From Above or Below: The Controversy and Historical Evolution of Tuberculum Sellae Meningioma Resection from Open to Endoscopic Skull Base Approaches

The initial descriptions of tuberculum sellae meningiomas date back to the latter half of the 19th century. However, it was not until the early 20th century that the first successful surgical removal of these tumors was performed and described by Harvey Cushing and Louise Eisenhardt. It was soon recognized that tuberculum sellae meningiomas pose a formidable challenge for skull base surgeons, not only because of their sensitive location and proximity to critical neurovascular elements, but also because of their dense and fibrous nature in some cases. Because of this, over the next several decades, controversy transpired regarding their optimal method of resection.

Early surgical attempts involved utilization of open transcranial routes. This included the classic bilateral and unilateral frontal approaches and the pterional or frontotemporal approaches, and has since evolved to incorporate newer skull base techniques, such as the supraorbital approach, orbitozygomatic approach, and orbitopterional approach. More recently, minimally invasive supraorbital keyhole approaches through eyebrow incisions have also been adopted for these tumors. Over the past 25 years, the microsurgical transsphenoidal approach, classically used for pituitary and parasellar tumors, was extended to resect tuberculum sellae meningiomas (extended transsphenoidal approach). In more recent years, with the advent of the endoscope and programmatic development of combined neurosurgery/otolaryngology skull base teams, resection of these lesions has been achieved using purely endoscopic endonasal transplanum transtuberculum approaches.

Although each of these techniques has been successfully described for the treatment of tuberculum sellae meningiomas, the question still remains: is it better to access and operate on these lesions via a traditional transcranial avenue, or are they better treated via minimal access endoscopic endonasal techniques? In this paper, we outline the surgical management of tuberculum sellae meningiomas as it has unfolded through history, from the early use of open transcranial and transsphenoidal approaches to the modern use of extended endoscopic endonasal procedures. In addition, we briefly explore the arguments favoring each of the surgical methods and the advancements that have emerged to further optimize surgical resection.