Preoperative Evaluation of the Interface Between Tuberculum Sellae Meningioma and the Optic Nerves on Fast Imaging with Steady-State Acquisition for Extended Endoscopic Endonasal Transsphenoidal Surgery

Contralateral subfrontal approach for tuberculum sellae meningioma: techniques and clinical outcomes

OBJECTIVE

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.

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

INTRODUCTION

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 effectiveness, 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.

Accuracy and Interrater Reliability of CISS Versus Contrast-Enhanced T1-Weighted VIBE for the Presence of Optic Canal Invasion in Tuberculum Sellae Meningiomas

BACKGROUND

The magnetic resonance imaging sequence used to assess optic canal invasion by tuberculum sella meningiomas (TSMs) has not been standardized. Both constructive interference in steady state (CISS) and contrast-enhanced T1-weighted volume-interpolated breath-hold examination (VIBE) sequences are frequently used. The aim of the present study was to compare the accuracy and interrater reliability of these sequences in predicting optic canal invasion by TSMs.

METHODS

In the present retrospective study of 27 patients (54 optic canals) who had undergone endoscopic transtuberculum transplanum resection of TSMs, images from preoperative CISS and contrast-enhanced T1-weighted VIBE sequences were assessed by 5 neuroradiologists who were unaware of the operative findings. The readers evaluated the optic canal in 4 quadrants at 2 locations (the posterior tip of the anterior clinoid process and the optic strut). A quadrant was considered positive for tumor invasion if invasion was present at either of these 2 locations. The reference standard was intraoperative observation of gross optic canal invasion.

RESULTS

The interrater agreement was good for the presence or absence of tumor involvement in a particular quadrant (CISS, 0.635; VIBE, 0.643; 95% confidence interval for the difference, -0.086 to 0.010). The mean sensitivity and specificity for optic nerve invasion were 0.643 and 0.438 with CISS and 0.643 and 0.454 with VIBE, respectively. No significant differences were seen between the sequences in terms of reader accuracy when the intraoperative findings were used as the reference standard.

CONCLUSION

CISS and VIBE sequences both have good accuracy in predicting for optic canal tumor invasion by TMEs.

Surgical management of Tuberculum sellae Meningiomas: Myths, facts, and controversies

BACKGROUND

The optimal management of tuberculum sellae (TS) meningiomas, especially the surgical strategy, continues to be debated along with several controversies that persist.

METHODS

A task force was created by the EANS skull base section committee along with its members and other renowned experts in the field to generate recommendations for the surgical management of these tumors on a European perspective. To achieve this, the task force also reviewed in detail the literature in this field and had formal discussions within the group.

RESULTS

The constituted task force dealt with the practice patterns that exist with respect to pre-operative radiological investigations, ophthalmological and endocrinological assessments, optimal surgical strategies, and follow-up management.

CONCLUSION

This article represents the consensually derived opinion of the task force with respect to the surgical treatment of tuberculum sellae meningiomas. Areas of uncertainty where further clinical research is required were identified.

Surgical outcome of tuberculum sellae and planum sphenoidale meningiomas based on Sekhar-Mortazavi Tumor Classification

BACKGROUND

Results from surgical series of tuberculum and planum sphenoidale meningiomas tends to be heterogeneous. Sekhar-Mortazavi tumor classification system has been recently proposed in order to predict the surgical risk and outcome.

METHODS

We retrospectively reviewed a consecutive series of tuberculum and planum sphenoidale meningioma operated at our institution between 2009 and 2016. Sekhar-Mortazavi Tumor Classification was applied to classify these tumors and evaluate the outcome.

RESULTS

Twenty-seven patients were included in the study. There were 22 females (81%) and 5 males (19%). The mean age was 54 years (range 33-78). According to Sekhar-Mortazavi Tumor Classification: 14 patients (51.85%) were class I, 11 (40.74%) patients were in class II and 2 patients (7.41%) were in class III. Twenty-one patients (77.7%) presented with visual symptoms and deficits at preoperative neuro-ophthalmological examination. Sekhar-Mortazavi class I tumors had a postoperative visual improvement in 77.7% of cases while patients in Sekhar-Mortazavi class II-III had a postoperative visual improvement in 66.6% of cases (P=0.5). No patient had deterioration of optic nerve/chiasmal function following surgery. Gross total resection was obtained in 25 patients (92.5%) without any significative difference between class I and Class II-III tumors. Permanent endocrine dysfunction was observed only in one patient in SM Class II tumor. 3 patients (11%) showed a postoperative persistent cranial nerve deficit (2 patients were anosmic and one patient had a trochlear nerve deficit). None of the patients showed postoperative CSF leak. No onset of new seizures was observed postoperatively. There was no mortality or major morbidity in this series.

CONCLUSIONS

Transcranial surgery provided very satisfying results with respect to visual and endocrine outcomes with very low surgical morbidity. The Sekhar-Mortazavi classification showed a trend towards better visual outcomes in Class I tumors. The classification system is easy to apply and could therefore prove useful to compare results between studies reported in literature, especially when comparisons are made between transcranial and endonasal surgery.