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S201: TUBERCULUM SELLAE MENINGIOMAS: ANATOMICAL DETERMINANTS OF SURGICAL APPROACH
Silky Chotai, MD; Alan J Gordillo; Aritra Nag, MD; Erion De Andrade, MD; Pranay Soni, MD; Varun Kshettry, MD; Pablo Recinos, MD; Cleveland Clinic Lerner College of Medicine of Case Western Reserve University

Introduction: Endoscopic endonasal (EEA) and transcranial (TCA) approaches for tuberculum sellae meningiomas (TSMs)  have advantages and limitations. This study aimed to identify anatomical factors influencing surgical approach selection.

Methods: TSM surgeries between 2014–2024 were reviewed, excluding tumors centered on the planum, extending to the olfactory groove, or multiple anterior skull base tumors. Preoperative MRI and CT sinus were reviewed for anatomical and tumor-specific features (Table). Univariable and multivariable analyses were performed.

Results: Total 82 patients were analyzed (EEA,n=43; TC,n=39). Most patients with ACA encasement (64% vs 30%, p=0.002) and those with extent of tumor >1mm lateral to the cisternal segment of the optic nerve underwent TCA (p<0.001). Tumors with larger maximum diameter (2.8±0.8 cm vs. 2.1±0.8 cm,p<0.001) and wider dural base at TS (25.2 ± 5.3 vs. 21.4 ± 5.6, p=0.002) underwent TCA. The optic canal invasion did not impact the approach selection. The patients with bilateral optic nerve compression were more likely to undergo TCA (84.6% vs. 48.8%). The rates of GTR (72.1% vs. 74.4%,p =0.508), preoperative visual deficits (81.6% vs. 77.5%,p=0.201), and postoperative improvement were similar (61.3% vs. 67.7%,p=0.435). Adjusting for ACA encasement, tumor size, extent of optic canal invasion, and widest dural base, the lateral tumor extent significantly influenced surgical approach selection (OR=2.63, p=0.019).

Conclusion: In a single-center study where there is equipoise in the approach selection for TSM, we demonstrate that the tumor extent >1 mm lateral to the cisternal segment of the optic nerve is a key determinant of approach selection. ACA encasement, larger tumors, and wider dural base also favored TCA. Both EEA and TCAs achieve comparable GTR and visual outcomes. 

	Endocopic (n=43)	Transcranial (n=39)	p-value
ACA encasement	13(30.2%)	25(64.1%)	0.002
ICA encasement	6(14%)	7(17.9%)	0.423
Optic canal invasion	42(97.7%)	38(97.4%)	0.728
<3 mm	26 (61.9%)	26 (68.4%)	0.354
>3 mm	16(38.1%)	12(31.6%)
Optic nerves			0.01
Not involved	1(2.4%)	0
Unilateral compressed	13(31.7%)	0
Bilateral compressed	20(48.8%)	33(84.6%)
Abutting	5(12.2%)	1(2.6%)
Thinned	2(4.9%)	5(12.8%)
Interoptic distance	16.6±1.9	17.1±2.1	0.201
Lateral extent of tumor			<0.001
No	37(86%)	20(51.3%)
<1 mm	6(13.9%)	7(17.9%)
>1 mm	0	12(30.8%)
Pneumatization			0.078
Pre-sellar	4(9.5%)	7(17.9%)
Sellar	10(23.8%)	13(33.3%)
Post-sellar	28(66.7%)	19(48.7%)
Angle of sella	107.8±9.2	110.7±12.2	0.241
Widest dural base (mm)	21.4±5.6	25.2±5.3	0.002
Tumor diameter (cm)	2.1±0.8	2.8±0.8	<0.001

 

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