2026 Poster Presentations
P130: REFINING SURGICAL APPROACH SELECTION FOR TUBERCULUM SELLAE MENINGIOMAS: A RETROSPECTIVE COHORT STUDY
Danielle Golub, MD, MSCI1; Joshua D McBriar, MD1; Harshal A Shah, BS1; Ehsan Dowlati, MD2; Daniele Starnoni, MD1; Mark B Chaskes, MD3; Judd H Fastenberg, MD3; Amir R Dehdashti1; 1Department of Neurosurgery, Northwell Health, Manhasset, New York, USA; 2Department of Neurosurgery, Georgetown University School of Medicine, Washington, DC, USA; 3Department of Otolaryngology-Head and Neck Surgery, Northwell Health, Manhasset, NY, USA
Background: Tuberculum sellae meningiomas (TSMs) remain a significant surgical challenge due to their proximity to critical neurovascular structures at the anterior skull base, particularly the optic nerves and the supraclinoid carotid arteries. Several grading systems for predicting the morbidity associated with surgical resection of TSMs (especially with regards to visual outcomes) have been well-described. For example, the UCSF score estimates visual outcomes and extent of resection based on tumor size and extent of carotid artery and optic canal involvement. The comparative efficacy of endoscopic endonasal (EEN) versus transcranial approaches remains a subject of ongoing debate, particularly for lesions with high UCSF scores.
Methods: Retrospective chart review from 2016–2024 of all cases involving surgical resection of a TSM in adult patients by the senior author was performed. TSMs were defined as having a PS/TS ratio ≤ 0.5 as previously described by Henderson et al. (2023): The orthogonal distance along the tumor in the midsagittal plane is measured both anterior (PS) and posterior (TS) to a line drawn through the center of the tuberculum sellae perpendicular to the planum sphenoidale; the TS/PS ratio [PS/(TS + PS)] is then calculated. Cases with a PS/TS ratio > 0.5 were considered planum sphenoidale meningiomas and were excluded from further analysis. Patient presentation, imaging features including tumor morphological details, surgical, pathology, and clinical outcomes data were systematically extracted from patient charts.
Results: A total of 21 TSM cases were identified with a mean age of 53.8 years (range 34–82 years) with a majority of female patients (80.9%). Mean follow-up was 28.2 months. A transcranial approach was employed in 16 cases (76.2%) and an EEN approach was used in 5 cases (23.8%). Transcranial approaches most commonly involved a lateral supraorbital craniotomy (81.2%), a bifrontal craniotomy (12.5%), or a cranio-orbito-zygomatic approach (6.3%). There were no major differences in patient comorbidities or presenting symptoms between the transcranial and EEN cases, however the majority of the EEN cases (n=3, 60%) were notably re-resections. Transcranial cases involved larger tumors (largest diameter 3.3cm vs. 2.0cm, p=0.034*), with a higher PS/TS ratio (0.46 vs. 0.20, p=0.024*), and had a higher UCSF Artery Score (1.8 vs. 1.0, p=0.047*). The degree of optic canal invasion, sellar extension, sphenoid sinus extension, ACA involvement, and peritumoral edema were similar between the transcranial and EEN groups. Additionally, there were no significant differences in surgical time, estimated blood loss, extent of resection, pathological findings, or visual outcomes. However, two EEN cases (40.0%) required further interventions to manage postoperative cerebrospinal fluid leaks while there were no leaks observed in the transcranial group. Additionally, two ischemic strokes with only transient focal symptoms were seen only in the transcranial group (12.5%), both involving the artery of Hubner territory.
Conclusions: This retrospective cohort series, while limited by sample size and single-surgeon experience, validates the utility of the existing TSM scoring systems and provides a basis for further exploration of the benefits and limitations of transcranial and EEN approaches for TSMs.