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Lasica N, Parikh KA, Arnautović KI. Cranio-Orbital Approach and Decompression of the Optic Nerves: A 2-Stage, 4-by-4-Step Approach to Improve Vision in Sellar and Parasellar Lesions. Oper Neurosurg (Hagerstown) 2024:01787389-990000000-01331. [PMID: 39292768 DOI: 10.1227/ons.0000000000001344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2024] [Accepted: 07/09/2024] [Indexed: 09/20/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Despite advances in cranial base techniques, surgery of the sellar and parasellar regions remains challenging because of complex neurovascular relationships. Lesions within this region frequently present with progressive visual deterioration caused by distortion and compression of the optic chiasm and nerves. In addition to the direct mass effect from mechanical forces acting on the optic apparatus, these lesions alter blood supply and reduce vascular perfusion, prompting surgical treatment to remove the lesion, alleviate compression, and improve blood flow to the optic nerve. We sought to describe a 2-stage, 4-by-4-step approach, broken down and described as a "four-by-four" technique for optic apparatus decompression and a wide approach to different sellar and parasellar lesions. METHODS We describe the operative nuances and key anatomic points in the microsurgical removal of sellar and parasellar lesions. The technique is illustrated with examples of different cases with pre- and follow-up MRI imaging and a brief overview of visual outcomes. RESULTS The described technique has been demonstrated in various lesions in 5 patients. Patients presented with bilateral visual loss in 4 (80.0%) cases and with unilateral visual loss in 1 (20.0%) case. Improvement in visual function was noted in all cases, confirmed with visual acuity and visual field testing. DISCUSSION The transcranial approach ("from above") remains an important surgical option for patients with excellent exposure and visualization of the sellar and parasellar regions. It permits early access to the optic canal for careful microsurgical decompression and relaxation of the optic nerve to preserve and improve its microvascularization and ultimately vision. CONCLUSION The authors augmented the 2-stage, 4-by-4-step technique of decompression with elaborate illustrations of diverse sellar and parasellar lesions to demonstrate the versatility of this approach.
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Affiliation(s)
- Nebojsa Lasica
- Clinic of Neurosurgery, University Clinical Center of Vojvodina, Novi Sad, Serbia
- Faculty of Medicine, University of Novi Sad, Novi Sad, Serbia
| | | | - Kenan I Arnautović
- Semmes-Murphey Clinic, Memphis, Tennessee, USA
- Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA
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Duan C, Song D, Wang F, Wang Y, Wei M, Fang J, Zhai T, An Y, Zuo Y, Hu Y, Li G, Yu Z, Guo F. Factors influencing postoperative visual improvement in 208 patients with tuberculum sellae meningiomas. Acta Neurochir (Wien) 2024; 166:140. [PMID: 38491189 DOI: 10.1007/s00701-024-06033-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2023] [Accepted: 02/20/2024] [Indexed: 03/18/2024]
Abstract
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.
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Affiliation(s)
- Chengcheng Duan
- Department of Neurosurgery, The First Affiliated Hospital of Zhengzhou University, No.1, East Jianshe Road, Zhengzhou, Henan Province, 450001, China
- International Joint Laboratory of Nervous System Malformations, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan Province, China
| | - Dengpan Song
- Department of Neurosurgery, The First Affiliated Hospital of Zhengzhou University, No.1, East Jianshe Road, Zhengzhou, Henan Province, 450001, China
- International Joint Laboratory of Nervous System Malformations, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan Province, China
| | - Fang Wang
- Department of Neurosurgery, The First Affiliated Hospital of Zhengzhou University, No.1, East Jianshe Road, Zhengzhou, Henan Province, 450001, China
- International Joint Laboratory of Nervous System Malformations, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan Province, China
| | - Youjun Wang
- Department of Neurosurgery, The First Affiliated Hospital of Zhengzhou University, No.1, East Jianshe Road, Zhengzhou, Henan Province, 450001, China
- International Joint Laboratory of Nervous System Malformations, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan Province, China
| | - Mingkun Wei
- Department of Neurosurgery, The First Affiliated Hospital of Zhengzhou University, No.1, East Jianshe Road, Zhengzhou, Henan Province, 450001, China
- International Joint Laboratory of Nervous System Malformations, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan Province, China
| | - Junhao Fang
- Department of Neurosurgery, The First Affiliated Hospital of Zhengzhou University, No.1, East Jianshe Road, Zhengzhou, Henan Province, 450001, China
- International Joint Laboratory of Nervous System Malformations, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan Province, China
| | - Tingting Zhai
- Department of Neurosurgery, The First Affiliated Hospital of Zhengzhou University, No.1, East Jianshe Road, Zhengzhou, Henan Province, 450001, China
- International Joint Laboratory of Nervous System Malformations, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan Province, China
| | - Yuan An
- Department of Neurosurgery, The First Affiliated Hospital of Zhengzhou University, No.1, East Jianshe Road, Zhengzhou, Henan Province, 450001, China
- International Joint Laboratory of Nervous System Malformations, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan Province, China
| | - Yuchao Zuo
- Department of Neurosurgery, The First Affiliated Hospital of Zhengzhou University, No.1, East Jianshe Road, Zhengzhou, Henan Province, 450001, China
- International Joint Laboratory of Nervous System Malformations, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan Province, China
| | - Yan Hu
- Department of Neurosurgery, The First Affiliated Hospital of Zhengzhou University, No.1, East Jianshe Road, Zhengzhou, Henan Province, 450001, China
- International Joint Laboratory of Nervous System Malformations, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan Province, China
| | - Guihong Li
- Department of Neurosurgery, The First Affiliated Hospital of Zhengzhou University, No.1, East Jianshe Road, Zhengzhou, Henan Province, 450001, China
- International Joint Laboratory of Nervous System Malformations, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan Province, China
| | - Zhiyun Yu
- Department of Neurosurgery, The First Affiliated Hospital of Zhengzhou University, No.1, East Jianshe Road, Zhengzhou, Henan Province, 450001, China
- International Joint Laboratory of Nervous System Malformations, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan Province, China
| | - Fuyou Guo
- Department of Neurosurgery, The First Affiliated Hospital of Zhengzhou University, No.1, East Jianshe Road, Zhengzhou, Henan Province, 450001, China.
- International Joint Laboratory of Nervous System Malformations, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan Province, China.
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Sakata K, Komaki S, Takeshige N, Negoto T, Kikuchi J, Kajiwara S, Orito K, Nakamura H, Hirohata M, Morioka M. Visual Outcomes and Surgical Approach Selection Focusing on Active Optic Canal Decompression and Maximum Safe Resection for Suprasellar Meningiomas. Neurol Med Chir (Tokyo) 2023; 63:381-392. [PMID: 37423756 PMCID: PMC10556211 DOI: 10.2176/jns-nmc.2021-0142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Accepted: 04/17/2023] [Indexed: 07/11/2023] Open
Abstract
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.
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Affiliation(s)
- Kiyohiko Sakata
- Department of Neurosurgery, Kurume University School of Medicine
| | - Satoru Komaki
- Department of Neurosurgery, Kurume University School of Medicine
| | | | - Tetsuya Negoto
- Department of Neurosurgery, Kurume University School of Medicine
| | - Jin Kikuchi
- Department of Neurosurgery, Kurume University School of Medicine
| | - Sosho Kajiwara
- Department of Neurosurgery, Kurume University School of Medicine
| | - Kimihiko Orito
- Department of Neurosurgery, Kurume University School of Medicine
| | - Hideo Nakamura
- Department of Neurosurgery, Kurume University School of Medicine
| | - Masaru Hirohata
- Department of Neurosurgery, Kurume University School of Medicine
| | - Motohiro Morioka
- Department of Neurosurgery, Kurume University School of Medicine
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Leclerc A, Gaberel T, Laville MA, Derrey S, Quintyn JC, Emery E. Predictive Factors of Favorable Visual Outcomes After Surgery of Tuberculum Sellae Meningiomas: A Multicenter Retrospective Cohort Study. World Neurosurg 2022; 164:e557-e567. [PMID: 35568126 DOI: 10.1016/j.wneu.2022.05.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2022] [Revised: 05/03/2022] [Accepted: 05/04/2022] [Indexed: 10/18/2022]
Abstract
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.
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Affiliation(s)
- Arthur Leclerc
- Department of Neurosurgery, Centre Hospitalier Universitaire Caen, Caen, France; Medical School, Université Caen Normandie, Caen, France.
| | - Thomas Gaberel
- Department of Neurosurgery, Centre Hospitalier Universitaire Caen, Caen, France; Medical School, Université Caen Normandie, Caen, France; Physiopathology and Imaging of Neurological Disorders, Institut National de la Santé et de la Recherche Médicale, UMR-S U1237, GIP Cyceron, Caen, France
| | - Marie-Alice Laville
- Department of Ophthalmology, Centre Hospitalier Universitaire Caen, Caen, France
| | - Stephane Derrey
- Department of Neurosurgery, Centre Hospitalier Universitaire Rouen, Rouen, France; Medical School, Université Rouen Normandie, Rouen, France
| | - Jean-Claude Quintyn
- Department of Ophthalmology, Centre Hospitalier Universitaire Caen, Caen, France; Medical School, Université Caen Normandie, Caen, France
| | - Evelyne Emery
- Department of Neurosurgery, Centre Hospitalier Universitaire Caen, Caen, France; Medical School, Université Caen Normandie, Caen, France; Physiopathology and Imaging of Neurological Disorders, Institut National de la Santé et de la Recherche Médicale, UMR-S U1237, GIP Cyceron, Caen, France
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Eichberg DG, Komotar RJ, Ivan ME. Commentary: Microsurgical Transcranial Approach of 112 Paraoptic Meningiomas: A Single-Center Case Series. Oper Neurosurg (Hagerstown) 2020; 19:E557-E558. [PMID: 32710759 DOI: 10.1093/ons/opaa233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Accepted: 05/22/2020] [Indexed: 11/13/2022] Open
Affiliation(s)
- Daniel G Eichberg
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida
| | - Ricardo J Komotar
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida.,Sylvester Comprehensive Cancer Center, Miami, Florida
| | - Michael E Ivan
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida.,Sylvester Comprehensive Cancer Center, Miami, Florida
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