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

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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.



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    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.

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    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.

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    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.

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    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.

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    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.



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