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Surgical Management of Tuberculum Sellae and Planum Sphenoidale Meningiomas

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Surgical Management of Tuberculum Sellae and Planum Sphenoidale Meningiomas Romanian Neurosurgery (2013) XX 1: 92 – 99 92 DOI: 10.2478/v10282-012-0025-y Surgical management of tuberculum sellae and planum sphenoidale meningiomas Adrian Bălașa, Rareș Chinezu1, Dorin Nicolae Gherasim2 Neurosurgery Departement, Targu Mures Clinical Emergency Hospital 16th year neurosurgery resident 22nd year neurosurgery resident Abstract cases we chose a subfrontal approach. Introduction: Tuberculum sellae and Tumor has been further resected using planum sfenoidale meningiomas represent standard microsurgical techniques, total 5% to 10% of intracranial meningiomas and tumoral resection being the preoperative represent a subgroup of anterior skull base goal in all surgical interventions meningiomas. Approximately two thirds of Results: Out of the 18 cases operated, 13 patients complain of failing vision in one cases were of tuberculum sellae eye as the first symptom, and monocular meningiomas, while 5 cases were of planum blindness may be present in half of patients sphenoidale meningiomas. before surgery. Due to the constant All patients in the early decompression antomical relationship of these tumors with group (9 cases) have presented visual the optic nerves there is a classic improvement, whilst of the late presentation of these tumors represented by decompression group 5 cases (55,5%) the chiasmal syndrome. presented constant visual deficit, 2 cases Material and methods: In this study, we (22,25%) presented visual improvement have retrospectively analyzed 18 cases and 2 cases (22,25%) presented a decrease consecutively operated between 2006 and of the visual deficit. 2012 at the Targu Mures Neurosurgery The visual disturbances have improved Department. Considering the length of the in 11 cases (61.1%), in 5 cases (27,7%) the visual disturbances we have divided the visual deficit has remained constant, and in study group in two categories: early 2 cases (11,2%) the visual deficit has decompression with visual distubances worsened postoperatively. Conclusions: We expressed within at most 12 months prior consider that the optimal approach should to surgery, and late decompression with be based on tumor anatomy and surgeon visual disturbances of more than 1 year. experience and from this point of view Surgical technique: Sugical approach has frontolateral and pterional approaches been performed on the side with the most provide remarkable improvement visual deficit, and if visual deterioration was compared to the bifrontal approach. found to be approximative on both sides we Regardless of the selected surgical approach chose the right side for surgical approach. it is essential to avoid injury to the blood In all the patients, we have performed a supply of the optic apparatus.Endoscopy fronto-pterional craniotomy. In all the will have a role in skull base surgery with 93 Bălașa et al Surgical management of tuberculum sellae proper indications and well trained volume before diagnosis and treatment. surgeons. In this study we present our surgical Key words: tuberculum sellae, planum experience in the treatment of 18 patients sphenoidale, chiasmatic syndrome, sub- with tuberculum sella and planum frontal approach sfenoidale meningiomas using a subfrontal aproach. We have evaluated the visual Introduction deficit pre and postoperatively as well as the Tuberculum sellae and planum degree of resection. sphenoidale meningiomas represent 5% to 10% of intracranial meningiomas and Material and methods represent a subgroup of anterior skull base Clinical data meningiomas (10, 11, 19). In this study, we have retrospectively Tuberculum sellae meningiomas are analyzed 18 cases consecutively operated located not only on the limited surface between 2006 and 2012 at the Targu Mures between the prechiasmatic sulcus and and Neurosurgery Department. We have diaphragm sellae, but also on the limbus excluded from our study 3 cases initially sphenoidalis, chiasmatic sulcus and operated elsewhere and recidivated cases diaphragma sellae. Planum sphenoidale operated in this period. meningiomas are located more anterior and All the patients in the study group have in proximity of the olfactory groove been imagisticaly examined preoperatively location (4, 10). with CT and MRI studies. As described in The mean age at diagnosis is in the the literature, we considered tubercullum fourth decade, and women/men ratio sellae meningiomas the ones located on the affected by this patology is 3:1. Due to the small surface between the chiasmatic sulcus constant antomical relationship of these and diaphragma sellae. We classified as tumors with the optic nerves there is a planum sphenoidale meningiomas, the ones classic presentation of these tumors localised more anteriorly near to the represented by the chiasmal syndrome, a olfactory groove location. primary optic atrophy with bitemporal field We have determined the sizes of the defects in adult patients with a meningiomas by analyzing the preoperative radiologically normal sellae (18). MRI and calculating the largest tumoral In most patients visual loss has an diameter found. insidious onset, and the course is At one patient we have performed a progressive. It may, however, be acute or digital substraction cerebral angiography to fluctuating. Approximately two thirds of determine the patency of one of the internal patients complain of failing vision in one carotid arteries. No kind of embolization eye as the first symptom, and monocular has been attempted at any of the cases. blindness may be present in half of the The symptomatology of the patients at patients before surgery. admission is presented in Table 1, Preoperative signs of pituitary radiological findings being presented in involvement and failure are rare (12, 17). Table 2. Severe visual deficit was Because the visual loss is usually slowly considered the inability to count raised progressive, some tumors may reach a large fingers at an arm length distance. Romanian Neurosurgery (2013) XX 1: 92 – 99 94 DOI: 10.2478/v10282-012-0025-y TABLE 1 extended downwards in order to maximize Clinical findings the view of the orbital roof and reduce the Duration of visual deficit amount of traction. <3 months 1 Sugical approach has been performed on 3 months – 12 months 8 the side with the most visual deficit, and if 2 – 48 months 6 visual deterioration was found to be > 4 years 3 approximative on both sides we chose the Type of visual deficit right side for surgical approach. Unilateral partial visual deficit 2 In all the patients, we performed a Bilateral partial visual deficit 7 fronto-pterional craniotomy. Using Unilateral severe visual deficit 2 preoperative CT examinations, we tried not Severe visual deficit on one side with partial 3 to open the frontal aeric sinus, but this was visual deficit on the contralateral side not always possible. When opened, the Bilateral severe visual deficit 4 frontal aeric sinus was plugged with gelatin Other clinical symptoms sponge soaked in antibiotic (gentamicin) Personality changes 5 and homologous fatty tissue. Epileptic seizures 4 The dura mater was incised in Motor deficit 1 curvilinear fashion, with an inferior Other important comorbidities oriented pedicle. The basal cisterns were Hypertension 3 opened and CSF suctioned. In order to Obesity 6 further enhance the surgical field and to Type 2 diabetes 2 reduce the traction applied to the brain, the Sylvian fissure was opened in all the cases. TABLE 2 In all the cases we chose a subfrontal Radiological findings approach, the frontal lobe being gently Localization tractioned with the use of an autostatic Tuberculum sellae 13 retractor, whilst attempting to preserve the Planum sphenoidale 5 olfactive nerve. Internal carotid encasement 1 With the tumor expressed we proposed Involvement of the optic canal 4 that prior to the start of the tumoral Hydrocephalus (moderate) 2 resection an inspection and a blunt disection of the tumoral margins be Considering the length of the visual performed so that as many as possible of the disturbances we have divided the study key anatomical landmarks could be group in two categories: early identified as early as possible during surgery decompression with visual disturbances (Figure 1). expressed within at most 12 months prior Tumoral resection was started at the to surgery, and late decompression with level of the tumoral insertion on the dura visual disturbances of more than 1 year. mater, further dissection space being made Surgical technique via debulking of the tumor (Figure 2). All patients have been operated using Dissection of the tumor from the optic general gaseous anesthesia (Sevoflurane). nerves was performed using a combination Patients have been positioned in supine of blunt and sharp dissection position the head being fixed in a three-pin techniques.The optic nerve was not head holder, flexed to the side and gently resected in order to enhance the surgical 95 Bălașa et al Surgical management of tuberculum sellae field even in the 2 cases with complete visual loss. Optic nerve unroofing was performed in the cases with tumoral invasion of the optic canal. The tumor has been further resected using standard microsurgical techniques, total tumoral resection being the preoperative goal in all surgical interventions (Figure 3). After the resection of the meningioma the dural insertion was further coagulated in order to reduce the tumoral recurrence rate. Dura mater was sutured in a watertight fashion and the bone flap was repositioned Figure 3. Complete tumor removal with bilateral in all the cases. optic nerves decomprssion R.O.N right optic nerve, L.O.N left optic nerve ,R.F.L right frontal lobe, TU tumor, P.S. planum sphenoidale Results In this study we have included 18 patients with ages between 31 and 64 years old. We have observed greater prevalence in women – 13 cases versus 5 cases in men. Summarized results are found in Table 3. Out of the 18 cases operated, 13 cases were of tuberculum sellae meningiomas, while 5 cases were of planum sphenoidale meningiomas. Figure 1. Tumoral expression R.O.N right optic The average tumor size determined on nerve, R.F.L right frontal lobe, TU tumor the preoperative IRM scans was determined in our series to be of 2.4 cm.
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