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suprasellar_meningioma

Suprasellar meningioma

Classification

Suprasellar meningiomas can be classified as tubercular, combined, or diaphragmatic based on preoperative MRI.

Exclusively tubercular meningiomas (type A) require only a supradiaphragmatic approach.

Tumor involvement of the sellar diaphragm (type B or C) requires resection of the diaphragm and thus a combined infra- and supradiaphragmatic approach 1).

Liu divided it into

Group A - planum sphenoidale meningioma

Group B - tuberculum sellae meningioma

Group C -diaphragma sellae meningioma (DSM), based on their growth pattern in relation to the optic pathway and pituitary stalk, group C was then divided into groups C1 and C2 2).

For Suri et al. the anterior clinoid process, and sphenoidal planum, account for about 5% to 10% of intracranial meningiomas 3).

The tumour is located in the midline at the base of the skull and originates in the sella 4).

Clinical features

Its clinical manifestations are mainly monocular or binocular hypopsia and bitemporal hemianopsia, optic atrophy without papilloedema, and smell and mental disorders. However, some patients exhibit endocrine disorders 5). The most common symptoms are visual disturbance (58 %), headache (16 %) and incidental finding (12 %). The mean duration of symptoms was 13 months. Hyperprolactinemia was found in 36 %, with mean value of 51.6 ng/ml (median 41.8, range 22.5-132). 6).

Diagnosis

Mean maximal diameter was 2.9 cm (median 2.7, range 0.9-6.8), and most tumors enhanced homogeneously on MRI after gadolinium. A dural tail sign was reported in a third. The radiologist reported “likely meningioma” in 65 %, “possible meningioma” in 8.7 %, and pituitary adenoma in 11 %. The diagnosis is suggested by the radiologist in approximately 2/3 of the cases. An improved method to differentiate preoperatively these tumors from adenomas would be desirable 7).

Treatment

The endonasal endoscopic transtuberculum transplanum approach is a safe and effective minimal access approach to midline pathology in the suprasellar cistern 8).

With the goal of gross-total tumor resection and visual improvement, endoscopic endonasal surgery (EES) can achieve very good results, (comparable to microscopic approaches) for the treatment of suprasellar meningiomas. Avoidance of brain and optic nerve retraction, preservation of the vascularization of the optic apparatus, and wide decompression of the optic canals are the main advantages of EES for the treatment of suprasellar meningiomas, while cerebrospinal fluid leakage remain a disadvantage 9).

Once the learning curve is overcome, endonasal endoscopic resection of suprasellar meningiomas can achieve high rates of gross total resection (GTR) with low complication rates in well-selected cases 10).

Interhemispheric approach

The small bone window interhemispheric approach can be used to expose tumours, lightly stretch brain tissues, reduce the incidence of complications, and improve the total resection rate of tumours of patients with sellae meningiomas growing forward, upward, and into the sella 11).

Outcome

After surgery, visual disturbances improved in most patients (80 %) but headache only in 7 %. Post-operative complications at 1 and 3 months occurred 38.6 and 33.3 % respectively. There was no mortality. Sellar/suprasellar meningiomas represent 4 % of all meningiomas, and have a particularly high female predominance. 12).

1)
Ajlan AM, Choudhri O, Hwang P, Harsh G. Meningiomas of the tuberculum and diaphragma sellae. J Neurol Surg B Skull Base. 2015 Feb;76(1):74-9. doi: 10.1055/s-0034-1390400. Epub 2014 Sep 29. PubMed PMID: 25685653; PubMed Central PMCID: PMC4318732.
2)
Liu Y, Chotai S, Ming C, Jin S, Pan J, Qi S. Characteristics of midline suprasellar meningiomas based on their origin and growth pattern. Clin Neurol Neurosurg. 2014 Oct;125:173-81. doi: 10.1016/j.clineuro.2014.08.002. Epub 2014 Aug 10. PubMed PMID: 25171391.
3)
Suri A, Narang KS, Sharma BS, Mahapatra AK. Visual outcome after surgery in patients with suprasellar tumors and preoperative blindness. J Neurosurg. 2008;108:19–25.
4)
Dehdashti AR, Ganna A, Witterick I, Gentili F. Expanded endoscopic endonasal approach for anterior cranial base and suprasellar lesions: indications and limitations. Neurosurgery. 2009;64:677–87.
5)
Ceylan S, Koc K, Anik I. Extended endoscopic approaches for midline skull-base lesions. Neurosurg Rev. 2009;32:309–19.
6) , 7) , 12)
Kwancharoen R, Blitz AM, Tavares F, Caturegli P, Gallia GL, Salvatori R. Clinical features of sellar and suprasellar meningiomas. Pituitary. 2013 Aug 22. [Epub ahead of print] PubMed PMID: 23975080.
8)
Mascarenhas L, Moshel YA, Bayad F, Szentirmai O, Salek AA, Leng LZ, Hofstetter CP, Placantonakis DG, Tsiouris AJ, Anand VK, Schwartz TH. The Transplanum Transtuberculum Approaches for Suprasellar and Sellar-Suprasellar Lesions: Avoidance of Cerebrospinal Fluid Leak and Lessons Learned. World Neurosurg. 2013 Feb 9. pii: S1878-8750(13)00297-0. doi: 10.1016/j.wneu.2013.02.032. [Epub ahead of print] Review. PubMed PMID: 23403355.
9)
Koutourousiou M, Fernandez-Miranda JC, Stefko ST, Wang EW, Snyderman CH, Gardner PA. Endoscopic endonasal surgery for suprasellar meningiomas: experience with 75 patients. J Neurosurg. 2014 Jun;120(6):1326-39. doi: 10.3171/2014.2.JNS13767. Epub 2014 Mar 28. PubMed PMID: 24678782.
10)
Ottenhausen M, Banu M, Placantonakis DG, Tsiouris AJ, Khan OH, Anand VK, Schwartz TH. Endoscopic Endonasal Resection of Suprasellar Meningiomas: The Importance of Case Selection and Experience in Determining Extent of Resection, Visual improvement and Complications. World Neurosurg. 2014 Mar 19. pii: S1878-8750(14)00280-0. doi: 10.1016/j.wneu.2014.03.032. [Epub ahead of print] Review. PubMed PMID: 24657254.
11)
Lu ZF, Cheng XB, Zhao YG, Shi BZ. Twenty-nine cases of resection of suprasellar meningioma through small bone window: an interhemispheric approach. Contemp Oncol (Pozn). 2013;17(6):525-9. doi: 10.5114/wo.2013.38913. Epub 2013 Dec 19. PubMed PMID: 24592141; PubMed Central PMCID: PMC3934039.
suprasellar_meningioma.txt · Last modified: 2016/08/09 12:37 (external edit)