Tuberculum Sella Meningioma: Transcranial Corridor

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Small tuberculum sella meningiomas are ideal candidates for the endoscopic transnasal approach. However, some colleges prefer the transcranial pterional approach and I'm going to review the endonasal technique for the transcranial approach here. This is a 44 year old female with chiasmal syndrome and my evaluation reveal the small tuberculum sella meningioma. Again, centered over the tuberculum. Evidence of her endonasal tumor into sella turcica and some infiltration of the tumor along the medial aspect of the optic canal bilaterally. Again, you can see on this coronal enhanced MRI, the location of the optic nerve in the proximal optic canal as well as the location of the tumor medial to the canal causing compression of the nerve. Tumor infiltration is worse on the left rather than on the right. I prefer to approach this tumor from the right side, because the exposure of the medial part of the nerve on the left is more readily available via a right sided pterional craniotomy. Let's go ahead and review the intraoperative events in this case. Here's a right front temple craniotomy, Sylvian fissure. Optical carotid cisterns are opened early to achieve brain relaxation. The interior limb of the Sylvian fissure is carefully dissected. Here's the carotid artery at the level of the skull base optic nerve and tumor based at the level of the tuberculum. The tumor is first devascularized at it's base along the midline to avoid any injury to the contralateral or ipsilateral optic nerves. Here's tumor devascularization. Irrigation is used to avoid thermal injury. The base of this small tumor is very limited. After the tumor is devascularized, the part of the tumor herniating into the sella is also mobilized. You can see the tail of the tumor into the optic canal. That was just mobilized. Let's go ahead and review this part of the video one more time. Just to emphasize the importance of this maneuver. You can see this medial part of the nerve. That was decompressed. Here you can see the part of the tumor infiltrating the medial aspect of the ipsilateral nerve is also removed. Here's the portion of the tumor going into the sella. Tumor is almost completely disconnected at space. And the small tumor is readily extracted. Further inspection of the operative blind spots is carried out using ring curettes. Fast form ligaments are opened on both optic nerves to assure further decompression of the nerves. Inspection of the medial part of the optic nerve and the canal is preformed. The dura over the base of the tumor is heavily coagulated to minimize the risk of future recurrence. Post operative MRI demonstrated complete removal of the mass. Including the portion of the tumor herniating into the sella. There is no tumor along the medial aspect of the optic canals and this patient's vision improved significantly after the surgery. Thank you.

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