Journal of Clinical Neuroscience 16 (2009) 889–893
Contents lists available at ScienceDirect
Journal of Clinical Neuroscience journal homepage: www.elsevier.com/locate/jocn
Clinical Study
Extended endoscopic endonasal transsphenoidal removal of tuberculum sellae meningiomas: A preliminary report Qing Wang, Xiao-jie Lu *, Bing Li, Wei-yang Ji, Kai-lai Chen Department of Neurosurgery, Wuxi Second Hospital Affiliated Nanjing Medical University, 68 Zhong Shan Road, Wuxi 214002, Jiangsu Province, China
a r t i c l e
i n f o
Article history: Received 27 July 2008 Accepted 4 October 2008
Keywords: Endoscopy Extended endonasal approach Meningioma Transsphenoidal surgery Tuberculum sellae
a b s t r a c t In this present study, we reviewed our management of seven patients by an extended endoscopic endonasal transsphenoidal approach to resect tuberculum sellae meningiomas. All surgery was performed using pure endoscopy and a neuronavigation system. In six patients, total resection of the tumor was accomplished; one patient had subtotal tumor removal. Post-operatively, visual function was improved in six patients, and was unchanged in one patient. There was asymptomatic tumor recurrence on MRI during the follow-up period in the patient in whom a subtotal resection had been performed. This preliminary report suggests that an extended endoscopic endonasal transsphenoidal approach is an effective, minimally invasive approach for small and medium-sized tuberculum sellae meningiomas located in the midline. However, this approach should be limited to an experienced and coordinated endoneurosurgical team. Ó 2008 Elsevier Ltd. All rights reserved.
1. Introduction Tuberculum sellae meningiomas frequently arise from the tuberculum sellae, chiasmatic sulcus, planum sphenoidale, and diaphragma sellae and comprise 4–10% of all intracranial meningiomas.1,2 The most common presenting symptoms on admission include visual loss and headache. The standard techniques for resection of tuberculum sellae meningiomas include unilateral subfrontal, bifrontal, or frontotemopral approaches,1,3–5 although a transsphenoidal approach has been reported.6–9 However, these techniques may injure the frontal lobe, olfactory nerve, and optic nerve or provide limited surgical exposure.3–9 To overcome these obstacles, to improve visualization and minimize morbidity, the tuberculum sellae meningiomas have been resected using an extended endoscopic endonasal transsphenoidal approach.10,11 An obvious advantage of this approach over a transcranial one in removing tuberculum sellae meningiomas is that brain retraction is obviated, manipulation of the optic nerves and pituitary stalk is minimized, and the dura and bone involved by the tumor can be completely resected.12–14 So far there have been only few reports using an extended transsphenoidal approach with pure endoscopy: Jho15 reported on pure endoscopic endonasal surgery for sellar and suprasellar lesions and Cook6 used endoscopy to ascertain the extent and location of residual tumors and to help
* Corresponding author. Tel.: +86 510 82727501; fax: +86 510 82734243. E-mail address:
[email protected] (X.-j. Lu). 0967-5868/$ - see front matter Ó 2008 Elsevier Ltd. All rights reserved. doi:10.1016/j.jocn.2008.10.003
visualize structures during microsurgery for three tuberculum sellae meningiomas. We report on seven patients with tuberculum sellae meningiomas managed with an extended endoscopic endonasal transsphenoidal approach. We describe the surgical technique and review our experience. 2. Patients and methods Seven patients with tuberculum sellae meningiomas (5 females and 2 males, 27–67 years of age) were treated in the Neurosurgery Department at the Wuxi Second Hospital Affiliated Nanjing Medical University between February 2002 and August 2007 (Table 1). Six patients presented with unilateral visual acuity deterioration and two patients had bilateral visual acuity deterioration. Three patients presented with severely decreased visual acuity (>20/400). Visual field defects existed in five patients as follows: two patients had classic bitemporal hemianopsia, two patients had unilateral temporalanopia, and one patient had quadrantanopia. Two patients had normal visual fields as revealed by neuro-ophthalmologic testing. Only one patient had headaches. All patients had normal endocrine function and were otherwise neurologically intact. The operation was performed under general anesthesia with orotracheal intubation. We administered broad spectrum antibiotics prior to surgery, and harvested adipose tissue from the patient’s abdomen for post-surgical skull base reconstruction. The patients were placed in the supine position with moderate hyperextension
890
Q. Wang et al. / Journal of Clinical Neuroscience 16 (2009) 889–893
Table 1 Tumor characteristics and outcome for tuberculum sellae meningiomas Patient
Surgical complication
Age (years)
Sex
Presenting symptom
Size (cm)
Tumor resection
1 2 3 4 5 6 7
None None None None Transient DI None None
58 27 62 54 67 63 42
Female Female Male Female Female Male Female
R-VA deterioration VA deterioration R-VA deterioration L-VA deterioration VA deterioration L-VA deterioration HA
2.7 2.3 1.9 3 3 2.2 2.5 2 2 2.7 2 1.5 4 2.8 2 3.6 2.6 2.2 3 2.5 2
Total Total Total Total Subtotal Total Total
DI = diabetes insipidus; HA = headache; L = left; R = right; VA = visual acuity.
of the head, fixed in a Mayfield headrest. Neuronavigation was used in all patients. A reference arc with five infrared light-reflecting spheres was locked to the headholder and recognized by a twin infrared light-emitting and light-detecting camera placed in front of the operating surgeon. The spatial position of the skin marker was confirmed by a five-infrared light-reflecting sphere pointer, tracked by the camera group. A cross-shaped array of four-infrared light-reflecting spheres was tightly affixed to the endoscope so that it could be used as a pointer throughout the procedure. We used a rigid endoscope of 4 mm diameter, 18 cm length and 30° optics width (Karl Storz Endoscope, Tuttlingen, Germany). No nasal retractor was used. For surgical access and exposure, the approach to the sphenoid sinus was through both nasal cavities, but the superior turbinates and posterior end of the middle turbinates were not resected. Subsequently, a partial posterior septectomy was performed, exposing the sphenoid rostrum. This provided adequate bilateral exposure of the posterior nasal cavity and permitted the endoscope to be placed through one nostril while the operative instruments were placed through the other. An anterior sphenoidotomy involved wide bone exposure from the anterior surface of the sella to the medial portion of each cavernous sinus, followed by removal of the posterior portion (about 8–10 mm) of the planum sphenoidale. Removal of the planum sphenoidale was accomplished by thinning the bone with a high-speed drill, and then using a 2 mm footplate Kerrison rongeur to remove the remaining bone. The lateral limits to this exposure in the region of the tuberculum sella were the medial margins of the optic nerves as they entered the optic canal. The most medial portion of the superior segment of the intracavernous internal carotid artery (ICA) limited the lateral extent of the exposure in these patients. With the removal of the planum sphenoidale, tuberculum sellae, and anterior skull base, the base dura mater of the tumor was exposed and coagulated. The dura overlying the planum sphenoidale and tuberculum sellae was incised at the midline to reach the prechiasmatic cistern, providing access to the suprasellar cistern. The dura covering the anterior surface of the pituitary gland was also opened. The anterior and superior intercavernous portion of the circular sinus was divided and coagulated or filled with small pieces of gelfoam. With the dura mater opened via a low curvilinear incision, the tumor was exposed and the tumor in the center was freed until the capsule was mobile when countertraction was applied with suction. The remainder of the tumor dissection was performed under direct vision by using an angle endoscopic technique to separate the tumor margin from the adjacent vascular and neural structures. Further arachnoid attachments to the tumor laterally and superiorly along the optic nerves and optic chiasm were cut sharply with microscissors. Finally, the tumor was dissected from the pituitary stalk and from the interpeduncular cistern. Following dissection, the defect left by the dural opening was plugged with gelfoam or a graft of autologous abdominal fat that was held in place by a strut of the vomer. The reconstruction of the sella was used with collagen sponge, abdominal fat, nonabsorbable artificial dura, and tissue glue. A no.14 French Foley
balloon catheter was used in all patients to support the reconstruction, as described by Kassam.16 Nasal packing was not used. 3. Results A total of seven patients (five females and two males) had a mean age of 53.3 years, ranging from 27 to 67 years. The most common presenting symptoms were visual disturbances. Gross total tumor resection was achieved in six patients, and subtotal resection was performed in one patient, who had residual tumor in the left optic canal, and the dural attachment at the left optic canal was not removed. The average length of hospital stay was 4 days (range, 2–5 days). There were no significant post-operative complications, including no leaks of cerebrospinal fluid (CSF) or persistent diabetes insipidus (DI). One patient had transient DI post-operatively. There were no deaths in the peri-operative period. The visual acuity improved in five patients, remained unchanged in one patient, and did not deteriorate in any patient. The improvement in visual acuity occurred within the first postoperative week and continued to improve or remained stable during follow-up. Visual field deficits also improved in five patients after surgery. All seven patients were followed regularly by the neurosurgery service for periods from 6 months to 4 years (mean, 23 months). An MRI obtained 3 months after surgery in one patient showed a small subcentimeter area of enhancement in the left optic canal. This patient had a small asymptomatic tumor regrowth seen on MRI 15 months after surgery. 4. Illustrative case reports 4.1. Patient 4 This 54-year-old woman with a 2 month history of progressive visual loss was transferred to the Wuxi Second Hospital, where an MRI revealed a 2.7 cm 2 cm 1.5 cm suprasellar dural-based mass arising from the tuberculum sellae. An enhanced MRI revealed a homogeneously enhanced lesion centered on the tuberculum sellae and chiasmatic sulcus. The optic chiasm was elevated significantly by the mass, and the pituitary stalk was pushed posteriorly. She underwent an endoscopic extended endonasal transsphenoidal approach to debulk the tuberculum sellae meningioma. The patient’s post-operative course was uncomplicated, the mild bitemporal quadrantanopsia resolved and her vision normalized. She was discharged home on post-operative day 4. No residual tumor was detected on immediate post-operative MRI (Fig. 1). 4.2. Patient 7 A 42-year-old woman presented with a 2 month history of worsening headaches. An MRI obtained elsewhere showed a 3 cm lesion based on the tuberculum sellae that enhanced strongly after
Q. Wang et al. / Journal of Clinical Neuroscience 16 (2009) 889–893
891
Fig. 1. Patient 4, a 54-year-old woman with progressive visual loss secondary to tuberculum sellae meningioma. (A) T1-weighted sagittal MRI post gadolinium administration revealing a 2.7 cm 2 cm 1.5 cm homogeneously enhancing tumor with the epicenter at the tuberculum sellae. (B) T1-weighted coronal MRI showing the upward displacement of the optic apparatus and the tumor surrounding the carotid arteries. (C) T1-weighted axial MRI showing the tumor enveloping the anterior cerebral arteries. (D) Sagittal MRI 24 h post-surgery showing gross total resection. The infundibulum and pituitary stalk are preserved. (E) Coronal MRI 24 h post-surgery showing the resection bed and decompression of the optic chiasm. (F) Axial MRI 24 h post-surgery showing the suprasellar region devoid of tumor.
gadolinium administration. The lesion was removed via an endoscopic extended endonasal transsphenoidal approach with complete resection of the tumor. The intraoperative endoscopic exposure displayed the pituitary stalk, pituitary gland, optic nerve, and optic chiasm. MRI after 12 months of follow-up showed no evidence of recurrence. The patient’s headaches resolved post-operatively (Fig. 2). 5. Discussion Transnasal transsphenoidal microscopic surgery is a viable option for the management of tuberculum sellae meningiomas.6–9,17 Although this surgery carries minimal morbidity, it provides limited exposure, precluding the effective resection of many tumors. These obstacles can be avoid with the use of rigid endoscopes. With advances in sophisticated surgical instrumentation and evolution of neuronavigation, endoscopic techniques are used increasingly to manage complex skull base pathologies.6,14 The advantages of the approach include unparalleled visualization of key structures with the rigid endoscope and preservation of uninvolved structures. Superior cosmetic results are achieved by avoiding facial incisions. In this preliminary report, we successfully managed seven patients with tuberculum sellae meningiomas with minimal morbidity. The safety of endoscopic endonasal pituitary surgery is superior to that of the traditional microscopic approach. Furthermore, the length of hospital stay and the use of lumbar drainage and nasal packing are also reduced.5,6 Given the favorable track record of the endoscopic approach to the sella, it was therefore logical to approach the anterior skull base similarly.14,15 In 2001, Jho reported pure endoscopic endonasal surgery for a variety of sellar and suprasellar lesions,18 followed by a more recent cadaveric study and illustrative patient cases describing the same technique. When compared with the operative microscope, the use of the angled endoscope in the sellar area offers specific advantages.6,10,19,20
First, it provides excellent maneuverability and a magnified, comprehensive view of the surgical field. Second, an angled endoscope provides excellent visualization of the suprasellar structures beyond the relatively narrow field of view provided by the operating microscope, allowing access to and around the lateral aspect of the lesion. Third, and probably the most significant advantage of the endoscopic approach, it affords an expanded close-up visualization both in the transverse and vertical dimensions, from the sella to the foramen magnum. Also, in the post-operative period, the endoscope has a critical role in debridement and tumor surveillance. Finally, the endoscopic transsphenoidal approach obviates the need for sublabial incisions and septal displacement. Unlike pituitary adenomas, which are typically soft and easily removed with ring curettes and suction, tuberculum sellae meningiomas are often fibrous and rubbery.10,21 Consequently, these tumors require initial internal debulking by sharp dissection using straight and curved microscissors and grasping forceps. Tumor size seems to be an important limitation in performing safe complete resections.6,11,21 For large suprasellar meningiomas (P4 cm), a transcranial approach may still be required, although total tumor removal is often impossible because these tumors often adhere to key neural and vascular structures. Although many authors have described using the extended transsphenoidal route to remove relatively small suprasellar lesions, such as craniopharyngiomas and meningiomas, through a sublabial route,7,8,20,21 only Kaptain et al.20 and Kitano and Taneda21 have specified using a sublabial extended transsphenoidal approach to remove tuberculum sellae meningiomas. Kouri et al.22 were also challenged in their attempts to remove a tuberculum sellae meningioma measuring 3.5 cm in diameter. The difficulties encountered during resection are partly associated with the deep narrow working channel intrinsic to this approach, which is not a significant disadvantage when treating smaller lesions. Additionally, as with standard transsphenoidal surgery, there are significant limitations to the exposure of tumors with lateral extensions. Regarding endoscopic removal, Jho18 was
892
Q. Wang et al. / Journal of Clinical Neuroscience 16 (2009) 889–893
Fig. 2. Patient 7, a 42-year-old woman with headache secondary to a tuberculum sellae meningioma. (A) Pre-operative T1-weighted sagittal, (B) coronal and (C) axial MRI with gadolinium enhancement showing a 3 cm 2.5 cm 2 cm lesion above the tuberculum sellae, producing chiasm compression. An extended endoscopic transsphenoidal approach was performed, with removal of the bone of the tuberculum sellae. Complete resection of the tumor was achieved. (D–F) Post-operative T1-weighted MRI post gadolinium more than 2 years post-procedure showing no residual or recurrent lesions. (G) Intraoperative endoscopic panoramic view after resecting the tumor showing the sellae structures. L-ICA = left internal carotid artery; L-ON = left optic nerve; OC = optic chiasm; P-CP = posterior clinoid process; PG = pituitary gland; PS = pituitary stalk; RON = right optic nerve; S = suction; sis = superior intercavernous sinus.
able to completely remove anterior cranial fossa meningiomas from 7 of 9 patients using purely endoscopic endonasal surgery but did not describe the exact location or size of these meningiomas. In our series, two tumors measured >3.5 cm in diameter, but one tumor (4 cm in diameter) encased the main vascular structures and involved the left optic canal, and thus subtotal removal was performed. The other was dissected carefully from the pituitary stalk and the anterior communicating artery with a close-up view provided by the endoscope. One of the potential concerns of the endoscopic approach to tumors in this critical location is that of bleeding.23 Even for the most experienced endoscopist, significant bleeding may seriously compromise the safety and completeness of the resection. Tumors that involve the anterior cranial base often receive most of their blood supply from the anterior and posterior ethmoid arteries. A complete ethmoidectomy is first necessary to expose the roof of the ethmoid sinus. The anterior ethmoid artery crosses the skull base just posterior to the nasofrontal recess. The thin lamina papyracea of the medial orbital wall is fractured and removed up to the plane of the cranial base. Further elevation of the periosteum on the orbital side exposes the vessel where it leaves the orbit, and a hemoclip
can be placed. The posterior ethmoid artery is ligated in the roof of the posterior ethmoid air cells. The extended endonasal approach provides early exposure of the dural base, facilitating further devascularization in the case of anterior skull base lesions. Tuberculum sellae meningiomas often receive a blood supply from the dural base in addition to the ethmoid arteries. It is not uncommon in tuberculum sellae meningiomas to find an additional feeding artery arising from the distal portion of the paraclinoid carotid at the level of the opticocarotid recess. This vessel should be specifically identified and coagulated. Thus, the approach enables early devascularization of the tumor at its base and removal of the tumor without excessive bleeding. Care should be taken to prevent the anterior and superior intercavernous portion of the circular sinus from bleeding. Most bleeding can be controlled with use of topical oxymetazoline on cotton pledgets or bipolar cautery. Intraoperative bleeding precluding successful tumor removal was not encountered in this series. The most feared complication after surgical removal of tuberculum sellae meningiomas is post-operative CSF leak. Difficulty with effective and consistent reconstruction of the dura mater has hindered the extension of transsphenoidal approaches to regions be-
Q. Wang et al. / Journal of Clinical Neuroscience 16 (2009) 889–893
yond the paranasal sinuses.7,16,24 We repaired the skull base of all patients in this series using lightly packed gelfoam, a collagen sponge or abdominal fat, non-absorbable artificial dura, and tissue glue. In two patients we used a no. 14 French Foley balloon catheter.16 Fortunately, none of our patients developed a persistent post-operative CSF leak. One patient with a CSF leak, who also developed transient DI, showed recovery after 3 days of drainage. References 1. Arai H, Sato K, Okuda O, et al. Transcranial transsphenoidal approach for tuberculum sellae meningiomas. Acta Neurochir (Wien) 2000;142:751–7. 2. Bassiouni H, Asgari S, Stolke D. Tuberculum sellae meningiomas: functional outcome in a consecutive series treated microsurgically. Surg Neurol 2006;66:37–45. 3. Chi JH, McDermott MW. Tuberculum sellae meningiomas. Neurosurg Focus 2003;14:E6. 4. Benjamin V, Russell SM. The microsurgical nuances of resecting tuberculum sellae meningiomas. Neurosurgery 2005;56(Suppl. 2):411–7. 5. 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;96:235–43. 6. Cook SW, Smith Z, Kelly DF. Endonasal transsphenoidal removal of tuberculum sellae meningiomas: technical note. Neurosurgery 2004;55:239–46. 7. Frank G, Pasquini E, Mazzatenta D. Extended transsphenoidal approach. J Neurosurg 2001;95:917–8. 8. Kato T, Sawamura Y, Abe H, et al. Transsphenoidal–transtuberculum sellae approach for supradiaphragmatic tumors: technical note. Acta Neurochir(Wien) 1998;140:715–9. 9. Laws ER, Kanter AS, Jane Jr JA, et al. Extended transsphenoidal approach. J Neurosurg 2005;102:825–8.
893
10. Prevedello DM, Thomas A, Gardner P, et al. Endoscopic endonasal resection of a synchronous pituitary adenoma and a tuberculum sellae meningioma: technical case report. Neurosurgery 2007;60(Suppl. 2):E401. 11. de Divitiis E, Cavallo LM, Esposito F, et al. Extended endoscopic transsphenoidal approach for tuberculum sellae meningiomas. Neurosurgery 2007;61:229–38. 12. Cappabianca P, Cavallo LM, de Divitiis E. Endoscopic endonasal transsphenoidal surgery. Neurosurgery 2004;55:933–41. 13. Cappabianca P, de Divitiis E. Endoscopy and transsphenoidal surgery. Neurosurgery 2004;54:1043–50. 14. Kassam A, Snyderman CH, Mintz A, et al. Expanded endonasal approach: the rostrocaudal axis. Part I. Crista galli to the sella turcica. Neurosurg Focus 2005;19:E3. 15. Jho HD, Ha HG. Endoscopic endonasal skull base surgery: part 1–the midline anterior fossa skull base. Minim Invasive Neurosurg 2004;47:1–8. 16. Kassam A, Carrau RL, Snyderman CH, et al. Evolution of reconstructive techniques following endoscopic expanded endonasal approaches. Neurosurg Focus 2005;19:E8. 17. Dusick JR, Esposito F, Kelly DF, et al. The extended direct endonasal transsphenoidal approach for nonadenomatous suprasellar tumors. J Neurosurg 2005;102:832–41. 18. Jho HD. Endoscopic transsphenoidal surgery. J Neurooncol 2001;54:187–95. 19. de Divitiis E. Endoscopic transsphenoidal surgery: stone-in-the-pond effect. Neurosurgery 2006;59:512–20. 20. Kaptain GJ, Vincent DA, Sheehan JP, et al. Transsphenoidal approaches for the extracapsular resection of midline suprasellar and anterior cranial base lesions. Neurosurgery 2001;49:94–101. 21. Laufer I, Anand VK, Schwartz TH. Endoscopic, endonasal extended transsphenoidal, transplanum transtuberculum approach for resection of suprasellar lesions. J Neurosurg 2007;106:400–6. 22. Kouri JG, Chen MY, Watson JC, et al. Resection of suprasellar tumors by using a modified transsphenoidal approach. J Neurosurg 2000;92:1028–35. 23. Kassam A, Snyderman CH, Carrau RL, et al. Endoneurosurgical hemostasis techniques: lessons learned from 400 cases. Neurosurg Focus 2005;19:E7. 24. Snyderman CH, Kassam AB, Carrau R, et al. Endoscopic reconstruction of cranial base defects following endonasal skull base surgery. Skull Base 2007;17:73–8.
