Extended, Endoscopic, Transsphenoidal Surgery for Resection of Anterior Skull Base Meningioma

Introduction: Meningiomas arising in the region of the sella can occasionally be treated minimally-invasively using the extended, endoscopic, transsphenoidal approach. This surgical approach spares morbidity and allows for debulking of tumors that might otherwise be difficult to access.

Methods: Medical records were retrospectively reviewed from April 2008 to August 2016 to identify patients who underwent transsphenoidal resection of meningioma with the senior author.

Results: Seven patients (four women, three men) underwent transsphenoidal resection of meningioma during the study period. Six patients presented with visual field deficit, three presented with headache, three presented with hypopituitarism, and one woman presented with infertility. Prior interventions among these patients included craniotomy and Gamma Knife radiosurgery in one patient, two prior craniotomies with LINAC radiation in another, and systemic hormone-based chemotherapy for breast cancer (anastrozole) in one.

The median maximum tumor diameter was 2.2 cm (mean: 3.1 cm). All seven tumors had suprasellar extension, four were intrasellar and four were parasellar. All patients underwent transsphenoidal resection. Four of seven patients received subtotal resection and had firm tumors intra-operatively, while three patients received gross total resection of a loosely organized tumor. On pathology, all patients had meningioma, two of which were atypical. The median MIB-1 index was 3.0 (mean: 4.9). Five tumors were WHO grade I, and two were grade II.

Complications included two readmissions (one on POD48 for epistaxis, one on POD6 for SIADH), one reoperation by craniotomy after five years of observation, and development of new onset thyroid deficiency and transient diabetes insipidus in one patient.

Conclusion: Although more commonly treated transcranially, meningiomas are sometimes amenable to resection transsphenoidally. Patient selection is critical, as tumor invading the optic canal cannot safely and completely be resected via an endonasal approach, and may necessitate a transcranial operation. Transsphenoidal surgery for a select sub-group of patients can be used to debulk tumor safely and alleviate mass effect on parasellar structures, including the optic chiasm.

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