MENINGIOMA DE TUBÉRCULO SELAR: HÁ UMA ABORDAGEM CIRÚRGICA IDEAL?

Estevão, Iracema Araújo; Camporeze, Bruno; Matricardi, Giovanna; Silva Júnior, Pedro da; Gripp, Daniel A; Santiago, Natally M; Aguiar, Paulo Henrique Pires de

Iracema Araújo Estevão

Universidade de São Francisco, Faculdade de Medicina, Bragança Paulista, SP, Brasil.

Bruno Camporeze

Universidade de São Francisco, Faculdade de Medicina, Bragança Paulista, SP, Brasil.

Giovanna Matricardi

Pontifícia Universidade Católica de São Paulo, Departamento de Neurologia, Sorocaba, SP, Brasil.

Pedro da Silva Júnior

Hospital Santa Paulo, Divisão de Neurocirurgia, São Paulo, SP, Brasil.

Daniel A Gripp

Hospital Santa Paulo, Divisão de Neurocirurgia, São Paulo, SP, Brasil.

Natally M Santiago

Hospital Santa Paulo, Divisão de Neurocirurgia, São Paulo, SP, Brasil.

Paulo Henrique Pires de Aguiar

Pontifícia Universidade Católica de São Paulo, Departamento de Neurologia, Sorocaba, SP, Brasil.

Hospital Santa Paulo, Divisão de Neurocirurgia, São Paulo, SP, Brasil.

Hospital do Servidor Publico de São Paulo, Departamento de Neurocirurgia, São Paulo, SP, Brasil.

Universidade Federal do Rio Grande do Sul, Departamento de Cirurgia, Secção de Pós-Graduação em Cirurgia, Porto Alegre, RS, Brasil.

Hospital Oswaldo Cruz, Divisão de Neurocirurgia, São Paulo, SP, Brasil.

E-mail: iaestevao@gmail.com

CONFLICT OF INTEREST

Authors declare no conﬂict of interest concerning the materials discussed in this study.

AUTHOR PARTICIPATION

Paulo Henrique Pires de Aguiar contributed to the conception of the project, revised the manuscript, approved the completed manuscript and participate of all steps of study; Iracema Araújo Estevão and Bruno Camporeze performed the bibliographical research, analyzed the data and wrote the draft manuscript; Giovanna Matricardi, Pedro da Silva Júnior, Daniel A. Gripp and Natally M. Santiago collected the clinical data of participants and contributed to the conception of the project.

Figuras (4)
Tabelas (2)

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Figure 1
Anatomy of tuberculum sellae. A - The region of the tubercullum sellae comprises the space belonging to the sphenoid bone between the two anterior clinoids (red circle), limited posteriorly by the dorsum sellae, before the planum sphenoidale. The optical column and the optic canal on each side form the posterior lateral limit (black circles). B - CT angiography with 3D reconstruction shows the relationship between the arteries and the tubercullum sellae.

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Figure 2
A - Microsurgical vision of the frontotemporal approach of Tuberculum Sellae Meningioma by subfrontal access through the transsylvian fissure. B - Microsurgical vision, showing the tumor compressing the optic chiasm. C - Microscopic view of the dissection into the space between the optical nerve and the tumor using pterional access. D - Microscopic view shows the complete removal with preservation of the optic nerve and pituitary stalk.

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Figure 3
Three cases (CASE 1: panels A and B; CASE 2: - panels C and D; CASE 3 - panels E and F) of Tuberculum Sellae Meningioma operated in our neurosurgery service. Panel A: MRI of a 63-year-old male patient showing a tuberculum sellae meningioma after contrast. Panel B: same patient, CT scan, showing complete resection of tumor associated to an increase of ventricular dilation. Panel C: MRI T1 of a 62-year old female patient, complaining of preoperative visual impairment, showing (in sagittal section) an injury in tuberculum sellae and diaphragm with sellar invasion after contrast. Panel D: ame patient, postoperative MRI T1 in sagittal section shows complete resection, with residual intrasellar component. Panel E: preoperative MRI T1 in coronal section, with contrast, showing a tumor with suprasellar extension. Panel F: postoperative MRI in coronal section, showing the radical resection.

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Figure 4
Techniques in surgical approach of TSM. A - Patient positioned with bicoronal marked incision to perform bifrontal craniotomy. B - Inter-hemispheric access for tuberculum sellae meningioma approach. C - Patient positioning for frontotemporal approach. D - Pterional craniotomy.

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Table 1
Tumor size of the patients with visual impairment.

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Table 2
Advantages, disadvantages and indications of techniques in surgical approach of TSM.

Tumor Size	Visually impaired patients	Recovery number (5)
< 2 cm	4	3 (75%)
3 - 4 cm	10	4 (40%)
4 -5 cm	7	1 (14%)
5 - 6 cm	2	1 (50%)
> 6 cm	2	0 (0%)
Total	25

Techniques	Tumor Size	Advantages / Indications	Disadvantages
Bicoronal Subfrontal⁹9 Chokyu I, Goto T, Ishibashi K, Nagata T, Ohata K. Bilateral subfrontal approach for tuberculum sellae meningiomas in long-term postoperative visual outcome. J Neurosurg. 2011;115(4):802-10. DOI: 10.3171/2011.5.JNS101812. https://doi.org/10.3171/2011.5.JNS101812... ^,¹⁶16 Goel A, Muzumdar D, Desai KI. Tuberculum sellae meningioma: A report on management on the basis of a surgical experience with 70 patients. Neurosurgery. 2002;51(6):1358-64. DOI:10.1227/01.NEU.0000309111.78968.BC https://doi.org/10.1227/01.NEU.000030911... 17 Koutourousiou M, Fernandez-Miranda JC, Stefko ST. Endoscopic endonasal surgery for suprasellar meningiomas: experience with 75 patients. J Neurosurg. 2014;120:1326-39. DOI:10.3171/2014.2.JNS13767. https://doi.org/10.3171/2014.2.JNS13767... 18 Honegger J, Fahlbusch R, Buchfelder M, Huk WJ, Thierauf P. The role of transsphenoidal microsurgery in the management of sellar and parasellar meningioma. Surg Neurol. 1993;39(1):18-24.^-¹⁹19 Romani R, Laakso A, Kangasniemi M, Niemelä M, Hernesniemi J. Lateral supraorbital approach applied to tuberculum sellae meningiomas: experience with 52 consecutive patients. Neurosurg. 2012;70(6):1504-19. DOI:10.1227/NEU.0b013e31824a36e8 https://doi.org/10.1227/NEU.0b013e31824a... (Figure 4A)	> 2,5 cm	• Presence of bioptic canal involvement;	• Partial exposure of the tumor height;
	> 2,5 cm	• Wide surgical field	• The need of some degree of frontal lobe retraction for adequate tumor exposure;
Unilateral Subfrontal⁹9 Chokyu I, Goto T, Ishibashi K, Nagata T, Ohata K. Bilateral subfrontal approach for tuberculum sellae meningiomas in long-term postoperative visual outcome. J Neurosurg. 2011;115(4):802-10. DOI: 10.3171/2011.5.JNS101812. https://doi.org/10.3171/2011.5.JNS101812... ^,¹⁶16 Goel A, Muzumdar D, Desai KI. Tuberculum sellae meningioma: A report on management on the basis of a surgical experience with 70 patients. Neurosurgery. 2002;51(6):1358-64. DOI:10.1227/01.NEU.0000309111.78968.BC https://doi.org/10.1227/01.NEU.000030911... 17 Koutourousiou M, Fernandez-Miranda JC, Stefko ST. Endoscopic endonasal surgery for suprasellar meningiomas: experience with 75 patients. J Neurosurg. 2014;120:1326-39. DOI:10.3171/2014.2.JNS13767. https://doi.org/10.3171/2014.2.JNS13767... 18 Honegger J, Fahlbusch R, Buchfelder M, Huk WJ, Thierauf P. The role of transsphenoidal microsurgery in the management of sellar and parasellar meningioma. Surg Neurol. 1993;39(1):18-24.^-¹⁹19 Romani R, Laakso A, Kangasniemi M, Niemelä M, Hernesniemi J. Lateral supraorbital approach applied to tuberculum sellae meningiomas: experience with 52 consecutive patients. Neurosurg. 2012;70(6):1504-19. DOI:10.1227/NEU.0b013e31824a36e8 https://doi.org/10.1227/NEU.0b013e31824a... (Figure 2)	< 2,5 cm	• Minimally invasive technique for suprasellar meningiomas	• Limited surgical field;
	< 2,5 cm	• Minimally invasive technique for suprasellar meningiomas	• Partial exposure of the tumor height.
Pterional Transsylvian⁹9 Chokyu I, Goto T, Ishibashi K, Nagata T, Ohata K. Bilateral subfrontal approach for tuberculum sellae meningiomas in long-term postoperative visual outcome. J Neurosurg. 2011;115(4):802-10. DOI: 10.3171/2011.5.JNS101812. https://doi.org/10.3171/2011.5.JNS101812... ^,¹⁰10 Fahlbusch R, Schott W. Pterional surgery of meningiomas of the tuberculum sellae and planum sphenoidale: Surgical results with special consideration of ophthalmological and endocrinological outcomes. J Neurosurg, 2002;96(2):235-43. DOI:10.3171/jns.2002.96.2.0235 https://doi.org/10.3171/jns.2002.96.2.02... ^,¹³13 Margalit NS, Lesser JB, Moche J, Sen C. Meningiomas involving the optic nerve: Technical aspects and outcomes for a series of 50 patients. Neurosurgery. 2003;53(2):523-33. DOI: 10.1227/01.NEU.0000079506.75164.F4 https://doi.org/10.1227/01.NEU.000007950... ^,¹⁶16 Goel A, Muzumdar D, Desai KI. Tuberculum sellae meningioma: A report on management on the basis of a surgical experience with 70 patients. Neurosurgery. 2002;51(6):1358-64. DOI:10.1227/01.NEU.0000309111.78968.BC https://doi.org/10.1227/01.NEU.000030911... ^,¹⁷17 Koutourousiou M, Fernandez-Miranda JC, Stefko ST. Endoscopic endonasal surgery for suprasellar meningiomas: experience with 75 patients. J Neurosurg. 2014;120:1326-39. DOI:10.3171/2014.2.JNS13767. https://doi.org/10.3171/2014.2.JNS13767... ^,²¹21 Schick U, Hassler W. Surgical management of tuberculum sellaemeningiomas: involvement of the optic canal and visual outcome. J Neurol Neurosurg Psychiatry. 2005;76(7):977-83. DOI:10.1136/jnnp.2004.039974. https://doi.org/10.1136/jnnp.2004.039974... (Figures 4D)	Any size	• Early exposure of the ipsilateral supraclinoid carotid artery, optic nerve, and anterior cerebral artery;	• Inadequate visualization of optic nerve and carotid artery;
		• Absence or decreased need of brain retraction;	• Higher rates of visual deterioration;
		• Higher rates of gross total resection when compared with other techniques;	• High degree of difficulty in cases of invasion of the optic canal and intrasellar extension of the tumor
		• Presence of bioptic canal involvement
Anterior Interhemispheric¹³13 Margalit NS, Lesser JB, Moche J, Sen C. Meningiomas involving the optic nerve: Technical aspects and outcomes for a series of 50 patients. Neurosurgery. 2003;53(2):523-33. DOI: 10.1227/01.NEU.0000079506.75164.F4 https://doi.org/10.1227/01.NEU.000007950... ^,¹⁴14 Terasaka S, Asaoka K, Kobayashi H, Yamaguchi S. Anterior Interhemispheric approach for Tuberculum Sellae Meningioma. Neurosurgery. 2011 Mar;68(1 Suppl Operative):84-8. DOI:10.1227/NEU.0b013e31820781e1 https://doi.org/10.1227/NEU.0b013e318207... ^,¹⁷17 Koutourousiou M, Fernandez-Miranda JC, Stefko ST. Endoscopic endonasal surgery for suprasellar meningiomas: experience with 75 patients. J Neurosurg. 2014;120:1326-39. DOI:10.3171/2014.2.JNS13767. https://doi.org/10.3171/2014.2.JNS13767... ^,²⁰20 Ganna A, Dehdashti AR, Karabatsou K, Gentili F. Fonto-basal interhemispheric approach for tuberculum sellae meningiomas; long-term outcome. Br J Neurosurg. 2009;23(4):422-30. DOI:10.1080/02688690902968836 https://doi.org/10.1080/0268869090296883... ^,²¹21 Schick U, Hassler W. Surgical management of tuberculum sellaemeningiomas: involvement of the optic canal and visual outcome. J Neurol Neurosurg Psychiatry. 2005;76(7):977-83. DOI:10.1136/jnnp.2004.039974. https://doi.org/10.1136/jnnp.2004.039974... (Figure 4B)	Any size	• Wide surgical field;	• Long surgical duration;
		• Full exposure of the entire tumor height;	• Higher rates of anosmia and rhinoliquorrhea;
		• Visualization of the entire optic apparatus and surrounding structures, including the tuberculum sellae;	• Inadequate access to cases with significant extension into the optic canal;
		• Minimal or no frontal lobe retraction;	• Very difficult to perform an early unrousing of the optic canal, which is known to improve visual outcome.
		• Preservation of the optic and olfactory nerves;
		• Significant surgical results (higher than 80% of visual improvement) associated to absence or low rates of postoperative visual deterioration;
		• Higher rate of total excision;
		• Preservation of the subdural space;
		• In cases of tumor debulking without bleeding this approach is the most reliable method to preserve the arachnoid plane and the small vessels supplying the optic apparatus.
Extended Bifrontal⁹9 Chokyu I, Goto T, Ishibashi K, Nagata T, Ohata K. Bilateral subfrontal approach for tuberculum sellae meningiomas in long-term postoperative visual outcome. J Neurosurg. 2011;115(4):802-10. DOI: 10.3171/2011.5.JNS101812. https://doi.org/10.3171/2011.5.JNS101812... ^,¹⁶16 Goel A, Muzumdar D, Desai KI. Tuberculum sellae meningioma: A report on management on the basis of a surgical experience with 70 patients. Neurosurgery. 2002;51(6):1358-64. DOI:10.1227/01.NEU.0000309111.78968.BC https://doi.org/10.1227/01.NEU.000030911... 17 Koutourousiou M, Fernandez-Miranda JC, Stefko ST. Endoscopic endonasal surgery for suprasellar meningiomas: experience with 75 patients. J Neurosurg. 2014;120:1326-39. DOI:10.3171/2014.2.JNS13767. https://doi.org/10.3171/2014.2.JNS13767... 18 Honegger J, Fahlbusch R, Buchfelder M, Huk WJ, Thierauf P. The role of transsphenoidal microsurgery in the management of sellar and parasellar meningioma. Surg Neurol. 1993;39(1):18-24.^-¹⁹19 Romani R, Laakso A, Kangasniemi M, Niemelä M, Hernesniemi J. Lateral supraorbital approach applied to tuberculum sellae meningiomas: experience with 52 consecutive patients. Neurosurg. 2012;70(6):1504-19. DOI:10.1227/NEU.0b013e31824a36e8 https://doi.org/10.1227/NEU.0b013e31824a...	> 2,5 cm	• Wide surgical field;	• Requires some degree of frontal lobe retraction for adequate tumor exposure;
		• Flexibility of surgical trajectories;	• Significant potential loss of olfaction;
		• Avoidance of excessive brain retraction;	• High risk of occlusion of superior sagittal sinus leading to venous infarction;
		• Direct view of both optic nerves, internal carotid and anterior cerebral arteries.	• Difficulty in reaching the undersurface of the optic nerves or the intrasellar extension of the tumor.
Endonasal Approach⁹9 Chokyu I, Goto T, Ishibashi K, Nagata T, Ohata K. Bilateral subfrontal approach for tuberculum sellae meningiomas in long-term postoperative visual outcome. J Neurosurg. 2011;115(4):802-10. DOI: 10.3171/2011.5.JNS101812. https://doi.org/10.3171/2011.5.JNS101812... ^,²²22 Gadgil N, Thomas JG, Takashima M, Yoshor D. Endoscopic Resection of Tuberculum Sellae Meningiomas. J Neurol Surg B Skull Base. 2013;74(4):201-10. DOI:10.1055/s-0033-1342922. https://doi.org/10.1055/s-0033-1342922... 23 Ajlan AM, Choudhri O, Hwang P, Harsh G. Meningiomas of the Tuberculum and Diaphragma Sellae. J Neurol Surg B Skull Base. 2015;76(1):74-9. DOI:10.1055/s-0034-1390400. https://doi.org/10.1055/s-0034-1390400... 24 Clark AJ, Jahangiri A, Garcia RM, George JR, Sughrue ME, McDermott MW, et al. Endoscopic surgery for tuberculum sellae meningiomas: a systematic review and metaanalysis. Neurosurg Rev. 2013;36(3):349-59. DOI:10.1007/s10143-013-0458-x. https://doi.org/10.1007/s10143-013-0458-... ^-²⁵25 Nakamura M, Roser F, Struck M, Vorkapic P, Samii M. Tuberculum sellae meningiomas: clinical outcome considering different surgical approaches. Neurosurgery. 2006;59(5):1019-29. DOI:10.1227/01.NEU.0000245600.92322.06. https://doi.org/10.1227/01.NEU.000024560...	-	• Minimally invasive technique for suprasellar meningiomas;	• This approach is contraindicates in the presence of medial optic canal invasion;
		• Lower rates of complications	• Limited lateral extensional;
		• Lower rates of complications	• Lower rates of complete resection of tumor;
FTOZ¹⁷17 Koutourousiou M, Fernandez-Miranda JC, Stefko ST. Endoscopic endonasal surgery for suprasellar meningiomas: experience with 75 patients. J Neurosurg. 2014;120:1326-39. DOI:10.3171/2014.2.JNS13767. https://doi.org/10.3171/2014.2.JNS13767...	Any size	• Presence of bioptic canal involvement;	• Limited surgical field;
	Any size	• Presence of bioptic canal involvement;	• Partial exposure of the tumor height.

[1] E-mail: iaestevao@gmail.com

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MENINGIOMA DE TUBÉRCULO SELAR: HÁ UMA ABORDAGEM CIRÚRGICA IDEAL?

INTRODUÇÃO:

CASUÍSTICA E MÉTODOS:

RESULTADOS:

CONCLUSÃO: