Clinical Study
Extended endoscopic endonasal transsphenoidal removal of tuberculum sellae meningiomas: A preliminary report

https://doi.org/10.1016/j.jocn.2008.10.003Get rights and content

Abstract

In this present study, we reviewed our management of seven patients by an extended endoscopic endonasal transsphenoidal approach to resect tuberculum sellae meningiomas. All surgery was performed using pure endoscopy and a neuronavigation system. In six patients, total resection of the tumor was accomplished; one patient had subtotal tumor removal. Post-operatively, visual function was improved in six patients, and was unchanged in one patient. There was asymptomatic tumor recurrence on MRI during the follow-up period in the patient in whom a subtotal resection had been performed. This preliminary report suggests that an extended endoscopic endonasal transsphenoidal approach is an effective, minimally invasive approach for small and medium-sized tuberculum sellae meningiomas located in the midline. However, this approach should be limited to an experienced and coordinated endoneurosurgical team.

Introduction

Tuberculum sellae meningiomas frequently arise from the tuberculum sellae, chiasmatic sulcus, planum sphenoidale, and diaphragma sellae and comprise 4–10% of all intracranial meningiomas.[1], [2] The most common presenting symptoms on admission include visual loss and headache. The standard techniques for resection of tuberculum sellae meningiomas include unilateral subfrontal, bifrontal, or frontotemopral approaches,[1], [3], [4], [5] although a transsphenoidal approach has been reported.[6], [7], [8], [9] However, these techniques may injure the frontal lobe, olfactory nerve, and optic nerve or provide limited surgical exposure.[3], [4], [5], [6], [7], [8], [9] To overcome these obstacles, to improve visualization and minimize morbidity, the tuberculum sellae meningiomas have been resected using an extended endoscopic endonasal transsphenoidal approach.[10], [11] An obvious advantage of this approach over a transcranial one in removing tuberculum sellae meningiomas is that brain retraction is obviated, manipulation of the optic nerves and pituitary stalk is minimized, and the dura and bone involved by the tumor can be completely resected.[12], [13], [14] So far there have been only few reports using an extended transsphenoidal approach with pure endoscopy: Jho15 reported on pure endoscopic endonasal surgery for sellar and suprasellar lesions and Cook6 used endoscopy to ascertain the extent and location of residual tumors and to help visualize structures during microsurgery for three tuberculum sellae meningiomas.

We report on seven patients with tuberculum sellae meningiomas managed with an extended endoscopic endonasal transsphenoidal approach. We describe the surgical technique and review our experience.

Section snippets

Patients and methods

Seven patients with tuberculum sellae meningiomas (5 females and 2 males, 27–67 years of age) were treated in the Neurosurgery Department at the Wuxi Second Hospital Affiliated Nanjing Medical University between February 2002 and August 2007 (Table 1). Six patients presented with unilateral visual acuity deterioration and two patients had bilateral visual acuity deterioration. Three patients presented with severely decreased visual acuity (>20/400). Visual field defects existed in five patients

Results

A total of seven patients (five females and two males) had a mean age of 53.3 years, ranging from 27 to 67 years. The most common presenting symptoms were visual disturbances. Gross total tumor resection was achieved in six patients, and subtotal resection was performed in one patient, who had residual tumor in the left optic canal, and the dural attachment at the left optic canal was not removed. The average length of hospital stay was 4 days (range, 2–5 days). There were no significant

Patient 4

This 54-year-old woman with a 2 month history of progressive visual loss was transferred to the Wuxi Second Hospital, where an MRI revealed a 2.7 cm × 2 cm × 1.5 cm suprasellar dural-based mass arising from the tuberculum sellae. An enhanced MRI revealed a homogeneously enhanced lesion centered on the tuberculum sellae and chiasmatic sulcus. The optic chiasm was elevated significantly by the mass, and the pituitary stalk was pushed posteriorly. She underwent an endoscopic extended endonasal

Discussion

Transnasal transsphenoidal microscopic surgery is a viable option for the management of tuberculum sellae meningiomas.[6], [7], [8], [9], [17] Although this surgery carries minimal morbidity, it provides limited exposure, precluding the effective resection of many tumors. These obstacles can be avoid with the use of rigid endoscopes. With advances in sophisticated surgical instrumentation and evolution of neuronavigation, endoscopic techniques are used increasingly to manage complex skull base

References (24)

  • H. Arai et al.

    Transcranial transsphenoidal approach for tuberculum sellae meningiomas

    Acta Neurochir (Wien)

    (2000)
  • H. Bassiouni et al.

    Tuberculum sellae meningiomas: functional outcome in a consecutive series treated microsurgically

    Surg Neurol

    (2006)
  • J.H. Chi et al.

    Tuberculum sellae meningiomas

    Neurosurg Focus

    (2003)
  • V. Benjamin et al.

    The microsurgical nuances of resecting tuberculum sellae meningiomas

    Neurosurgery

    (2005)
  • R. Fahlbusch et al.

    Pterional surgery of meningiomas of the tuberculum sellae and planum sphenoidale: surgical results with special consideration of ophthalmological and endocrinological outcomes

    J Neurosurg

    (2002)
  • S.W. Cook et al.

    Endonasal transsphenoidal removal of tuberculum sellae meningiomas: technical note

    Neurosurgery

    (2004)
  • G. Frank et al.

    Extended transsphenoidal approach

    J Neurosurg

    (2001)
  • T. Kato et al.

    Transsphenoidal–transtuberculum sellae approach for supradiaphragmatic tumors: technical note

    Acta Neurochir(Wien)

    (1998)
  • E.R. Laws et al.

    Extended transsphenoidal approach

    J Neurosurg

    (2005)
  • D.M. Prevedello et al.

    Endoscopic endonasal resection of a synchronous pituitary adenoma and a tuberculum sellae meningioma: technical case report

    Neurosurgery

    (2007)
  • E. de Divitiis et al.

    Extended endoscopic transsphenoidal approach for tuberculum sellae meningiomas

    Neurosurgery

    (2007)
  • P. Cappabianca et al.

    Endoscopic endonasal transsphenoidal surgery

    Neurosurgery

    (2004)
  • Cited by (39)

    • Clinical Outcomes with Transcranial Resection of the Tuberculum Sellae Meningioma

      2017, World Neurosurgery
      Citation Excerpt :

      GOS depended more on tumor size, duration of operation, EBL, and hospital length of stay, factors suggesting more complex disease. Our clinical complications and visual outcomes are better than those reported in other recent trials evaluating TSM treatment.1,18,27 A meta-analysis reported by Ruggeri et al.1 evaluated 60 articles covering olfactory groove meningiomas and TSMs, in which 1656 patients underwent TCR and 292 underwent an ETA.

    • From above or below: The controversy and historical evolution of tuberculum sellae meningioma resection from open to endoscopic skull base approaches

      2014, Journal of Clinical Neuroscience
      Citation Excerpt :

      Over the past 25 years, the microsurgical transsphenoidal approach, classically used for pituitary and parasellar tumors, has been utilized to resect TSM via the extended transsphenoidal approach [8,31–36]. In more recent years, with the advent of the surgical endoscope and development of multi-disciplinary skull base teams, resection of these lesions has been achieved using purely endoscopic endonasal transplanum transtuberculum approaches [5,6,35,37–42]. Historically, it has been clear that regardless of the surgical approach chosen, the primary treatment objectives for TSM have remained the same: gross total tumor resection with adequate decompression of the optic apparatus, improved or preserved visual function, and prevention of future recurrence.

    View all citing articles on Scopus
    View full text