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Table of Contents    
COMMENTARY
Year : 2021  |  Volume : 69  |  Issue : 3  |  Page : 636-637

Suprasellar Meningiomas: The Quest for an Ideal Minimally Invasive Surgical Approach


Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Raebareli Road, Lucknow, Uttar Pradesh, India

Date of Submission02-Jun-2021
Date of Decision02-Jun-2021
Date of Acceptance02-Jun-2021
Date of Web Publication24-Jun-2021

Correspondence Address:
Dr. Awadhesh Kumar Jaiswal
Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Raebareli Road, Lucknow - 226 014, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.319244

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How to cite this article:
Jaiswal AK, Das KK, Mehrotra A, Verma PK. Suprasellar Meningiomas: The Quest for an Ideal Minimally Invasive Surgical Approach. Neurol India 2021;69:636-7

How to cite this URL:
Jaiswal AK, Das KK, Mehrotra A, Verma PK. Suprasellar Meningiomas: The Quest for an Ideal Minimally Invasive Surgical Approach. Neurol India [serial online] 2021 [cited 2021 Jul 28];69:636-7. Available from: https://www.neurologyindia.com/text.asp?2021/69/3/636/319244




In this retrospective study, Gupta et al.,[1] presented a series of 12 cases of suprasellar meningioma (planum sphenoidal-9; tuberculum sella-3) operated by endonasal endoscopic approach (EEA). They achieved a gross total resection (GTR) in 11 (91.6%) cases. All patients had improvement in their vision with a resolution of the headache. No patient had postoperative cerebrospinal fluid (CSF) leak or any other major complication.[1]

Suprasellar meningiomas are conventionally managed by transcranial microscopic approach (TCA). Conventional TCAs include pterional, bifrontal, interhemispheric, transbasal, orbitozygomatic approaches. TCAs can address almost all types of suprasellar meningiomas irrespective of their size, vascular encasement, consistency and offer excellent rates of GTR. However, the disadvantages are a large skin incision, often a large craniotomy, requirement of brain retraction, postoperative seizures and other approach related morbidities.[2]

With the advancement in neuro-endoscopic techniques, EEA is being increasingly used to address these tumors. This approach offers certain distinct advantages such as direct access to tumor while avoiding the brain, an excellent tumor visualization, a panoramic view, an early devascularization of tumor with an oncologically more radical resection by dint of removal of the hyperostotic bone and involved dura. Also, the prospect of bilateral optic nerve decompression makes EEA ideal for these tumors with optic canal invasion. Genuinely speaking, EEA converts a suprasellar meningioma into a convexity meningioma. A combination of gravity and downward push by the swollen brain ensures a tumor removal with minimal manipulation of surrounding neurovascular structures.[2],[3]

Despite many of the aforementioned advantages, EEA is also associated with a few limitations, the most important one being a high postoperative CSF leak rate. With the use of vascularized nasoseptal flaps and meticulous dural reconstruction methods such as “gasket seal” and “bath plug” techniques, the CSF leak rates have markedly reduced. Other risks with this approach relate to vascular injury and anosmia. A thorough pre-operative radiological evaluation, gentle dissection of the tumor from the neurovascular structures and judicious handling of nasal mucosa goes a long way in avoiding these complications. Neuronavigation, neuromonitoring, microvascular doppler are important surgical adjuncts to ensure a safe surgical resection and should be used when available.

Needless to mention, an appropriate case selection is of paramount importance for ensuring a good surgical outcome in suprasellar meningiomas operated by EEA. Patients having small tumor size (<3 cm), no vascular encasement, no tumor extension lateral to the carotid or optic nerve and well pneumatized sphenoid sinus are excellent candidates for EEA. Moreover, a wide exposure offered by posterior septectomy, bilateral posterior ethmoidectomy, wide anterior sphenoidotomy, drilling of planum sphenoidale, tuberculum sellae, unroofing of the medial optic canal and medial optico-carotid recesses allows enough working space through this approach. Sellar floor and clival recess should also be exposed in order to facilitate instrument maneuverability. The tumor becomes almost avascular and soft after the dural attachment has been coagulated. Such a broad exposure offers excellent working space and facilitates a circumferential dissection around the tumor, once the centre of the tumors has been decompressed. Every effort should be made to preserve the arachnoid layer covering the tumor, a step which is perhaps the single most important principle in skull base meningioma surgery. In case of an accidental arachnoid breach, the suprasellar cistern gets communicated with the surgical path. Such arachnoid defects should be promptly recognized and the defect should be plugged with fat (bath plug technique) and a robust skull base reconstruction should be done by a multilayer closure technique including vascularized nasoseptal flap to avoid postoperative CSF leaks.

Recently, a third surgical alternative combining the conventional surgical technique with the concept of minimal bony opening has emerged in surgeries of these lesions. The supraorbital keyhole approach (SOKHA) represents one such approach and remains frequently used to address suprasellar meningioma.[4] This approach is performed either fully microscopic or fully endoscopic or using microscope and endoscope both. The use of an endoscope can increase the utility of this approach by reducing the so-called “blind corners”. It offers certain advantages like small skin incision, less tissue dissection, less brain retraction and less procedure related complications and most importantly minimal CSF leak rate. Besides, it can address large size tumor (>3 cm size) and tumor extending laterally to the carotids and optic nerve (Not amenable to EEA). Moreover, when SOKHA is used with an endoscope, it has additional advantages of excellent vision and panoramic view. The skin incision is also cosmetically acceptable. Also, the likelihood of preservation of olfaction makes this approach the first choice in patients with preserved preoperative olfaction. Recently, Ottenhausen et al.,[5] have presented an algorithmic approach to the anterior skull base meningiomas. The SOKHA, however, should be avoided in patients with large frontal sinuses. Other minimally invasive transcranial approaches applied for these tumors include a lateral supraorbital approach and a minipterional approach.[6] The latter two approaches provide an additional Transylvanian trajectory to the sub frontal trajectory of SOKHA.

In summary, suprasellar meningioma can be managed by TCA, EEA or a minimally invasive transcranial technique like SOKHA. The decision of surgical approach should be taken based on tumor size, vascular encasement, tumor extension, local surgical anatomy, surgeon's experience and surgeon's preference. Ideally, the neurosurgeon should be familiar and experienced with all the approaches and choose one approach based on individual patient's need.



 
  References Top

1.
Gupta PP, Shaikh ST, Deopujari CE, Shah NJ. Transnasal Endoscopic Surgery for Suprasellar Meningiomas. Neurol India 2021;69:630-5.  Back to cited text no. 1
  [Full text]  
2.
Bander ED, Singh H, Ogilvie CB, Cusuc RC, Pisapia DJ, Tsiouris AJ, et al. Endoscopic endonasal versus transcranial approach to tuberculum sellae and planum sphenoidale meningioma in a similar cohort of patients. J Neurosurg 2018;128:40-8.  Back to cited text no. 2
    
3.
Zoli M, Guaraldi F, Pasquini E, Frank G, Mazzatenta D. The endoscopic endonasal management of anterior skull base meningioma. J Neurol Surg B Skull Base 2018;79:S300-S310.  Back to cited text no. 3
    
4.
Linsler S, Fischer G, Skliarenko V, Stadie A, Oertel J. Endoscopic assisted supraorbital keyhole approach or endoscopic endonasal approach in case of tuberculum sellae meningioma: Which surgical route should be favoured? World Neurosurg 2017;104: 601-11.  Back to cited text no. 4
    
5.
Ottenhausen M, Rumalla K, Alalade AF, Nair P, La Corte E, Younus I, et al. Decision-making algorithm for minimally invasive approaches to anterior skull base meningiomas. Neurosurg Focus 2018;44, E7.  Back to cited text no. 5
    
6.
Park HH, Sung KS, Moon JH, Kim EH, Kim SH, Lee KS, et al. Lateral supraorbital versus pterional approach for parachiasmal meningiomas: surgical indications and esthetic benefits. Neurosurg Rev 2020;43:313-322.  Back to cited text no. 6
    




 

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