A Systematic Review of Transcranial versus Endoscopic Endonasal Approach for Suprasellar Meningiomas

Background: Suprasellar meningiomas, inclusive of both tuberculum sellae and planum meningiomas, represent a unique treatment challenge. They often present with visual disturbances and endocrine dysfunction due to compression of the optic apparatus and pituitary stalk/gland, respectively. Before the advent of the endoscopic endonasal approach (EEA), these tumors were primarily treated with transcranial approaches (TCA). Prior studies suggest that EEAs are associated with better visual outcomes and fewer complications in exchange for an increased risk of subtotal resection (STR) and cerebrospinal fluid (CSF) leak.

Objective: To systematically review and compare literature analyzing outcomes for suprasellar meningioma resections via TCA versus EEA.

Methods: The literature was systematically reviewed using PubMed via PubMed.gov, Embase via Ambase.com, Cochrane Library via Wiley, and clinicaltrials.gov with standard search criteria (2014–2020). All studies which included at least five patients undergoing TCA and/or EEA for suprasellar meningiomas with reported outcomes were included. Data for vision changes, rates of gross-total resection (GTR), CSF leaks, complications, and recurrences were compared between groups. Chi-square analysis was performed with SPSS Statistics, version 26 (IBM corporation, Armonk, NY).

Results: A total of 645 studies were captured after removing duplicates; 502 of these were excluded after title and abstract review, and a further 101 were excluded upon full-text review. A total of 27 studies were included in this study, comprising 573 TCA and 451 EEA patients; 9 included studies compared EEA and TCA directly. A total of 357 patients presented with visual disturbances in the TCA group, and 190 (53.2%) improved after surgery, whereas 311 patients presented with visual disturbances in the EEA, and 231 (74.3%) improved after surgery (p ≤ 0.0001). GTR was achieved in 403/503 (80.1%) patients in the TCA group and 335/449 (79.1%) patients in the EEA group (p = 0.687). A total of 11/514 (2.1%) patients in the TCA group developed CSF leak, whereas 49/449 (10.9%) in the EEA group developed this complication (p ≤ 0.0001). CSF leak occurred in 34/349 (9.7%) patients in studies where nasoseptal flap use was specified. A total of 105 complications were reported in 417 patients (25.2%) among TCA studies inclusive of CSF leaks, while 102 complications were reported in 371 patients (27.5%) among EEA studies inclusive of CSF leaks (p = 0.461). Tumors recurred in 17/288 (5.6%) patients undergoing resection via TCA (mean follow-up 33.8 months) and in 22/251 (8.1%) patients undergoing resection via EEA (mean follow-up 29.8; p = 0.234).

Conclusion: In this systematic review, EEAs afforded similar rates of GTR, tumor recurrence, and all-cause complications relative to TCAs while offering more favorable rates of visual improvement. However, EEAs were associated with significantly increased risk of CSF leak, though rates of CSF leak following EEA declined following advent of the vascularized nasoseptal flap. With appropriate patient selection, team-based surgical expertise in endoscopic techniques, and use of vascularized nasoseptal flaps in repairs, EEAs appear to be a safe and viable alternative to TCA in the treatment of suprasellar meningiomas.

No conflict of interest has been declared by the author(s).

Publication History

Article published online:
12 February 2021