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      Tuberculum sellae meningiomas: A series of 41 cases; surgical and ophthalmological outcomes with proposal of a new prognostic scoring system

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          Abstract

          Context:

          Tuberculum sellae meningiomas have proved difficult to treat, partly because of their intimate association with the optic nerves and chiasma, hypothalamus, and internal carotid arteries.

          Aims:

          The aim of this study is to analyze the degree of influence of various prognostic factors affecting visual outcome; the pattern of visual recovery and develop a scoring system for prognostication.

          Settings and Design:

          This is a retrospective study carried out from January 2004 till June 2011.

          Materials and Methods:

          Patients were analyzed on the basis of clinical, radiological, and surgical factors that appeared to affect the outcome. A special scoring system (according to the guidelines of the German Ophthalmological Society) was adopted to quantify the extent of ophthalmological disturbances.

          Statistical Analysis Used:

          Comparison of categorical variables between the two was performed using chi-square test and a P value of ≤ 0.05 was considered significant. Logistic regression was used when multivariate analysis was required.

          Results:

          Vision improved in 27% and deteriorated in 7.3%. A prognostic scoring system (score 4–13) was developed depending on the degree of influence of significant prognostic factors. The patients with a score of ≤6 had improved vision postoperatively (44%), whereas none of those with a score > 6 improved. Completeness of visual recovery was perceived in 100% of patients within 3 months. Complete resectability was achieved in 73% of patients.

          Conclusions:

          The proposed scoring system is very useful in prognosticating the visual outcome of these patients. The patients with a score of ≤6 have the best visual outcome postoperatively. Complete resectability is better achieved with extended bifrontal and unilateral frontal approaches. Short-term postoperative visual outcome is a strong indicator of permanent visual outcome after surgery.

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          Most cited references 32

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          Pterional surgery of meningiomas of the tuberculum sellae and planum sphenoidale: surgical results with special consideration of ophthalmological and endocrinological outcomes.

          The authors reviewed 47 cases of suprasellar meningiomas with special attention to ophthalmological and endocrinological outcomes. All patients underwent surgery performed via a unilateral pterional approach between January 1983 and January 1998. Ophthalmological and endocrinological examinations were performed before the operation as well as 1 week and 3 months postoperatively. A special scoring system was adopted to quantify the extent of ophthalmological disturbances. Complete tumor resection was possible in all but one patient. There were no fatalities and the rate of visual improvement was 80%. The best prognoses were found in patients younger than 50 years and in patients in whom the duration of symptoms was less than 1 year. Before surgery, tumor-related endocrine disturbances were present in only three women who suffered from secondary hypogonadism; two of these patients recovered after surgery. Postoperatively, no patient needed replacement therapy for pituitary dysfunction. The overall tumor recurrence rate was 2.1% (one of 47 cases). For patients in whom long-term (> 5 years) follow-up data were available, the recurrence rate was 4.2% (one of 24 cases). In this series, complete resection of suprasellar meningiomas was possible through a unilateral pterional craniotomy and was associated with a low morbidity rate and no deaths.
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            Tuberculum sellae meningioma: a report on management on the basis of a surgical experience with 70 patients.

            The surgical strategies and outcomes for 70 patients operated on for tuberculum sellae meningioma were analyzed retrospectively. The analysis was based on factors that probably determined the difficulties encountered during surgery, assisted in predicting the extent of resectability, and helped in predicting the surgical outcome. Seventy patients with tuberculum sellae meningiomas were operated on in the neurosurgery department at King Edward Memorial Hospital and Seth Gordhandas Sunderdas Medical College, Bombay, India, between 1991 and May 2001. The patients were analyzed retrospectively on the basis of clinical and radiological factors that appeared to affect the outcome. Each factor was given points, and for each tumor, the points were added to obtain a score. On the basis of the score, the tumors were then divided into three grades. The grades determined the difficulties that could be anticipated during surgery. The majority of patients were operated on by use of unifrontal craniotomy on the side of worse vision by standard dissection techniques. Total tumor resection was achieved in 59 patients, and subtotal tumor resection with less than 7% of tumor left behind was achieved in 11 patients. All patients with subtotal resection had higher-grade tumors. Preoperative visual status had a bearing on the visual outcome after surgery. Four patients were misdiagnosed as having a pituitary tumor. Two patients died in the immediate postoperative period. The average follow-up was 46 months (range, 6 mo to 9 yr). There was symptomatic recurrence in one patient in whom a subtotal resection had been performed. The extent and duration of visual symptoms, encasement of the anterior cerebral artery complex, and size of the tumor were the more important factors that affected the surgery. The grading system gave a reasonable assessment concerning the possible surgical problems.
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              Tuberculum sellae meningiomas: clinical outcome considering different surgical approaches.

              Tuberculum sellae meningiomas present a special challenge because of their proximity to arteries of the anterior circulation, anterior visual pathways, and the hypothalamus. The authors report on the clinical outcome after surgical treatment of tuberculum sellae meningiomas in our neurosurgical department. A retrospective study was conducted analyzing the charts of the patients, including surgical records, discharge letters, histological records, follow-up records, and imaging studies. Patients with associated neurofibromatosis Type 2 were excluded from the study. One thousand eight hundred meningiomas were operated on between 1978 and 2002. Seventy-two of these patients had tuberculum sellae meningiomas; four had undergone previous surgical procedures in outside hospitals. Fifty-five patients were women; 17 were men. Their mean age was 54.3 years (range, 30-86 yr). All patients had visual disturbances at presentation. Tumors were operated through the bifrontal approach (n = 21, from 1978 through 1995), the pterional/frontotemporal approach (n = 21, from 1982 through 2002), and the frontolateral approach (n = 30, from 1984 through 2002). Total tumor removal was achieved in most patients (Simpson 1 + 2, 91.7%). The perioperative mortality rate was 2.8% (two out of 72 patients). Immediate postoperative improvement of visual disturbance was observed in 65% of patients. Visual improvement was dependent on the duration of preoperative visual symptoms, but not on preoperative visual acuity or tumor size. The visual improvement rate was significantly better in patients who underwent frontolateral tumor resection (77.8%) compared with those who underwent bifrontal craniotomy (46.2%). The overall recurrence rate was 2.8% (two out of 72 patients). The mean follow-up time for all patients was 4 to 238 months (mean, 45.3 mo [3.8 yr]). From 1978 through 2002, tuberculum sellae meningiomas were removed microsurgically using three different surgical approaches. Considering the operative morbidity and mortality, the frontolateral and pterional approach provided remarkable improvement compared with the bifrontal approach. These approaches allowed quick access to the tumor and were minimally invasive with less brain exposure, but still engendered high rates of total tumor removal. By comparison, the frontolateral approach provided the best results concerning visual outcome while representing the least invasive surgical approach.
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                Author and article information

                Journal
                J Neurosci Rural Pract
                J Neurosci Rural Pract
                JNRP
                Journal of Neurosciences in Rural Practice
                Medknow Publications & Media Pvt Ltd (India )
                0976-3147
                0976-3155
                Sep-Dec 2012
                : 3
                : 3
                : 286-293
                Affiliations
                Department of Neurosurgery, Manipal Super Specialty Hospital, Vijayawada, India
                [1 ] Department of Neurosurgery, Krishna Institute of Medical Sciences, Secunderabad, India
                [2 ] Department of Neurosurgery, Nizam's Institute of Medical Sciences, Hyderabad, Andhra Pradesh, India
                Author notes
                Address for correspondence: Dr. Arun Palani, Manipal Super Specialty Hospital, Tadepalli, Vijayawada, Andhra Pradesh, India. E-mail: p.arun@ 123456jipmer.net
                Article
                JNRP-3-286
                10.4103/0976-3147.102608
                3505319
                23188980
                Copyright: © Journal of Neurosciences in Rural Practice

                This is an open-access article distributed under the terms of the Creative Commons Attribution-Noncommercial-Share Alike 3.0 Unported, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

                Categories
                Original Article

                Neurosciences

                meningioma, visual outcome, tuberculum sellae, prognostic factors

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