University of Pennsylvania Health System

Clinical Briefings™: Clinical Reports from Penn Medicine

Wednesday, November 17, 2010

Three-Dimensional Stereoendoscopic Surgery for Tuberculum Sellae Meningiomas

Neurosurgeons at Penn Medicine are using a three-dimensional (3-D) stereoendoscopic video system to remove benign skull base meningiomas and avoid their long-term recurrence. The 3-D endoscope permits greater depth perception and enhanced illumination and has been shown to improve dissection during the resection of intracranial lesions.

Meningiomas, which comprise about 20 percent of all primary intracranial tumors, are usually benign. Treatment of these lesions is often determined by location and size. Smaller tumors (3cm or less) and residual or recurrent lesions involving the skull base or the cavernous sinus are amenable to radiosurgery.

However, for tumors located in the proximity of the optic chiasm and other radiosensitive organs (including tuberculum sellae meningiomas), surgery is the treatment of choice.

Removal of tuberculum sellae lesions is complicated by their anatomic nuances and their tendency to envelope and adhere to nervous and vascular structures and infiltrate surrounding dura and bone.

As a result of these characteristics, incomplete resection of tuberculum sellae tumors is not uncommon and recurrence rates of 10 to 20 percent of cases are not unusual.

Case Study
Mr. M, a 40-year-old with no prior history of neurological disease, was referred to Penn Medicine for evaluation after experiencing a substantial vision loss over a period of a few weeks.

At Penn, an ophthalmologic examination demonstrated bilateral hemianopsia with a progressive decrease of visual acuity. An MRI scan was ordered, which demonstrated a large (3.2cm) tuberculum sellae meningioma (Figure 1).

After a neurosurgical consultation, Mr. M chose to have a 3-D stereoendoscopic endonasal resection of the lesion. At the outset of the surgery, a vascularized portion of the posterior nasal septum was removed to create a nasoseptal flap for later reconstruction, and set aside in the maxillary septum.

An opening was then drilled in the sphenoid floor, with the greater visual acuity of the 3-D endoscope permitting optimal tissue preservation. Following the removal of the sphenoid sinus mucosa, a drill was used to thin and remove the tuberculum and planum, exposing the tumor. Next, the vessels serving as feeders to the lesion were ligated and the critical arteries and optic nerves identified.

The dura surrounding the tumor was then carefully incised to the tumor margins and the brain/tumor interface located. Benefiting from the 3-D endoscope’s enhanced depth perception, the surgeons then dissected the tumor away from the blood vessels and nerves and removed it through the nasal cavity.

With the completion of the resection, a fascia lata and fat autograft was placed as dural substitute, and the vascularized nasoseptal flap was rotated to seal the defect.

Following the surgery, Mr. M remained in the hospital for two days. His recovery was uneventful. At his two-week follow-up, his vision was found to be dramatically improved, and within six weeks had returned to pre-surgery levels.

Team of Faculty
The faculty of the Department of Neurosurgery at Penn is comprised of 12 neurosurgeons whose experience spans the entire spectrum of surgically treated disorders of the nervous system.

Together, these neurosurgeons perform more than 4,000 operations annually, and, when surgery involves tumors of the skull base, participate with a cross-disciplinary array of specialists within the Penn Center for Cranial Base Surgery at Penn. The combination of experience, high volume and a multidisciplinary approach to treatment ensures that neurosurgery patients at Penn achieve the best possible result.

Performing 3-D Endoscopic Endonasal Surgery for Skull Base Meningiomas at Penn Medicine

Neurosurgery

M. Sean Grady, MD
Charles Harrison Frazier Professor of Neurosurgery

John Y.K. Lee, MD
Assistant Professor of Neurosurgery

Access

Department of Neurosurgery
Hospital of the University of Pennsylvania
3 Silverstein
3400 Spruce Street
Philadelphia, PA 19104

Penn Neurosurgery at Pennsylvania Hospital
Washington Square West Building
235 South 8th Street
Philadelphia, PA 19106

To refer a patient and/or consult with a physician:
Call 800-789-PENN (7366) or visit:
PennMedicine.org/referral

Download a pdf of this Clinical Briefing.





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