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Microsurgery with 26 cases of tuberculum sellae meningiomas
International Congress Series 1259 (2004) 65 – 69
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Microsurgery with 26 cases of tuberculum sellae meningiomas Vo Van Nho *, Nguyen Phong Department of Neurosurgery, Cho Ray Hospital, Ho Chi Minh City, Viet Nam Received in revised form 14 July 2003; accepted 31 July 2003
Abstract. Objective: The long-term outcome of the total removal of the tuberculum sellae meningiomas (TSM) with microsurgery through the subfrontal approach was fully evaluated in 26 cases. Methods: To make an accurate diagnosis before operation using CT scan, magnetic resonance imaging (MRI) and digital subtraction angiography, with evaluation of visual field and acuity. Applying the right subfrontal approach to these tumors. Result: Of 26 cases where microsurgery was performed, there were 4 patients who became completely blind in 1 eye, 2 patients remained 4/10 in visual acuity and 2 other patients with 6/10 in the left visual acuity. Fourteen patients had reduced visual acuity in both eyes and eight patients had reduced visual acuity only in one eye. In these 26 patients, mild and moderate headache occurred. Endocrinological feature did not appear in any of these patients. The size of the tumor was arranged into four groups with the diameter as small (under 2 cm: 0 patients), moderate (2 – 3 cm: 6 patients), large (3 – 4 cm: 16 patients) and giant (>4 cm: 4 patients). Twenty-five patients underwent microsurgery to remove the tumor completely with excellent outcome, and in one case there remained a small part due to too much more neovascular and a second operation was performed 3 months after the first operation to rule out this remaining completely. Conclusion: In general, in order to obtain a better outcome, the TSM must be diagnosed early and the operation must be performed in time. D 2003 Published by Elsevier B.V. Keywords: Meningiomas; Imaging; Subfrontal approach
1. Introduction Tuberculum sellae meningiomas (TSM) is rare, about 17% among supra and infratentorial meningiomas. Symptoms of this tumor are not clear; when this tumor gradually grows, it will block the eyesight interfering field and cause a decrease of vision in one or both eyes depending on its growth; however, this tumor can cause the state of hemianopsia the same as pituitary tumors. Headache is the first sign in TSM. This tumor can be discovered early by use of CT scan and magnetic resonance imaging (MRI). Digital subtruction angiogramme (DSA) is used to evaluate clearly and completely the blood * Corresponding author. Fax: +84-8855-7267. E-mail address: [email protected] (V.V. Nho). 0531-5131/ D 2003 Published by Elsevier B.V. doi:10.1016/S0531-5131(03)01209-3
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V.V. Nho, N. Phong / International Congress Series 1259 (2004) 65–69
vessels which are bringing up the tumor. The best treatment is still microsurgery to remove the entire tumor. If the dimension of the tumor is medium or small, the tumor is removed more easily, there are less complications and a better quality of life. 2. Clinical material and methods Prospective research with data of 26 cases from April 1997 to March 2003. Research based on clinical examination: – – – –
Measurement of visual acuity Measurement of visual field Picture of fundus Endocrine as prolactin, GH, cortisol
Diagnosis is based on CT scan, MRI and DSA with the following classification of tumor as: Grade
I (small)
II (moderate)
III (large)
IV (giant)
Size (cm)
<2
2–3
3–4
>4
With the right subfrontal, a trans-cranial approach was applied. Evaluating the result post-operation: 1. Repeat CT scan and MRI to ensure that the entire tumor was removed. 2. Evaluation of the result of recovery of visual acuity after surgery. 3. Evaluation of the quality of life based on the KARNOFSKY classification. 3. Results Twenty-six cases: 21 females and 5 males. Evaluation of vision pre- and post-operation: Pre-operation
Blind one eye
Blind two eyes
Decrease visual one eye
Decrease visual two eyes
Disorder endocrine
Cases Recovering after surgery
4 no
0
8 better
14 better
0
Dimension of tumor and result of surgery: Grade
I
II
III
IV
Patient Removal of entire tumor
0 0
6 6
16 16
4 4
V.V. Nho, N. Phong / International Congress Series 1259 (2004) 65–69
Fig. 1.
Fig. 2.
Fig. 3.
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68
V.V. Nho, N. Phong / International Congress Series 1259 (2004) 65–69
Evaluation of the quality of life based on Karnofsky’s classify table: 26 patients who had the entire tumor removed. All 26 post-operation cases have an index of 100 marks following Karnofsky’s classification (Figs. 1 – 3). 4. Discussion TSM occupy a low ratio with 1.7% compared to 9% of Ojemann in the total of intracranial meningiomas. There were 5 men and 21 women with an average age of 43.7 years compared to Ohta study of 4 men and 29 women with an average age of 46.7 years [1]. This kind of tumor grows very slowly, and its trend is to invade suprasellar region and to compress the optic nerve and chiasma. The earliest symptom is light headache in all 26 cases, then gradual reduction of the visual acuity. Visual acuity decreasing in both eyes in 14 patients and complete blindness of one eye in four patients are found in these data. Eight patients show decreased visual acuity in one eye. The sign of visual acuity decreasing strongly points to a lesion in the pituitary region. Because of this convincing sign, the patient should have a CE CT scan immediately to discover promptly the cause effecting the optic nerve. Among 26 cases that have the symptom of a gradual decrease in visual acuity in one or both eyes, we recommend performing a CT scan or MRI when the following symptoms are noted: – – – – –
Gradual decrease in visual acuity in one or both eyes. Pituitary fossa X-ray whether it is stretched or eroded. If visual field is affected by light or to a severe degree. Endocrine disorder. Diabetes insipidus.
There was a patient who was blind in one eye, vision of the left eye was 4/10; however, after removal of the entire tumor, up to 4 cm, his left eye was blind. After 1 week, the left eye gradually recovered and improved to 8/10 when he was discharged. We may think of the tumor as causing gradual compression on the optic nerve, but after the tumor was removed, suddenly it made the optic nerve slip through diaphragm membrane and led to blindness in the left eye. After that, perhaps high vein pressure pushed the optic nerve back to the former position, so the vision was restored. Most cases in our series are up to 3 cm in diameter, only six cases at grade II. Of course, the smaller the tumor, the easier the entire tumor is removed, so the result will be better and complications will be less. All 26 cases have undergone microsurgery through the right subfrontal approach to remove the entire tumor. The anatomy structure of this field has a lot of vessels and important nerves, such as optic nerve, the III cranial nerve, and the III, IV, VI and V1 nerve in cavernous sinus [6]. To eliminate a tumor in this region, it is necessary to preserve the optic nerve and chiasma as Ojemann [8] and Al-Mefty [4] touched upon. In this study, there was a case which a second operation was performed to remove tumor totally due to the tumor extended to the left middle fossa and into the left cavernous sinus causing blindness in the left eye. Most cases recovered vision after surgery to different degrees. The cases concerning one-eye complete blindness before the operation with optic atrophy were unable to recover after elimination of the tumor. This is emphasized by Matsumoto et al. [3], Long [5] and Apuzzo [7].
V.V. Nho, N. Phong / International Congress Series 1259 (2004) 65–69
69
After the symptom of visual reduction, early diagnosis is especially important in selecting a suitable treatment method for a small tumor, since the tumor will be easily eliminated and the preservation of vision will be better. When the tumor is invading the pituitary fossa, it can affect a disorder of endocrine and can be mistakenly diagnosed as pituitary tumors and craniopharyngiomas. Of these 26 cases, there were 3 cases with invasion to pituitary fossa, but it did not cause any disorder of endocrine. The right subfrontal approach to remove the tumor must be done carefully with possible complications such as hematoma, brain contusion or edema or infarction as Fiume et al. [2] touched upon. These are very dangerous complications and can lead to death. Besides, there are still other complications such as damaging vessels and nerves around the tumor such as internal carotid artery, anterior cerebral artery, Heubner artery, hypothalamic artery, perforating artery and posterior cerebral artery and nerves such as II and III cranial nerves. In this series, none of the above complications was involved. There were only two cases of epilepsy after the operation, which account for 7.6%. The compression of surrounding structures still depends on the size of tumor. There were 12 cases larger than 4 cm in diameter invaded to cavernous sinus but not affecting cranial nerves. Our patients did not have these complications, although the tumors were at II and III degrees, and this matter coincides with many authors as. To evaluate the quality of life after operation, we have used Karnofsky’s classification with 26 patients who gained index 100 marks, and so they returned to work and live normally. Nowadays, besides the surgical method, some authors have used X-knife and Gammaknife to treat TSM that has grade I like the above classification. There were no cases in our series that used this method. 5. Conclusion TSMs are usually benign tumors, with slow development; its tendency going up to suprasellae and compressing the optic nerve and chiasm as an early clinical appearance. CT scan and MRI will give an exact diagnosis. Microsurgery to remove the entire tumor should be used to avoid damage in the optic nerve and to keep other complications to a minimum. References [1] K. Ohta, K. Yasuo, M. Morikawa, T. Nagashima, N. Tamaki, Treatment of tuberculum sellae meningiomas: a long term follow up study, J. Clin. Neurosci. 8 (Suppl. 1) (2001 May) 26 – 31. [2] D. Fiume, F. Caputi, R. Gazzeri, Daphragma sellae meningiomas. Report of two cases and a review of the literature, J. Neurosurg. Sci. 45 (1) (2001 Mar.) 38 – 42. [3] S. Matsumoto, M. Hayase, H. Imamura, Y. Oda, H. Kikuchi, M. Katayama, T. Ishihara, A case of intrasellar meningioma mimicking pituitary adenoma, No-Shinkei-Geka 29 (6) (2001 June) 551 – 557. [4] O. Al-Mefty, Operative Atlas of Meningiomas, Lippincott-Raven, Philadelphia, 1998, pp. 1 – 23. [5] D.-M. Long, The treatment of meningiomasin the region of the cavernous sinus, Childs Nerv. Syst. 17 (3) (2001 Feb.) 168 – 172. [6] W.C. Shen, C.A. Chenn, C.T. Hsue, T.Y. Lin, Dural cavernous angioma mimicking a meningioma and causing facial pain, J. Neurosurg. 10 (3) (2000 July) 183 – 185. [7] M.I.J. Apuzzo, Brain Surgery, Churchill Livingstone, New York, 1993. [8] R.H Winkin, S.S. Rengachary, Neurosurgery, McGraw-Hill, New York, 1985, pp. 664 – 667.
www.ics-elsevier.com
Microsurgery with 26 cases of tuberculum sellae meningiomas Vo Van Nho *, Nguyen Phong Department of Neurosurgery, Cho Ray Hospital, Ho Chi Minh City, Viet Nam Received in revised form 14 July 2003; accepted 31 July 2003
Abstract. Objective: The long-term outcome of the total removal of the tuberculum sellae meningiomas (TSM) with microsurgery through the subfrontal approach was fully evaluated in 26 cases. Methods: To make an accurate diagnosis before operation using CT scan, magnetic resonance imaging (MRI) and digital subtraction angiography, with evaluation of visual field and acuity. Applying the right subfrontal approach to these tumors. Result: Of 26 cases where microsurgery was performed, there were 4 patients who became completely blind in 1 eye, 2 patients remained 4/10 in visual acuity and 2 other patients with 6/10 in the left visual acuity. Fourteen patients had reduced visual acuity in both eyes and eight patients had reduced visual acuity only in one eye. In these 26 patients, mild and moderate headache occurred. Endocrinological feature did not appear in any of these patients. The size of the tumor was arranged into four groups with the diameter as small (under 2 cm: 0 patients), moderate (2 – 3 cm: 6 patients), large (3 – 4 cm: 16 patients) and giant (>4 cm: 4 patients). Twenty-five patients underwent microsurgery to remove the tumor completely with excellent outcome, and in one case there remained a small part due to too much more neovascular and a second operation was performed 3 months after the first operation to rule out this remaining completely. Conclusion: In general, in order to obtain a better outcome, the TSM must be diagnosed early and the operation must be performed in time. D 2003 Published by Elsevier B.V. Keywords: Meningiomas; Imaging; Subfrontal approach
1. Introduction Tuberculum sellae meningiomas (TSM) is rare, about 17% among supra and infratentorial meningiomas. Symptoms of this tumor are not clear; when this tumor gradually grows, it will block the eyesight interfering field and cause a decrease of vision in one or both eyes depending on its growth; however, this tumor can cause the state of hemianopsia the same as pituitary tumors. Headache is the first sign in TSM. This tumor can be discovered early by use of CT scan and magnetic resonance imaging (MRI). Digital subtruction angiogramme (DSA) is used to evaluate clearly and completely the blood * Corresponding author. Fax: +84-8855-7267. E-mail address: [email protected] (V.V. Nho). 0531-5131/ D 2003 Published by Elsevier B.V. doi:10.1016/S0531-5131(03)01209-3
66
V.V. Nho, N. Phong / International Congress Series 1259 (2004) 65–69
vessels which are bringing up the tumor. The best treatment is still microsurgery to remove the entire tumor. If the dimension of the tumor is medium or small, the tumor is removed more easily, there are less complications and a better quality of life. 2. Clinical material and methods Prospective research with data of 26 cases from April 1997 to March 2003. Research based on clinical examination: – – – –
Measurement of visual acuity Measurement of visual field Picture of fundus Endocrine as prolactin, GH, cortisol
Diagnosis is based on CT scan, MRI and DSA with the following classification of tumor as: Grade
I (small)
II (moderate)
III (large)
IV (giant)
Size (cm)
<2
2–3
3–4
>4
With the right subfrontal, a trans-cranial approach was applied. Evaluating the result post-operation: 1. Repeat CT scan and MRI to ensure that the entire tumor was removed. 2. Evaluation of the result of recovery of visual acuity after surgery. 3. Evaluation of the quality of life based on the KARNOFSKY classification. 3. Results Twenty-six cases: 21 females and 5 males. Evaluation of vision pre- and post-operation: Pre-operation
Blind one eye
Blind two eyes
Decrease visual one eye
Decrease visual two eyes
Disorder endocrine
Cases Recovering after surgery
4 no
0
8 better
14 better
0
Dimension of tumor and result of surgery: Grade
I
II
III
IV
Patient Removal of entire tumor
0 0
6 6
16 16
4 4
V.V. Nho, N. Phong / International Congress Series 1259 (2004) 65–69
Fig. 1.
Fig. 2.
Fig. 3.
67
68
V.V. Nho, N. Phong / International Congress Series 1259 (2004) 65–69
Evaluation of the quality of life based on Karnofsky’s classify table: 26 patients who had the entire tumor removed. All 26 post-operation cases have an index of 100 marks following Karnofsky’s classification (Figs. 1 – 3). 4. Discussion TSM occupy a low ratio with 1.7% compared to 9% of Ojemann in the total of intracranial meningiomas. There were 5 men and 21 women with an average age of 43.7 years compared to Ohta study of 4 men and 29 women with an average age of 46.7 years [1]. This kind of tumor grows very slowly, and its trend is to invade suprasellar region and to compress the optic nerve and chiasma. The earliest symptom is light headache in all 26 cases, then gradual reduction of the visual acuity. Visual acuity decreasing in both eyes in 14 patients and complete blindness of one eye in four patients are found in these data. Eight patients show decreased visual acuity in one eye. The sign of visual acuity decreasing strongly points to a lesion in the pituitary region. Because of this convincing sign, the patient should have a CE CT scan immediately to discover promptly the cause effecting the optic nerve. Among 26 cases that have the symptom of a gradual decrease in visual acuity in one or both eyes, we recommend performing a CT scan or MRI when the following symptoms are noted: – – – – –
Gradual decrease in visual acuity in one or both eyes. Pituitary fossa X-ray whether it is stretched or eroded. If visual field is affected by light or to a severe degree. Endocrine disorder. Diabetes insipidus.
There was a patient who was blind in one eye, vision of the left eye was 4/10; however, after removal of the entire tumor, up to 4 cm, his left eye was blind. After 1 week, the left eye gradually recovered and improved to 8/10 when he was discharged. We may think of the tumor as causing gradual compression on the optic nerve, but after the tumor was removed, suddenly it made the optic nerve slip through diaphragm membrane and led to blindness in the left eye. After that, perhaps high vein pressure pushed the optic nerve back to the former position, so the vision was restored. Most cases in our series are up to 3 cm in diameter, only six cases at grade II. Of course, the smaller the tumor, the easier the entire tumor is removed, so the result will be better and complications will be less. All 26 cases have undergone microsurgery through the right subfrontal approach to remove the entire tumor. The anatomy structure of this field has a lot of vessels and important nerves, such as optic nerve, the III cranial nerve, and the III, IV, VI and V1 nerve in cavernous sinus [6]. To eliminate a tumor in this region, it is necessary to preserve the optic nerve and chiasma as Ojemann [8] and Al-Mefty [4] touched upon. In this study, there was a case which a second operation was performed to remove tumor totally due to the tumor extended to the left middle fossa and into the left cavernous sinus causing blindness in the left eye. Most cases recovered vision after surgery to different degrees. The cases concerning one-eye complete blindness before the operation with optic atrophy were unable to recover after elimination of the tumor. This is emphasized by Matsumoto et al. [3], Long [5] and Apuzzo [7].
V.V. Nho, N. Phong / International Congress Series 1259 (2004) 65–69
69
After the symptom of visual reduction, early diagnosis is especially important in selecting a suitable treatment method for a small tumor, since the tumor will be easily eliminated and the preservation of vision will be better. When the tumor is invading the pituitary fossa, it can affect a disorder of endocrine and can be mistakenly diagnosed as pituitary tumors and craniopharyngiomas. Of these 26 cases, there were 3 cases with invasion to pituitary fossa, but it did not cause any disorder of endocrine. The right subfrontal approach to remove the tumor must be done carefully with possible complications such as hematoma, brain contusion or edema or infarction as Fiume et al. [2] touched upon. These are very dangerous complications and can lead to death. Besides, there are still other complications such as damaging vessels and nerves around the tumor such as internal carotid artery, anterior cerebral artery, Heubner artery, hypothalamic artery, perforating artery and posterior cerebral artery and nerves such as II and III cranial nerves. In this series, none of the above complications was involved. There were only two cases of epilepsy after the operation, which account for 7.6%. The compression of surrounding structures still depends on the size of tumor. There were 12 cases larger than 4 cm in diameter invaded to cavernous sinus but not affecting cranial nerves. Our patients did not have these complications, although the tumors were at II and III degrees, and this matter coincides with many authors as. To evaluate the quality of life after operation, we have used Karnofsky’s classification with 26 patients who gained index 100 marks, and so they returned to work and live normally. Nowadays, besides the surgical method, some authors have used X-knife and Gammaknife to treat TSM that has grade I like the above classification. There were no cases in our series that used this method. 5. Conclusion TSMs are usually benign tumors, with slow development; its tendency going up to suprasellae and compressing the optic nerve and chiasm as an early clinical appearance. CT scan and MRI will give an exact diagnosis. Microsurgery to remove the entire tumor should be used to avoid damage in the optic nerve and to keep other complications to a minimum. References [1] K. Ohta, K. Yasuo, M. Morikawa, T. Nagashima, N. Tamaki, Treatment of tuberculum sellae meningiomas: a long term follow up study, J. Clin. Neurosci. 8 (Suppl. 1) (2001 May) 26 – 31. [2] D. Fiume, F. Caputi, R. Gazzeri, Daphragma sellae meningiomas. Report of two cases and a review of the literature, J. Neurosurg. Sci. 45 (1) (2001 Mar.) 38 – 42. [3] S. Matsumoto, M. Hayase, H. Imamura, Y. Oda, H. Kikuchi, M. Katayama, T. Ishihara, A case of intrasellar meningioma mimicking pituitary adenoma, No-Shinkei-Geka 29 (6) (2001 June) 551 – 557. [4] O. Al-Mefty, Operative Atlas of Meningiomas, Lippincott-Raven, Philadelphia, 1998, pp. 1 – 23. [5] D.-M. Long, The treatment of meningiomasin the region of the cavernous sinus, Childs Nerv. Syst. 17 (3) (2001 Feb.) 168 – 172. [6] W.C. Shen, C.A. Chenn, C.T. Hsue, T.Y. Lin, Dural cavernous angioma mimicking a meningioma and causing facial pain, J. Neurosurg. 10 (3) (2000 July) 183 – 185. [7] M.I.J. Apuzzo, Brain Surgery, Churchill Livingstone, New York, 1993. [8] R.H Winkin, S.S. Rengachary, Neurosurgery, McGraw-Hill, New York, 1985, pp. 664 – 667.