E n d o s c o p i c En d o n a s a l A p p ro a c h f o r Re m o v a l o f Tub e rc u l u m S e l l a e Meningiomas Leo F.S. Ditzel Filho, MDa, Daniel M. Prevedello, MDa,b,*, Ali O. Jamshidi, MDa, Ricardo L. Dolci, MDb, Edward E. Kerr, MDa, Raewyn Campbell, MDb, Bradley A. Otto, MDa,b, Ricardo L. Carrau, MDa,b KEYWORDS Endonasal Endoscopic Meningioma Skull base Tuberculum sellae
KEY POINTS
INTRODUCTION Tuberculum sellae meningiomas are challenging lesions; located in the suprasellar space, they can displace and distort the superjacent optic apparatus causing visual impairment, encase critical neurovascular structures, and promote hyperostosis and optic canal invasion.1 These features render their safe resection a daunting task. Historically, this has been accomplished through open transcranial approaches, especially the classic pterionaltranssylvian route2 or through more complex skull
base approaches, such as the cranio-orbito-zygomatic3 and its variants and even the fronto-basal interhemispheric technique.4 More recently, less invasive methods also have been proposed, including the lateral supraorbital5 and the “eyebrow” subfrontal6–8 craniotomies. Regardless of which technique is chosen, all transcranial routes require a certain degree of cerebral retraction; in some instances, even some manipulation of the optic apparatus is necessary for tumor removal, especially the component located underneath the chiasm and ipsilateral optic nerve, often demanding “blind”
a Department of Neurological Surgery, Wexner Medical Center, The Ohio State University, 410 West 10th Avenue, Columbus, OH 43210, USA; b Department of Otolaryngology – Head & Neck Surgery, Wexner Medical Center, The Ohio State University, 410 West 10th Avenue, Columbus, OH 43210, USA * Corresponding author. Department of Neurological Surgery, The Ohio State University Wexner Medical Center, 410 West 10th Avenue, N-1049 Doan Hall, Columbus, OH 43210. E-mail address: [email protected]
Neurosurg Clin N Am - (2015) -–http://dx.doi.org/10.1016/j.nec.2015.03.005 1042-3680/15/$ – see front matter Ó 2015 Elsevier Inc. All rights reserved.
neurosurgery.theclinics.com
Nearly all tuberculum sellae meningiomas are amenable to endonasal resection; lateral extension beyond the internal carotid arteries is the major limitation to resection. Vascular encasement or optic canal invasion increases the complexity of the surgery but is not a limitation of the approach. Potential advantages of the approach include the absence of neurovascular retraction or displacement, increased visibility underneath the optic apparatus, and removal of infiltrated hyperostotic bone. The main disadvantages include the risk for cerebrospinal fluid leakage, need for dedicated training and equipment, and steep learning curve. The endonasal approach for removal of tuberculum sellae meningiomas requires a wide transnasal corridor, with removal of the right middle turbinate, posterior ethmoidectomies, resection of the posterior third of the septum for creation of a single working cavity, and elevation of a pedicled nasoseptal flap.
2
Ditzel Filho et al curettage of that space. Furthermore, given the pattern of growth typical of these lesions, rising from the tuberculum arachnoid and projecting upward and posteriorly, the superior hypophyseal arteries are often displaced along with the tumor capsule and are thus directly in the surgeon’s angle of attack, demanding the dissection to take place within an even tighter window. The past decade witnessed several technological advances in skull base surgery, the most important of which arguably is the rise of endoscopic endonasal surgery.9–23 When applied to tuberculum sellae meningiomas,24 expanded endoscopic endonasal approaches (EEAs) seem to present several advantages: the need for cerebral retraction is obviated, given the ventral angle through which the surgeon tackles these lesions; because the optic apparatus is displaced superiorly and posteriorly, it is involved only in dissection at the end stages of surgery, during release of the tumor capsule from the optic nerves themselves, thus lowering the amount of optic manipulation. Moreover, because the superior hypophyseal arteries are also typically dislodged toward the optic chiasm, freeing them from the tumor capsule is also facilitated and takes place only at the end of tumor removal, with minimal handling. Based on these potential features, EEAs have become the workhorse for the authors in nearly all suprasellar tumors, meningiomatous or otherwise. Hence, herein we describe our current indications and contraindications, surgical technique and anatomy, as well as complication management and avoidance strategies for the endoscopic endonasal resection of tuberculum sellae meningiomas.
INDICATIONS/CONTRAINDICATIONS For indications and contraindications, see Table 1.
SURGICAL ANATOMY The surgical anatomy and spatial relations of the ventral skull base and the suprasellar space have been described in detail25–27; the main pertinent structures and landmarks are depicted in Fig. 1.
SURGICAL TECHNIQUE Preoperative Planning All patients submitted to endonasal resection of tuberculum sellae meningiomas undergo the following: Anesthesia evaluation with nasal swab and culture; if positive for methicillin-resistant Staphylococcus aureus (MRSA), the patient
is treated in the morning of surgery with a single nasal application of a povidone-iodine solution at 5% (3M, St. Paul, MN). Magnetic resonance imaging (MRI) of the brain and computed axial tomography (CT) scan, both thinly sliced (
KEY POINTS
INTRODUCTION Tuberculum sellae meningiomas are challenging lesions; located in the suprasellar space, they can displace and distort the superjacent optic apparatus causing visual impairment, encase critical neurovascular structures, and promote hyperostosis and optic canal invasion.1 These features render their safe resection a daunting task. Historically, this has been accomplished through open transcranial approaches, especially the classic pterionaltranssylvian route2 or through more complex skull
base approaches, such as the cranio-orbito-zygomatic3 and its variants and even the fronto-basal interhemispheric technique.4 More recently, less invasive methods also have been proposed, including the lateral supraorbital5 and the “eyebrow” subfrontal6–8 craniotomies. Regardless of which technique is chosen, all transcranial routes require a certain degree of cerebral retraction; in some instances, even some manipulation of the optic apparatus is necessary for tumor removal, especially the component located underneath the chiasm and ipsilateral optic nerve, often demanding “blind”
a Department of Neurological Surgery, Wexner Medical Center, The Ohio State University, 410 West 10th Avenue, Columbus, OH 43210, USA; b Department of Otolaryngology – Head & Neck Surgery, Wexner Medical Center, The Ohio State University, 410 West 10th Avenue, Columbus, OH 43210, USA * Corresponding author. Department of Neurological Surgery, The Ohio State University Wexner Medical Center, 410 West 10th Avenue, N-1049 Doan Hall, Columbus, OH 43210. E-mail address: [email protected]
Neurosurg Clin N Am - (2015) -–http://dx.doi.org/10.1016/j.nec.2015.03.005 1042-3680/15/$ – see front matter Ó 2015 Elsevier Inc. All rights reserved.
neurosurgery.theclinics.com
Nearly all tuberculum sellae meningiomas are amenable to endonasal resection; lateral extension beyond the internal carotid arteries is the major limitation to resection. Vascular encasement or optic canal invasion increases the complexity of the surgery but is not a limitation of the approach. Potential advantages of the approach include the absence of neurovascular retraction or displacement, increased visibility underneath the optic apparatus, and removal of infiltrated hyperostotic bone. The main disadvantages include the risk for cerebrospinal fluid leakage, need for dedicated training and equipment, and steep learning curve. The endonasal approach for removal of tuberculum sellae meningiomas requires a wide transnasal corridor, with removal of the right middle turbinate, posterior ethmoidectomies, resection of the posterior third of the septum for creation of a single working cavity, and elevation of a pedicled nasoseptal flap.
2
Ditzel Filho et al curettage of that space. Furthermore, given the pattern of growth typical of these lesions, rising from the tuberculum arachnoid and projecting upward and posteriorly, the superior hypophyseal arteries are often displaced along with the tumor capsule and are thus directly in the surgeon’s angle of attack, demanding the dissection to take place within an even tighter window. The past decade witnessed several technological advances in skull base surgery, the most important of which arguably is the rise of endoscopic endonasal surgery.9–23 When applied to tuberculum sellae meningiomas,24 expanded endoscopic endonasal approaches (EEAs) seem to present several advantages: the need for cerebral retraction is obviated, given the ventral angle through which the surgeon tackles these lesions; because the optic apparatus is displaced superiorly and posteriorly, it is involved only in dissection at the end stages of surgery, during release of the tumor capsule from the optic nerves themselves, thus lowering the amount of optic manipulation. Moreover, because the superior hypophyseal arteries are also typically dislodged toward the optic chiasm, freeing them from the tumor capsule is also facilitated and takes place only at the end of tumor removal, with minimal handling. Based on these potential features, EEAs have become the workhorse for the authors in nearly all suprasellar tumors, meningiomatous or otherwise. Hence, herein we describe our current indications and contraindications, surgical technique and anatomy, as well as complication management and avoidance strategies for the endoscopic endonasal resection of tuberculum sellae meningiomas.
INDICATIONS/CONTRAINDICATIONS For indications and contraindications, see Table 1.
SURGICAL ANATOMY The surgical anatomy and spatial relations of the ventral skull base and the suprasellar space have been described in detail25–27; the main pertinent structures and landmarks are depicted in Fig. 1.
SURGICAL TECHNIQUE Preoperative Planning All patients submitted to endonasal resection of tuberculum sellae meningiomas undergo the following: Anesthesia evaluation with nasal swab and culture; if positive for methicillin-resistant Staphylococcus aureus (MRSA), the patient
is treated in the morning of surgery with a single nasal application of a povidone-iodine solution at 5% (3M, St. Paul, MN). Magnetic resonance imaging (MRI) of the brain and computed axial tomography (CT) scan, both thinly sliced (
