Musulevska V. “Diagnosis and differentiated surgical treatment of tuberculum sellae meningiomas”.
Among tumors of the anterior cranial fossa, tuberculum sellae meningiomas (TSM) account for about 25 %. Their proximity to important neurovascular structures, involving these structures into the tumor process complicates the diagnostic and treatment process. Since meningiomas are predominantly slow – growing benign tumors, the diagnosis of this pathology usually occurs with the emergence of visual disturbances. Treatment of TSM aims for radical removal of the tumor while preserving the anatomical integrity of surrounding structures and the functional status of the patient which in this case is determined mainly by ophthalmologic symptoms. Currently, there are no alternatives to surgical removal of meningiomas at this location. Among modern surgical treatment methods, the following are used: transcranial "aggressive" approach, endoscopic endonasal approach, and minimally invasive transcranial approach (with endoscopic assistance). The choice of intervention method is a controversial issue, as there are many factors that influence the decision-making. The emergence and development of endoscopic technologies have enabled the removal of MTS using a minimally invasive endonasal method, which reduces the patient's hospital stay and ensures a better cosmetic result. However, it is worth noting that the indications for both endonasal endoscopic and minimally invasive transcranial interventions with endoscopic assistance are quite limited and require comprehensive preoperative diagnostics using neuroimaging and clinical-instrumental examination methods. It confirms the relevance of the research topic, as it is dedicated to establishing clear indications and contraindications for various approaches to TSM, performing differential diagnostic examinations with virtual 3D modeling at the preoperative preparation stage, methods of surgical removal of TSM using modern endoscopic technologies, and combining them with «traditional»surgical approaches.
The dissertation research is based on the analysis of data from a retrospective series of 91 cases diagnosed with "tuberculum sellae meningioma", who were treated at the State Institution "A.P. Romodanov Institute of Neurosurgery of the National Academy of Medical Sciences of Ukraine" from December 2013 to November 2023.
The main clinical manifestations were: headache of “diaphragmatic nature” and visual disturbances manifested as decreased visual acuity and visual field loss. Visual impairments were diagnosed in 100 % of observations.
At the stage of preparation for surgery, clinical, instrumental and neuroimaging, ophthalmological and endocrinological examination were performed. 3D modeling was also conducted to create a virtual tumor model while considering the relationship between the tumor, neurovascular structures, and involved bone. Based on these examinations, an assessment of tumor invasion into the optic nerve canal, tumor lateralization, extent of hyperostosis, vascular structure involvement was carried out, determining the most appropriate method for TSM removal.
Modified fronto-temporo-orbitozygomatic and pterional approaches were used in 45 cases (49.4 %), minimally invasive transcranial (lateral supraorbital and "keyhole" access with endoscopic assistance) in 19 patients (20.9 %), and the proportion of endoscopic endonasal approaches to TSM was 29.7 % (27 observations). In this case, invasion into the optic nerve canal was diagnosed in 100 % of patients who underwent aggressive transcranial access, in 63.2 % (12 patients) who underwent minimally invasive access, and in 40.7 % (11 observations) who were operated on using endoscopic endonasal access.
Improvement in visual function was achieved in 32 patients (72.7 %) after aggressive transcranial access, in 17 patients (89.5 %) after minimally invasive removal, and in 100 % (27 observations) after endoscopic endonasal removal. Vision deteriorated in 6 patients (13.6 %), 1 patient (5.3 %) in the first and second groups, respectively, while no increase in ophthalmological disorders was found in the postoperative period in the third group.
Total removal (Simpson I and II) was achieved in 86 patients (94.5 %), and subtotal removal (Simpson III and IV) - in 5 patients (5.5 %). The follow-up period ranged from 12 to 118 months.
Keywords: meningioma, tuberculum sellae, endoscopy, microsurgery, brain tumors, surgical treatment, tumor volume, general resection, tumor, neurosurgical interventions, neurological complications, MRI, complications, prognosis, treatment.
