Introduction: In this study, we set out to define our institutional criteria for patient eligibility for transsphenoidal resection of parasellar meningiomas, and to report our experience with extended transnasal approaches for these lesions. We aimed to discuss the important considerations of patient selection and risk stratification to optimize outcomes for patients with these difficult lesions, and also include considerations that should be reviewed during approach selection.
Methods: Medical records from Brigham and Women’s Hospital were retrospectively reviewed for all patients who underwent transsphenoidal surgery for pituitary disease with the senior author from April 2008 to March 2017 (938 procedures). Patients undergoing surgery for anterior skull base meningioma were identified and patient data were collected.
Results: Seven patients (four women, three men) underwent transsphenoidal resection (five endoscopic, one microscopic, and one hybrid endoscopic/microscopic) of pathologically-confirmed anterior skull base meningioma during the study period. Five patients presented with visual field deficit, three presented with headache, two presented with hypopituitarism, and one woman presented with infertility. The median maximum tumor diameter was 1.7 cm (range=1.4–4.2 cm). Six patients underwent subtotal resection, and one underwent gross total resection. The median MIB-1 index was 2.3 (range=1.0–7.6). Complications included two readmissions (one on POD11 for small bowel obstruction, one on POD48 for epistaxis) and development of new onset thyroid deficiency and transient diabetes insipidus in one patient. Two patients had reoperations for recurrence after five and six years.
Conclusions: Although more commonly treated transcranially, meningiomas are sometimes amenable to resection transphenoidally. Patient selection is critical, and multiple factors, including tumor size, consistency, and location, patient and surgeon preference, and presenting symptoms each affect the optimum surgical approach. We have developed an algorithm for patient selection so that transsphenoidal surgery can be used to resect or debulk anterior skull base meningiomas safely and with favorable outcomes.
Patient Care: This research will improve patient care by helping surgeons understand the multiple factors which in combination affect whether extended transnasal transsphenoidal surgery is appropriate for anterior skull base meningioma resection. A case series from a tertiary care center, with an emphasis on the importance of patient selection, helps to illustrate these factors.
Learning Objectives: 1) To understand important considerations of patient selection and risk stratification in patients with anterior skull base meningiomas.
2) To appreciate the advantages and disadvantages of the extended, transnasal, transsphenoidal approach compared to craniotomy in anterior skull base meningioma patients.
3) To identify features on radiographic imaging which can be used in conjunction with clinical factors to determine the appropriate approach for meningioma resection.