Roman BOSNJAK: Small tuberculum sellae meningioma - endonasal endoscopic removal. A video slide show and bonus video (2 cases in one video)

This presentation includes 2 cases of transplanum transtubercle transsellar approach, used for endonasal endoscope-controlled removal of small to moderate sized tuberculum sellae meningiomas. The importance of arachnoid-meningioma dissection plane emphasized: case 1 (2023; slides only) with well preserved arachnoid and case 2 (2012; video) with invaded and absent arachnoid.

Presentation includes detailed close-view of anatomical details of suprasellar region. Preserved arachnoid plane makes dissection easier and safer. Arachnoid protects microvasculature to anterior optic apparatus, to stalk and optic nerves and chiasm and results in better outcome. At the end of slide show, there is a bonus video of another opposite early case from 2012, where arachnoid was invaded and dissection of meningioma from the flattened optic nerves and chiasm and preservation of chiasmatic vasculature was more challenging and difficult (resulted in new bitemporal hemianopsia). Opening of the dural sleeve of optic nerve and it relation to distal dural ring is shown. The dural attachment of TBS meningioma (the outgrowth point), tipically from tuberculum sellae dura medial to optic nerve, was excised (no recidiv till today - after 14 years). The evolution of surgical technique is also obvious. Debulking first is always recommended and would ease removal.

Suggested literature

BOŠNJAK, Roman. Endoscopic endonasal excision of meningiomas. In: DEOPUJARI, Chandrashekhar (ur.), QURESHI, Mahmood (ur.), THOMBRE, Bhushan (ur.). WFNS guide for neuroendoscopy. Mumbai: Salubris Medical Publishers, 2022. Str. 113-124, ilustr. ISBN 978-81-956012-2-6. [COBISS.SI-ID 203555587]
Link: www.neurosurgery-prof-bosnjak.com (see Publications)

Khan OH, Krischek B, Holliman D, et al. Pure endoscopic expanded endonasal approach for olfactory groove and tuberculum sellae meningiomas. J Clin Neurosci. 2014;21:927-933

Magill ST, Morshed RA, Lucas CG, Aghi MK, Theodosopoulos PV, Berger MS, de Divitiis O et al. Tuberculum sellae meningiomas: grading scale to assess surgical outcomes using the transcranial versus transsphenoidal approach. Neurosurg Focus. 2018 Apr;44(4):E9. doi: 10.3171/2018.1.FOCUS17753.

Giammattei L , Starnoni D , Cossu G, Bruneau M, Cavallo LM, Cappabianca P et al. Surgical management of tuberculum sellae meningiomas: Myths, facts, and controversies. Acta Neurochir (Wien) 2020 Mar;162(3):631-640. doi: 10.1007/s00701-019-04114-w.

Khan OH, Anand VK, Schwartz TH. Endoscopic endonasal resection of skull base meningiomas: the significance of a "cortical cuff" and brain edema compared with careful case selection and surgical experience in predicting morbidity and extent of resection. Neurosurg Focus 2014;37(4):E7. doi: 10.3171/2014.7.FOCUS14321.

Kong, D.-S., Hong, C.-K., Hong, S. D., Nam, D.-H., Lee, J.-I., Seol, H. J., … Kim, Y. H. (2018). Selection of endoscopic or transcranial surgery for tuberculum sellae meningiomas according to specific anatomical features: a retrospective multicenter analysis (KOSEN-002). J Neurosurg 2018 May 18;130(3):838-847, doi:10.3171/2017.11.jns171337

Wang EW, Zanation AM, Gardner PA, Schwartz TH, Eloy JA, Adappa ND, et al. ICAR: endoscopic skull base surgery. Int Forum Allergy Rhinol. 2019 Jul;9(S3):S145-S365. doi: 10.1002/alr.22326.

Xiao L, Xie S, Tang B, Hu J, Hong T. Endoscopic endonasal anterior clinoidectomy: surgical anatomy, technique nuance, and case series. J Neurosurg. 2019 Jul 5:1-11. doi: 10.3171/2019.4.JNS183213. Online ahead of print.