Chowdhury Forhad H, Haque Mohammod R, Goel Atul H, Kawsar Khandkar A
Department of Neurosurgery, Dhaka Medical College Hospital, Dhaka, Bangladesh.
Br J Neurosurg. 2012 Oct;26(5):692-9. doi: 10.3109/02688697.2012.673648. Epub 2012 Apr 6.
Tuberculum sellae meningiomas (TSMs) are usually removed through a transcranial approach. Recently, the sublabial transsphenoidal microscopic approach has been used to remove such tumours. More recently, endonasal extended transsphenoidal approach is getting popular for removal of tuberculum sellae meningioma. Here, we describe our initial experience of endonasal extended transsphenoidal approach for removal of suprasellar meningiomas in six consecutive cases.
Six patients (four female and two male) who presented for headache and visual loss were investigated with MRI of brain that showed tuberculum sellae meningioma compressing visual apparatus. Average size was 3 × 3 cm in three cases and 4 × 4 cm in rest of the three. All patients underwent endoscopic endonasal extended transsphenoidal tumour removal, but in two patients with large tumour, microscopic assistance was needed. Complete tumour removal was done in all cases except one case where perforators seemed to be encased by the tumour and resulted in incomplete removal. The surgical dural and bony defects were repaired in all patients with thigh fat graft. Nasal packing was not used, but inflated balloon of Foley's catheter was used to keep fat in position.
There was mild postoperative cerebrospinal fluid (CSF) leakage in one patient on the fourth postoperative day after removal of lumbar CSF drain and stopped spontaneously on the seventh postoperative day. There were no postoperative CSF leaks or meningitis in the rest of the cases. In one patient, there was visual deterioration due to pressure on optic nerve by grafted fat and improved within 4 weeks. At 4 months after surgery, three patients had normal vision, two patients improved vision comparing with that of preoperative state but with some persisting deficit; one patient had static vision, no new endocrinopathy and no residual tumour on MRI in five cases but residual tumour in remaining case was static at the end of the ninth month.
The endoscopic endonasal extended transsphenoidal approach appears to be an effective minimally invasive method for removing relatively small to medium tuberculum sellae meningiomas. With more experience of the surgeon, larger tuberculum sellae meningioma may be removed by purely endoscopic techniques in near future.
鞍结节脑膜瘤（TSMs）通常通过经颅入路切除。近来，经唇下经蝶窦显微镜入路已被用于切除此类肿瘤。更近一些时候，鼻内镜扩大经蝶窦入路在鞍结节脑膜瘤切除中越来越受欢迎。在此，我们描述连续6例经鼻内镜扩大经蝶窦入路切除鞍上脑膜瘤的初步经验。
6例因头痛和视力丧失就诊的患者接受脑部MRI检查，显示鞍结节脑膜瘤压迫视觉器官。3例肿瘤平均大小为3×3 cm，其余3例为4×4 cm。所有患者均接受内镜下经鼻扩大经蝶窦肿瘤切除术，但2例肿瘤较大的患者需要显微镜辅助。除1例穿支血管似乎被肿瘤包裹导致切除不完全外，所有病例均实现肿瘤全切。所有患者均用大腿脂肪移植修复手术造成的硬脑膜和骨缺损。未使用鼻腔填塞，但使用福勒氏导尿管的充气气囊将脂肪固定在位。
1例患者在拔除腰大池脑脊液引流管后术后第4天出现轻度脑脊液（CSF）漏，术后第7天自行停止。其余病例术后无脑脊液漏或脑膜炎发生。1例患者因移植脂肪对视神经产生压迫导致视力恶化，4周内好转。术后4个月，3例患者视力正常，2例患者视力较术前有所改善但仍有一些持续的缺损；1例患者视力无变化，5例患者无新发内分泌病变且MRI检查无残留肿瘤，但其余1例患者在术后第9个月末残留肿瘤无变化。
内镜下经鼻扩大经蝶窦入路似乎是切除相对较小至中等大小鞍结节脑膜瘤的一种有效的微创方法。随着术者经验的增加，在不久的将来，更大的鞍结节脑膜瘤可能通过单纯内镜技术切除。
