International Tuberculum Sellae Meningioma Study: Surgical Outcomes and Management Trends

Abstract

Background and objectives: Tuberculum sellae meningiomas (TSMs) can be resected through transcranial (TCA) or expanded endonasal approach (EEA). The objective of this study was to report TSM management trends and outcomes in a large multicenter cohort.

Methods: This is a 40-site retrospective study using standard statistical methods.

Results: In 947 cases, TCA was used 66.4% and EEA 33.6%. The median maximum diameter was 2.5 cm for TCA and 2.1 cm for EEA ( P < .0001). The median follow-up was 26 months. Gross total resection (GTR) was achieved in 70.2% and did not differ between EEA and TCA ( P = .5395). Vision was the same or better in 87.5%. Vision improved in 73.0% of EEA patients with preoperative visual deficits compared with 57.1% of TCA patients ( P < .0001). On multivariate analysis, a TCA (odds ratio [OR] 1.78, P = .0258) was associated with vision worsening, while GTR was protective (OR 0.37, P < .0001). GTR decreased with increased diameter (OR: 0.80 per cm, P = .0036) and preoperative visual deficits (OR 0.56, P = .0075). Mortality was 0.5%. Complications occurred in 23.9%. New unilateral or bilateral blindness occurred in 3.3% and 0.4%, respectively. The cerebrospinal fluid leak rate was 17.3% for EEA and 2.2% for TCA (OR 9.1, P < .0001). The recurrence rate was 10.9% (n = 103). Longer follow-up (OR 1.01 per month, P < .0001), World Health Organization II/III (OR 2.20, P = .0262), and GTR (OR: 0.33, P < .0001) were associated with recurrence. The recurrence rate after GTR was lower after EEA compared with TCA (OR 0.33, P = .0027).

Conclusion: EEA for appropriately selected TSM may lead to better visual outcomes and decreased recurrence rates after GTR, but cerebrospinal fluid leak rates are high, and longer follow-up is needed. Tumors were smaller in the EEA group, and follow-up was shorter, reflecting selection, and observation bias. Nevertheless, EEA may be superior to TCA for appropriately selected TSM.

FIGURE 1.

Use of the EEA for TSM resection increased over time. Percent of TSM resected with an EEA compared with a TCA from 1993 to 2019. The total number of cases per year is shown below the x-axis. EEA, expanded endonasal approach; TCA, transcranial approach; TSM, tuberculum sellae meningiomas.

FIGURE 2.

For tuberculum sellae meningiomas resected through a TCA (n = 629), a unilateral approach (n = 487, 77.4%) is more commonly used than a bilateral or midline approach (n = 142, 22.6%). The total number of cases per year is shown below the x-axis. TCA, transcranial approach.

FIGURE 3.

Specific TCAs used over time (n = 629). The most common approaches were the unilateral cranio-orbital/modified orbito-zygomatic approach without zygomatic osteotomy (CO/mOZ). Although the use of the pterional approach increased over time, the extended bifrontal approach (Ext. bifrontal) decreased over time. Bilat. CO, bilateral cranio-orbital approach; Bifront, no orb., bifrontal no orbitotomies; Interhem, interhemispheric; OZ, orbitozygomatic; SO, supraorbital; TCA, transcranial approach.

FIGURE 4.

Visual outcomes stratified by pre-operative visual deficit. A, Patients with no pre-operative visual deficit had no difference in visual worsening rates between TCA and EEA. B, Patients with a preoperative visual deficits are more likely to have visual improvement if they have an EEA versus a TCA. p-values are for Pearson's chi square test.

FIGURE 5.

CSF leak rate requiring reoperation over time. There were significantly more CSF leaks with an EEA compared with a TCA (P < .0001). The total number of cases per year by approach is shown below the x-axis. CSF, cerebrospinal fluid; EEA, expanded endonasal approach; TCA, transcranial approach.