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

Comparative Efficacy of Transsphenoidal and Transcranial Approaches for Treating Tuberculum Sellae Meningiomas: A Systematic Review and Meta-Analysis

Background/Objectives: Tuberculum sellae meningiomas (TSMs) constitute 5-10% of intracranial meningiomas, often causing visual impairment. Traditional microsurgical transcranial approaches (MTAs) have been effective, but the emergence of innovative surgical trajectories, such as endoscopic endonasal approaches (EEAs), has sparked debate. While EEAs offer advantages like reduced brain retraction, they are linked to higher cerebrospinal fluid leak (CSF leak) risk. This meta-analysis aims to comprehensively compare the efficacy and safety of EEAs and MTAs for the resection of TSMs, offering insights into their respective outcomes and complications. Methods: A comprehensive literature review of the databases PubMed, Ovid MEDLINE, and Ovid EMBASE was conducted for articles published on TSMs treated with either EEA or MTA until 2024. The systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. Meta-analysis was performed to estimate pooled event rates and assess heterogeneity. Fixed- and random-effects were used to assess 95% confidential intervals (CIs) of presenting symptoms, outcomes, and complications. Results: A total of 291 papers were initially identified, of which 18 studies spanning from 2000 to 2024 met the inclusion criteria. The exclusion of 180 articles was due to reasons such as irrelevance, non-reporting of selected results, systematic literature review or meta-analysis, and a lack of details on method/results. The 18 studies comprised a total sample of 1093 patients: 444 patients who underwent EEAs and 649 patients who underwent MTAs for TSMs. Gross total resection (GTR) rates ranged from 80.9% for EEAs to 79.8% for MTAs. The rate of visual improvement was 86.6% in the EEA group and 65.4% in the MTA group. The recurrence rate in the EEA group was 6.9%, while it was 5.1% in MTA group. The postoperative complications analyzed were CSF leak, infections, dysosmia, intracranial hemorrhage (ICH), and endocrine disorders. The rate of CSF leak was 9.8% in the EEA group and 2.1% in MTA group. The rate of infections in the EEA group was 5.7%, while it was 3.7% in the MTA group. The rate of dysosmia ranged from 10.3% for MTAs to 12.9% for EEAs. The rate of ICH in the EEA group was 0.9%, while that in the MTA group was 3.8%. The rate of endocrine disorders in the EEA group was 10.8%, while that in the MTA group was 10.2%. No significant difference was detected in the rate of GTR between the EEA and MTA groups (OR 1.15, 95% CI 0.7-0.95; p = 0.53), while a significant benefit in visual outcomes was shown in EEAs (OR 3.54, 95% CI 2.2-5.72; p < 0.01). There was no significant variation in the recurrence rate between EEA and MTA groups (OR 0.92, 95% CI 0.19-4.46; p = 0.89). While a considerably increased chance of CSF leak from EEAs was shown (OR 4.47, 95% CI 2.52-7.92; p < 0.01), no significant difference between EEA and MTA groups was detected in the rate of infections (OR 1.92, 95% CI 0.73-5.06; p = 0.15), the rate of dysosmia (OR 1.25, 95% CI 0.31-4.99; p = 0.71), the rate of ICH (OR 0.61, 95% CI 0.20-1.87; p = 0.33), and the rate of endocrine disorders (OR 1.16, 95% CI 0.69-1.95; p = 0.53). Conclusions: This meta-analysis suggests that both EEAs and MTAs are viable options for TSM resection, with distinct advantages and drawbacks. The EEAs demonstrate superior visual outcomes in selected cases while GTR and recurrence rates support the overall effectiveness of MTAs and EEAs. Endoscopic endonasal approaches had a higher chance of CSF leaks, but there are no appreciable variations in other complications. These results provide additional insights regarding patient outcomes in the intricate clinical setting of TSMs.

Comparison of the Endoscopic Endonasal Approach with the Endoscopic Supraorbital Keyhole Approach to the Tuberculum Sellae Region: A Quantitatively Cadaveric Study

BACKGROUND

 The endoscopic endonasal approach (EEA) and the endoscopic supraorbital keyhole approach (eSKA) provide minimally invasive access to tuberculum sellae (TS) tumors. Evaluation of the operating maneuverability is helpful for approach selection. Herein, we compared the two approaches and aimed to provide quantitative anatomic data for surgical decision-making in the management of TS lesions.

METHODS

 Fifteen dissections were performed on five silicone-injected cadaveric heads. The EEA and eSKA (both right and left) were performed on each head. Surgical freedom and working angles in the axial and sagittal planes were calculated using the stereotactic navigation system in the selected six targets: the midpoint of the leading edge of the sphenoid sinus (leSS), the midpoint of the edge of the dorsum sellae (eDS), the ipsilateral medial opticocarotid recess (imOCR), the contralateral medial opticocarotid recess (cmOCR), the ipsilateral lateral opticocarotid recess (ilOCR), and the contralateral lateral opticocarotid recess (clOCR).

RESULTS

 The surgical freedom at the ilOCR and the axial working angles at the leSS, ilOCR, and imOCR (imOCR with excessive manipulation of the optic apparatus) were greater in the eSKA. The EEA provided greater surgical freedom and/or working angles at most targets than eSKA (the surgical freedom at the imOCR, cmOCR, clOCR, and eDS; the axial working angles at the cmOCR and clOCR; and the sagittal working angles at the leSS, imOCR, cmOCR, clOCR, and eDS).

CONCLUSION

 The EEA provides greater surgical freedom and working angles for paramedian lesions, whereas the eSKA provides better surgical maneuverability for lesions with lateral extension.

Health-Related Quality of Life Outcomes in Meningioma Patients Based upon Tumor Location and Treatment Modality: A Systematic Review and Meta-Analysis

Patients with meningiomas may have reduced health-related quality of life (HRQoL) due to postoperative neurological deficits, cognitive dysfunction, and psychosocial burden. Although advances in surgery and radiotherapy have improved progression-free survival rates, there is limited evidence regarding treatment outcomes on HRQoL. This review examines HRQoL outcomes based on tumor location and treatment modality. A systematic search in PubMed yielded 28 studies with 3167 patients. The mean age was 54.27 years and most patients were female (70.8%). Approximately 78% of meningiomas were located in the skull base (10.8% anterior, 23.3% middle, and 39.7% posterior fossae). Treatment modalities included craniotomy (73.6%), radiotherapy (11.4%), and endoscopic endonasal approach (EEA) (4.0%). The Karnofsky Performance Scale (KPS) was the most commonly utilized HRQoL instrument (27%). Preoperative KPS scores > 80 were associated with increased occurrence of postoperative neurological deficits. A significant difference was found between pre- and post-operative KPS scores for anterior/middle skull base meningiomas (SBMs) in comparison to posterior (SBMs) when treated with craniotomy. Post-craniotomy SF-36 scores were lower for posterior SBMs in comparison to those in the anterior and middle fossae. Risk factors for poor neurological outcomes include a high preoperative KPS score and patients with posterior SBMs may experience a greater burden in HRQoL.

Efficiency and safety of optic canal unroofing in tuberculum sellae meningiomas: a meta-analysis and systematic review

Optic canal unroofing (OCU) has gradually become a routine technique for tuberculum sellae meningiomas (TSMs) resection. This meta-analysis aimed to evaluate the efficacy and safety of OCU. A systematic review and meta-analysis of the published literature on this topic from 2003 to 2023 were conducted in accordance with the PRISMA guidelines. Rigorous statistical analysis with a p-value was performed for related change in visual improvement, gross total resection (GTR), visual deterioration, and olfactory nerve damage. The study included 15 articles with 384 patients in whom OCU was performed by the transcranial approach (TCA) or the endoscopic endonasal approach (EEA). Of these, 341 patients had preoperative visual loss, and 266 patients had postoperative visual recovery. The overall rate of visual improvement was 0.803 (95% CI: 0.733-0.874, p < 0.01). The rate of visual improvement in the EEA and TCA groups was 0.884 (95% CI: 0.803-0.965, p < 0.01) and 0.788 (95% CI: 0.700-0.875, p < 0.01). Further analysis of classification shows that the rate of visual improvement in Type I: < 2 cm was 0.889(95% CI: 0.739-0.969), Type II:2-4 cm was 0.844(95% CI: 0.755-0.910), Type III: > 4 cm was 0.500(95% CI: 0.068-0.932) and the total was 0.853(95% CI: 0.779-0.927 p < 0.01) with low heterogeneity of I2 = 20.80%.Twelve studies separately reported GTR with OCU was 293; the rate of GTR was 0.911 (95% CI: 0.848-0.961, p < 0.01). And the rate of GTR in Type I: < 2 cm was 0.933(95% CI: 0.817-0.986), Type II:2-4 cm was 0.880(95% CI: 0.800-0.936), Type III: > 4 cm was 0.600(95% CI: 0.147-0.947). The total was 0.897(95% CI: 0.830-0.965 p < 0.01) with low heterogeneity of I2 = 34.57%. The related complications of OCU were visual deterioration and olfactory nerve damage. Visual decline was reported in nine studies, and the rate was 0.077 (95% CI: 0.041-0.113, p < 0.01). Six studies reported olfactory nerve damage, and the overall rate was 0.054 (95% CI: 0.019-0.090, p < 0.01). OCU could significantly recover preoperative impaired vision and make GTR easier to achieve, which was also a safe and effective technique in TSM.

Endoscopic Endonasal Transplanum-Transtuberculum Approach for Pituitary Adenomas/PitNET: 25 Years of Experience

The role of the endoscopic transplanum-transtuberculum approach (ETTA) in the treatment of pituitary adenomas/PitNETs (PAs) is sparsely analyzed in the literature, and its use is still debated in the current practice. The aim of this study was to report our experience with this approach. Our institutional registry was retrospectively reviewed, and patients who underwent ETTA for a PA from 1998 to 2022 were included. Fifty-seven cases were enrolled over a time span of 25 years, corresponding to 2.4% of our entire PA caseload. Radical resection was achieved in 57.9% of cases, with re-do surgery (p = 0.033) and vessel encasement/engulfment (p < 0.001) as predictors of partial resection. CSF leak incidence stood at 8.8%, with higher BMI (p = 0.038) as its only significant predictor. Partial or full improvement of the visual field deficits was achieved in 73.5% of cases. No surgical mortality was observed. According to our results, ETTA for the treatment of PAs is characterized by a satisfactory surgical outcome but with greater morbidity than the conventional endoscopic approach. Therefore, it should be reserved for the few selected cases otherwise unsuitable for the endoscopic trans-sphenoidal route, representing a valid alternative and an effective complementary route for the transcranial approach for these challenging PAs.

Pterional Approach for Anterior Skull Base Midline Meningiomas against "The More The Merrier" Approach: An Institutional Experience

Objective  Anterior midline skull base meningiomas involving olfactory groove, planum sphenoidale, and tuberculum sellae were usually managed with bifrontal craniotomy until the dawn of advanced microsurgical techniques. With the emergence of microsurgical techniques, midline meningiomas could be tackled solely from a unilateral pterional approach. We present our experience with pterional approach in managing anterior skull base midline meningiomas, including the technical nuances and outcomes. Methods  Fifty-nine patients who underwent excision of anterior skull base midline meningiomas through a unilateral pterional craniotomy between 2015 and 2021 were retrospectively analyzed. The surgical technique and patient outcomes in the context of visual, behavioral, olfaction, and quality of life were evaluated during the follow-up. Results  A total of 59 consecutive patients were assessed over an average follow-up period of 26.6 months. Twenty-one (35.5%) patients had planum sphenoidale meningioma. Olfactory groove and tuberculum sellae meningioma groups consist of 19 (32%) patients each. Visual disturbance was the predominant symptom with almost 68% of patients presented with it. A total of 55 (93%) patients had complete excision of the tumor with 40 patients (68%) achieving Simpson grade II excision, and 11 (19%) patients had Simpson grade I excision. Among operated cases, 24 patients (40%) had postoperative edema among which 3 (5%) patients had irritability and 1 patient had diffuse edema requiring postoperative ventilation. Only 15 (24.6%) patients had contusion of the frontal lobe and were managed conservatively. Five patients (50%) with seizures had an association with contusion. Sixty-seven percent of patients had improvements in vision and 15% of patients had a stable vision. Only eight (13%) patients had postoperative focal deficits. Ten percent of patients had new-onset anosmia. The average Karnofsky score was improved. Only two patients had recurrence during follow-up. Conclusion  A unilateral pterional craniotomy is a versatile approach for the excision of anterior midline skull base meningioma, even for the larger lesions. The ability of this approach in the visualization of posterior neurovascular structures at the earlier stages of surgery while avoiding the opposite frontal lobe retraction and frontal sinus opening makes this approach more preferable over the other approaches.

History, Current Techniques, and Future Prospects of Surgery to the Sellar and Parasellar Region

The sellar and parasellar region can be affected by diverse pathologies. The deep-seated location and surrounding critical neurovascular structures make treatment challenging; there is no singular, optimal approach for management. The history and development of transcranial and transsphenoidal approaches by pioneers in skull base surgery were largely aimed at treating pituitary adenomas, which are the most common lesions of the sella. This review explores the history of sellar surgery, the most commonly used approaches today, and future considerations for surgery of the sellar/parasellar region.

Comparative analysis of outcomes following craniotomy and expanded endoscopic endonasal approach resection of tuberculum sellae meningiomas: a single-institution study

Background

Traditionally, supratentorial craniotomy has been used to sever tuberculum sellae meningiomas (TSMs), but there has been a remarkably increasing tendency of extended endoscopic endonasal approach (EEEA) used to treat TSMs in the recent decade. Several documents have described the advantages and disadvantages of both approaches, but there is no consensus on whether one is superior to the other.

Objective

This study aimed to compare surgical outcomes between craniotomy and EEEA for TSMS treated at our institution.

Methods

From January 2015 to December 2021, a total of 84 cases of TSMs were included in this study. Cases were separated into two groups: the craniotomy group and the EEEA group. Their anamneses and surgical records were reviewed. Demographic data, presenting symptoms, tumor volume, extent of resection, visual outcomes, and follow-up data were tabulated. The Kaplan-Meier curves were constructed for the PFS for both cohorts.

Results

Complete data were available for 84 surgeries; 39 cases were treated via craniotomy, and 45 were treated via EEEA. Patient demographic data, pre-operative symptoms, and tumor characteristics were similar between the two cohorts. The extent of resection was similar between the two groups (GTR: 91.11% EEEA vs. 87.18% craniotomy; STR 8.89 vs. 12.82%, p = 0.91). There was no difference in visual outcomes between both groups (92.1 vs. 84.84%, p = 0.46). An increased rate of cranial nerve injury was noted in the craniotomy group (0 vs. 10.25%, p = 0.04). Post-operative CSF leak rate occurred in one patient in the EEEA group. The PFS curves (p = 0.52) and recurrence/progression rates (13.33 vs. 20.51%, p = 0.39) were similar between the two groups.

Conclusion

Both EEEA and craniotomy can successfully sever TSMs. The recurrence/progression rate and PFS appear to be similar between the two groups. Although there are no differences in EOR and visual outcomes between the two groups, there was a clear trend in the EEEA group to obtain a better outcome. CSF leakage was common in the EEEA cohort, whereas the rate of cranial nerve injury was found to be higher in the craniotomy cohort. We believe that our data support the conclusion that EEEA surgery is the preferred approach for the removal of TSMs.

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.

Diagnostic value of magnetic resonance imaging ectopic posterior pituitary hyperintense signal in pituitary macroadenoma

Objective

When the lesions in the sellar region are large, they can involve both the inside and outside the sella, which brings challenges to the differential diagnosis of pituitary macroadenoma and lesions other than macroadenoma. Therefore, this study explored the diagnostic value of an ectopic posterior pituitary hyperintense signal (EPPHS) in pituitary macroadenoma and its possible causes.

Methods

The clinical and imaging data of 131 patients with sellar tumors or tumor-like lesions involving both intrasellar and extrasellar regions in the Affiliated Hospital of Guizhou Medical University from February 2011 to December 2021 were analyzed retrospectively. The diagnostic value of EPPHS in pituitary macroadenoma was analyzed. The differences in clinical and imaging indexes between the EPPHS-positive group and the EPPHS-negative group were compared.

Results

These 131 cases of sellar tumors or tumor-like lesions involving both intrasellar and extrasellar regions included 91 cases of pituitary macroadenoma and 40 cases of lesions other than macroadenoma. The receiver operator characteristic (ROC) curve analysis suggested that EPPHS had a diagnostic value in diagnosing pituitary macroadenoma [area under the curve (AUC) = 0.857, P = 0.0001]. Compared with the EPPHS negative group, the median prolactin level in the EPPHS positive group was significantly higher (P &lt; 0.05). Through ROC curve analysis, prolactin value was found to be of diagnostic value for EPPHS (AUC = 0.612, P = 0.0312).

Conclusion

In sellar tumors or tumor-like lesions involving both intrasellar and extrasellar regions, the appearance of EPPHS is helpful in the diagnosis of pituitary macroadenoma. The formation of EPPHS may be related to injuries to the pituitary stalk.

Keyhole supraorbital eyebrow approach for fully endoscopic resection of tuberculum sellae meningioma

Background

The fully endoscopic supraorbital trans-eyebrow keyhole approach is a technique utilized for the transcranial resection of tuberculum sellae meningioma (TSM). Surgery is the first choice for TSM treatment. This study aimed to summarize and analyze the safety, feasibility, limitations, and technical requirements of the fully endoscopic supraorbital trans-eyebrow keyhole approach for TSM resection.

Methods

Data of 19 TSM fully endoscopic supraorbital trans-eyebrow keyhole approach resections cases (six and 13 on the left and right eyebrows, respectively) were retrospectively analyzed at the Neurosurgery Department of the First Affiliated Hospital of Bengbu Medical College (Bengbu, China) from August 2015 to March 2022.

Results

All 19 patients were diagnosed with meningioma (World Health Organization grade I), and according to the scope of tumor resection (EOR), 18 patients (94.7%) had gross total resection (GTR), and one patient (5.3%) had near-total resection (NTR). Preoperative chief complaints were symptomatic visual dysfunction (n = 12), headache and dizziness (n = 6), and accidental discovery (n = 1). Postoperative visual function improved in 83.3% of cases (10/12), and headache and dizziness were relieved in 83.3% of cases (5/6 patients). Postoperative intracranial infection occurred in one case and was cured by external drainage of the lumbar cistern and anti-infective treatment. Two cases of frontal lobe injury were discharged after conservative treatment. There was no postoperative olfactory dysfunction, eyelid ptosis, cerebrospinal fluid leakage, or death. There were no reports of disease recurrence or death during the 3-month follow-up at an outpatient clinic or by telephone.

Conclusion

Fully endoscopic TSM resection through the keyhole approach is safe and feasible. It can be used to explore angles that cannot be seen under a microscope and show the true value of endoscopy technology. The endoscopic equipment and technical skills of the surgeon and surgical team are important in this technique.

Endonasal transsphenoidal surgery for planum sphenoidale versus tuberculum sellae meningiomas

OBJECTIVE

The aim of this study was to determine if the distinction between planum sphenoidale (PS) and tuberculum sellae (TS) meningiomas is clinically meaningful and impacts the results of the endoscopic endonasal approach (EEA).

METHODS

A consecutive series of patients who were 18 years of age or older and underwent EEA for newly diagnosed grade I PS meningiomas (PSMs) and TS meningiomas (TSMs) between October 2007 and May 2021 were included. The PS and TS were distinguished by drawing a line passing through the center of the TS and perpendicular to the PS on postcontrast T1-weighted MRI. Probabilistic heatmaps were created to display the actual distribution of tumor volumes. Tumor volume, extent of resection (EOR), visual outcome, and complications were assessed.

RESULTS

The 47 tumors were distributed in a smooth continuum. Using an arbitrary definition, 24 (51%) were PSMs and 23 (49%) were TSMs. The mean volume of PSMs was 5.6 cm3 compared with 4.5 cm3 for TSMs. Canal invasion was present in 87.5% of PSMs and 52% of TSMs. GTR was achieved in 38 (84%) of 45 cases in which it was the goal, slightly less frequently for PSMs (78%) compared with TSMs (91%), although the difference was not significant. Th mean EOR was 99% ± 2% for PSMs and 98% ± 11% for TSMs. Neither the suprasellar notch angle nor the percentage of tumor above the PS impacted the rate of GTR. After a median follow-up of 28.5 months (range 0.1–131 months), there were 2 (5%) recurrences after GTR (n = 38) both of which occurred in patients with PSMs. Forty-two (89%) patients presented with preoperative impaired vision. Postoperative vision was stable or improved in 96% of patients with PSMs and 91% of patients with TSMs. CSF leakage occurred in 4 (16.6%) patients with a PSM, which resolved with only lumbar drainage, and in 1 (4.3%) patient with a TSM, which required reoperation.

CONCLUSIONS

PSM and TSMs arise in a smooth distribution, making the distinction arbitrary. Those classified as PSMs were larger and more likely to invade the optic canals. Surgical outcome for both locations was similar, slightly favoring TSMs. The arbitrary distinction between PSMs and TSMs is less useful at predicting outcome than the lateral extent of the tumor, regardless of the site of origin.

Management of Recurrent Meningiomas: State of the Art and Perspectives

Simple Summary

Intracranial meningiomas account for 30% to 40% of the primary lesions of the central nervous system. Surgery is the mainstay treatment whenever symptoms related to an intra-cranial meningioma are encountered. However, the management of recurrences after initial surgery, which are not uncommon, is still a matter of debate. Here, we present the alternatives described in the management of meningioma recurrence (radiotherapy, stereotaxic radiosurgery, protontherapy, and chemotherapy, among others). Their overall results are compared to surgery and future perspectives are presented.

Abstract

Background: While meningiomas often recur over time, the natural history of repeated recurrences and their management are not well described. Should recurrence occur, repeat surgery and/or use of adjuvant therapeutic options may be necessary. Here, we summarize current practice when it comes to meningioma recurrence after initial surgical management. Methods: A total of N = 89 articles were screened. N = 41 articles met the inclusion criteria and N = 16 articles failed to assess management of meningioma recurrence. Finally, N = 24 articles were included in our review. Results: The articles were distributed as follows: studies on chemotherapy (N = 14), radiotherapy, protontherapy, and stereotaxic radiosurgery (N = 6), boron-neutron capture therapy (N = 2) and surgery (N = 3). No study seems to provide serious alternatives to surgery in terms of progression-free and overall survival. Recurrence can occur long after the initial surgery and also affects WHO grade 1 meningiomas, even after initial gross total resection at first surgery, emphasizing the need for a long-term and comprehensive follow-up. Conclusions: Surgery still seems to be the state-of-the-art management when it comes to meningioma recurrence, since none of the non-surgical alternatives show promising results in terms of progression-free and overall survival.

The use of optical coherence tomography angiography in patients with chiasmal compression (literature review)

Optical coherence tomography (OCT) is currently the leading method for the observation and evaluation of microstructural changes in the retina in vivo. In recent years, OCT has been used in clinical practice to monitor the progression of compressive optic neuropathy in patients with chiasmal-sellar region neoplasms. The results obtained in the course of the studies opened up new opportunities for studying the pathogenesis of the development of compressive optic neuropathy in patients of this group. The advent of OCT-angiography (OCTA), developed on the basis of OCT, made it possible to study changes in the blood flow of the radial peripapillary capillary network, superficial and deep capillary plexuses, which opens up many opportunities for further research into the pathogenesis of visual impairment in this group of patients, prognosis of the development of the disease, and selection optimal terms of treatment. The literature review presents and analyzes the currently available results of the use of OCTA in patients with chiasmal compression.

Olfactory Outcomes after Resection of Tuberculum Sella and Planum Sphenoidale Meningiomas via a Transcranial Approach

Objectives Controversy exists surrounding the optimal approaches to tuberculum sella meningioma (TSM) and planum meningioma (PM). Olfaction is infrequently considered within this context but is nonetheless an important quality of life measure. The evolution of olfactory outcomes following contemporary transcranial surgery remains unclear. This study reviews olfactory outcomes after supraorbital craniotomy for TSM or PM and defines temporal trends in its recovery.

Study Design A prospective study of a patients who underwent a minimally invasive supraorbital craniotomy for TSM or PM was conducted at a single neurosurgical center.

Participants & Main Outcome Measures All patients were questioned about olfaction at presentation 3 months postoperatively, 12 months postoperatively, and annually thereafter (median follow-up = 37 months). The olfactory status of patients was categorized as normosmia, anosmia, hyposmia, parosmia, (altered perception of odours), or phantosmia, (olfactory hallucinations).

Results Twenty-two patients were included in the study analysis, (range = 27–76). Precisely, 3 months after surgery, seven patients had normal olfaction (32%). Six patients were anosmic, (27%) four hyposmic, (18%), three parosmic, (14%), and two were phantosmic (9%). At 1-year follow-up, almost half of patients (10; 48%) were normosmic, while two patients (9.5%) were anosmic. There were no further improvements in olfaction between 1 year and long-term follow-up.

Conclusion Subfrontal transcranial approaches for TSM or PM appear to be associated with changes in olfaction that can improve with time; these improvements occur within the first year after surgery. Impacts upon olfaction should be considered when selecting a surgical approach and patients counseled appropriately.

Predictive Factors of Favorable Visual Outcomes After Surgery of Tuberculum Sellae Meningiomas: A Multicenter Retrospective Cohort Study

BACKGROUND

Because of their proximity to the visual structures, tuberculum sellae meningiomas are frequently revealed by ophthalmologic impairment. The goal of surgery is gross total resection and improvement of visual function. The purpose of the present study was to identify the predictors of favorable visual outcomes after surgery of tuberculum sellae meningioma.

METHODS

We retrospectively collected tuberculum sellae meningiomas treated at 2 neurosurgical centers from 2010 to 2020. We collected the clinical, imaging and surgical data and analyzed their effects on the visual outcome. A favorable visual outcome was defined as an increase in visual acuity of ≥0.2 point and/or an increase of >25% of the visual field or complete recovery.

RESULTS

A total of 50 patients were included. At 4 months after surgery, 30 patients (60%) had experienced visual improvement. The predictors of a favorable visual outcome were a symptom duration of <6 months, preoperative visual acuity >0.5, a smaller tumor size, and tumor with T2-weighted/fluid attenuated inversion recovery hypersignal on magnetic resonance imaging. During surgery, a soft tumor and a clear brain-tumor interface were associated with favorable visual outcomes. Preoperative optic coherence tomography measurements of the retinal nerve fiber layer thickness >80 μM and ganglion cell complex thickness >70 μM were also associated with a better ophthalmologic outcome.

CONCLUSIONS

In tuberculum sellae meningiomas, rapid surgical treatment must be performed to optimize vision improvement. A hyperintense lesion on T2-weighted/fluid attenuated inversion recovery magnetic resonance imaging and minor vision impairment at the initial ophthalmologic presentation might give hope for a favorable outcome. Performing optic coherence tomography measurements before surgery could clarify patients' expectations regarding their recovery.

Optical coherence tomography and visual evoked potentials in evaluation of optic chiasm decompression

Chiasmal compression is a known cause of visual impairment, often leading to surgical decompression of the optic chiasm (OC). A prospective study was held at University Hospital in Hradec Králové to explore sensitivity of optical coherence tomography (OCT) and visual evoked potentials (VEPs) to OC compression and eventual changes after a decompression. 16 patients with OC compression, caused by different sellar pathologies, were included. The main inclusion criterion was the indication for decompressive surgery. Visual acuity (VA), visual field (VF), retinal nerve fibre layer (RNFL) and ganglion cell layer (GCL) thickness, and peak time and amplitude of pattern-reversal (P-VEPs) and motion-onset VEPs (M-VEPs) were measured pre- and postoperatively. The degree of OC compression was determined on preoperative magnetic resonance imaging. For M-VEPs, there was a significant postoperative shortening of the peak time (N160) (p < 0.05). P100 peak time and its amplitude did not change significantly. The M-VEPs N160 amplitude showed a close relationship to the VF improvement. Thinner preoperative RNFL does not present a statistically important limiting factor for better functional outcomes. The morphological status of the sellar region should be taken into consideration when one evaluates the chiasmal syndrome. M-VEPs enable detection of functional changes in the visual pathway better than P-VEPs.

Management of cavernous sinus meningiomas: Consensus statement on behalf of the EANS skull base section

Introduction

The evolution of cavernous sinus meningiomas (CSMs) might be unpredictable and the efficacy of their treatments is challenging due to their indolent evolution, variations and fluctuations of symptoms, heterogeneity of classifications and lack of randomized controlled trials. Here, a dedicated task force provides a consensus statement on the overall management of CSMs.

Research question

To determine the best overall management of CSMs, depending on their clinical presentation, size, and evolution as well as patient characteristics.

Material and methods

Using the PRISMA 2020 guidelines, we included literature from January 2000 to December 2020. A total of 400 abstracts and 77 titles were kept for full-paper screening.

Results

The task force formulated 8 recommendations (Level C evidence). CSMs should be managed by a highly specialized multidisciplinary team. The initial evaluation of patients includes clinical, ophthalmological, endocrinological and radiological assessment. Treatment of CSM should involve experienced skull-base neurosurgeons or neuro-radiosurgeons, radiation oncologists, radiologists, ophthalmologists, and endocrinologists.

Discussion and conclusion

Radiosurgery is preferred as first-line treatment in small, enclosed, pauci-symptomatic lesions/in elderly patients, while large CSMs not amenable to resection or WHO grade II-III are candidates for radiotherapy. Microsurgery is an option in aggressive/rapidly progressing lesions in young patients presenting with oculomotor/visual/endocrinological impairment. Whenever surgery is offered, open cranial approaches are the current standard. There is limited experience reported about endoscopic endonasal approach for CSMs and the main indication is decompression of the cavernous sinus to improve symptoms. Whenever surgery is indicated, the current trend is to offer decompression followed by radiosurgery.

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A thorough evaluation of cavernous sinus meningiomas by a multidisciplinary team is mandatory.

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Microsurgery should be considered for aggressive lesions in young patients.

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Extended endoscopic approaches can be effective when combined with radiotherapy.

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Stereotaxic radiotherapy and stereotaxic radiosurgery offer excellent tumour control in small/asymptomatic lesions .

Surgical management of anterior clinoidal meningiomas: consensus statement on behalf of the EANS skull base section

BACKGROUND

The optimal management of clinoidal meningiomas (CMs) continues to be debated.

METHODS

We constituted a task force comprising the members of the EANS skull base committee along with international experts to derive recommendations for the management of these tumors. The data from the literature along with contemporary practice patterns were discussed within the task force to generate consensual recommendations.

RESULTS AND CONCLUSION

This article represents the consensus opinion of the task force regarding pre-operative evaluations, patient's counselling, surgical classification, and optimal surgical strategy. Although this analysis yielded only Class B evidence and expert opinions, it should guide practitioners in the management of patients with clinoidal meningiomas and might form the basis for future clinical trials.

The Suprasellar Meningioma Patient-Reported Outcome Survey: a disease-specific patient-reported outcome measure for resection of suprasellar meningioma

OBJECTIVE

Suprasellar meningioma resection via either the transcranial approach (TCA) or the endoscopic endonasal approach (EEA) is an area of controversy and active evaluation. Skull base surgeons increasingly consider patient-reported outcomes (PROs) when choosing an approach. No PRO measure currently exists to assess quality of life for suprasellar meningiomas.

METHODS

Adult patients undergoing suprasellar meningioma resection between 2013 and 2019 via EEA (n = 14) or TCA (n = 14) underwent semistructured interviews. Transcripts were coded using a grounded theory approach to identify themes as the basis for a PRO measure that includes all uniquely reported symptoms. To assess content validity, 32 patients and 15 surgeons used a Likert scale to rate the relevance of items on the resulting questionnaire and the general Patient-Reported Outcomes Measurement Information System-29 (PROMIS29). The mean scores were calculated for all items and compared for TCA versus EEA patient cohorts by using unpaired t-tests. Items on either questionnaire with mean scores ≥ 2.0 from patients were considered meaningful and were aggregated to form the novel Suprasellar Meningioma Patient-Reported Outcome Survey (SMPRO) instrument.

RESULTS

Qualitative analyses resulted in 55 candidate items. Relative to patients who underwent the EEA, those who underwent the TCA reported significantly worse future outlook before surgery (p = 0.01), tiredness from medications 2 weeks after surgery (p = 0.001), and word-finding and memory difficulties 3 months after surgery (p = 0.05 and < 0.001, respectively). The items that patients who received a TCA were most concerned about included medication-induced lethargy after surgery (2.9 ± 1.3), blurry vision before surgery (2.7 ± 1.5), and difficulty reading due to blurry vision before surgery (2.7 ± 2.7). Items that patients who received an EEA were most concerned about included blurry vision before surgery (3.5 ± 1.3), difficulty reading due to blurry vision before surgery (2.4 ± 1.3), and problems with smell postsurgery (2.9 ± 1.3). Although surgeons overall overestimated how concerned patients were about questionnaire items (p < 0.0005), the greatest discrepancies between patient and surgeon relevance scores were for blurry vision pre- and postoperatively (p < 0.001 and < 0.001, respectively) and problems with taste postoperatively (p < 0.001). Seventeen meningioma-specific items were considered meaningful, supplementing 8 significant PROMIS29 items to create the novel 25-item SMPRO.

CONCLUSIONS

The authors developed a disease- and approach-specific measure for suprasellar meningiomas to compare quality of life by operative approach. If demonstrated to be reliable and valid in future studies, this instrument may assist patients and providers in choosing a personalized surgical approach.

ABBREVIATIONS

EEA = endoscopic endonasal approach; GTR = gross-total resection; PRO = patient-reported outcome; PROMIS29 = Patient-Reported Outcomes Measurement Information System-29; QOL = quality of life; SMPRO = Suprasellar Meningioma Patient-Reported Outcome Survey; TCA = transcranial approach.

Cerebrospinal Fluid Leak after Transsphenoidal Surgery: A Systematic Review and Meta-analysis

Background Cerebrospinal fluid (CSF) leak is widely recognized as a challenging and commonly occurring postoperative complication of transsphenoidal surgery (TSS).

The primary objective of this study is to benchmark the current prevalence of CSF leak after TSS in the adult population.

Methods The authors followed the PRISMA guidelines. The PubMed, Embase, and Cochrane Library databases were searched for articles reporting CSF leak after TSS in the adult population. Meta-analysis was performed using the Untransformed Proportion metric in OpenMetaAnalyst. For two between-group comparisons a generalized linear mixed model was applied.

Results We identified 2,408 articles through the database search, of which 70, published since 2015, were included in this systematic review. These studies yielded 24,979 patients who underwent a total of 25,034 transsphenoidal surgeries. The overall prevalence of postoperative CSF leak was 3.4% (95% confidence interval or CI 2.8–4.0%). The prevalence of CSF leak found in patients undergoing pituitary adenoma resection was 3.2% (95% CI 2.5–4.2%), whereas patients who underwent TSS for another indication had a CSF leak prevalence rate of 7.1% (95% CI 3.0–15.7%) (odds ratio [OR] 2.3, 95% CI 0.9–5.7). Patients with cavernous sinus invasion (OR 3.0, 95% CI 1.1–8.7) and intraoperative CSF leak (OR 5.9, 95% CI 3.8–9.0) have increased risk of postoperative CSF leak. Previous TSS and microscopic surgery are not significantly associated with postoperative CSF leak.

Conclusion The overall recent prevalence of CSF leak after TSS in adults is 3.4%. Intraoperative CSF leak and cavernous sinus invasion appear to be significant risk factors for postoperative CSF leak.

How I do it: endoscopic endonasal resection of tuberculum sellae meningioma

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.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00701-021-04784-5.

Meningiomas of the Planum Sphenoidale and Tuberculum Sella

Patients with meningiomas of the planum sphenoidale and tuberculum sella often present with insidious vision loss in one or both eyes as the only sign or symptom of their disease, although other sensory, oculomotor, and even endocrine abnormalities may be seen in a minority of cases. Incidentally discovered tumors also are common, as patients may undergo neuroimaging for unrelated symptoms or events. Depending on the size and orientation of the tumor, central vision loss from optic nerve compression may be a later sign, and loss of peripheral vision in one or both eyes may not be recognized until it has progressed to areas closer to fixation. A thorough neuroophthalmologic assessment including visual field testing will help to define the extent of optic pathway involvement. Both fundus examination and optical coherence tomography of the retinal nerve fiber layer and macular ganglion cell complex will aid in determining prognosis after treatment of the tumor. Orbital surgery rarely is indicated as primary therapy for meningiomas in this location, and surgical resection or debulking is usually pursued before consideration is given to radiation therapy. Because of the long-term risk of residual tumor growth or recurrence, neuroophthalmic surveillance along with serial neuroimaging is required for years after tumor resection and/or radiation therapy.

Supraorbital transciliary keyhole approach for removal of tuberculum sellae meningioma: 3D surgical video

Background:

Tuberculum 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 Description:

A 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.

Conclusion:

Performing 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.

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.

Surgery for diaphragma sellae meningioma: how I do it

Background

Surgery for diaphragma sellae meningiomas (DSM) remains challenging due to the intimate neurovascular relationships of the tumor. Excision of DSM along with a decompression of the optic apparatus requires a good knowledge of the skull base anatomy and a precise preoperative evaluation of the tumor extensions.

Method

We describe the key steps of transcranial approach for DSM with a video illustration. The surgical anatomy is described along with the advantages and limitations of this approach.

Conclusions

The transcranial approach allows a safe tumor excision with an early and adequate control of the neurovascular structures, while minimizing postoperative CSF rhinorrhea.

Electronic supplementary material

The online version of this article (10.1007/s00701-020-04581-6) contains supplementary material, which is available to authorized users.