Tuberculum Sellae Meningioma: Techniques, Complications and Pitfalls in Casuistic of 38 Patients

Background: Tuberculum sellae meningioma is a serious challenge for neurosurgeons. It accounts for up to 10% of all intracranial meningiomas. The difficulty in surgically excising a tuberculum sellae meningioma comes from its anatomical relationship to the optic nerves and chiasm and to the anterior cerebral and internal carotid arteries and their perforators.

Objective: Discuss the complications and pitfalls of each main surgical technique used for resection of tuberculum sellae meningiomas based on our experience in comparison to previously reported data.

Methods: The authors report a personal case series of senior authors composed by 38 patients with tuberculum sellae meningiomas submitted at surgery during the period from 1995 to 2016. All patients underwent evaluation by CT scan and MRI. The radiological parameters included tumor size, brain-tumor interface, perilesional edema, arterial encasement, optic canal extension, and hyperostosis. The patients underwent an endoscopic endonasal approach or conventional craniotomy for tumor resection by bifrontal, pterional, supraciliary, unilateral frontal, or fronto-orbitozygomatic surgical access. The Simpson grade of meningioma resection as well as the non-visual morbidity and the mortality rates were analyzed.

Results: The study was performed with 30 female patients and 8 male patients, whose average age was 52 years. Regarding the surgical procedure, 94.7% (n = 36) patients was underwent craniotomy for tumor resection (31.5% bifrontal, 31.5% pterional, 15.8% supraciliary, 10.6% unilateral frontal, and 5.3% fronto-orbitozygomatic access), while in two patients’ excision was performed through an endoscopic endonasal approach. Thirty-one patients had Simpson grades 1 and 2 excisions, while seven had Simpson grade 4 excisions. The overall rate of non-visual morbidity was 13.15% (5 of 38 patients) and mortality was 5.2%. The pterional access was associated to the worse inadequate visualization of optic nerve and carotid artery, as well as higher rates of visual deterioration and high degree of difficulty in cases invasion of the optic canal and intrasellar extension of the tumor.

Conclusion: The primary symptom leading to the diagnosis of a tuberculum sellae meningioma was visual compromise, and the main goal of surgery was to achieve improvement of vision. Favorable outcomes were achieved with appropriate selection of surgical approach.