Case Prep: Tuberculum Sellae Meningioma Resection

Case / Approach Snapshot

• Anatomy at risk: tumor compartment, arterial supply, venous drainage/sinuses, cranial nerves, white-matter tracts, pituitary/CSF pathways when relevant, and functional cortex.
• Operative steps: review imaging and goals, choose exposure, obtain brain relaxation, devascularize when possible, debulk internally, dissect capsule from critical structures, verify extent/safety, and reconstruct watertight closure; use the detailed operative sequence and approach notes below as the step-by-step source.
• Rescue plans: venous or arterial injury, swelling, seizure, cranial nerve or endocrine change, CSF leak, residual tumor left for safety, staged surgery, radiation, or adjuvant therapy.
• Figures: review Figures, Imaging & Video and the Curated Image Set; embedded local figures should remain open-access, public-domain, or otherwise reusable with attribution.
• Papers: review High-Yield Literature for seminal sources, modern reviews, and outcome data specific to this page.

One-Liner

[Age]yo [M/F] with a tuberculum sellae meningioma presenting with [progressive visual loss / bitemporal or junctional field defect] planned for [pterional / supraorbital / endoscopic endonasal] approach for resection.

Figures, Imaging & Video

🎥 Operative video — search operative video on YouTube ▸ · The Neurosurgical Atlas ▸

CNS Video Library

🧭 Operative approach: Supraorbital keyhole craniotomy — detailed corridor setup, step-by-step technique & figures

Operative figures/atlases are © (linked, not copied). See media-sources.md.

• Technique/approach: The Neurosurgical Atlas — search “tuberculum sellae meningioma”
• Imaging: Radiopaedia — tuberculum sellae meningioma
• Open-access figures: PubMed Central

High-Yield Literature

• International Tuberculum Sellae Meningioma Study: Surgical Outcomes and Management Trends — Magill ST. Neurosurgery 2023. PubMed
• Tuberculum Sellae Meningioma: Report of Two Cases and Literature Review of Limits of the Transcranial and Endonasal Endoscopic Approaches — Silvestri M. Acta neurochirurgica. Supplement 2023. PubMed
• International Tuberculum Sellae Meningioma Study: Preoperative Grading Scale to Predict Outcomes and Propensity-Matched Outcomes by Endonasal Versus Transcranial Approach — Magill ST. Neurosurgery 2023. PubMed
• Surgical Management of Tuberculum Sellae Meningioma: Our Experience and Review of the Literature — Sankhla SK. Neurology India 2021. PubMed
• Olfactory groove and tuberculum sellae meningioma resection by endoscopic endonasal approach versus transcranial approach: A systematic review and meta-analysis of comparative studies — Lu VM. Clinical neurology and neurosurgery 2018. PubMed
• Surgical management of tuberculum sellae meningioma: Transcranial approach or endoscopic endonasal approach? — Qian K. Frontiers in surgery 2022. PubMed
• Contralateral supraorbital eyebrow approach for tuberculum sellae meningioma — Das KK. Acta neurochirurgica 2023. PubMed
• Tuberculum sellae meningioma surgery: visual outcomes and surgical aspects of contralateral approach — Voznyak O. Neurosurgical review 2021. PubMed
• Contralateral subfrontal approach for tuberculum sellae meningioma: techniques and clinical outcomes — Kim YJ. Journal of neurosurgery 2023. PubMed
• Microsurgical Resection of Tuberculum Sellae Meningioma through Pterional Approach with Extradural Optic Canal Unroofing — Matsuo S. Journal of neurological surgery. Part B, Skull base 2022. PubMed

Curated Image Set

Open-access figures are embedded from PubMed Central articles and kept unique to this guide.

Figure 1. Pterional approach marking (a) A representative head CT scan before; (b) and after pterional approach surgery; (c) Red arrow: Tuberculum sellae meningioma Source: Pterional approach versus unilateral frontal approach on tuberculum sellae meningioma: Single centre experiences — Asian Journal of Neurosurgery 2012; CC BY-NC-SA.

Figure 2. Source: Pterional approach versus unilateral frontal approach on tuberculum sellae meningioma: Single centre experiences — Asian J Neurosurg. 2012 Jan-Mar;7(1):21–4. doi: 10.4103/1793-5482.95691; CC BY-NC-SA.

Figure 3. Source: Pterional approach versus unilateral frontal approach on tuberculum sellae meningioma: Single centre experiences — Asian J Neurosurg. 2012 Jan-Mar;7(1):21–4. doi: 10.4103/1793-5482.95691; CC BY-NC-SA.

Figure 4. Source: Pterional approach versus unilateral frontal approach on tuberculum sellae meningioma: Single centre experiences — Asian J Neurosurg. 2012 Jan-Mar;7(1):21–4. doi: 10.4103/1793-5482.95691; CC BY-NC-SA.

Figure 5. Source: Pterional approach versus unilateral frontal approach on tuberculum sellae meningioma: Single centre experiences — Asian J Neurosurg. 2012 Jan-Mar;7(1):21–4. doi: 10.4103/1793-5482.95691; CC BY-NC-SA.

Figure 1. Magnetic resonance images: T1 weighted contrast-enhanced sagittal (a) and coronal (b) preoperative images showing coexistent macroadenoma and tuberculum sellae meningioma. Postoperative… Source: Endoscopic endonasal transsphenoidal approach for resection of a coexistent pituitary macroadenoma and a tuberculum sellae meningioma — Asian Journal of Neurosurgery 2014; CC BY-NC-SA.

Figure 2. (a) The intraoperative endoscopic view (screenshot) of the endonasal transsphenoidal approach to the planum sphenoidale and tuberculum sellae and identification of the meningioma. (b)… Source: Endoscopic endonasal transsphenoidal approach for resection of a coexistent pituitary macroadenoma and a tuberculum sellae meningioma — Asian Journal of Neurosurgery 2014; CC BY-NC-SA.

Fig. 1. ( A ) Preoperative MRI shows a contrast-enhanced tuberculum sellae lesion, suspicious of meningioma. ( B ) The left optic nerve (II c.n.) is evidenced through a left pterional approach…. Source: Tuberculum Sellae Meningioma Resection: Technical Nuances on the Frontopterional Approach — Journal of Neurological Surgery. Part B, Skull Base 2018; CC BY-NC-ND.

Figure. Figure 1 Source: Keyhole supraorbital eyebrow approach for the resection of a tuberculum sellae meningioma with intraoperative endoscopic assistance — Surgical Neurology International 2022; CC BY-NC-SA.

Figure 10. Source: Keyhole supraorbital eyebrow approach for the resection of a tuberculum sellae meningioma with intraoperative endoscopic assistance — Surg Neurol Int. 2022 Mar 18;13:93. doi: 10.25259/SNI_1173_2021; CC BY-NC-SA.

History of Present Illness

• Chief complaint: Progressive asymmetric visual loss (chiasmal compression) — the hallmark
• Classic: junctional scotoma or bitemporal field defect
• Headache, endocrine usually intact (vs pituitary)

Imaging Review

MRI (T1+Gad, thin-cut sella, T2) + MRA

• Tumor centered on tuberculum sellae, suprasellar
• Optic nerve/chiasm displacement (usually superior/posterior) — chiasm prefixed?
• Optic canal extension (common — must decompress)
• ICA and branches relationship; ACA complex superiorly
• Pituitary stalk/gland (usually separate, displaced inferiorly)
• Vascular supply

CT

• Hyperostosis of tuberculum/planum, optic canal anatomy, sphenoid pneumatization (for endonasal)

Ophthalmology

• Formal fields, acuity, OCT/RNFL

Labs

• CBC, BMP, Coags, Type and screen; pituitary panel (baseline)

Neurological Examination

• Detailed visual assessment, EOM, endocrine review

Surgical Planning

Case Logistics, OR Needs & Orders

• OR setup: navigation, endoscope/microscope as approach requires, ENT co-surgeon for endonasal cases, Doppler, lumbar drain only when indicated, reconstruction materials, and visual/endocrine baseline available.
• Special needs: steroid strategy individualized (Cushing workup may require avoiding preop steroids), DI/sodium protocol, AM cortisol/endocrine labs, visual-check plan, arterial line for large/vascular cases, and CSF-leak/nasal precautions.
• Immediate postop orders: neuro and visual checks, strict I/O with sodium/urine specific gravity schedule when pituitary stalk risk exists, cortisol/endocrine replacement plan, nasal precautions, MRI/CT timing, steroid taper, and DVT prophylaxis timing.

Approach Selection

• Pterional/supraorbital (transcranial): Lateral view, early ICA/optic control, good for lateral extension or vessel encasement
• Endoscopic endonasal: Direct inferior-to-superior access, early devascularization, decompresses optic canals medially, no brain/optic nerve retraction — favored for midline tumors without significant lateral/vascular encasement; requires skull base reconstruction
• Side (transcranial): side of worse vision or larger tumor extension

Position

• Pterional: supine, rotated 20-30 degrees contralateral, extended, Mayfield
• Endonasal: supine, slight extension, navigation

Key Surgical Steps (Transcranial)

1. Pterional/supraorbital craniotomy, drill sphenoid wing
2. Open sylvian/basal cisterns, drain CSF
3. Identify ipsilateral optic nerve, ICA, chiasm
4. Unroof optic canal to decompress and free the optic nerve (improves visual outcome)
5. Devascularize tumor base at tuberculum/planum
6. Internal debulking; dissect tumor off optic apparatus (preserve pial vessels/superior hypophyseal arteries to chiasm)
7. Protect ACA complex superiorly, ICA laterally, stalk inferiorly
8. Resect base dura/bone (Simpson I if safe)
9. Reconstruction, closure

Critical Anatomy & Structures at Risk

1. Optic nerves / chiasm — primary structure; preserve superior hypophyseal artery branches to chiasm (visual outcome)
2. ICA and branches
3. ACA / A1 complex (superior)
4. Pituitary stalk and gland
5. Optic canal (decompress)

Equipment

• Microscope (± endoscope), navigation, high-speed drill (optic canal), CUSA, ICG
• Skull base reconstruction (nasoseptal flap if endonasal; graft/sealant)

Monitoring

• SSEPs; VEPs (optional)

Anesthesia

• Arterial line, mannitol, dexamethasone, lumbar drain (endonasal)

Potential Complications

1. Visual worsening — devascularization of chiasm (superior hypophyseal artery injury)
2. ICA injury, CSF leak (esp. endonasal), hypopituitarism/DI
3. Residual in optic canal → recurrence

Operative Note Template

Preoperative Diagnosis: Tuberculum sellae meningioma with progressive [asymmetric] visual loss

Postoperative Diagnosis: Same

Procedure: [Pterional / endoscopic endonasal extended transtuberculum] approach for resection of tuberculum sellae meningioma [with optic canal decompression]

Surgeon / Assistant: [± ENT co-surgeon if endonasal] Anesthesia: General endotracheal EBL / Fluids: Adjuncts: Neuronavigation, high-speed drill (optic canal), microscope/endoscope, ICG; [lumbar drain if endonasal] Implants: Dural substitute [/ nasoseptal flap, fascia/fat, sealant if endonasal] Complications: None

Indications: [Age]yo [M/F] with a tuberculum sellae meningioma causing progressive visual decline (chiasmal compression, [junctional/bitemporal] field defect). Approach selected for [midline without vascular encasement → endonasal / lateral extension/vessel encasement → pterional]. Risks (visual worsening, ICA injury, CSF leak, endocrine) discussed.

Description of Procedure: After consent and time-out, general anesthesia was induced and navigation registered. [Pterional: the head was rotated ~20–30° contralateral, a pterional craniotomy performed, the sphenoid wing drilled, and the basal cisterns opened with CSF egress to relax the brain. The ipsilateral optic nerve, ICA, and chiasm were identified.] The involved optic canal was unroofed to decompress and free the optic nerve.

The tumor base at the tuberculum/planum was devascularized, the tumor internally debulked, and the capsule dissected off the optic apparatus and chiasm, preserving the superior hypophyseal artery branches supplying the chiasm; the ACA complex, ICA, and stalk were protected. The involved dura/bone was addressed (Simpson [I/II]) and the skull base reconstructed [multilayer with nasoseptal flap if endonasal].

Closure was completed and the patient transferred to the ICU with serial visual checks.

Postoperative Plan

• ICU, neuro checks q1h, visual checks
• Endonasal: DI/Na monitoring, CSF leak precautions, AM cortisol
• MRI postop, ophthalmology and endocrine follow-up
• Steroid taper, DVT prophylaxis

Chief-Level Case Review

Use these as the senior-level mental model for Tuberculum Sellae Meningioma Resection:

• Decision point: Decide the real endpoint before opening: cure, cytoreduction, diagnosis, decompression, separation from critical structures, or safe maximal resection.
• Technical lever: Map what must be left behind: perforators, cranial nerves, venous sinuses, eloquent cortex/tracts, hypothalamus/pituitary axis, and adherent capsule planes.
• Bailout: Sequence matters: devascularize early when safe, create CSF/working space, debulk before traction, and preserve the arachnoid plane unless oncologic goals justify violating it.
• Postop watch: The postop plan should match the risk structure: endocrine/vision/swallow/CN checks, steroid taper, seizure plan, MRI timing, CSF-leak watch, and adjuvant-treatment handoff.

Common Pimp Questions

Use these to pressure-test preparation for Tuberculum Sellae Meningioma Resection:

1. What is the surgical goal: gross-total, maximal safe, decompression, diagnosis, or cytoreduction?
2. What eloquent cortex, tract, cranial nerve, vessel, or sinus defines the stopping point?
3. What adjunct changes the case: navigation, mapping, 5-ALA, ultrasound, endoscope, ICG, or neuromonitoring?
4. What is the edema, steroid, seizure, DVT, and postop imaging plan?
5. What complication would you check for first in PACU based on this lesion location?

Attending Preference Variables

Items that commonly vary by surgeon or institution:

• Extent-of-resection goal and functional stopping points: [attending-specific]
• Mapping/monitoring, 5-ALA, ultrasound, ICG, endoscope, or tractography preferences: [attending-specific]
• Steroid, antiepileptic, mannitol/hypertonic saline, and antibiotic plan: [attending-specific]
• Postop MRI timing, ICU/floor threshold, and adjuvant-referral workflow: [attending-specific]