Tuberculum sellae meningiomas: Microsurgical anatomy and surgical technique

OBJECTIVE: Despite Cushing's accurate description of the anatomic origin of tuberculum sellae meningiomas, many subsequent authors have included tumors originating from the neighboring sella region in this classification. This has led to difficulty in evaluating the surgical results and consensus for an optimal surgical technique. We think this confusion has arisen from Cushing's description of these tumors under the heading "suprasellar meningiomas," which referred to their distinctive clinical symptoms and not their anatomic origin. We describe the microsurgical anatomy and tumor growth patterns to reemphasize the original classification of Cushing's tuberculum sellae meningiomas. Additionally, we describe our surgical approach, which decreases the risk of injury to anterior visual pathways and anterior cerebral circulation arteries. METHODS: During a 19-year period, 23 patients with meningiomas arising from the tuberculum and diaphragma sellae underwent craniotomies at New York University Medical Center. The tumor size ranged from 2 to 5 cm. All patients presented with symptoms of visual dysfunction; 15 were asymmetrical. Magnetic resonance imaging with and without gadolinium differentiated these tumors from other suprasellar tumors with a high degree of accuracy. All patients underwent a pterional transsylvian approach. RESULTS: Twenty patients had total tumor removal, and three had subtotal tumor removal. There was one regrowth in the subtotal tumor removal group. Patients were observed for a mean follow-up time of 9.3 years (range, 3.6-18.5 yr). Visual acuity improved in 55%, was unchanged in 26%, and worsened in 19% of patients. Two of the oldest patients died from pulmonary complications, resulting in a mortality rate of 8.7%. CONCLUSION: We think that tuberculum and diaphragma sellae meningiomas are anatomically indistinguishable and should be termed tuberculum sellae meningioma. A pterional craniotomy with microsurgical dissection of the sylvian fissure allows access to these tumors with minimal neurological and ophthalmological morbidity.