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