Supraorbital and Endonasal Approaches: Tailoring Surgical Techniques for Tuberculum Sellae Meningiomas Based on Preoperative Grading Systems—Minimally Invasive Approaches for Tuberculum Sellae Meningiomas

Abstract

Background

Tuberculum sellae meningiomas (TSMs) tend to compress the optic apparatus and an ideal surgical route, whether transcranial or endonasal, is still debated. Another issue is if the minimally invasive supraorbital (SO) approach offers the same results compared with the more invasive craniotomies. Aiming to guide approach selection, preoperative grading systems have been described.

Methods

All cases of TSMs treated from 2013 to 2018 by extended endoscopic endonasal approach (EEA) or SO approach have been reviewed and classified according to three preoperative grading systems: McDermott scale, Optic Nerve Laterality Score, and Yaşargil criteria.

Results

A total of 15 patients with TSMs were treated with the EEA (n = 6) or the SO (n = 9) approach. Globally, gross total resection was obtained in 87% (n = 13) of cases and was higher with the SO (100%, n = 9) compared with the EEA (67%, n = 4). Visual function improved in all but one patient (n = 14). Compared with the EEA group, patients treated by the SO approach had larger tumors (32.3 mm vs. 24.5 mm), a higher rate of optic canal invasion (4/9 vs. 0/6), and arterial encasement (6/9 vs. 1/5). Patients with McDermott total points of 1 to 2 (7/15) were treated mainly by the EEA; all patients with McDermott total score of ≥3 (8/15) were treated by the SO approach. All patients with optic canal invasion (4/15) and lateral extension of the tumor (ONL score = 1–3) were treated by the SO approach.

Conclusion

The SO and EEA are two minimally invasive approaches safe and effective for treating TSMs. For tumors with lateral extension (optic nerve laterality [ONL] score = 1–3), larger diameter (>30–35 mm), vascular encasement, or optic canal involvement (McDermott total point = 2–3), the SO craniotomy is preferred. For small and median tumors with no optic canal invasion or vascular encasement (McDermott total point = 1–2), the EEA represents a valid option.

Keywords

tuberculum sellae - supraorbital - EEA - meningiomas - optic canal

Disclosure

The authors report no involvement in the research by the sponsor that could have influenced the outcome of this work.

Authors' Contributions

F.M. and R.A.R. contributed equally to the design of the study.

R.P., M.M.O. and D.D.P. were responsible for study planning and writing.

S.V. and C.C. were responsible for supervision.

S.P., F.R.B., and D.M. were responsible for data collection.

Publication History

Received: 03 August 2024

Accepted: 19 November 2024

Accepted Manuscript online:
20 November 2024

Article published online:
09 January 2026

• References

• 1 Al Mefty O, Smith RR. Tuberculum sellae meningiomas. In: Meningiomas. New York: Raven Press Ltd; 1991: 395-411
• 2 Jallo GI, Benjamin V. Tuberculum sellae meningiomas: microsurgical anatomy and surgical technique. Neurosurgery 2002; 51 (06) 1432-1439 , discussion 1439–1440
• 3 Andrews BT, Wilson CB. Suprasellar meningiomas: the effect of tumor location on postoperative visual outcome. J Neurosurg 1988; 69 (04) 523-528
• 4 Kadis GN, Mount LA, Ganti SR. The importance of early diagnosis and treatment of the meningiomas of the planum sphenoidale and tuberculum sellae: a retrospective study of 105 cases. Surg Neurol 1979; 12 (05) 367-371
• 5 Rosenstein J, Symon L. Surgical management of suprasellar meningioma. Part 2: Prognosis for visual function following craniotomy. J Neurosurg 1984; 61 (04) 642-648
• 6 Samanci Y, Ardor GD, Peker S. Gamma Knife radiosurgery for tuberculum sellae meningiomas: a series of 78 consecutive patients. Neurosurg Rev 2022; 45 (03) 2315-2322
• 7 Chokyu I, Goto T, Ishibashi K, Nagata T, Ohata K. Bilateral subfrontal approach for tuberculum sellae meningiomas in long-term postoperative visual outcome. J Neurosurg 2011; 115 (04) 802-810
• 8 Xiao F, Shen J, Zhang L. et al. Unilateral subfrontal approach for giant tuberculum sellae meningioma: single center experience and review of the literature. Front Oncol 2021; 11: 708235
• 9 Wilk A, Zielinski G, Witek P, Koziarski A. Outcome assessment after surgical treatment of tuberculum sellae meningiomas - a preliminary report. Turk Neurosurg 2016; 26 (06) 824-832
• 10 Curey S, Derrey S, Hannequin P. et al. Validation of the superior interhemispheric approach for tuberculum sellae meningioma: clinical article. J Neurosurg 2012; 117 (06) 1013-1021
• 11 Fatemi N, Dusick JR, de Paiva Neto MA, Malkasian D, Kelly DF. Endonasal versus supraorbital keyhole removal of craniopharyngiomas and tuberculum sellae meningiomas. Neurosurgery 2009; 64 (5 Suppl 2): 269-284 , discussion 284–286
• 12 Rigante L, Evins AI, Berra LV, Beer-Furlan A, Stieg PE, Bernardo A. Optic nerve decompression through a supraorbital approach. J Neurol Surg B Skull Base 2015; 76 (03) 239-247
• 13 Linsler S, Fischer G, Skliarenko V, Stadie A, Oertel J. Endoscopic assisted supraorbital keyhole approach or endoscopic endonasal approach in cases of tuberculum sellae meningioma: which surgical route should be favored?. World Neurosurg 2017; 104: 601-611
• 14 Magill ST, Morshed RA, Lucas CG. et al. Tuberculum sellae meningiomas: grading scale to assess surgical outcomes using the transcranial versus transsphenoidal approach. Neurosurg Focus 2018; 44 (04) E9
• 15 Youngerman BE, Banu MA, Gerges MM. et al. Endoscopic endonasal approach for suprasellar meningiomas: introduction of a new scoring system to predict extent of resection and assist in case selection with long-term outcome data. J Neurosurg 2020; 135 (01) 113-125
• 16 Bander ED, Singh H, Ogilvie CB. et al. Endoscopic endonasal versus transcranial approach to tuberculum sellae and planum sphenoidale meningiomas in a similar cohort of patients. J Neurosurg 2018; 128 (01) 40-48
• 17 Cushing H, Eisenhardt L. Suprasellar meningiomas. In: Meningiomas: Their Classification, Regional Behaviour, Life History, and Surgical End Results. Springfield: Charles C. Thomas; 1938: 224-249
• 18 Nakamura M, Roser F, Struck M, Vorkapic P, Samii M. Tuberculum sellae meningiomas: clinical outcome considering different surgical approaches. Neurosurgery 2006; 59 (05) 1019-1028 , discussion 1028–1029
• 19 de Divitiis E, Cavallo LM, Esposito F, Stella L, Messina A. Extended endoscopic transphenoidal approach for tuberculum sellae meningiomas. Neurosurgery 2007; 61 (5 Suppl 2): ONS229-ONS238
• 20 de Divitiis E, Esposito F, Cappabianca P, Cavallo LM, de Divitiis O. Tuberculum sellae meningiomas: high route or low route? A series of 51 consecutive cases. Neurosurgery 2008; 62 (03) 556-563 , discussion 556–563
• 21 Dusick JR, Esposito F, Kelly DF. et al. The extended direct endonasal transsphenoidal approach for nonadenomatous suprasellar tumors. J Neurosurg 2005; 102 (05) 832-841
• 22 Hadad G, Bassagasteguy L, Carrau RL. et al. A novel reconstructive technique after endoscopic expanded endonasal approaches: vascular pedicle nasoseptal flap. Laryngoscope 2006; 116 (10) 1882-1886
• 23 Zamanipoor Najafabadi AH, Khan DZ, Muskens IS. et al. Trends in cerebrospinal fluid leak rates following the extended endoscopic endonasal approach for anterior skull base meningioma: a meta-analysis over the last 20 years. Acta Neurochir (Wien) 2021; 163 (03) 711-719
• 24 Wilson DH. Limited exposure in cerebral surgery. Technical note. J Neurosurg 1971; 34 (01) 102-106
• 25 Mathiesen T, Kihlström L. Visual outcome of tuberculum sellae meningiomas after extradural optic nerve decompression. Neurosurgery 2006; 59 (03) 570-576 , discussion 570–576
• 26 Figueiredo EG, Deshmukh V, Nakaji P. et al. An anatomical evaluation of the mini-supraorbital approach and comparison with standard craniotomies. Neurosurgery 2006; 59 (4 Suppl 2): ONS212-ONS220 , discussion ONS220
• 27 Mahmoud M, Nader R, Al-Mefty O. Optic canal involvement in tuberculum sellae meningiomas: influence on approach, recurrence, and visual recovery. Neurosurgery 2010; 67 (3 Suppl Operative): ons108-ons118 , discussion ons118–ons119
• 28 Cai M, Ye Z, Ling C, Zhang B, Hou B. Trans-eyebrow supraorbital keyhole approach in suprasellar and third ventricular craniopharyngioma surgery: the experience of 27 cases and a literature review. J Neurooncol 2019; 141 (02) 363-371
• 29 Wilson DA, Duong H, Teo C, Kelly DF. The supraorbital endoscopic approach for tumors. World Neurosurg 2014; 82 (1-2): e243-e256
• 30 van Lindert EJ, Grotenhuis JA. The combined supraorbital keyhole-endoscopic endonasal transsphenoidal approach to sellar, perisellar and frontal skull base tumors: surgical technique. Minim Invasive Neurosurg 2009; 52 (5-6): 281-286
• 31 Gardner PA, Kassam AB, Thomas A. et al. Endoscopic endonasal resection of anterior cranial base meningiomas. Neurosurgery 2008; 63 (01) 36-52 , discussion 52–54