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The contralateral subfrontal approach can simplify surgery and provide favorable visual outcome in tuberculum sellae meningiomas

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Abstract

The ipsilateral approach for the tumor-dominant or amblyopic side in surgery of tuberculum sellae meningiomas (TSMs) frequently requires manipulation of the optic nerve and unroofing of the optic canal, which results in postoperative visual aggravation. We suggest a contralateral approach and discuss the benefits with respect to the postoperative visual outcome. Between 2005 and August 2011, 24 patients with TSMs underwent surgical resection via the contralateral approach. The contralateral approach accesses the tumor from the opposite side of the tumor-dominant or amblyopic side. Using this technique, the tumor was separated from the noncompromised optic nerve with only internal debulking. The tumor was dissected from the optic nerve without manipulation of the compromised optic nerve under the direct view of the inferomedial aspect of the optic nerve. The tumor that extended into the optic canal could be removed easily via dural unroofing of the medial wall of the optic canal. Seventeen patients (70.8 %) were improved, 6 (25 %) were unchanged, and 1 (4.2 %) worsened on visual acuity of the affected eye. Fifteen (62.5 %) were improved, 8 (33.3 %) were unchanged, and 1 patient (4.2 %) worsened on visual field defect of the affected eye. However, deterioration of visual acuity and visual field defect of the nonaffected eye was developed in one (4.2 %) and three patients (12.5 %), respectively. Surgical approach-related visual field defect was developed on two patients (8.3 %). The contralateral approach reduces manipulation of the involved optic nerve and directly visualizes the inferomedial aspect of the compromised optic nerve which could result in improvement of postoperative visual outcomes.

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Acknowledgments

This Study was supported by the Brain Korea 21 Project, Center for Biomedical Human Resources at Chonnam National University.

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Authors and Affiliations

  1. Department of Neurosurgery, Chonnam National University Research Institute of Medical Sciences, Chonnam National University Hwasun Hospital and Medical School, Gwangju, South Korea

    Woo-Youl Jang, Shin Jung, Tae-Young Jung, Kyung-Sub Moon & In-Young Kim

  2. Department of Neurosurgery, Brain Tumor Clinic and Gamma Knife Center, Chonnam National University Hwasun Hospital and Medical School, 322 Seoyong-ro, Hwasun-eup, Hwasun-gun, Jeollanam-do, 519-763, South Korea

    Shin Jung

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  1. Woo-Youl Jang
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  2. Shin Jung
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Correspondence to Shin Jung.

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Comments

Ahmed Alferayan, Riyadh, Saudi Arabia

Dr. Jung et al. have studied retrospectively 24 cases of TSMs over a 6-year period, and those patients underwent a contralateral approach to have a better and safer approach for such tumors as they approach them from the good optic nerve side. They found out that it is an easy and safe approach, so it is an addition and guide to the neurosurgical literature as the other approach still carries a significant risk to the optic apparatus. Although we commend the authors on this study, we would like the neurosurgeons especially the young ones to pay attention to the fact that such tumor images have to be studied thoroughly and the surgery planned according to the following factors: the size of the tumor and not extending lateral to the ICA and optic nerve and the consistency of the tumor by looking at T2 MRI. Hope this study helps patients to have better outcome and less morbidity

Miguel A. Arraez, Malaga, Spain

Dr. Shin Jung and colleagues have studied 24 cases of tuberculum sellae meningiomas approached through a contralateral craniotomy to the more affected optic nerve to better control the plane between the tumor and the more damaged nerve. This article includes a very original concept, as the usual manner in any neurosurgical approach is to try to get the shortest route to the more compromised aspect of the neural tissue. They actually follow this principle considering that contralateral frontal craniotomy gives the best view to the tumor-compromised optic nerve interphase. Although the inferolateral aspect of the contralateral optic nerve can be better seen from the contralateral view, we have to mention that the standard way of approaching the lesions from the ipsilateral side is good enough for the removal of the tumors shown in this paper taking into account that the cases included in this study are not really big: ranging between 7 and 33 mm and provoking visual symptoms 21 out of 24. From these 21, only 11 provoked bilateral symptoms. Due to the size of the tumor of the present series, the involvement of the optic canal is obviously lesser than in bigger cases. We have to mention that the contralateral approach provides a longer working distance. Another disadvantage of this conception comes up when the extension of the tumor is beyond the lateral aspect of the carotid artery (see patient number 22). Generally speaking, the subfrontal unilateral ipsilateral approach seems to be good enough to carry out the removal of a great majority of these tumors. In the case of huge lesions, the subfrontal–interhemispheric approach must be kept in mind, as it provides a pure from above midline view that allows for good control of both optic nerves and also of the intracanalicular extension at the optic canal. I do not agree with the statement of the authors that the bilateral subfrontal approach requires excessive frontal lobe retraction. For giant cases, the subfrontal–interhemispheric route can be considered the approach of choice. In spite of these considerations, this very well-written article deserves attention for its original conception about the treatment of tuberculum sellae meningiomas.

Siamak Asgari, Ingolstadt, Germany

The authors reported on 24 patients who underwent surgery for tuberculum sellae meningioma. Preoperatively, most of the patients suffered from visual disturbances on one or both eyes. In all patients, the tumor was assessed via a contralateral subfrontal approach to the more affected optic nerve. Postoperatively, impairment of visual function was observed in 4 % of patients for the predominantly affected eye and in 12 % of the patients for the primary unaffected or minor affected eye. The contralateral pterional or frontolateral approach is a well-known and established route to intracavernous pathologies and some paraophthalmic aneurysms of the internal carotid artery. I have experience with the contralateral frontolateral approach in lateralized medium-sized tuberculum sellae or suprasellar meningiomas, too. In these few patients, functional deterioration of the ipsilateral olfactory tract may occur. But more important, the postoperative impairment rate of the “better” optic nerve is relatively high. An effective unroofing of the contralateral optic canal is not possible with low risk. The authors discuss that they performed contralateral opening of the dural sheet in front of the osseous canal only. From my experience, decompression effect of dural sheet opening is less than combined osseous-dural opening. The furrow in the optic nerve is frequently seen at the level of the entrance into the osseous canal. I can recommend the contralateral approach in suprasellar meningiomas only under the consideration of postoperatively unchanged function of the preoperatively “better” optic nerve.

Tetsuya Goto, Matsumoto, Japan

The authors have been operating in many cases of tuberculum sellae meningiomas via the contralateral subfrontal approach with a low risk of injury of the noncompromised optic nerve. Accordingly, they concluded that the contralateral approach was superior to the ipsilateral approach. Dissection of the tumor from the important structure must be easier under direct vision. However, selection of the approach side, ipsilateral or contralateral, might be the surgeon’s preference, and it might be chosen in each patient.

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Jang, WY., Jung, S., Jung, TY. et al. The contralateral subfrontal approach can simplify surgery and provide favorable visual outcome in tuberculum sellae meningiomas. Neurosurg Rev 35, 601–608 (2012). https://doi.org/10.1007/s10143-012-0397-y

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