Endonasal surgical management of tuberculum sellae meningiomas. Our experience

Abstract

Purpose: to evaluate the results of endonasal interventions in patients with meningioma of the TS, to determine the criteria for selecting patients for endonasal approach, to establish indications and contraindications, to analyze the radicalism of operations, their technical features and complications associated with this approach.

Materials and methods. the indications and contraindications for endonasal surgery of meningioma of the TS, which were performed in Romodanov Neurosurgery Institute from 2014 to 2022. The study includes 32 patients with a diagnosis confirmed by instrumental examinations: meningioma of the TS, who underwent endonasal tumour removal. The results of interventions were evaluated based on the postoperative ophthalmological (with optical coherence tomography - OCT), endocrinological (laboratory), instrumental (CT and MRI) and rhinoscopic follow-up of patients.

Results. Performance of endonasal surgery for TS meningioma, method of bony defect plastic surgery, which significantly reduces the percentage of CSF leak was described in our article. Thus, it was confirmed that our percentage of CSF leak (9.4%) was significantly lower compared to other authors.

We also assessed radicality of endonasal removal of TS meningioma of the TS. Simpson I was achieved in 87.5%.

In 26 patients (81.2%) in the early postoperative period improvement of visual acuity and expansion of visual fields has been noted, which was confirmed by an ophthalmologist's examination and optical coherence tomography. In 4 patients (12.5%) no dynamic of visual disturbances was noted, in 2 patients (6.25%) a slight decrease of visual acuity was noted. Intra- and postoperative complications in patients with TS meningiomas were analyzed. There were no mortality, hemorrhagic complications and postoperative meningitis. Five (15.6%) patients had postoperative hypopituitarism. Two (6.25%) patients had a syndrome of inadequate secretion of antidiuretic hormone, manifested by hyponatremia. Among postoperative complications there were 3 cases of CSF leak (9.38%). One case of CSF leak required reoperation (3.13%). We also observed an overpacking with a fat graft (1 case), which led to decreased visual acuity in the early postoperative period and required reoperation (3.13%). In 6 (18.7%) cases in the postoperative period, anosmia occurred due to the extended approach and traumatization of the nasal mucous membrane.

Conclusions. The main complications of endonasal interventions are: intraoperative damage of neurovascular structures, CSF leak, meningitis, necrosis of the nasoseptal flap, hemorrhages in the tumour bed, overpacking with a fat graft which leads to decreased vision in the early postoperative period and anosmia. The rate of major complications described in this article is low and quite acceptable. Critical issues such as meningitis and hemorrhagic complications are completely absent in this study.