Tuberculum sellae meningioma

Introduction

Tuberculum sellae meningiomas are often grouped with the midline anterior skull base meningiomas. These lesions account for 3% to 10% of intracranial meningiomas, and typically arise from arachnoid cells at the limbus sphenoidale, chiasmatic sulcus, and/or tuberculum. These lesions often invade the bone and generate an osteoblastic resection, as well as displace critical neurovascular structures, including the optic nerve and chiasm, infundibulum, and anterior cerebral artery vessels. Surgery for these lesions is associated with significant morbidity that ranges from 10% to 25% in several series, and can include vision loss, hormonal dysfunction, and cerebrospinal fluid leak, among others. ^, In this chapter, we present a case of a patient with a tuberculum sellae meningioma.

Example case

Chief complaint: vision loss

History of present illness

A 42-year-old, right-handed woman with a history of hypertension presented with vision loss. She noticed that over the past several months she had an increasing difficulty with seeing things in her peripheral fields. She noticed this especially at intersections when driving. Visual field testing showed optic nerve atrophy and right greater than left superior and inferior temporal field cuts ( Fig. 43.1 ).

Medications : Lisinopril.
Allergies : No known drug allergies.
Past medical and surgical history : Hypertension, appendectomy, tonsillectomy.
Family history : No history of intracranial malignancies.
Social history : Lawyer, no smoking or alcohol.
Physical examination : Awake, alert, oriented to person, place, and time; Cranial nerves II to XII intact, except bitemporal field cuts to confrontation; No drift, moves all extremities with full strength.

	Pablo Augusto Rubino, MD, Román Pablo Arévalo, MD, Hospital El Cruce, Buenos Aires, Argentina	James J. Evans, MD, Tomas Garzon-Muvdi, MD, Thomas Jefferson University, Philadelphia, PA, United States	Ricardo J. Komotar, MD, University of Miami, Miami, FL, United States	Jorge Navarro-Bonnet, MD, Oncologic Neurosurgery, Medica Sur, Mexico City, Mexico
Preoperative
Additional tests requested	Neuropsychological assessmentPituitary hormone panel MRA	CT CT angiography	Endocrinology evaluation Ophthalmology evaluation	CT of the paranasal sinuses ENT evaluation Endocrinology evaluation Ophthalmology evaluation (visual fields)
Surgical approach selected	Right pterional craniotomy and anterior clinoidectomy	Endoscopic endonasal transplanum transtubercular	Right frontotemporal craniotomy	Extended endoscopic endonasal transsphenoidal
Anatomic corridor	Subfrontal, trans-Sylvian	Endonasal	Trans-Sylvian	Endonasal
Goal of surgery	Preservation of vision Simpson grade II	Maximal debulking, preservation of visual function, Simpson grade II–III	Simpson grade II	Simpson grade I
Perioperative
Positioning	Supine neutral with slight rotation	Supine no pins	Right supine with slight rotation	Supine in pins
Surgical equipment	Surgical microscope Doppler Ultrasonic aspirator	Surgical navigation Endoscope Ultrasonic aspirator	Surgical navigation Surgical microscope Ultrasonic aspirator	Lumbar drain Surgical navigation Endoscope Ultrasonic aspirator
Medications	Mannitol Antiepileptics	None	Mannitol Steroids	None
Anatomic considerations	Bilateral ICAs, bilateral optic nerves, pituitary stalk	Bilateral ICAs, ACAs, superior hypophyseal arteries, optic nerves/chiasm, cavernous sinuses, basilar artery, pituitary gland	Bilateral ICAs and ACAs, bilateral optic nerves, pituitary stalk	Olfactory nerves, ICA, ACA, optic chiasm
Complications feared with approach chosen	ICA and optic nerve injury	Brain retraction	ICA, ACA, optic nerve, infundibulum injuries	Vascular injury, optic chiasm injury
Intraoperative
Anesthesia	General	General	General	General
Skin incision	Right pterional	Fascia lata	Right pterional	None
Bone opening	Right frontal/temporal	Sphenoid bone, sella, tuberculum sellae, planum sphenoidale	Right frontal/temporal	Sphenoid bone, tuberculum sellae
Brain exposure	Right frontal/temporal	Anterior skull base	Right frontal/temporal	Tuberculum sellae
Method of resection	Craniotomy on side with worse optic nerve functioning, drilling lesser sphenoid wing and supraorbital region parallel to orbital roof, dura opening, Sylvian fissure is split along the anterior limb, subfrontal approach with early identification of optic nerve/chiasm/ICA, wide dissection of arachnoid and opening of opticocarotid cistern, intradural anterior clinoidectomy, decompression of optic canal, tumor devascularization and debulking along the paramedian plane to avoid injuring contralateral optic nerve, identification of contralateral optic nerve once tumor is debulked sufficiently, continue debulking tumor with ultrasonic aspirator, mobilize capsule sharply from critical structures including ICA/ACA/infundibulum through interoptic and opticocarotid cisterns, attempt to dissect from optic nerves but if cannot leave small remnant attached, inspect both optic canals	Obtain fascia lata graft for dural repair, ENT to assist, nasoseptal flap harvest, lateralization of bilateral middle turbinates, partial removal of posterior ethmoids, removal of skull base spanning tumor from planum to clivus, coagulation of dura, dura opened in midline and tumor debulked with ultrasonic aspirator or sharp/dull dissection, extracapsular dissection sharply, margin of dura removed, fascia lata button graft used to reconstruct dura, nasoseptal flap applied, dural sealant, medialization of middle turbinates, no lumbar drain	Craniotomy, drill lesser sphenoid wing, open dura, open Sylvian fissure under microscopic visualization, wide arachnoid dissection with accessing the opticocarotid cistern, CSF drainage with brain relaxation, send off pathology, early identification of optic nerves/ICAs, tumor debulking with ultrasonic aspirator, dissect capsule from brain, protect critical structures (optic nerves, ICA, ACA, infundibulum), complete resection, dural closure with dural substitute	ENT to assist, harvest nasoseptal flap, removal of sphenoid bone and tuberculum sellae, coagulation of dura, dural opening, debulking with ultrasonic aspirator, sharp dissection to adherent structures, reconstruction using dural substitute as inlay and onlay with gasket seal, nasoseptal flap, lumbar drain for 3 days
Complication avoidance	Early identification of critical structures, wide arachnoid opening, sharp dissection from critical structures	Fascia lata button graft, coagulation of dura, debulk tumor prior to manipulation, nasoseptal flap	Early identification of critical structures, wide arachnoid and Sylvian fissure opening	Nasoseptal flap, gasket seal closure, lumbar drain, coagulation of dura
Postoperative
Admission	ICU	ICU	ICU	Intermediate care
Postoperative complications feared	CSF leak, visual decline	CSF leak, visual decline, pituitary dysfunction	Visual decline, stroke, pituitary dysfunction	Anosmia, vasospasm, diabetes insipidus, CSF leak
Follow-up testing	MRI within 48 hours after surgery	MRI within 3 months after surgery	MRI within 24 hours after surgery Endocrine evaluation	Head CT immediately after surgery MRI within 48 hours after surgery Neuroophthalmology and endocrinology evaluation
Follow-up visits	1 month, 3 months, 6 months after surgery	1 week after surgery with ENT 3 weeks after surgery with neurosurgery	14 days after surgery	10 days after surgery
Adjuvant therapies recommended for WHO grade	Grade I–observation Grade II–observation Grade III–radiation	Grade I–observation Grade II–clinical trial Grade III–clinical trial	Grade I–observation Grade II–radiation Grade III–radiation/chemotherapy	Grade I–radiation Grade II–radiation Grade III–radiation