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

Surgical Management and Outcome of the Planum Sphenoidale Meningioma: A Single-Center Strobe Compliant Study

BACKGROUND

The resection of the jugum (planum) sphenoidale meningioma (JSM) is challenging, and there is a scarcity of available data in the literature. This study aimed to describe the surgical management and long-term outcome of jugum sphenoidale meningioma.

METHODS

This was a retrospective, single-center, cohort study of 91 JSM patients treated in our department from 2005 to 2022. All the included patients have undergone surgical treatment. Clinical, radiologic, and surgical data were extracted with specific attention to the age at onset, family history, duration from symptoms to diagnosis, clinical presentation, quality of excision, recurrence, and treatment outcome.

RESULTS

WHO grade I and grade II meningioma were 83.5% (n = 76) and 16.5% (n = 15) respectively. Fronto-lateral 42.9% (n = 39) and pterional approaches 57.1% (n = 52) were the 2 major surgical approaches used for the management of planum sphenoidale meningioma. Twelve patients needed emergency surgical treatment at admission: 4 (4.4%) External CSF Shunt and 8 (8.8%) VP-Shunt. We have found a statistically significant (P = 0.032) association between the quality of excision and the risk of recurrence. The GTR (Hazard ratio = 1) of the planum meningioma protects the patient from recurrence within 60 months of follow-up. Postoperative complications encountered were CSF-Leak in 2.2%, Meningitis 4.4%, surgical site infection 2.2%, and surgical site hematoma 3.3%. The overall postoperative favorable outcome was 68.1% (n = 62).

CONCLUSIONS

The pterional approach has allowed the achievement of GTR for jugum sphenoidale meningioma with protective odds from recurrence risk.

Factors influencing postoperative visual improvement in 208 patients with tuberculum sellae meningiomas

OBJECTIVE

Tuberculum sellae meningiomas (TSMs) usually compress the optic nerve and optic chiasma, thus affecting vision. Surgery is an effective means to remove tumors and improve visual outcomes. On a larger scale, this study attempted to further explore and confirm the factors related to postoperative visual outcomes to guide the treatment of TSMs.

METHODS

Data were obtained from 208 patients with TSMs who underwent surgery at our institution between January 2010 and August 2022. Demographics, ophthalmologic examination results, imaging data, extent of resection, radiotherapy status, and surgical approaches were included in the analysis. Univariate and multivariate logistic regressions were used to assess the factors that could lead to favorable visual outcomes.

RESULTS

The median follow-up duration was 63 months, and gross total resection (GTR) was achieved in 174 (83.7%) patients. According to our multivariate logistic regression analysis, age < 60 years (odds ratio [OR] = 0.310; P = 0.007), duration of preoperative visual symptoms (DPVS) < 10 months (OR = 0.495; P = 0.039), tumor size ≤ 27 mm (OR = 0.337; P = 0.002), GTR (OR = 3.834; P = 0.006), and a tumor vertical-to-horizontal dimensional ratio < 1 (OR = 2.593; P = 0.006) were found to be significant independent predictors of favorable visual outcomes.

CONCLUSION

Age, DPVS, tumor size, GTR, and the tumor vertical-to-horizontal dimensional ratio were found to be powerful predictors of favorable visual outcomes. This study may help guide decisions regarding the treatment of TSMs.

Ipsilateral Visual Loss Caused by Optic Nerve Compression between a Tuberculum Sellae Meningioma and the Internal Carotid Artery

We report a rare case of ipsilateral visual loss caused by compression of the optic nerve between a tuberculum sellae meningioma (TSM) and the internal carotid artery (ICA). The patient was a 70-year-old female who presented with a 2-year history of left visual disturbance with a TSM on magnetic resonance imaging. No tumor infiltration to the optic canal was identified in the preoperative images. Extended endoscopic transsphenoidal surgery was performed and showed no infiltration to the optic canal. The tumor was removed completely, and optic nerve compression was found between the TSM and atherosclerotic ICA. This report shows an atypical case in which compression of the optic nerve between a TSM and the ICA caused ipsilateral visual loss despite no infiltration to the optic canal.

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.

Olfactory Groove Meningiomas: Comprehensive assessment between the different microsurgical transcranial approaches and the Endoscopic Endonasal Approaches, systematic review and metanalysis on behalf of the EANS skull base section

•OGM surgery is much more complex than a simple debate of "from above or from below" (transcranial vs endoscopic).•Lateral Sub-frontal and Superior Interhemispheric seem the most effective, superior and versatile approaches for OGM.•Minimally Invasive Transcranial approaches showed no inferiority in OGM sized <4 ​cm.•Endoscopic Endonasal Approaches showed inferior results in surgical and in functional outcomes for OGM.

The Endoscopic-Assisted Supraorbital Approach for Resection of Anterior Skull Base Meningiomas: A Large Single-Center Retrospective Surgical Study

Objective The endoscopic-assisted supraorbital approach (eSOA) constitutes a minimally invasive strategy for removing anterior skull base meningiomas (ASBM). We present the largest retrospective single-institution and long-term follow-up study of eSOA for ASBM resection, providing further insight regarding indication, surgical considerations, complications, and outcome.

Methods We evaluated data of 176 patients operated on ASBM via the eSOA over 22 years.

Results Sixty-five tuberculum sellae (TS), 36 anterior clinoid (AC), 28 olfactory groove (OG), 27 planum sphenoidale, 11 lesser sphenoid wing, seven optic sheath, and two lateral orbitary roof meningiomas were assessed. Median surgery duration was 3.35 ± 1.42 hours, being significantly longer for OG and AC meningiomas (p <0.05). Complete resection was achieved in 91%. Complications included hyposmia (7.4%), supraorbital hypoesthesia (5.1%), cerebrospinal fluid fistula (5%), orbicularis oculi paresis (2.8%), visual disturbances (2.2%), meningitis (1.7%) and hematoma and wound infection (1.1%). One patient died due to intraoperative carotid injury, other due to pulmonary embolism. Median follow-up was 4.8 years with a tumor recurrence rate of 10.8%. Second surgery was chosen in 12 cases (10 via the previous SOA and two via pterional approach), whereas two patients received radiotherapy and in five patients a wait-and-see strategy was adopted.

Conclusion The eSOA represents an effective option for ASBM resection, enabling high complete resection rates and long-term disease control. Neuroendoscopy is fundamental for improving tumor resection while reducing brain and optic nerve retraction. Potential limitations and prolonged surgical duration may arise from the small craniotomy and reduced maneuverability, especially for large or strongly adherent lesions.

Tuberculum Sella Meningioma: Surgical Management and Results with Emphasis on Visual Outcome

Background  Tuberculum sella meningioma form a distinct surgical entity with significant morbidity for the patient due to early and profound visual involvement. Surgical treatment of tuberculum sella meningioma is challenging in view of the proximity of vital neuro-vasculature. These lesions may be approached via a high-route (trans-cranial) or a low-route (trans-sphenoidal).

Materials and Methods  The authors present a consecutive series of 36 patients, operated by the first author from 1996 onward, with an analysis of clinical presentation (emphasizing visual deterioration), imaging features, operative approaches, and outcome with postoperative visual status.

Results  There were 36 patients (72 eyes) in the series, 75% females and 25% males. The mean age of patients was 48.05 ± 10.02 years. In all, 88.89% had visual diminution, 50% had headache, 5.56% had behavioral changes, and 2.78% had seizures. The mean tumor size was 4.01 ± 1.01 cm. The frontotemporal approach was employed in 66.67% of patients, and all patients underwent a right-sided approach. There was no significant difference between improvement in the vision between the right eye and left eye, despite the fact that right-sided approach was employed in nearly cases.

Conclusion  While tuberculum sella meningioma have profound morbidity in terms of visual deterioration, timely surgical intervention may help patients gain serviceable vision postoperatively. We advocate the trans-cranial approach and find no difference in visual outcomes on employing right-sided approach, regardless of the side with worse vision.

Skull Base Meningiomas in Patients with Neurofibromatosis Type 2: An International Multicenter Study Evaluating Stereotactic Radiosurgery

Objective  Meningiomas are the second most common tumors in neurofibromatosis type 2 (NF-2). Microsurgery is challenging in NF-2 patients presenting with skull base meningiomas due to the intrinsic risks and need for multiple interventions over time. We analyzed treatment outcomes and complications after primary Gamma Knife radiosurgery (GKRS) to delineate its role in the management of these tumors. Methods  An international multicenter retrospective study approved by the International Radiosurgery Research Foundation was performed. NF-2 patients with at least one growing and/or symptomatic skull base meningioma and 6-month follow-up after primary GKRS were included. Clinical and radiosurgical parameters were recorded for analysis. Results  In total, 22 NF-2 patients with 54 skull base meningiomas receiving GKRS as primary treatment met inclusion criteria. Median age at GKRS was 38 years (10-79 years). Most lesions were located in the posterior fossa (55.6%). Actuarial progression free survival (PFS) rates were 98.1% at 2 years and 90.0% at 5 and 10 years. The median follow-up time after initial GKRS was 5.0 years (0.6-25.5 years). Tumor volume at GKRS was a predictor of tumor control. Lesions >5.5 cc presented higher chances to progress after radiosurgery ( p  = 0.043). Three patients (13.64%) developed adverse radiation effects. No malignant transformation or death due to meningioma or radiosurgery was reported. Conclusions  GKRS is effective and safe in the management of skull base meningiomas in NF-2 patients. Tumor volume deserve greater relevance during clinical decision-making regarding the most appropriate time to treat. GKRS offers a minimally invasive approach of particular interest in this specific group of patients.

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.

Skull Base Approaches for Tuberculum Sellae Meningiomas: Institutional Experience in a Series of 34 Patients

(1) Background: The aim of the present study was to evaluate our institutional outcome in tuberculum sellae meningioma (TSM) patients treated microsurgically using multiple skull base approaches, including a transcranial approach and an extended endonasal transsphenoidal approach. (2) Materials and Methods: This is a retrospective study that includes 34 patients with TSM. The study aimed to observe the efficacy of the different common approaches used by a single neurosurgeon. All the patients were evaluated preoperatively and during follow-up with campimetry, head CT scan, and post-contrast MRI. (3) Results: After a transcranial approach, visual acuity improved in 86.20%, was stable in 10.34%, and deteriorated in 3.45%. Through transsphenoidal surgery, vision improved in 80%, was static in 20%, and deteriorated in 0%. Transcranial approaches included pterional, mini-bifrontal basal, and supraciliary keyhole microscopic craniotomies. Gross total removal was performed in 58.82%, near total in 10.34%, and partial removal in 3.45%. The transcranial/supraciliary keyhole endoscopic-assisted approach showed a gross total removal rate of 80%, and near total in 20%. The transsphenoidal approach showed a gross total removal rate of 60%, near total in 20%, and partial removal in 20%. (4) Conclusion: Endoscopic-assisted keyhole supraciliary mini craniotomy for resection of tuberculum sellae meningioma offers low morbidity and good visual outcome. The endonasal route is preferred for the removal of TSM when they are small and midline placed. The major limitation of this approach is a narrow surgical corridor and the restriction on midline-placed lesions. Gross total removal was better achieved with mini-bifrontal basal and pterional craniotomies.

Endocrinological outcomes after transcranial resection of tuberculum sellae meningiomas: a systematic review and meta-analysis

Tuberculum sellae meningiomas (TSMs) arise from the anterior skull base. Endocrine status after TSM resection is an important determinant of quality of life. We sought to better characterize the risk of postoperative endocrinopathy for patients with TSM undergoing open transcranial approach (TCA) microsurgical resection. A systematic review was conducted following MOOSE and PRISMA guidelines. Results were screened against predefined criteria, which included studies evaluating endocrinopathy rates after open transcranial microsurgery for TSM. Outcome incidence was calculated using random-effect meta-analysis of proportions. Eight studies met the inclusion criteria, comprising 406 patients. The average age of the cohort was 52.2 years, and a majority (70%) of the patients were female. The pooled incidence of postoperative transient diabetes insipidus (DI) was 7.5% (95% CI 2.9-12%; p = 0.001; I² = 75.9%) and permanent DI was 1.6% (95% CI 0.3-2.7%; p = 0.01; I² = 0%). The pooled rate of postoperative hypopituitarism was 3.6% (95% CI 1.6-5.7%; p < 0.001; I² = 22.2%), while the incidence of hyperprolactinemia was 1.3% (95% CI 0.1 = 2.6%; p = 0.036; I² = 8.74%). The incidence of SIADH was 4% in one study but was not included in the meta-analysis. Endocrinopathy after TSM microsurgical resection is rare, but the available studies' poor quality of evidence and inconsistent methodology may reflect that it is underreported in the literature. Nevertheless, clinicians should consider the risk of hormonal impairment and counsel their patients accordingly when selecting a TCA for these lesions.

Gamma Knife radiosurgery for tuberculum sellae meningiomas: a series of 78 consecutive patients

Outcomes of Gamma Knife radiosurgery (GKRS) for tuberculum sellae meningiomas (TSMs) have not been reported explicitly within any meningioma series. We present the first and largest TSM series with clinical, radiosurgical, and outcome features for 78 consecutive patients managed with GKRS. Patients who underwent GKRS for TSMs between 2005 and 2021 and had a minimum of 6 months of follow-up were included. Medical records, imaging studies, and follow-up examinations were evaluated retrospectively. A total of 78 patients with a median age of 50.5 years were included. SRS was conducted as an upfront treatment for 38 patients (48.7%). The median target volume was 1.7 cm³ (range, 0.1-14.6). During a median follow-up of 78.5 months, the cumulative PFS rates of the whole cohort at 1, 5, and 10 years by Kaplan-Meier analysis were 100%, 97.9%, and 94.5%, respectively. Of 47 patients with impaired vision, improvement and/or preservation of visual acuity, and visual field were achieved in 55.3% and 42.6%, respectively. No new-onset hormonal deficits were observed. Based on our data, SRS represents an effective and safe modality for unresected or recurrent/residual TSMs. SRS should be offered to patients who are not willing or not ideal candidates for surgery.

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 .

Visual Outcomes in Surgically Treated Intracranial Meningiomas

BACKGROUND

Intracranial meningiomas that arise from the medial sphenoid ridge, anterior clinoid process, tuberculum sellae, or planum sphenoidale often impair vision by compressing the optic nerves and optic chiasm. Although many studies have reported visual outcome following surgery for these tumors, documentation has often been incomplete and not validated by patient self-report.

METHODS

Retrospective study of 40 patients drawn from a single, academic, medical center. We used a unique method of assessing visual outcome based on whether the change in visual function affected the preoperatively better-sighted or worse-sighted eye in the belief that this method would correlate with effects on activities of daily living (ADL). To elicit patient self-reports of those effects, we conducted telephone interviews of 25 patients with a standard questionnaire. We also assessed putative ophthalmic, imaging, and surgical predictors of visual outcome.

RESULTS

Visual improvement occurred in 61% of patients with preoperative monocular visual dysfunction, but only 22% of patients reported improvement in their ability to conduct ADL, and 17% lost vision. Visual outcomes were better in patients with preoperative binocular visual dysfunction, where visual improvement occurred in 73% and no patient lost vision in the preoperatively better-sighted eye. However, only 27% of patients with preoperative binocular visual dysfunction reported improvement in their ability to conduct ADL. Long duration of vision impairment, presence of optic disc pallor, large tumor size, and imaging-based preoperative optic canal involvement did not preclude a favorable visual outcome. Aggressive surgical reduction in displacement of the optic nerves was not necessary to obtain a favorable visual outcome and sometimes led to an unfavorable visual outcome.

CONCLUSIONS

In this study, surgery often improved vision, especially in patients with preoperative binocular visual dysfunction. But patients indicated that the effect on their ability to perform ADL was more modest. Moreover, 17% of patients with preoperative monocular visual dysfunction lost vision in the only affected eye, often to a considerable degree. In those patients, surgery would be justified primarily to relieve the concern of having a large brain tumor and to prevent tumor growth. Preoperative ophthalmic and imaging features poorly predicted visual outcomes. Favorable visual outcomes occurred without aggressive surgical debulking of the tumors.

The unilateral frontotemporal approach for large and giant olfactory groove meningioma: Experience with 18 consecutive patients

AIM

Although the bifrontal approach used to be recommended for large olfactory groove meningioma (OGM), recent studies showed that large OGMs can also be resected safely via unilateral approaches. The present study aimed to discuss reasons for preferring a unilateral frontotemporal approach (UFTA), and the technical nuances and results of the UFTA, based on 18 cases.

MATERIAL AND METHODS

The clinical and surgical data of patients who had been operated on for large (4-6cm) or giant (>6cm) OGM via a UFTA between 2011 and 2018 were retrospectively collected.

RESULTS

In all, 18 patients were included. All tumors were compatible with a diagnosis of OGM in the light of peri-operative examinations. 11 cases (61%) were large and 7 (39%) giant OGM; mean diameter was 6.1cm (range, 4-10cm). Resection extent was Simpson grade II in 14 cases (78%), grade III in 1 (5%), and grade IV in 3 (17%). Sixteen cases (89%) had no peri-operative complications, while 2 patients (11%) showed cerebrospinal fluid leakage and hemorrhagic deposition in the surgical area. There were no new neurological deficits nor deaths.

CONCLUSION

The UFTA for OGM is a relatively safe and effective approach, ensuring a high total removal rate with low mortality and morbidity. This study, with a reasonable number of patients, is one of the few in the literature on the outcome of this approach.

Meningiomas in the elderly

Meningiomas are benign tumors that arise from the meningo-epithelial cells of the arachnoid dura and account for approximately one-third of all adult intracranial tumors. With the evolution of diagnostic imaging and the average life span increasing, meningiomas are being detected more frequently in an older population. In the elderly population, defined by patients aged 60 years or older, meningiomas are the most incidentally detected benign primary brain tumor. As a patient ages, the rate of growth of the meningioma decreases, while comorbidities increase, making the elderly population a unique group when it comes to decision-making for treatment. Treatment options for intracranial meningiomas in the elderly include surgery, radiosurgery, or observation. Although age may have some part in treatment considerations, comorbidities, overall state of health, and tumor characteristics play a more significant role in patient outcome. This chapter will investigate the incidence, evaluation, treatment, and outcomes of intracranial meningiomas in the elderly population.

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.

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.

Secondary pituitary hormonal dysfunction patterns: tumor size and subtype matter

PURPOSE

Patients with sellar masses (SM) frequently have secondary hormonal deficiency (SHD) at initial presentation. While larger SM are more likely to present with SHD, it is unclear whether SHD at presentation is influenced by the type of SM.

METHODS

We conducted a retrospective analysis of patients with SM prospectively enrolled in our comprehensive provincial neuropituitary registry between November 2005 and December 2018. SM were subdivided based on size: < 1 cm, 1-1.9 cm, 2-2.9 cm, and > 3 cm.

RESULTS

A total of 914 patients met the inclusion criteria, including: 346 nonfunctioning adenomas (NFA), 261 prolactinomas (PRLoma), 51 growth hormone adenomas, 36 adrenocorticotropic adenomas, 93 Rathke's cleft cysts, 70 craniopharyngiomas and 57 meningiomas. The overall rate of SHD at presentation was highest in PRLoma (62.8%) and craniopharyngiomas (64.3%) and lowest in meningiomas (14%). While larger SM were significantly more likely to have SHD, the rate of SHD within each group was significantly different despite similar size (p < 0.001). Of the two largest groups of SM (NFA and PRLoma), NFA had significantly higher odds ratio (3.34, CI 1.89-5.89) of having multiple SHDs when compare with PRLoma, even when corrected for age, gender and size of tumor (p < 0.001).

CONCLUSION

Our study shows that the rate and distribution of SHD in SM vary dependent upon the size of the tumor and specific pathology; in particular, NFA are more likely to present with multiple SHDs. Our data will help clinicians in determining adequate hormonal testing strategy for different SM.

Keyhole Superior Interhemispheric Transfalcine Approach for Tuberculum Sellae Meningioma: Technical Nuances and Visual Outcomes

BACKGROUND

Tuberculum sellae meningiomas are challenging tumors often compressing the optic apparatus and involving the optic canals. Traditional approaches provide wide exposure, but optic canal access can remain difficult. Endonasal approaches offer a less invasive option that allows access to the medial optic canals, but larger tumors can still be challenging along with a higher risk of postoperative spinal fluid leak. We present the use of a keyhole superior interhemispheric approach for tuberculum sellae meningioma resection.

METHODS

Five patients with tuberculum sellae meningioma who underwent a keyhole superior interhemispheric approach were retrospectively reviewed. Preoperative tumor volumes, visual outcomes, extent of resection, pathologic grading, perioperative complications, recurrence rates, operative times, and hospital length of stays were analyzed.

RESULTS

The average age of the patients was 68.6 ± 7.7 years old (range 57-78). Average tumor volume was 8 ± 1.8 cm³. All patients had a gross total resection. Three out of 5 patients had World Health Organization grade 1 meningioma, and the other 2 had World Health Organization grade 2 meningioma. There were no recurrences over an average follow-up of 18.6 months (range 1-44). On preoperative visual assessment, 9 out of 10 eyes (90%) had a deficit. Postoperative visual assessment found 9 out of 9 eyes with preoperative deficits had improvement (100%). There were no perioperative or postoperative complications.

CONCLUSIONS

The keyhole superior interhemispheric approach provides a transcranial alternative that allows excellent exposure of the vasculature and both optic canals, resulting in good extents of resection and recovery of vision.

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.

Parasellar Meningiomas

Parasellar spaces remain particularly singular, comprising the most important neurovascular structures such as the internal carotid artery and optic, oculomotor, and trigeminal nerves. Meningiomas are one of the most frequent tumors arising from parasellar spaces. In this location, meningiomas remain mostly benign tumors with WHO grade I and a meningothelial subtype. Progestin intake should be investigated and leads mostly to conservative strategies. In the case of benign nonsymptomatic tumors, observation should be proposed. Tumor growth will lead to the proposition of surgery or radiosurgery. In the case of an uncertain diagnosis and an aggressive pattern, a precise diagnosis is required. For cavernous sinus and Meckel's cave lesions, complete removal is rarely considered, leading to the proposition of an endoscopic endonasal or transcranial biopsy. Optic nerve decompression could also be proposed via these approaches. A case-by-case discussion about the best approach is recommended. A transcranial approach remains necessary for tumor removal in most cases. Vascular injury could lead to severe complications. Cerebrospinal fluid leakage, meningitis, venous sacrifice, visual impairment, and cranial nerve palsies are more frequent complications. Pituitary dysfunctions are rare in preoperative assessment and in postoperative follow-up but should be assessed in the case of meningiomas located close to the pituitary axis. Long-term follow-up is required given the frequent incomplete tumor removal and the risk of delayed recurrence. Radiosurgery is relevant for small and well-limited meningiomas or intra-cavernous sinus postoperative residue, whereas radiation therapy and proton beam therapy are indicated for large, extended, nonoperable meningiomas. The place of the peptide receptor radionuclide therapyneeds to be defined. Targeted therapy should be considered in rare, recurrent, and aggressive parasellar meningiomas.

Clinical Outcome after Endoscopic Endonasal Resection of Tuberculum Sella Meningiomas

BACKGROUND

In select cases, the endoscopic endonasal approach (EEA) has distinct advantages for resection of tuberculum sella meningiomas (TSM).

OBJECTIVE

To report the extent of resection (EOR), complication rates, and outcomes in a large series of TSM treated by the EEA.

METHODS

Twenty-five consecutive TSM cases treated by EEA from 2008 to 2016 were retrospectively reviewed. Patient history, imaging, volumetric EOR, complications, and outcomes are presented.

RESULTS

Mean patient age was 53.9 yr, with female predominance (84%). Preoperatively, 84% of patients had vision impairment and 68% had optic canal tumor invasion. The tumor was abutting or partially encasing the anterior cerebral artery in 14 (56%) and 3 (12%) patients, respectively. The supraclinoid internal carotid artery (ICA) was partially or completely encased in 4 (16%) and 4 (16%) patients, respectively. Gross total resection (GTR) was achieved in 19/25 (76%) cases. Complete ICA encasement was the most common reason for subtotal resection. Among patients without complete ICA encasement, GTR was achieved in 19/20 (95%) patients. Optic canal invasion, tumor volume, intratumoral calcifications, and partial vascular encasement were not limiting factors for GTR. Eighty-eight percent of patients with preoperative visual impairment had improvement or normalization of vision. No patient experienced permanent visual deterioration or new permanent pituitary dysfunction. Cerebrospinal fluid leakage occurred in 2 (8%) cases.

CONCLUSION

The EEA for resection of TSM provides high rates of GTR and visual improvement with a low rate of complications. Direct contact or partial encasement of the ICA and anterior cerebral artery does not limit the EOR.

Selection of endoscopic or transcranial surgery for tuberculum sellae meningiomas according to specific anatomical features: a retrospective multicenter analysis (KOSEN-002)

OBJECTIVE

The endoscopic endonasal approach (EEA) and the transcranial approach (TCA) are good options for the treatment of tuberculum sellae (TS) meningiomas. The objective of this study was to identify the key anatomical features in TS meningiomas and compare the two surgical approaches.

METHODS

The authors retrospectively reviewed clinical data in 178 patients with TS meningiomas treated at 3 institutions between January 2010 and July 2016. Patients with tumors encasing the internal carotid artery or anterior cerebral artery or involving the anterior clinoid process or cavernous sinus were excluded. Tumors were classified as high-lying or low-lying based on their location, and involvement of the optic canal was evaluated. The surgical outcomes of EEA and TCA were analyzed according to the relevant anatomical features.

RESULTS

During the study period, 84 patients underwent EEA and 94 patients underwent TCA. Based on preoperative MR images, 43 (24.2%) meningiomas were classified as high-lying tumors, 126 (70.8%) as low-lying, and 9 (5.0%) as nonspecific. Gross-total resection (GTR) was performed in 145 patients (81.5%); the GTR rate did not differ significantly between the EEA and TCA groups. Of 157 patients with preoperative visual disturbance, 140 had improved or stable vision postoperatively. However, 17 patients (9.6%) experienced some visual deterioration after surgery. The TCA group had a worse visual outcome than the EEA group in patients with preoperative optic canal involvement (77.6% vs 93.2%, p = 0.019), whereas there was no significant difference in visual outcome based on whether tumors were high-lying or low-lying.

CONCLUSIONS

The results of this study support EEA over TCA, at least with respect to visual improvement with acceptable complications, although TCA is still an effective approach for TS meningioma.

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.

The endoscopic endonasal approach is not superior to the microscopic transcranial approach for anterior skull base meningiomas-a meta-analysis

Object

In the past decade, the endonasal transsphenoidal approach (eTSA) has become an alternative to the microsurgical transcranial approach (mTCA) for tuberculum sellae meningiomas (TSMs) and olfactory groove meningiomas (OGMs). The aim of this meta-analysis was to evaluate which approach offered the best surgical outcomes.

Methods

A systematic review of the literature from 2004 and meta-analysis were conducted in accordance with the PRISMA guidelines. Pooled incidence was calculated for gross total resection (GTR), visual improvement, cerebrospinal fluid (CSF) leak, intraoperative arterial injury, and mortality, comparing eTSA and mTCA, with p-interaction values.

Results

Of 1684 studies, 64 case series were included in the meta-analysis. Using the fixed-effects model, the GTR rate was significantly higher among mTCA patients for OGM (eTSA: 70.9% vs. mTCA: 88.5%, p-interaction < 0.01), but not significantly higher for TSM (eTSA: 83.0% vs. mTCA: 85.8%, p-interaction = 0.34). Despite considerable heterogeneity, visual improvement was higher for eTSA than mTCA for TSM (p-interaction < 0.01), but not for OGM (p-interaction = 0.33). CSF leak was significantly higher among eTSA patients for both OGM (eTSA: 25.1% vs. mTCA: 10.5%, p-interaction < 0.01) and TSM (eTSA: 19.3%, vs. mTCA: 5.81%, p-interaction < 0.01). Intraoperative arterial injury was higher among eTSA (4.89%) than mTCA patients (1.86%) for TSM (p-interaction = 0.03), but not for OGM resection (p-interaction = 0.10). Mortality was not significantly different between eTSA and mTCA patients for both TSM (p-interaction = 0.14) and OGM resection (p-interaction = 0.88). Random-effect models yielded similar results.

Conclusion

In this meta-analysis, eTSA was not shown to be superior to mTCA for resection of both OGMs and TSMs.

Electronic supplementary material

The online version of this article (10.1007/s00701-017-3390-y) contains supplementary material, which is available to authorized users.

Outcomes After Transcranial and Endoscopic Endonasal Approach for Tuberculum Meningiomas-A Retrospective Comparison

BACKGROUND

Degree of resection and visual outcome are the main concerns in the surgical resection of tuberculum sellae meningioma (TSM). In addition to the transcranial approach (TCA), the endoscopic endonasal approach (EEA) has been used increasingly. However, the controversy regarding the optimal surgical approach is not clearly resolved.

METHODS

We compared the surgical outcomes of each approach for TSMs from 44 patients receiving EEA and 40 patients receiving TCA in 2 institutions between 2004 and 2015. We analyzed the surgical outcomes and affecting factors for the relapse of tumor and visual outcome.

RESULTS

Gross total resection rates and relapse-free survival were not different between the 2 groups; however, the locations of residual or recurred tumor definitely differed. All recurrences in the TCA group were in the sella turcica, whereas residual tumors in EEA group were mainly located at lateral or superior to the clinoid process. The complete or partial improvement rate of visual function in the EEA group was 97.7%, but 9 patients (23.7%) in the TCA group experienced visual deterioration after surgery. EEA and younger age (<55 years) were associated with favorable visual outcome. Cerebrospinal fluid leakage occurred in only one case in the EEA group.

CONCLUSIONS

Surgical approaches do not affect the gross total resection rates, but the locations of residual tumor or recurrence differ according to surgical approaches. EEA is superior to TCA in visual outcome. At least in pure TSMs, the trend seems to be shifting in favor of EEA, considering the huge difference in visual outcome.

Preoperative and Postoperative Pituitary Function in Patients with Tuberculum Sellae Meningioma -Based on Pituitary Provocation Tests

Given the anatomical proximity of tuberculum sellae meningioma (TSM) to the hypothalamo-pituitary system, pituitary function impairments are of great concern. We retrospectively investigated pituitary function changes following surgery in patients with TSM using pituitary provocation tests (PPTs). Thirty-one patients (27 females and 4 males) with TSM underwent initial transcranial surgery (29 patients) or transsphenoidal surgery (two patients); surgeries were performed carefully to avoid injuring the pituitary stalk. In 24 patients, the PPTs were performed via a triple bolus injection with regular insulin, thyrotropin-releasing hormone (TRH), and luteinizing hormone releasing hormone (LH-RH). Seven patients underwent a quadruple test (growth-hormone-releasing factor, corticotrophin-releasing hormone, TRH, and LH-RH). The preoperative and postoperative target hormone levels of the anterior pituitary were normal in 93.5% and 96.8% of patients, respectively. At least one hormonal axis demonstrated impaired PPT responses in two patients (6.5%) preoperatively and in one patient (3.2%) postoperatively. The growth hormone (GH) response was also well preserved. A compromised GH peak level was only observed in one patient (3.2%) preoperatively. Postoperatively, transient diabetes insipidus and transient hyponatremia were observed in four (12.9%) and eight (25.8%) patients, respectively. No patients needed permanent postoperative hormone replacement. The preoperative pituitary function was well preserved in most patients, including those with large tumors pushing against the pituitary stalk considerably or embedded in it. After careful surgery to avoid damaging the pituitary stalk, pituitary function was preserved. However, transient postoperative hyponatremia occurred in 25.8% of patients; thus, surgeons should pay careful attention to this issue.

Review of Current Evidence Regarding Surgery in Elderly Patients with Meningioma

The Japanese population features the highest rate of elderly individuals worldwide. Moreover, Japan has the highest number of computed tomography/magnetic resonance imaging devices in the world, which has led to an increase in the incidental detection of meningioma in healthy elderly patients. Many previous papers have discussed the risks and indications for surgery in this patient population, but available information remains insufficient, and the definition of “elderly” has not been standardized. This review tried to clarify the published evidence and challenges associated with elderly meningioma based on a search of the PubMed database using the terms “meningioma,” “elderly,” and “surgery” for English-language clinical studies and collected related papers published from 2000 to 2016. Twenty-four papers were reviewed and classified by definition of elderly age: over 60, 65, 70, and 80 years old. Six of seven papers that defined the elderly cutoff as over 65 years old were published after 2010, which suggested the consensus definition. Four preoperative grading scoring systems were described and associated with mortality. The 1-year and 5-year mortality rates ranged from 0% to 16.7% and from 7% to 27%, which were comparable with unselected cohorts. Review of risk factor analysis emphasized the importance of considering the preoperative status, presence of comorbidities, and optimum surgical timing during patient selection. Careful choice of patients can also lead to better quality of life. A prospective randomized study considering patient frailty should address the causes and prevention of complications.

Stereotactic radiosurgery in the treatment of parasellar meningiomas: long-term volumetric evaluation

OBJECTIVE Parasellar meningiomas tend to invade the suprasellar, cavernous sinus, and petroclival regions, encroaching on adjacent neurovascular structures. As such, they prove difficult to safely and completely resect. Stereotactic radiosurgery (SRS) has played a central role in the treatment of parasellar meningiomas. Evaluation of tumor control rates at this location using simplified single-dimension measurements may prove misleading. The authors report the influence of SRS treatment parameters and the timing and volumetric changes of benign WHO Grade I parasellar meningiomas after SRS on long-term outcome. METHODS Patients with WHO Grade I parasellar meningiomas treated with single-session SRS and a minimum of 6 months of follow-up were selected. A total of 189 patients (22.2% males, n = 42) form the cohort. The median patient age was 54 years (range 19-88 years). SRS was performed as a primary upfront treatment for 44.4% (n = 84) of patients. Most (41.8%, n = 79) patients had undergone 1 resection prior to SRS. The median tumor volume at the time of SRS was 5.6 cm³ (0.2-54.8 cm³). The median margin dose was 14 Gy (range 5-35 Gy). The volumes of the parasellar meningioma were determined on follow-up scans, computed by segmenting the meningioma on a slice-by-slice basis with numerical integration using the trapezoidal rule. RESULTS The median follow-up was 71 months (range 6-298 months). Tumor volume control was achieved in 91.5% (n = 173). Tumor progression was documented in 8.5% (n = 16), equally divided among infield recurrences (4.2%, n = 8) and out-of-field recurrences (4.2%, n = 8). Post-SRS, new or worsening CN deficits were observed in 54 instances, of which 19 involved trigeminal nerve dysfunction and were 18 related to optic nerve dysfunction. Of these, 90.7% (n = 49) were due to tumor progression and only 9.3% (n = 5) were attributable to SRS. Overall, this translates to a 2.64% (n = 5/189) incidence of direct SRS-related complications. These patients were treated with repeat SRS (6.3%, n = 12), repeat resection (2.1%, n = 4), or both (3.2%, n = 6). For patients treated with a margin dose ≥ 16 Gy, the 2-, 4-, 6-, 8-, 10-, 12-, and 15-year actuarial progression-free survival rates are 100%, 100%, 95.7%, 95.7%, 95.7%, 95.7%, and 95.7%, respectively. Patients treated with a margin dose < 16 Gy, had 2-, 4-, 6-, 8-, 10-, 12-, and 15-year actuarial progression-free survival rates of 99.4%, 97.7%, 95.1%, 88.1%, 82.1%, 79.4%, and 79.4%, respectively. This difference was deemed statistically significant (p = 0.043). Reviewing the volumetric patient-specific measurements, the early follow-up volumetric measurements (at the 3-year follow-up) reliably predicted long-term volume changes and tumor volume control (at the 10-year follow-up) (p = 0.029). CONCLUSIONS SRS is a durable and minimally invasive treatment modality for benign parasellar meningiomas. SRS offers high rates of growth control with a low incidence of neurological deficits compared with other treatment modalities for meningiomas in this region. Volumetric regression or stability during short-term follow-up of 3 years after SRS was shown to be predictive of long-term tumor control.

Analysis of the results of recurrent intracranial meningiomas treated with re-radiosurgery

OBJECTS

Meningioma is the most common intracranial neoplasm, comprising approximately 30% of all primary intracranial tumors (Claus et al., 2005) [1]. Treatment options include observation, microsurgical resection, stereotactic radiosurgery (SRS), and whole brain radiation therapy (WBRT). Gamma knife radiosurgery (GKRS) is a very effective treatment for intracranial meningiomas; previous studies showed the tumor control rate at 5-10 years of follow-up as 84.3%-100% in all cases (Feigl et al., 2005; Linskey et al., 2005; Malik et al., 2005; Aichholzer et al., 2000; Hakim et al., 1998; Chang and Adler 1997; Lunsford, 1994; Ganz et al., 1993) [2-9]. Many studies have discussed issues like optimal dose, conformal configurations, and adverse effects to improve the treatment result with GKRS (Malik et al., 2005; Kenai et al., 2005; Rowe et al., 2004; Shrieve et al., 2004) [4,10-12]. There are some cases in which the radiosurgery result is unfavorable and perhaps further treatment is needed. In these cases, re-radiosurgery can be an option. However, there have not been comprehensive studies discussing the issues of re-radiosurgery. Therefore, we analyzed the result of re-radiosurgery for recurrent meningiomas and their impact on clinical outcomes.

METHODS

From 1995 to 2015, we retrospectively reviewed 1163 patients who underwent GKRS for intracranial meningioma at the Asan Medical Center. Patients with multiple meningiomas or a follow-up with a period of less than a year were excluded from this study. Finally, 865 patients were enrolled in this study. Clinical symptoms and brain magnetic resonance imaging (MRI) scans were assessed by neurosurgeons. When tumor size increased together with newly developed neurologic symptoms, further management, such as microsurgical resection or SRS, was considered. Histologic analysis of the resected tumors was performed by neuropathologists. Clinical data, including patient's sex, age, and tumor locations were recorded. Treatment data included tumor volume, tumor grade, radiation dose, and presence of edema. Final outcome data including follow-up period, time to progression, interval between first and second radiosurgery courses and interval between microsurgery and radiosurgery were obtained.

RESULTS

Among 865 patients, tumor recurrence was found in 63 patients (7.28%). Seven patients showed transient tumor growth after GKRS. These patients have been under close observation without any further treatments. Fifty-six patients (6.47%) showed permanent tumor growth on follow-up MRI. Thirty-three patients from this group underwent repeated radiosurgery owing to tumor growth, resulting in a re-irradiation rate of 3.82% at our radiosurgery center. The other 23 patients were treated using methods other than re-radiosurgery. Among the 33 patients, 25 underwent microsurgical resection prior to their initial course of GKRS, and the other 8 were treated with re-radiosurgery only. An analysis was performed to determine factors that may have a role in treatment results. Of the many variables, tumor grade (p=0.004, Fisher's exact test) was the only significant factor for progression-free survival (PFS). Thirteen patients with unbiopsied or benign meningioma showed stable tumor size, while there was tumor growth in 8 patients. Among high-grade meningioma patients, 3 and 9 showed stable disease and tumor growth, respectively. As a result of re-radiosurgery, 11 out of 17 patients showed tumor growth and needed further treatments; this involved a third GKRS for 4 patients, microsurgical resection for 6 patients, and cyber knife radiosurgery (CKRS) for 1 patient. Four patients from this group were also treated with WBRT.

CONCLUSION

We analyzed the results of re-radiosurgery for recurrent meningiomas and observed that World Health Organization (WHO) grade II and III was significantly associated with a lower PFS rate compared with low-grade meningiomas (p=0.004). Conversely, patients with benign meningioma or unbiopsied tumors had much better results. Hence, re-radiosurgery is recommended for patients with unknown or benign meningiomas if their first GKRS result is unsatisfactory. However, re-radiosurgery should be considered carefully for recurrent high-grade tumors. Owing to the small number of recurrent meningioma patients treated with re-radiosurgery, further studies are required to delineate the role of this treatment.

Radiosurgical decompression for benign perioptic tumors causing compressive cranial neuropathies: a feasible alternative to microsurgery?

Several studies have reported the efficacy and safety of hypofractionated stereotactic radiosurgery (hSRS) in the treatment of benign perioptic tumors. This study went further and evaluated the feasibility of hSRS in the treatment of those causing compressive cranial neuropathies (CCNs) among perioptic tumors with special consideration of functional improvement. Twenty-six patients with CCNs (CN II = 19; CN III/IV/VI = 9; CN V = 3) caused by perioptic tumors underwent hSRS between 2011 and 2015. hSRS was delivered in five fractions with a median marginal dose of 27.8 Gy (≈14 Gy in a single fraction, assuming an α/β of three) to a tumor volume of 8.2 ± 8.3 cm³. All tumors except one shrank after treatment, with a mean volume decrease of 35 % (range 4-84 %) during the mean follow-up period of 20 months. In 19 patients (38 eyes) with compressive optic neuropathy, vision improved in 55.3 % of eyes (n = 21), was unchanged in 36.8 % (n = 14), and worsened in 7.9 % (n = 3) (2.6 % after excluding two eyes deteriorated due to transient tumor swelling). A higher conformity index (p = 0.034) and volume of the optic apparatus receiving >23.0 Gy (p = 0.019) were associated with greater tumor shrinkage. A greater decrease in tumor volume (p = 0.035) was associated with a better improvement in vision. Ophthalmoplegia and facial hypesthesia improved in six of nine (66.7 %) and three of three (100 %) patients, respectively. There was no newly developed neurological deficit. Decompressive SRS for benign perioptic tumors causing CCN is feasible using hypofractionation, representing a useful alternative to microsurgical resection.

Endoscopic transnasal surgery for planum and tuberculum sella meningiomas: decision-making, technique and outcomes

Tuberculum sella and planum sphenoidale meningiomas pose a management challenge given their intimate relationship to surrounding critical neurovascular structures. The development and advancement of expanded endoscopic transnasal surgery has provided a good surgical option that in well-selected cases, may provide several advantages over a transcranial route. These include early devascularization, complete dura and bone removal, elimination of brain retraction and enhanced visualization of the optic apparatus perforating vessels. The authors review the endoscopic transnasal approach to these tumors and discuss surgical decision-making and case selection, surgical technique and outcomes. We also discuss the expanding role of stereotactic radiosurgery and fractionated stereotactic radiotherapy for these challenging lesions.

Frontolateral Approach Applied to Sellar Region Lesions: A Retrospective Study in 79 Patients

Background:

Various surgical approaches for the removal of sellar region lesions have previously been described. This study aimed to evaluate the reliability and safety of the frontolateral approach (FLA) to remove sellar region lesions.

Methods:

We presented a retrospective study of 79 patients with sellar region lesions who were admitted and operated by the FLA approach from August 2011 to August 2015 in Department of Neurosurgery of Beijing Tian Tan Hospital. We classified FLA into three types, compared the FLA types to the areas of lesion invasion, and analyzed operation bleeding volume, gross total resection (GTR) rate, visual outcome, and mortality.

Results:

Seventy-nine patients were followed up from 2.9 to 50.3 months with a mean follow-up of 20.5 months. There were 42 cases of meningiomas, 25 cases of craniopharyngiomas, and 12 cases of pituitary adenomas. The mean follow-up Karnofsky Performance Scale was 90.4. GTR was achieved in 75 patients (94.9%). Two patients (2.5%) had tumor recurrence. No patients died perioperatively or during short-term follow-up. Three patients (3.8%) with craniopharyngioma died 10, 12, and 23 months, respectively, after surgery. The operative bleeding volume of this study was no more than that of the other approaches in the sellar region (P = 0.783). In this study, 35 patients (44.3%) had visual improvement after surgery, 38 patients (48.1%) remained unchanged, and three patients’ visual outcome (3.8%) worsened.

Conclusions:

FLA was an effective approach in the treatment of sellar region lesions with good preservation of visual function. FLA classification enabled tailored craniotomies for each patient according to the anatomic site of tumor invasion. This study found that FLA had similar outcomes to other surgical approaches of sellar region lesions.

Surgical Indications of Exploring Optic Canal and Visual Prognostic Factors in Neurosurgical Treatment of Tuberculum Sellae Meningiomas

Background:

Tuberculum sellae meningiomas (TSMs) present a special symptom because of the adherence and compression to the optic nerve, optic artery, and the chiasm. A significant number of patients with TSMs appear visual deficits. This study aimed to investigate the surgical indications of exploring the optic canal and visual prognostic factors in the neurosurgical treatment of TSMs.

Methods:

Totally 21 patients with TSM, who were operated from September 2007 to August 2011 in the Department of Neurosurgery, Tongren Hospital were enrolled in this study. Results of orbital computed tomography (CT) and magnetic resonance imaging (MRI), visual acuity, Goldmann visual field test, orbital color Doppler flow imaging (CDI) test in these patients were retrospectively analyzed.

Results:

Visual deficit and optic canal involvement (OCI) were detected in all the 21 patients. Fourteen patients had bone proliferation within the area of the optic canal. After the operation, visual outcomes were improved in 13 patients, unchanged in 7 patients, and deteriorated in 1 patient. All the 21 patients performed orbital CDI test preoperatively, the results showed that if the peak systolic velocity (PSV) of central retinal artery (CRA) value was ≤8 cm/s, the visual outcome would be better.

Conclusions:

The surgical indications of exploring optic canal in TSM cases included: (1) The neuroimaging evidences of OCI (CT and/or MRI); (2) PSV of CRA in orbital CDI test was ≤8 cm/s; (3) visual acuity was below 0.1; (4) visual field deficit. The PSV of CRA in CDI test could be a prognostic factor for visual outcomes of TSMs.

Intracranial Meningiomas: A 30-Year Experience and Literature Review

Intracranial meningiomas are tumors arising from the covering cells of the arachnoid layer of the dura mater or from the intraventricular choroid plexus. While mostly benign tumors, they still represent a major challenge to neurosurgeons and other medical disciplines involved in their diagnostic and therapeutic management. Although this review intends to give some state-of-the-art information from the literature, it is mainly based on personal experiences since more than 30 years caring for more than 1500 meningioma patients and point to a few new strategies to further improve on patient outcome.Diagnostics are based on magnetic resonance imaging which shows the relationship between tumor and surrounding intracranial structures, particularly the brain but also the vasculature and to some extent the cranial nerves. Furthermore, it may suggest the grading of the tumor and is very helpful in the postoperative diagnosis of complications and later follow-up course.Surgery still is the main treatment with the aim to completely remove the tumor; also in cases of recurrence, other additional options include radiotherapy and radiosurgery for incompletely removed or recurrent meningiomas. Postoperative chemotherapy has not been shown to provide substantial benefit to the patient especially in highly malignant meningiomas.All therapy options should be intended to provide the patient with the best possible functional outcome. Patients' perspective is not always equivalent to surgeons' perspectives. Neuropsychological evaluation and additional guidance of patients harboring meningiomas have proven to be important in modern neurosurgical intracranial tumor treatment. Their help beyond neurosurgical care facilitates the patients to lead an independent postoperative life.

Use of optical coherence tomography to predict visual outcome in parachiasmal meningioma

OBJECT

The authors investigated the value of retinal nerve fiber layer (RNFL) thickness in predicting visual outcome after surgery for parachiasmal meningioma.

METHODS

Forty-nine eyes of 25 patients who underwent craniotomy and resection of a parachiasmal meningioma were analyzed retrospectively. Visual parameters including visual field (VF) (recorded as the mean deviation [MD]), visual acuity (VA), and RNFL thickness (via optical coherence tomography) were measured before and 1 week, 6 months, and 1 year after surgery. Postoperative visual outcome was compared among the patients with a thin or normal RNFL. A separate analysis of data pertaining to 22 eyes of 13 patients with severe VF defects (MD ≤ −10 dB) was performed to compare visual outcome for those with a thin or normal RNFL.

RESULTS

Of the 23 eyes that showed VF improvement, 22 (95.7%) had normal RNFL thickness. The positive predictive value of normal RNFL thickness for VF improvement was 78.6%. The VF of patients with normal RNFL thickness improved in 6 months and continued improving 1 year after surgery (MD −5.9 dB before surgery, −5.5 dB 1 week after surgery, −2.8 dB 6 months after surgery [p < 0.01], and −1.1 dB 1 year after surgery [p < 0.01]). In contrast, those with a thin preoperative RNFL showed deterioration at first and then slower, worse visual recovery after surgery (MD −18.1 dB before surgery, −22.4 dB 1 week after surgery, −21.2 dB 6 months after surgery, and −19.1 dB 1 year after surgery). VA also showed significant progress 6 months after surgery in patients with normal RNFL thickness (0.6 before surgery, 0.7 one week after surgery, 0.9 six months after surgery [p = 0.025], and 0.9 one year after surgery [p = 0.050]) compared to those with a thin RNFL (0.3 before surgery, 0.2 one week after surgery, 0.3 six months after surgery, and 0.4 one year after surgery). Preoperative differences in VF MD and VA were noted between the 2 groups (p < 0.01). Even patients with severe VF defects and normal RNFL thickness improved by 11.1 dB by 1 year after surgery compared with patients with a thin RNFL (−0.01 dB) (p < 0.01). Patients with normal RNFL thickness also did better in VA improvement (from 0.7 to 1.1) than those with a thin RNFL (from 0.2 to 0.3), but these results were not statistically significant.

CONCLUSIONS

RNFL thickness measured by optical coherence tomography has significant value as a prognostic factor of postoperative visual recovery for parachiasmal meningioma. Patients with normal RNFL thickness before surgery are more likely to have visual improvement after surgery than patients with a thin RNFL.

Frontobasal Midline Meningiomas: Is It Right To Shed Doubt on the Transcranial Approaches? Updates and Review of the Literature

BACKGROUND

Traditionally, the surgical removal of tuberculum sellae meningioma (TSM) and olfactory groove meningioma (OGM) requires transcranial approaches and microsurgical techniques, but in the last decade endoscopic expanded endonasal approaches have been introduced: transcribriform for OGMs and transtuberculum-transplanum for TSM. A comparative analysis of the literature concerning the two types of surgical treatment of OGMs and TSM is, however, difficult.

METHODS

We conducted a literature search using the PubMed database to compare data for endoscopic and microsurgical techniques in the literature. We also conducted a retrospective analysis of selected cases from our series presenting favorable characteristics for an endoscopic approach, based on the criteria of operability of these lesions as generally accepted in the literature, and we compared the results obtained in these patients with those in the endoscopic literature.

RESULTS

We believe that making the sample more homogeneous, the difference between microsurgical technique and endoscopic technique is no longer so striking. A greater radical removal rate, a reduced incidence of cerebrospinal fluid fistula and, especially, the possibility of removing lesions of any size are advantages of transcranial surgery; a higher percentage of improvement in visual outcome and a lower risk of a worsening of a pre-existing deficit or onset of a new deficit are advantages of the endoscopic technique.

CONCLUSION

At present, the microsurgical technique is still the gold standard for the removal of the anterior cranial fossa meningiomas of all sizes, and the endoscopic technique remains a second option in certain cases.

Gamma Knife radiosurgery of large skull base meningiomas

OBJECT

Stereotactic radiosurgery (SRS) has become a common treatment modality for intracranial meningiomas. Skull base meningiomas greater than 8 cm3 in volume have been found to have worse outcomes following SRS. When symptomatic, patients with these tumors are often initially treated with resection. For tumors located in close proximity to eloquent structures or in patients unwilling or unable to undergo a resection, SRS may be an acceptable therapeutic approach. In this study, the authors review the SRS outcomes of skull base meningiomas greater than 8 cm3 in volume, which corresponds to a lesion with an approximate diameter of 2.5 cm.

METHODS

The authors reviewed the data in a prospectively compiled database documenting the outcomes of 469 patients with skull base meningiomas treated with single-session Gamma Knife radiosurgery (GKRS). Seventy-five patients had tumors greater than 8 cm3 in volume, which was defined as a large tumor. All patients had a minimum follow-up of 6 months, but patients were included if they had a complication at any time point. Thirty patients were treated with upfront GKRS, and 45 were treated following microsurgery. Patient and tumor characteristics were assessed to determine predictors of new or worsening neurological function and tumor progression following GKRS.

RESULTS

After a mean follow-up of 6.5 years (range 0.5–21 years), the tumor volume was unchanged in 37 patients (49%), decreased in 26 patients (35%), and increased in 12 patients (16%). Actuarial rates of progression-free survival at 3, 5, and 10 years were 90.3%, 88.6%, and 77.2%, respectively. Four patients had new or worsened edema following GKRS, but preexisting edema decreased in 3 patients. In Cox multivariable analysis, covariates associated with tumor progression were 1) presentation with any cranial nerve (CN) deficit from III to VI (hazard ratio [HR] 3.78, 95% CI 1.91–7.45; p < 0.001), history of radiotherapy (HR 12.06, 95% CI 2.04–71.27; p = 0.006), and tumor volume greater than 14 cm3 (HR 6.86, 95% CI 0.88–53.36; p = 0.066). In those patients with detailed clinical follow-up (n = 64), neurological function was unchanged in 37 patients (58%), improved in 16 patients (25%), and deteriorated in 11 patients (17%). In multivariate analysis, the factors predictive of new or worsening neurological function were history of surgery (OR 3.00, 95% CI 1.13–7.95; p = 0.027), presentation with any CN deficit from III to VI (OR 3.94, 95% CI 1.49–10.24; p = 0.007), and decreasing maximal dose (OR 0.76, 95% CI 0.63–0.93; p = 0.007). Tumor progression was present in 64% of patients with new or worsening neurological decline.

CONCLUSIONS

Stereotactic radiosurgery affords a reasonable rate of tumor control for large skull base meningiomas and does so with a low incidence of neurological deficits. Those with a tumor less than 14 cm3 in volume and without presenting CN deficit from III to VI were more likely to have effective tumor control.

Characteristics of midline suprasellar meningiomas based on their origin and growth pattern

BACKGROUND

The aim of the present study was to elucidate clinical and prognostic characteristics of the midline suprasellar meningiomas based on their origin and growth pattern.

METHODS

A retrospective review of the medical records was conducted for patients undergoing surgical resection of the midline suprasellar meningioma. The meningiomas were divided into group A - planum sphenoidale meningioma (PSM), group B - tuberculum sellae meningioma (TSM) and group C - diaphragma sellae meningioma (DSM), based on their growth pattern in relation to the optic pathway and pituitary stalk, group C was then divided into groups C1 and C2.

RESULTS

The mean age of 32 men and 74 women was 48.5±13.1 years (range, 20-78 years). The rate of visual impairment was highest in patients in group C2 and lowest in group A patients (P<0.001). The h-p axis impairment and MRI evidence of the pituitary stalk involvement was more frequent in patients with group C1 meningioma (P<0.001). The gross total resection (GTR) was achieved in 84/106 (79%) patients. The mean follow-up period was 70.4 months (median 86 months, range 64.5-76.3 months). The fronto-temporal approach was the only significant predictor of the postoperative visual acuity impairment (P=0.001, OR: 8.2, CI: 2.45-27.42) and visual field impairment (P=0.016, OR: 0.071, CI: 0.008-0.607). The meningiomas in groups B (P=0.024, OR: 0.198, CI: 0.049-0.812) and C1 (P=0.012, OR: 0.082, CI: 0.012-0.580) were significant predictors of the postoperative visual field deficits. The group C1 (P=0.036, OR: 0.244, CI: 0.065-0.912) and surgical approach employed (P=0.032, OR: 0.013, CI: 0.000-0.684) was significant predictors of the postoperative h-p function impairment. The mean recurrence free survival (RFS) time and rate were 102.9±3.2 months and 86%. The group C1 meningiomas had the lowest RFS rate and time (33.3% and 55.6±8.3 months). The subtotal resection and the group C1 meningioma (P=0.001, OR: 15.6, CI: 2.9-82.8) were the significant predictors of recurrence (P=0.008, OR: 0.08, CI: 0.014-0.529).

CONCLUSION

The group A meningioma had the high rate of complete resection and favorable RFS. Groups B and C2 involve optic pathway and optic canal predominately. The group C1 DSM was an independent predictor of subtotal resection, postoperative visual field and h-p axis impairment. The subtotal resection was an independent predictor of the recurrence.

Clinical features of sellar and suprasellar meningiomas

Meningiomas account for about 1% of sellar masses. Although they can mimic pituitary adenomas, they are more vascularized and invasive. To gain insights that would enhance our ability to establish a pre-surgical diagnosis of meningioma, we performed a retrospective study of these tumors. Query of the surgical pathology database identified 1,516 meningiomas operated at out institution between January 2000 and May 2012. Cases were matched to the radiology database to identify a strictly defined sellar and/or suprasellar location. We identified 57 meningiomas. F:M ratio was 6:1. The mean age was 52 years (median 50, range 30-78). The most common symptoms were visual disturbance (58%), headache (16%) and incidental finding (12%). The mean duration of symptoms was 13 months. Hyperprolactinemia was found in 36%, with mean value of 51.6 ng/ml (median 41.8, range 22.5-132). Mean maximal diameter was 2.9 cm (median 2.7, range 0.9-6.8), and most tumors enhanced homogeneously on MRI after gadolinium. A "dural tail" sign was reported in a third. The radiologist reported "likely meningioma" in 65%, "possible meningioma" in 8.7%, and pituitary adenoma in 11%. After surgery, visual disturbances improved in most patients (80%) but headache only in 7%. Post-operative complications at 1 and 3 months occurred 38.6 and 33.3% respectively. There was no mortality. Sellar/suprasellar meningiomas represent 4% of all meningiomas, and have a particularly high female predominance. The diagnosis is suggested by the radiologist in approximately 2/3 of the cases. An improved method to differentiate preoperatively these tumors from adenomas would be desirable.

Gamma Knife radiosurgery for sellar and parasellar meningiomas: a multicenter study

Object

Parasellar and sellar meningiomas are challenging tumors owing in part to their proximity to important neurovascular and endocrine structures. Complete resection can be associated with significant morbidity, and incomplete resections are common. In this study, the authors evaluated the outcomes of parasellar and sellar meningiomas managed with Gamma Knife radiosurgery (GKRS) both as an adjunct to microsurgical removal or conventional radiation therapy and as a primary treatment modality.

Methods

A multicenter study of patients with benign sellar and parasellar meningiomas was conducted through the North American Gamma Knife Consortium. For the period spanning 1988 to 2011 at 10 centers, the authors identified all patients with sellar and/or parasellar meningiomas treated with GKRS. Patients were also required to have a minimum of 6 months of imaging and clinical follow-up after GKRS. Factors predictive of new neurological deficits following GKRS were assessed via univariate and multivariate analyses. Kaplan-Meier analysis and Cox multivariate regression analysis were used to assess factors predictive of tumor progression.

Results

The authors identified 763 patients with sellar and/or parasellar meningiomas treated with GKRS. Patients were assessed clinically and with neuroimaging at routine intervals following GKRS. There were 567 females (74.3%) and 196 males (25.7%) with a median age of 56 years (range 8–90 years). Three hundred fifty-five patients (50.7%) had undergone at least one resection before GKRS, and 3.8% had undergone prior radiation therapy. The median follow-up after GKRS was 66.7 months (range 6–216 months). At the last follow-up, tumor volumes remained stable or decreased in 90.2% of patients. Actuarial progression-free survival rates at 3, 5, 8, and 10 years were 98%, 95%, 88%, and 82%, respectively. More than one prior surgery, prior radiation therapy, or a tumor margin dose < 13 Gy significantly increased the likelihood of tumor progression after GKRS.

At the last clinical follow-up, 86.2% of patients demonstrated no change or improvement in their neurological condition, whereas 13.8% of patients experienced symptom progression. New or worsening cranial nerve deficits were seen in 9.6% of patients, with cranial nerve (CN) V being the most adversely affected nerve. Functional improvements in CNs, especially in CNs V and VI, were observed in 34% of patients with preexisting deficits. New or worsened endocrinopathies were demonstrated in 1.6% of patients; hypothyroidism was the most frequent deficiency. Unfavorable outcome with tumor growth and accompanying neurological decline was statistically more likely in patients with larger tumor volumes (p = 0.022) and more than 1 prior surgery (p = 0.021).

Conclusions

Gamma Knife radiosurgery provides a high rate of tumor control for patients with parasellar or sellar meningiomas, and tumor control is accompanied by neurological preservation or improvement in most patients.

Delayed neurological deficit following resection of tuberculum sellae meningioma: report of two cases, one with permanent and one with reversible visual impairment

The most common presentation of patients with tuberculum sellae meningiomas is visual loss, and surgical resection is the main mode of treatment. Preservation of vision is not only the main objective of the surgery; loss of vision is also its main risk. Visual deterioration following surgery is usually apparent immediately post-operatively. Here we present two cases of patients who underwent resection of tuberculum sellae meningioma and whose vision following surgery was initially unchanged until the postoperative day two when dramatic visual deterioration occurred. In the first case this resulted in blindness, whereas in the second case vision recovered back to the preoperative state. The possible mechanisms of visual deterioration and modes of treatment are discussed.