October 07, 2015
I prefer to approach the small and medium size symptomatic tuberculum sella meningiomas via the transsphenoidal endoscopic approach. However, the transcranial route is very effective, and the use of such methodology will be described here. This is a 46-year-old female who presented with left-sided visual dysfunction and was diagnosed with a relatively moderate size tuberculum sella meningioma with a dural tail invading the sella. There is minimal amount of vascular encasement. This tumor is readily amenable through the transnasal endoscopic approach. A left sided frontotemporal craniotomy was used for exposure of the tuberculum. A relatively, minimal pterional craniotomy was elevated. The anterior limb of the Sylvian fissure was dissected. Here's the area of the tumor more anteriorly. The first step involves devascularization of the tumor along the midline of the tuberculum. Here is the optic nerve. Next the falciform ligament is dissected. An extradural clinoidectomy is also a reasonable option in this case. After the ipsilateral nerve is decompressed, it can be gently mobilized to remove the component of the tumor, medial to this nerve. The tumor frequently infiltrates the medial part of the optic foramen. This portion of the tumor is being gently pulled out of the foramen. The posterior capsule of the tumor is used as a landmark to find the contralateral optic nerve around the chiasm. Subsequently the contralateral optic nerve entering its corresponding foramina is also found and decompressed. You can see the tumor infiltrating the contralateral foramen medially to the nerve. Here's the contralateral carotid artery. Obviously the ophthalmic arteries should be protected. Here is the base of the tumor that is being disconnected along the poster tuberculum. The contralateral optic nerve is inspected and is thoroughly decompressed. The optical carotid space and triangle is used to remove the portion of a tumor in close proximity of the pituitary stalk, as evident here. This portion of the tumor within the sella is also mobilized out of the sella gently. The attachment of the base of the tumor to the dura of the tuberculum is generously coagulated. Note, the use of dynamic retraction. The optic foramen again, further decompressed. You can see the discoloration at the site of the compression of the nerve. Here's that decompression at the level of the falciform ligament, where the nerve was pinched leading to its symptoms. You can see the dura over the tuberculum was generously coagulated to minimize the risk of future recurrence. Post operative MRI reveals complete removal of the mass and this patient's vision improved after surgery. Thank you.
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