach to removing PCP meningioma. Furthermore, we perform a literature review of posterior clinoid process meningioma that undergoes surgical intervention, then summarize the benefits and limitations of each approach.ResultsWe present a case of right PCP meningioma that was removed using an endoscopic endonasal approach through the transposterior clinoid corridor in a 52-year-old-woman. We describe the technical notes in performing this approach to have the earliest devascularization and detachment of the tumor by performing posterior clinoidectomy. Safe tumor removal is performed with a wide and clear view of the surrounding neurovascular structure. Based on our database search, we found nine articles reported on the surgical management of PCP meningiomas, with a total number of 15 cases. All of the reported cases performed the tumor removal using the transcranial approach.ConclusionThe endoscopic endonasal transposterior clinoid approach circumvents all disadvantages faced by the traditional transcranial approach, providing the earliest approach to devascularized and detaching the tumor from its attachment at PCP. This approach demonstrates safety and efficacy, making it an acceptable alternative for PCP meningioma resections.
| S-EPMC11196407 | biostudies-literature
Project description: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.
| S-EPMC4318732 | biostudies-other
Project description:Tuberculum sellae meningiomas frequently produce visual loss by direct compression from tumor, constriction of the optic nerve (ON) under the falciform ligament, and/or ON ischemia. The authors hypothesized that changes in visual function after tumor removal may be related to changes in blood supply to the ON that might be seen in the pial circulation at surgery. Indocyanine green (ICG) angiography was used to attempt to document these changes at surgery. The first patient in whom the technique was used had a left-sided, 1.4-cm, tuberculum meningioma. Time-lapse comparison of images was done postsurgery, and the comparison of video images revealed both faster initial filling and earlier complete filling of the ON pial circulation, suggesting improved pial blood flow after surgical decompression. In follow-up the patient had significant improvements in both visual acuity and visual fields function. Intraoperative ICG angiography of the ON can demonstrate measurable changes in pial vascular flow that may be predictive of postoperative visual outcome. The predictive value of this technique during neurosurgical procedures around the optic apparatus warrants further investigation in a larger cohort.
| S-EPMC5125447 | biostudies-literature