Endoscopic Endonasal Approach for Resection of Diaphragma Sellae Meningiomas

Introduction: Diaphragma sellae meningiomas are a subset of suprasellar meningiomas originating from the dura of the diaphragma sellae as their name implies. Meningiomas in this location cause distortion of normal anatomy with potential displacement of the optic apparatus, pituitary stalk, and pituitary gland. Herein, we aim to present our experience in endoscopic endonasal surgery for resection of this uncommon entity.

Objectives: To describe the outcomes after endoscopic endonasal approach (EEA) for resection of diaphragma sellae meningioma.

Methods: We performed a retrospective review of all anterior cranial fossae meningiomas resected via EEA and identified those classified as meningiomas with invasion and/or growing from the diaphragma sellae between January 2000 and January 2023 in a single institution. Risk factors for recurrence were assessed using Kaplan–Meier and Cox survival analysis. Visual and pituitary function outcomes were analyzed.

Results: We identified 30 consecutive patients, 25 (83.3%) females and 5 (16.7%) males, mean age 62 years (37 to 78) who underwent EEA for resection of meningiomas growing/invading the diaphragma sellae in our institution. Fourteen (46.7%) patients had meningiomas arising purely from the diaphragma sellae, and 16 (53.3%) were described as diffusely invading the diaphragma in the postoperative report. Twenty-five (83.3%) patients presented as first-time diagnosis and 5 (16.7%) patients presented as recurrence after open craniotomy at a different institution. Bitemporal hemianopsia was the most common visual symptom on presentation in 13 (43.3%) patients, followed by unilateral optic neuropathy on the left (6 patients), and right (5 patients). Two patients presented with diplopia, and 4 (13.3%) patients had an incidental diagnosis after brain imaging was performed for unrelated reasons. The chiasma was most displaced superiorly in 17 (56.67%) patients, postero-superior in 8 (26.67%), and posteriorly in 5 (16.67%) patients. The stalk was most displaced posteriorly in 19 (63.3%) patients, neutral position in 10 (33.3%), and anteriorly in 1 (3.3%) patient. Only 1 patient presented with panhypopituitarism that persisted in the postoperative period. This patient had a meningioma arising from the posterior aspect of the diaphragma sellae and displaced the stalk anteriorly. All meningiomas were classified as WHO 1 with a mean Ki-67 of 3% (1–15). Gross total resection was achieved in 28 (93.3%) patients and subtotal resection in 2 (6.7%) patients. Twenty-one (70%) patients had improvement of their presenting visual symptoms, whereas 9 (30%) had no improvement. No patient developed new postoperative visual deficit. Three (10%) patients developed new permanent pituitary deficiency in the form of diabetes insipidus and 1 of them also had permanent adrenal insufficiency. With a mean follow up of 43 months (8–158), only 3 (10%) patients had recurrent tumors.

Conclusions: Our experience reinforces the viability and safety of the EEA for managing diaphragma sellae meningiomas, highlighting its potential advantages in preserving visual and pituitary function. Further studies can continue to refine surgical techniques and postoperative care to optimize outcomes for patients with this rare tumor location.