Selection of endoscopic or transcranial surgery for tuberculum sellae meningiomas according to specific anatomical features: a retrospective multicenter analysis (KOSEN-002)

Restricted access



The endoscopic endonasal approach (EEA) and the transcranial approach (TCA) are good options for the treatment of tuberculum sellae (TS) meningiomas. The objective of this study was to identify the key anatomical features in TS meningiomas and compare the two surgical approaches.


The authors retrospectively reviewed clinical data in 178 patients with TS meningiomas treated at 3 institutions between January 2010 and July 2016. Patients with tumors encasing the internal carotid artery or anterior cerebral artery or involving the anterior clinoid process or cavernous sinus were excluded. Tumors were classified as high-lying or low-lying based on their location, and involvement of the optic canal was evaluated. The surgical outcomes of EEA and TCA were analyzed according to the relevant anatomical features.


During the study period, 84 patients underwent EEA and 94 patients underwent TCA. Based on preoperative MR images, 43 (24.2%) meningiomas were classified as high-lying tumors, 126 (70.8%) as low-lying, and 9 (5.0%) as nonspecific. Gross-total resection (GTR) was performed in 145 patients (81.5%); the GTR rate did not differ significantly between the EEA and TCA groups. Of 157 patients with preoperative visual disturbance, 140 had improved or stable vision postoperatively. However, 17 patients (9.6%) experienced some visual deterioration after surgery. The TCA group had a worse visual outcome than the EEA group in patients with preoperative optic canal involvement (77.6% vs 93.2%, p = 0.019), whereas there was no significant difference in visual outcome based on whether tumors were high-lying or low-lying.


The results of this study support EEA over TCA, at least with respect to visual improvement with acceptable complications, although TCA is still an effective approach for TS meningioma.

ABBREVIATIONS EEA = endoscopic endonasal approach; GTR = gross-total resection; KOSEN = Korean Society of Endoscopic Neurosurgery; MPR = multiplanar reconstruction; PS = planum sphenoidale; TCA = transcranial approach; TS = tuberculum sellae; VIS = visual impairment score.

Article Information

Correspondence Yong Hwy Kim: Seoul National University Hospital, Seoul, Republic of Korea.

INCLUDE WHEN CITING Published online May 18, 2018; DOI: 10.3171/2017.11.JNS171337.

D.S.K. and C.K.H. contributed equally to this work.

Disclosures The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

© AANS, except where prohibited by US copyright law.



  • View in gallery

    Morphological measurement of TS meningioma on a sagittal T1-weighted MR image. The planum height (a) is defined as the distance from the frontobasal line (line passing through the anterior [white arrowhead, left] and posterior [white arrowhead, right] ends of the cribriform plate) to the top of the planum. The sella depth (b) is defined as the length from the TS to the deepest portion of the tumor within the sella.

  • View in gallery

    Schematic drawing of TS meningioma. Meningioma usually arises from the dura over the TS and extends to the PS and sellar fossa. A: Typical shape of TS meningioma. B: High-lying tumor with pneumosinus dilatans. High-lying tumors were defined in this study as meningiomas with pneumosinus dilatans > 5 mm above the frontobasal line. C: Tumor involving the optic canal on the right side. D: Low-lying tumor extending into the sella > 5 mm below the tuberculum. The black arrowheads indicate the anterior and posterior points of cribriform plate. Copyright Yong Hwy Kim. Published with permission.

  • View in gallery

    Midsagittal Gd-enhanced T1-weighted MR image obtained in a 34-year-old woman who presented with the visual disturbance. The image shows a tumor of the high-lying category, defined as TS meningiomas with pneumosinus dilatans > 5 mm above the frontobasal line (measurement indicated by double-headed arrow), which may require more cerebral retraction during surgery.

  • View in gallery

    Left: Midsagittal Gd-enhanced T1-weighted MR image obtained in a 64-year-old woman demonstrating a low-lying TS meningioma extending into the sella > 5 mm below the tuberculum (double-headed arrow indicates 5 mm, for reference). Right: Midsagittal Gd-enhanced T1-weighted MR image obtained in a 57-year-old woman showing another example of a low-lying TS meningioma. The double-headed arrow indicates the length of 5 mm.

  • View in gallery

    Left: Coronal view of 3D multiplanar MR image obtained in a 43-year-old woman showing a meningioma involving the optic canal on the right side (arrow). Right: Coronal Gd-enhanced T1-weighted MR image obtained in a 36-year-old woman showing a tumor without optic canal involvement.



Arai HSato KOkudaMiyajima MHishii MNakanishi H: Transcranial transsphenoidal approach for tuberculum sellae meningiomas. Acta Neurochir (Wien) 142:7517572000


Attia MKandasamy JJakimovski DBedrosian JAlimi MLee DL: The importance and timing of optic canal exploration and decompression during endoscopic endonasal resection of tuberculum sella and planum sphenoidale meningiomas. Neurosurgery 71 (1 Suppl Operative):58672012


Bander EDSingh HOgilvie CBCusic RCPisapia DJTsiouris AJ: Endoscopic endonasal versus transcranial approach to tuberculum sellae and planum sphenoidale meningiomas in a similar cohort of patients. J Neurosurg 128:40482018


Bassiouni HAsgari SStolke D: Tuberculum sellae meningiomas: functional outcome in a consecutive series treated microsurgically. Surg Neurol 66:37452006


Chicani CFMiller NR: Visual outcome in surgically treated suprasellar meningiomas. J Neuroophthalmol 23:3102003


Clark AJJahangiri AGarcia RMGeorge JRSughrue MEMcDermott MW: Endoscopic surgery for tuberculum sellae meningiomas: a systematic review and meta-analysis. Neurosurg Rev 36:3493592013


de Divitiis EEsposito FCappabianca PCavallo LMde Divitiis O: Tuberculum sellae meningiomas: high route or low route? A series of 51 consecutive cases. Neurosurgery 62:5565632008


de Notaris MSolari DCavallo LMD’Enza AIEnseñat JBerenguer J: The “suprasellar notch,” or the tuberculum sellae as seen from below: definition, features, and clinical implications from an endoscopic endonasal perspective. J Neurosurg 116:6226292012


Fahlbusch RSchott W: Pterional surgery of meningiomas of the tuberculum sellae and planum sphenoidale: surgical results with special consideration of ophthalmological and endocrinological outcomes. J Neurosurg 96:2352432002


Hayhurst CTeo C: Tuberculum sella meningioma. Otolaryngol Clin North Am 44:953963 viii–ix2011


Hirst LWMiller NRHodges FJ IIICorbett JJThompson S: Sphenoid pneumosinus dilatans. A sign of meningioma originating in the optic canal. Neuroradiology 22:2072101982


Kane AJSughrue MERutkowski MJShangari GFang SMcDermott MW: Anatomic location is a risk factor for atypical and malignant meningiomas. Cancer 117:127212782011


Lee JHJeun SSEvans JKosmorsky G: Surgical management of clinoidal meningiomas. Neurosurgery 48:101210212001


Li-Hua CLing CLi-Xu L: Microsurgical management of tuberculum sellae meningiomas by the frontolateral approach: surgical technique and visual outcome. Clin Neurol Neurosurg 113:39472011


Linsler SFischer GSkliarenko VStadie AOertel J: Endoscopic assisted supraorbital keyhole approach or endoscopic endonasal approach in cases of tuberculum sellae meningioma: which surgical route should be favored? World Neurosurg 104:6016112017


Mahmoud MNader RAl-Mefty O: Optic canal involvement in tuberculum sellae meningiomas: influence on approach, recurrence, and visual recovery. Neurosurgery 67:ons108ons1192010


Makarenko SCarreras EMAkagami R: Craniotomy for perisellar meningiomas: comparison of simple (appropriate for endoscopic approach) versus complex anatomy and surgical outcomes. J Neurosurg 126:119112002017


Margalit NSLesser JBMoche JSen C: Meningiomas involving the optic nerve: technical aspects and outcomes for a series of 50 patients. Neurosurgery 53:5235332003


Mathiesen TKihlström L: Visual outcome of tuberculum sellae meningiomas after extradural optic nerve decompression. Neurosurgery 59:5705762006


Morisako HGoto TGoto HBohoun CATamrakar SOhata K: Aggressive surgery based on an anatomical subclassification of craniopharyngiomas. Neurosurg Focus 41(6):E102016


Nanda AKonar SKMaiti TKBir SCGuthikonda B: Stratification of predictive factors to assess resectability and surgical outcome in clinoidal meningioma. Clin Neurol Neurosurg 142:31372016


Nozaki KKikuta KTakagi YMineharu YTakahashi JAHashimoto N: Effect of early optic canal unroofing on the outcome of visual functions in surgery for meningiomas of the tuberculum sellae and planum sphenoidale. Neurosurgery 62:8398462008


Pamir MNOzduman KBelirgen MKilic TOzek MM: Outcome determinants of pterional surgery for tuberculum sellae meningiomas. Acta Neurochir (Wien) 147:112111302005


Park HHOh MCKim EHKim CYKim SHLee KS: Use of optical coherence tomography to predict visual outcome in parachiasmal meningioma. J Neurosurg 123:148914992015


Park WHong SDNam DHKong DSRyu GKim HY: Nasoseptal flap elevation in patients with history of septal surgery: does it increase flap failure or cerebrospinal fluid leakage? World Neurosurg 93:1641672016


Sade BLee JH: High incidence of optic canal involvement in tuberculum sellae meningiomas: rationale for aggressive skull base approach. Surg Neurol 72:1181232009


Schick UHassler W: Surgical management of tuberculum sellae meningiomas: involvement of the optic canal and visual outcome. J Neurol Neurosurg Psychiatry 76:9779832005


Seol HJPark HYNam DHKong DSLee JIKim JH: Clinical outcomes of tuberculum sellae meningiomas focusing on reversibility of postoperative visual function. Acta Neurochir (Wien) 155:25312013


Song SWKim YHKim JWPark CKKim JEKim DG: Outcomes after transcranial and endoscopic endonasal approach for tuberculum meningiomas—a retrospective comparison. World Neurosurg 109:e434e4452018


Taha ANErkmen KDunn IFPravdenkova SAl-Mefty O: Meningiomas involving the optic canal: pattern of involvement and implications for surgical technique. Neurosurg Focus 30(5):E122011


Zada GFredrickson VLWrobel BB: Extended endoscopic endonasal approach for resection of tuberculum sellae meningioma. Neurosurg Focus 43 (VideoSuppl2):V22017


Zevgaridis DMedele RJMüller AHischa ACSteiger HJ: Meningiomas of the sellar region presenting with visual impairment: impact of various prognostic factors on surgical outcome in 62 patients. Acta Neurochir (Wien) 143:4714762001




All Time Past Year Past 30 Days
Abstract Views 97 97 97
Full Text Views 58 58 58
PDF Downloads 68 68 68
EPUB Downloads 0 0 0


Google Scholar