Meningiomas of the tuberculum and diaphragma sellae

Visual Outcomes and Surgical Approach Selection Focusing on Active Optic Canal Decompression and Maximum Safe Resection for Suprasellar Meningiomas

The goal of treating patients with suprasellar meningioma is improving or preserving visual function while achieving long-term tumor control. We retrospectively examined patient and tumor characteristics and surgical and visual outcomes in 30 patients with a suprasellar meningioma who underwent resection via an endoscopic endonasal (15 patients), sub-frontal (8 patients), or anterior interhemispheric (7 patients) approach. Approach selection was based on the presence of optic canal invasion, vascular encasement, and tumor extension. Optic canal decompression and exploration were performed as key surgical procedures. Simpson grade 1 to 3 resection was achieved in 80% of cases. Among the 26 patients with pre-existing visual dysfunction, vision at discharge improved in 18 patients (69.2%), remained unchanged in six (23.1%), and deteriorated in two (7.7%). Further gradual visual recovery and/or maintenance of useful vision were also observed during follow-up. We propose an algorithm for selecting the appropriate surgical approach to a suprasellar meningioma based on preoperative radiologic tumor characteristics. The algorithm focuses on effective optic canal decompression and maximum safe resection, possibly contributing to favorable visual outcomes.

Individualized surgical treatment of giant tuberculum sellae meningioma: Unilateral subfrontal approach vs. endoscopic transsphenoidal approach

Objective

Giant tuberculum sellae meningiomas (TSMs) are deeply located in the suprasellar region and extensively compressed or encased in the surrounding neurovascular structures, making gross total resection (GTR) without postoperative visual impairment challenging. The authors presented individualized unilateral subfrontal approach and endoscopic transsphenoidal approach (ETSA) in a series of patients and elaborated on their advantages and indications in resecting giant TSMs.

Methods

A total of 38 patients with giant TSMs operated by a single surgeon between March 2012 and November 2021 were retrospectively reviewed. Patients underwent unilateral subfrontal approach and ETSA according to preoperative imaging characteristics. Tumor characteristics, surgical details, preoperative symptoms, and neurological outcomes of TSMs patients were collected and analyzed.

Results

In 31 patients operated with the unilateral subfrontal approach, total resection (Simpson grade I or II) was achieved in 27 patients (87.0%), while 6 patients (85.7%) achieved GTR in 7 patients using ETSA. The postoperative visual improvement was maintained in 22 (81.5%) and 5 patients (83.3%). Recurrence or progression was only observed in 2 (7.4%) patients operated with the unilateral subfrontal approach. There was no mortality in our series.

Conclusions

Preoperative imaging and visual function are important for surgical approach selection. Maximum tumor resection and optic nerve protection can be achieved concurrently by taking advantage of these surgical approaches. The cerebral artery protection strategies and individualized surgical techniques provide great utility in improving a patient's quality of life.

Surgical management of tuberculum sellae meningioma: Transcranial approach or endoscopic endonasal approach?

Background

Tuberculum sellae meningioma (TSM), a common benign tumor in the sellae region, usually causes neurological deficits, such as vision impairment, by squeezing the peripheral neurovascular structures. Surgical management is recommended as the optimal strategy for TSM treatment and vision restoration. However, it remains challenging to resect TSM in the traditional transcranial approach (TCA). Recently, the endoscopic endonasal approach (EEA) has emerged as an effective option in skull base surgeries. Besides the effectivity, the advantages and limitations of EEA in TSM surgery remain controversial.

Object

We compared the surgical outcomes and complications between TCA and EEA surgeries to identify the principles in TSM surgical management.

Methods

Retrospective analysis was performed on the patients, who underwent TSM surgery in Wuhan Union Hospital between January 2017 and December 2021. The patients were assigned to TCA or EEA group according to the surgery they experienced. All patients were analyzed with the extent of tumor resection, vision outcome, postoperative complications, and follow-up results.

Results

A total of 112 patients were enrolled in this study, including 78 in TCA group and 34 in EEA group. The mean follow-up was 20.5 months (range 3–36 months). There were no statistically significant differences in patient demographic data, preoperative symptoms, and tumor characteristics between TCA and EEA groups. Both TCA and EEA surgeries are effective in TSM resection with relatively high gross total resection rates (85.9% in TCA vs. 91.2% in EEA, p > .05). Meanwhile, EEA surgery has a better outcome in vision restoration or stabilization than TCA surgery (74.6% in TCA vs. 93.1% in EEA, p < .05). Whereas EEA surgery causes more occurrences of cerebrospinal fluid (CSF) leakage than TCA surgery (0% in TCA vs. 11.8% in EEA, p < .05).

Conclusion

Both TCA and EEA surgeries are effective in TSM resection. EEA surgery has a better outcome in vision restoration or stabilization than TCA surgery, but induces higher risk of CSF leakage. As each approach has unique advantages and limitations, we must take all aspects into consideration, including approach feathers, tumor characteristics, and clinical requirements, to make the optimal choice in TSM surgical management.

Suprasellar Meningiomas: An Experience of Four Cases With Brief Review of Literature

Suprasellar meningiomas make a relevant differential when it comes to sellar/suprasellar masses. The most common pathology in this location is pituitary adenomas. It is imperative to differentiate the two entities based on imaging as the clinical picture, and sometimes the biochemical profile can show significant overlap. It is also essential for the neurosurgeons to have a preoperative diagnosis as the behavior of both tumors is different. This piece will give a pictorial review of the imaging features of suprasellar meningiomas, in patients who presented to us with sellar/suprasellar masses. The aim is to help the radiologists as well as fellow clinicians to diagnose this entity with confidence based on imaging.

Differentiating between non-functioning pituitary macroadenomas and sellar meningiomas using ADC

INTRODUCTION AND AIM

It is difficult to distinguish between non-functioning pituitary macroadenomas (NFPMAs) and sellar meningiomas because of their overlapping imaging manifestations on routine MRI, especially in cases of meningiomas growing into the saddle. Here, we aimed to differentiate between these two tumors using apparent diffusion coefficient (ADC) values and MRI characteristics.

METHODS

A total of 60 NFPMA and 52 sellar meningioma cases confirmed by the pathological analysis were retrospectively reviewed. All patients were examined via routine MRI and diffusion-weighted imaging (DWI) before undergoing surgery. The clinical characteristics, MRI characteristics, and max ADC (ADCmax), average ADC (ADCmean), and minimum ADC (ADCmin) values were compared between the two tumors via Chi-square test and two sample t-tests. Receiver operating characteristic (ROC) curve and binary logistic regression analyses were conducted to determine the discrimination ability.

RESULTS

The ADCmax, ADCmean, and ADCmin values were significantly higher in NFPMAs compared to sellar meningiomas (P < 0.001 for all). Among ADC values, ADCmax demonstrated good performance with an AUC of 0.896 (95% CI, 0.823-0.969) and accuracy of 88.7%. A cut-off value of 0.97 × 10-3 mm2/s was used for ADCmax for differentiation between tumors. A combination of ADCmax values and clinicoradiological features showed the best discrimination ability for differential diagnosis between the two tumors, with an AUC of 0.981 (95% CI, 0.958-1.000) and accuracy of 96.9%.

CONCLUSION

A combination of ADCmax and clinicoradiological features demonstrates good discrimination ability and high accuracy for differentiation between NFPMAs and sellar meningiomas, and is a potential quantitative tool to aid in the selection of surgical techniques.

Differentiation of suprasellar meningiomas from non-functioning pituitary macroadenomas by 18F-FDG and 13N-Ammonia PET/CT

Background

Differentiation of suprasellar meningiomas (SSMs) from non-functioning pituitary macroadenomas (NFPMAs) is useful for clinical management. We investigated the utility of ¹³N-ammonia combined with ¹⁸F-FDG positron emission tomography (PET)/computed tomography (CT) in distinguishing SSMs from NFPMAs retrospectively.

Methods

Fourteen NFPMA patients and eleven SSM patients with histopathologic diagnosis were included in this study. Every patient underwent both ¹⁸F-FDG and ¹³N-ammonia PET/CT scans. The tumor to gray matter (T/G) ratios were calculated for the evaluation of tumor uptake.

Results

The uptake of ¹⁸F-FDG was higher in NFPMAs than SSMs, whereas the uptake of ¹³N-ammonia was obviously lower in NFPMAs than SSMs. The differences of ¹⁸F-FDG and ¹³N-ammonia uptake between the two groups were significant respectively (0.92[0.46] vs 0.59[0.29], P < 0.05, ¹⁸F-FDG; 1.58 ± 0.56 vs 2.80 ± 1.45, P < 0.05, ¹³N-ammonia). Tumor classification demonstrated a high overall accuracy of 96.0% for differential diagnosis. When the two traces were combined, only 1 SSM was misclassified into the NFPMA group.

Conclusion

SSMs and NFPMAs have different metabolic characteristics on ¹⁸F-FDG and ¹³N-ammonia PET images. The combination of these two tracers can effectively distinguish SSMs from NFPMAs.

How I do it: contralateral supraorbital approach for tuberculum sellae meningioma

BACKGROUND

The resection of tuberculum sellae meningiomas poses a challenge particularly when dealing with the medial aspect of the optic nerve. Dissection of the tumor off the optic nerve is usually carried out in the blind spot "behind" the optic nerve. We describe a contralateral approach for asymmetric tuberculum sellae meningiomas, allowing direct visualization of the medial optic nerve.

METHOD

Contralateral lateral supraorbital approach was performed, and complete tumor resection was achieved without any injury to the optic nerve.

CONCLUSION

The contralateral approach for asymmetric tuberculum sellae meningioma is an efficient technique allowing improved visualization of the medial optic nerve.

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.

The Endoscopic Endonasal Management of Anterior Skull Base Meningiomas

Introduction  The endoscopic endonasal approach (EEA) might seem an "unnatural" route for intradural lesions such as meningiomas. The aim of this study is to critically revise our management of anterior skull base meningiomas to consider, in what cases it may be advantageous. Material and Methods  Each consecutive case of anterior skull base meningioma operated on through an EEA or combined endoscopic-transcranial approach at our institution, between 2003 and 2017, have been included. Tumors were classified on the basis of their location and intra or extracranial extension. Follow-up consisted of an MRI (magnetic resonance imaging) and a clinical examination 3 months after the surgery and then repeated annually. Results  Fifty-seven patients were included. The most common location was the tuberculum sellae (62%), followed by olfactory groove (14%), planum sphenoidale (12%), and frontal sinus (12%). Among these, 65% were intracranial, 7% were extracranial, and 28% both intra and extracranial. Radical removal was achieved in 44 cases (77%). Complications consisted in 10 CSF (cerebrospinal fluid) leaks (17.6%), 1 overpacking (1.7%), and 1 asymptomatic brain ischemia (1.7%). Visual acuity and campimetric deficits improved respectively in 67 and 76% of patients. Recurrence rate was of 14%. Conclusions  EEA presents many advantages in selected cases of anterior skull base meningioma. However, it is hampered by the relevant risk of CSF leak. We consider that it could be advantageous for planum/tuberculum sellae tumors. Conversely, for olfactory groove or frontal sinus meningiomas, it can be indicated for tumors with extracranial extension, while its role is still debatable for purely intracranial forms as considering our surgical results, it could be advantageous for midline planum/tuberculum sellae tumors. Conversely, it can be of first choice for olfactory groove or frontal sinus meningiomas with extracranial extension, while its role for purely intracranial forms is still debatable.