Objective: Tuberculum sellae and planum sphenoidale meningiomas (TSM, PSM) are rare anterior
skull base lesions, traditionally treated through various transcranial approaches.
Recently, the extended endoscopic endonasal approach (EEA) has become an alternative
for resection, offering early lesion devascularization and wide optic canals decompression,
while avoiding brain manipulation. We present a 13-year retrospective, double-institutional
experience using extended EEA approach, discussing the impact of tumor size, optic
canal involvement, vascular encasement, and tumor consistency on TSM and PSM resection.
Methods: This collaborative study analyzed patients, who underwent extended EEA surgery for
TSMs or PSMs removal between 2010 and 2022. Conducted by the Naples team at Division
of Neurosurgery, Università degli Studi di Napoli Federico II, Italy, and the Columbus
team at Department of Neurological Surgery, The Ohio State University Wexner Medical
Center, USA, the study evaluated demographic data, preoperative assessments, tumor
features, prior treatments, surgical results, complications, follow-up, and recurrence.
Meningiomas were also categorized using the Sekhar-Mortazavi classification.
Results: A total of 95 patients (71 with TSM and 24 with PSM) were included. Visual impairment
was the most common symptom at presentation, occurring in 83% (n:79) of patients.
Among those with TSMs, 62 patients had visual deficits, with 52 of them having optic
canal involvement. For PSMs, visual symptoms and headache were onset symptom in 20
patients, with optic canal involvement in 13. Based on the Sekhar-Mortazavi classification,
86 meningiomas were categorized into three classes. We enrolled 54 class I tumors,
31 class II, and 1 class III tumor. Gross-total resection (GTR) was achieved in 77.8%
(n:74) of cases, reaching 81.8% for class I tumors. GTR rates were inversely proportional
to tumor size, visual pathway involvement and vascular encasement. Moreover, fibrous
and fibro-elastic consistencies were strongly related to a lower rate of resection.
A decreasing trend in CSF leak was observed, from 32% in 2010 to 2014 to 10% in 2018
to 2022. Vision function improved in 75.9% (n:60) of patients. The overall rate of
endocrinological issues (SIADH/DI) was 4.2%.
Conclusion: The extended EEA is a secure and efficient method for removing TSMs and PSMs, preserving
vascularization of the optic apparatus while facilitating gross-total resection and
enhancing visual outcomes.
Extra-axial enhancing lesion arising from the tuberculum sellae and extending to the
planum sphenoidale, affecting the pituitary stalk (solid line), optic chiasm (asterisk),
and surrounding vasculature (dashed line).
Intraoperative image of a trans-sphenoidal transplanum/transtuberculum approach (yellow
line). TR, tubercular recess; ON, optic nerve; MOCR/LOCR, medial/lateral optic-chiasmatic
recess; ICA, internal carotid artery; FL, falciform ligament.
Intraoperative image of transplanum/transtuberculum approach. A 0° endoscopic view
during tumor dissection showing a clear plane between brain and tumor (asterisk),
facilitating GTR.
ICA, internal carotid artery; OC, optic chiasm; SHb, superior hypophyseal branches;
T, tumor; FL, frontal lobe; A1/A2, precommunicating and postcommunicating anterior
cerebral artery; ACoA, anterior communicating artery.
Intraoperative images of the reconstructive phase after transplanum/transtuberculum
approach. A) The fat is positioned across the dural breach and then B) covered with
Hadad flap. Dm: dura mater; F: fat pad; Pg: pituitary gland; C: clival indent; NSF:
naso-septal flap; P vascular pedicle.
