Unilateral Subfrontal Approach for Giant Tuberculum Sellae Meningioma: Single Center Experience and Review of the Literature

Abstract

BackgroundMicrosurgical Transcranial approach (mTCA) is the primary choice for the resection of giant Tuberculum Sellae Meningiomas (TSM). The objective of this study is to explore surgical details of unilateral subfrontal approach.MethodsTen patients with giant TSM treated by unilateral subfrontal approach were included from January 2018 to June 2021. Demographic characteristics, surgical data, post-procedure complications and outcomes of patients have been descriptive analyzed, combined with systematic literature review to explore the surgical details and the prognosis of unilateral subfrontal approach.ResultsTen patients include six male and four females, age range from 35 to 77 years, duration of visual impairment from 1 to 12 months, were all performed unilateral subfrontal approach. Nine patients achieved radical resection (Simpson grades I-II) through post-operative imaging confirmation, and Simpson IV resection was performed in the remaining one due to cavernous sinus invasion. The postoperative visual acuity was improved or maintained in 8 patients. Visual acuity decreased in 2 cases, including 1 case of optic nerve atrophy and the other case of optic canal not opening. Five cases with frontal sinus opened were repaired during the operation and there was no postoperative cerebrospinal fluid leakage or intracranial infection. One patient suffered from postoperative anosmia, one patient developed left limb weakness, but their symptoms have improved in the follow-up.ConclusionSummarize the experience of our center and previous literature, unilateral forehead bottom craniotomy is a feasible surgical approach for giant tuberculum sellae meningioma. Intraoperative application of EC glue and pedicled fascia flap to repair the frontal sinus can prevent complications associated with frontal sinus opening. Optic canal unroofing has huge advantage in visual improvement.

Midline Skull Base Meningiomas: Transcranial and Endonasal Perspectives

“…Contrariwise, unilateral frontal and orbitofrontal craniotomies exploit a subfrontal route, avoiding the downsides related to superior sagittal sinus ligation and bilateral frontal lobe retraction [ 69 ]. Moreover, the supraorbital keyhole approach, either purely microsurgical or endoscope-assisted, spares frontal sinus opening, further helping in reducing CSF leak rate [ 70 , 71 , 72 ].…”

“…Anterolateral corridors harbor several advantages: (i) the possibility of harnessing both subfrontal and transsylvian routes; (ii) frontal sinus sparing; (iii) early visualization and access to the optic chiasm and ipsi/contralateral crucial neurovascular structures; (iv) the early opening of arachnoid cisterns and brain relaxation; (v) a low rate of cerebral edema [ 69 ].…”

“…Contrariwise, some series reported an inadequate control of tumor extending in the ipsilateral optic canal and inferior surface of the chiasm, triggering post-operative visual deterioration, which is a major con [ 60 , 67 , 69 , 84 ].…”

Keyhole supraorbital eyebrow approach for fully endoscopic resection of tuberculum sellae meningioma

“…TSM accounts for 5%–10% of all meningiomas ( 14 – 16 ). These tumors originate from the planum sphenoidale, optic sulcus, and sphenoid margin and can extend to nearby areas, such as the sphenoid plateau, saddle area, posterior clinoid process, and cavernous sinus ( 16 ).…”

“…TSM accounts for 5%–10% of all meningiomas ( 14 – 16 ). These tumors originate from the planum sphenoidale, optic sulcus, and sphenoid margin and can extend to nearby areas, such as the sphenoid plateau, saddle area, posterior clinoid process, and cavernous sinus ( 16 ). Owing to the complex anatomical structure of this region, which includes important blood vessels and nerves (optic nerve, optic chiasm, internal carotid artery, anterior cerebral artery complex, cavernous sinus, pituitary stalk, etc.…”