Simpson Grade I Removal of Tuberculum Sella Meningioma Through the Supraorbital Approach: 2-Dimensional Operative Video

As described by Cushing1 in the chiasmatic syndrome, tuberculum sellae meningiomas induce progressive asymmetrical, incongruous visual loss, which would lead to blindness. The surgical removal of these lesions has been rewarding in regard to visual preservation, or recovery, and has passed the test of time. Optic canal extension, in one or both canals, is a consistent feature of these tumors, and removing the tumor from the optic canals is paramount in the treatment of these lesions.2 Despite the small target volume, radiosurgery is not applicable because of the lack of safe distance from the optic pathways. Tuberculum sella meningioma has been distinguished with good surgical outcomes and low recurrence rates; thus, Simpson grade I removal (tumor, dura, and bone invasion) confers a prospect of cure. Safe and successful resection of tuberculum meningiomas is achieved through the skull base supraorbital approach3 with several critical objectives: (1) visualization of the tumor without brain retraction; (2) 270° opening of the optic canal proximally and distally for safe tumor removal; (3) preservation of the vascular supply to the optic pathways and pituitary; (4) microsurgical dissection under high magnification on a short working distance to the encased carotid and anterior cerebral arteries; (5) complete resection of involved dura and bone at the skull base, particularly laterally; and (6) a robust skull base reconstruction with a vascularized pericranial flap.4 We present the case of a 45-yr-old female with a tuberculum sella meningioma who underwent Simpson grade I removal with an uneventful outcome. The patient consented for surgery. Image at 2:59 reprinted with permission from Al-Mefty O, Operative Atlas of Meningiomas. Vol 1, © LWW, 1998; Image at 9:33 public domain.4