Elsevier

Surgical Neurology

Volume 72, Issue 2, August 2009, Pages 118-123
Surgical Neurology

Technique
High incidence of optic canal involvement in tuberculum sellae meningiomas: rationale for aggressive skull base approach

https://doi.org/10.1016/j.surneu.2008.08.007Get rights and content

Abstract

Background

Current literature on TSMs underemphasizes the significance of OCI by the tumor. In this study, we aimed to document the incidence of OCI, its management using a SBT, and its significance with relation to the visual outcome.

Methods

Thirty-one patients with TSM were retrospectively analyzed. In 28 patients, SBT consisting of extradural anterior clinoidectomy with falciform ligament and optic nerve sheath opening was performed. Pre- and postoperative visual status was analyzed with respect to OCI.

Results

The incidences of OCI and preoperative visual deficit (VD) were 77.4% and 83.8%, respectively. With regard to preoperative visual status, OCI incidence was 84.6% in 26 patients with VD compared to 40% in 5 patients without (P = .016).

Among the 23 patients with VD and detailed postoperative neuroopthalmologic evaluation, 78.3% had visual improvement; and in 21.7%, vision was unchanged on the operated side. In one patient (3.2% in the whole series), vision deteriorated on the side contralateral to the side of surgery. In the presence of OCI in 20 patients, vision improved in 80% and remained unchanged in 20%, whereas 1 of the 3 patients without OCI improved and the other 2 remained unchanged. Simpson grade I or II resection was achieved in 83.8%.

Conclusion

Optic canal involvement is very common in TSM (77.4%), and it correlates well with preoperative visual status. With the use of SBT, without which the tumor in the optic canal could not have been removed completely and safely, visual improvement of 78.3% and stability of 21.7% were achieved on the operated side.

Introduction

A significant number of patients with TSM present with visual deficits. Despite the improvement of microsurgical techniques and refinement of microsurgical tools, the incidence of postoperative visual deterioration, although improved over in time [9], is still seen in a considerable number of patients. The current literature on the surgical management of TSM underemphasizes the incidence of OCI. Various preoperative factors such as the duration and severity of the visual symptoms, presence of optic atrophy, and intraoperative factors such as the tumor size, displacement pattern of the critical neurovascular structures, as well as the extent of surgical resection have been analyzed with regard to the visual outcome. However, OCI of the tumor has been mentioned in only a handful of articles and without much detailed analysis with respect to visual outcome. Its incidence ranges from 8% to 100% in the reported series [3], [8], [10], [17], [22].

In this study, we aimed to document the incidence of OCI in our series of TSM and assess its significance with respect to the preoperative visual status. In addition, we report on our patients' surgical outcome using the SBT described below, with a subanalysis of the significance of OCI.

Section snippets

Methods

Between June 1994 and June 2006, 31 patients with TSM have been operated by the senior author at the Cleveland Clinic. In 28 of the 31 patients, the tumor was approached via the SBT consisting of a standard pterional craniotomy, posterolateral orbitotomy with superior orbital fissure decompression, extradural anterior clinoidectomy, and opening of the falciform ligament and the optic nerve sheath (ONS). The details of the technique are described elsewhere [14]. In 2 patients, bilateral approach

Results

Visual deficit was present in 26 patients (83.8%), and OCI was detected in 24 (77.4%) (Table 1). Presence of OCI was strongly correlated with preoperative visual deficit (correlation coefficient, 0.392; P = .016).

Anterior clinoid process hypertrophy was documented in 11 patients (35.5%): in 11 (42.3%)of 26 patients with visual deficit compared to none in 5 patients without (correlation coefficient, 0.325; P = .037). Presence of ACPH showed a strong correlation with OCI as well (correlation

The significance of the OCI

In our experience, most (77.4%) of TSMs had extension of the tumor into the optic canal. The incidence was significantly higher in patients who presented with preoperative visual deficit (84.6%) compared to those whose vision was intact (40%).

Optic canal involvement may be appreciated in preoperative MRI in only a small number of the patients (Fig. 1) and is not visible in most mainly because of technical factors such as the slice thickness of the MRI. Given this observation of 77.4% incidence

Conclusions

There is a high incidence of OCI in TSM, and this correlates very strongly with the preoperative visual status. Because the OCI can be appreciated only in a small group of patients in preoperative MRI, lack of direct exploration of the optic canal may result in missing the small tumor extension in most of the cases. This may result in (1) unimproved or deteriorated vision or (2) higher recurrence as grade I or II resection will not be achieved.

Our results on visual outcome using the SBT

References (25)

  • GrisoliF. et al.

    Microsurgical management of tuberculum sellae meningiomas. Results in 28 consecutive cases

    Surg Neurol

    (1986)
  • AndrewsB.T. et al.

    Suprasellar meningiomas: the effect of tumor location on postoperative visual outcome

    J Neurosurg

    (1988)
  • AraiH. et al.

    Transcranial transsphenoidal approach for tuberculum sellae meningiomas

    Acta Neurochir (Wien)

    (2000)
  • BassiouniH. et al.

    Tuberculum sellae meningiomas: functional outcome in a consecutive series treated microsurgically

    Surg Neurol

    (2006)
  • ChiJ.H. et al.

    Tuberculum sellae meningiomas

    Neurosurg Focus

    (2003)
  • DolencV.

    Direct microsurgical repair of intracavernous vascular lesions

    J Neurosurg

    (1983)
  • EvansJ.J. et al.

    Pre- versus post-anterior clinoidectomy measurements of the optic nerve, internal carotid artery, and opticocarotid triangle: a cadaveric morphometric study

    Neurosurgery

    (2000)
  • FahlbuschR. et al.

    Pterional surgery of meningiomas of the tuberculum sellae and planum sphenoidale: surgical results with special consideration of ophthalmological and endocrinological outcomes

    J Neurosurg

    (2002)
  • GoelA. et al.

    Tuberculum sellae meningioma: a report on management on the basis of a surgical experience with 70 patients

    Neurosurgery

    (2002)
  • GokalpH.Z. et al.

    Meningiomas of the tuberculum sella

    Neurosurg Rev

    (1993)
  • HasslerW. et al.

    Extradural and intradural microsurgical approaches to lesions of the optic canal and the superior orbital fissure

    Acta Neurochir (Wien)

    (1985)
  • JalloG.I. et al.

    Tuberculum sellae meningiomas: microsurgical anatomy and surgical technique

    Neurosurgery

    (2002)
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