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Planum Sphenoidale and Tuberculum Sellae Meningiomas: Operative

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Planum Sphenoidale and Tuberculum Sellae Meningiomas: Operative Original Article Planum Sphenoidale and Tuberculum Sellae Meningiomas: Operative Nuances of a Modern Surgical Technique with Outcome and Proposal of a New Classification System Martin M. Mortazavi1, Harley Brito da Silva1, Manuel Ferreira Jr1, Jason K. Barber1, James S. Pridgeon1, Laligam N. Sekhar1,2 - BACKGROUND: The resection of planum sphenoidale common presenting symptom was visual disturbance and tuberculum sellae meningiomas is challenging. A (77%). Vision improved in 90% of those who presented with universally accepted classification system predicting sur- visual decline, and there was no permanent visual deteri- gical risk and outcome is still lacking. oration. Cerebrospinal fluid leak occurred in one of the 25 cranial cases (4%) and in 1 of 2 transphenoidal cases - OBJECTIVES: We report a modern surgical technique (50%), and in both cases it resolved with treatment. There specific for planum sphenoidale and tuberculum sellae was no surgical mortality. meningiomas with associated outcome. A new classifica- tion system that can guide the surgical approach and may - CONCLUSION: An orbitotomy and early decompression predict surgical risk is proposed. of the involved optic canal are important for achieving gross total resection, maximizing visual improvement, and - METHODS: We conducted a retrospective review of the avoiding recurrence. The visual outcomes were excellent. patients who between 2005 and March 2015 underwent a A new classification system that can allow the comparison craniotomy or endoscopic surgery for the resection of of different series and approaches and indicate cases that meningiomas involving the suprasellar region. Operative are more suitable for an endoscopic transsphenoidal nuances of a modified frontotemporal craniotomy and approach is presented. orbital osteotomy technique for meningioma removal and reconstruction are described. - RESULTS: Twenty-seven patients were found to have tumors arising mainly from the planum sphenoidale or the tuberculum sellae; 25 underwent frontotemporal crani- INTRODUCTION otomy and tumor removal with orbital osteotomy and eningiomas account for approximately 36% of all pri- bilateral optic canal decompression, and 2 patients un- mary central nervous system tumors, representing the derwent endonasal transphenoidal resection. The most M most frequently diagnosed primary brain tumor. Key words MRI: Magnetic resonance imaging - Classification NTR: Near-total resection - Meningioma OG: Olfactory groove - Olfactory groove PS: Planum sphenoidale - Planum sphenoidale TS: Tuberculum sellae - Suprasellar WHO: World Health Organization - Surgical technique - Tuberculum sellae From the Departments of 1Neurological Surgery and 2Radiology, University of Washington, Harborview Medical Center, Seattle, Washington, USA Abbreviations and Acronyms To whom correspondence should be addressed: Laligam N. Sekhar, M.D. AC: Anterior clinoid [E-mail: [email protected]] ACA: Anterior cerebral arteries CN: Cranial nerves Supplementary digital content available online. CSF: Cerebral spinal leakage Citation: World Neurosurg. (2016) 86:270-286. DI: Diabetes insipidus http://dx.doi.org/10.1016/j.wneu.2015.09.043 DS: Diaphgrama sellae Journal homepage: www.WORLDNEUROSURGERY.org GTR: Gross total resection Available online: www.sciencedirect.com ICA: Internal carotid arteries ª KPS: Karnofsky performance score 1878-8750/$ - see front matter 2016 Elsevier Inc. All rights reserved. 270 www.SCIENCEDIRECT.com WORLD NEUROSURGERY, http://dx.doi.org/10.1016/j.wneu.2015.09.043 ORIGINAL ARTICLE MARTIN M. MORTAZAVI ET AL. PLANUM SPHENOIDALE AND TUBERCULUM SELLAE MENINGIOMAS Twenty-five percent of all meningiomas consist of skull base osteotomy (1 patient). The 22 patients with small- to large-sized meningiomas. Suprasellar meningiomas account for 5%e10% of tumors (Table 2) underwent a frontotemporal craniotomy, orbital all meningiomas, a term first used by Cushing and Eisenhardt1 in osteotomy, and optic canal decompression in all cases with the 1929 to describe tumors arising from the tuberculum sellae. In exception of 2 who underwent an endoscopic approach and 1 who 1916, Cushing was the first to successfully resect such a tumor. underwent a fronto-temporal orbitozygomatic approach. Preoper- Following Cushing’s description, authors included meningiomas ative magnetic resonance imaging (MRI) was performed in all pa- of sellar and juxtasellar regions under the category of suprasellar tients to determine tumor location, size, and surrounding meningioma. With time, clearer terminology evolved, as most neurovascular structure involvement, as well as signs of brain in- neurosurgeons recognize the importance of anatomic origin in vasion. All patients received perioperative antibiotics, dexametha- surgical planning.2,3 Al-Mefty subclassified the term suprasellar sone, and mannitol. meningiomas to those arising from the planum sphenoidale (PS), MRI examination was done postoperatively as well in the tuberculum sellae (TS), diaphragma sellae (DS), and anterior cli- follow-up to assess the degree of resection. Computed tomogra- noid (AC) process. De Divitiis4,5 distinguished clinoidal menin- phy was performed instead of MRI if the patient could not have it giomas from other suprasellar meningiomas. for medical or financial reasons. Detailed histologic analysis of PS and TS meningiomas can extend into adjacent areas such as resected specimens was used to verify pathologic diagnosis and the DS, sella turcica, posterior clinoid, and superior wall of the grading of the meningioma. cavernous sinus. The sellar and juxtasellar regions are anatomi- Tumor size was obtained as the average of measurements in 3 cally complex and critical. Eloquent structures such as the optic dimensions in any plane on MRI, calculated by tumor equivalent nerves, internal carotid arteries (ICAs), anterior cerebral arteries diameter,7 d ¼ (D1 Â D2 Â D3)1/3. (ACA), cavernous sinuses, pituitary stalk, and hypothalamus sur- All statistical comparisons were performed by a statistician round the area. Complete meningioma resection including (JKB) on IBM SPSS version 19 (IBM Corp., Armonk, New York, vascular supply and the involved dura and bone may be difficult USA) using Fisher’s exact tests, t-tests, and Kaplan-Meier survival due to their intimate involvement with these nearby structures.6 estimation as appropriate. Moreover, closeness of the sphenoid sinus and a surgical corridor through the sinus also predisposes these patients to RESULTS postoperative cerebrospinal fluid (CSF) leak. In this study, we present our 10-year retrospective, single- Patient Population institutional experience with modern technique and its nuances Of the 27 patients, 20 (74%) were female and 7 (26%) were male. aimed at resecting PS and TS meningiomas operated by the same The female-to-male ratio was 2.85:1. The mean age was 55.40 years technique. The purposes of this study are to report the outcomes (range 28e81 years, SD 13.10). for modern skull base techniques for resecting this group of meningiomas and describe a classification system allowing com- Clinical Findings parison of different series and approaches that may also be pre- Visual disturbance was present in 21 (77%) patients, ranging from dictive of complication and outcome. slight decrease of vision and partial field cut to complete loss of vision. Other symptoms, in order of frequency, included seizure (5 patients, 16%), headache (4 patients, 15%), anosmia (2 patients, MATERIALS AND METHODS 7%), cognitive deficit (2 patient, 7%), diplopia (1 patient, 4%), and Approval to review patients’ data retrospectively was obtained dizziness, proptosis, and loss of balance (1 patient each, 4%) from the University of Washington Institutional Review Board. A (Table 3). Anosmia and cognitive defects were mainly present in retrospective analysis of all patients who underwent craniotomy tumors of giant sizes, extending into multiple regions, and in for resection of meningiomas involving the suprasellar region, tumors invading the brain. between 2005 and 2015 at the UW-Harborview Medical Center (HMC), Seattle, Washington, was performed. Radiologic Findings Twenty-seven consecutive patients with previously unoperated Preoperative MRI with and without contrast and magnetic reso- suprasellar meningiomas operated between 2005 and March 2015 nance angiography were used to determine tumor location, size, (by LNS and MJF) at HMC are included in the study. One had pre- and involvement of surrounding structures. These structures vious surgery at another institution from a large olfactory groove mainly included the ICA, ACA, optic canal and nerves, and sur- meningioma, resulting in blindness, and 10 years later she devel- rounding brain tissue. For tumors encasing the ICA and ACA, a oped an unrelated suprasellar meningioma and underwent an catheter intra-arterial digital subtraction angiogram was also endoscopic resection in our hospital. Overall, 2 patients underwent performed. an endonasal transphenoidal endoscopic tumor removal. There Tumors originated from both PS and TS in 10 (37%) patients, TS were 5 giant tumors that either extended into the PS/TS area from the in 5 (18.5%) patients, PS in 4 (15%) patients, PS and OG in 4 (15%) olfactory groove or the clinoidal area or from these expanded into patients, TS and AC in 1 (3.7%) patient, PS and AC in 1 (3.7%) the olfactory groove (Table 1). The resection approaches used for patient, TS and dorsum sellae in 1 (3.7%) patient, and TS and OG these giant tumors were frontotemporal with orbital
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