Preopertive patients’ clinical history and neurological examination were reviewed with special attention to data related to pituitary endocrine axis and cranial nerve affection and intracranial hypertension.

All patients underwent CT scan of the brain with and without contrast, magnetic resonance imaging (MRI) brain. Cerebral CT-Angiography in large lesions, were used in some patients for surgical planning.

Surgery was performed under general anesthesia using the operating microscope and microsurgical instrumentation in all patients. Tumors were operated via: the pterional and subfrontal approaches.

Pterional approach was chosen with:

● Small lesions

● Large frontal air sinuses

● Suprasellar and/or parasellar extension

● Severe optic nerve compression on one side

Subfrontal approach was chosen with:

● Large lesions

● Extension to the planum

● Severe optic nerve compression on both sides

A standard pterional approach was used in 10 patients and unilateral subfrontal approach in 7 patients. The surgical techniques were similar to previous descriptions and reports [13] [30]. In both approaches we preferred to operate through the same side of larger tumor extension and/or more manifest optic nerve affection, otherwise, we preferred to operate through the right non dominant side.

Intraoperative and postoperative results and complications were reviewed and analysed. Follw up data in our outpatient clinic for all patients were evaluated and presented.

Out of 17 patients with tuberculem sellae meningiomas: 12 were females (70%) and 5 were males (30%). Age varied from 33 years to 65 years with a mean value of 46.3 years.

The most common symptom was decreased vision and headache (100%), while the most common sign was bitemporal hemianopia (82%).

Suprasellar extension was evident in 82% of cases while bilateral optic nerve encasement was found in 18% of cases with the tumor invading the cavernous sinus and encasing anterior cereberal arteries.

Pterional approach was used in 59% of cases and Subfrontal approach was used in 41% of cases.

Extent of tumor resection:

Out of 17 patients gross total resection was achieved in 14 patients (82%). Residual tumors in the two cases were related to either the carotid artery or anterior cerebral artery that were adherent to these vessels, for which a more aggressive dissection was judged to be injurious. The third case subtotal resection was accepted due to a calcified portion of the lesion extending toward the brainstem, that could not be removed. The dural attachement at the tuberculum sellae and planum sphenoidale was thoroughly coagulated with bipolar cautery in all patients. Histopathologically all tumors were WHO grade I meningiomas.

Postoperative visual outcome analysis was performed by ophthalmologist for 16 patients postoperatively. Visual acuity improved in 8 patients (50%), remained unchanged in 7 patients (43%), and worsened in one patient (7%) of patients. One patient died before evaluation of post-operative vision.

Post-operative haematoma in tumor bed occurred in 1 patient and was small hematoma and managed conservatively. Another patient developed post-operative transient Diabetes inspidus and treated medically and improved within 1 week of surgery.

Mortality: 1 patient developed post-operative status epilepticus and died in ICU the second day of operation.

Here we present 2 cases of our series:

The first case was 45 years old female complaining of headache and diminution

of vision. Clinical and visual field examination showed bitemporal hemianopia and MRI brain showed tuberculem sellae meningioma with suprasellar extension. Figure 1 shows gross total removal via right subfrontal approach.

The second case was 52 years old female presented with headache and diminution of vision. Visual field examination showed bitemporal hemianopia and CT and MRI brain showed tuberculem sellae meningioma with suprasellar extension. Figure 2 shows operative view and postoperative gross total removal via Rt pterional approach.

In the literature, the overall morbidity and mortality rate associated with resection of tuberculum sellae meningiomas is quite low [31] [32] [33]. Morbidity has been divided into two types; ophthalmological or non ophthalmological. Causes of non ophthalmological morbidity may require surgical or just medical treatment. Postoperative complications such as cerebrospinal fluid leak (CSF), postoperative hematomas, infections, and psychotic alterations [10]. However in our series Post-operative haematoma occurred in 1 patient (5.9%) and was small hematoma and managed conservatively and no deterioration occurred for the patient. One patient (5.9%) developed post-operative transient Diabetes inspidus and improved spontaneously after 1 week of surgery without medication. There were no CSF leak or infection.

Mortality rates ranging from 0% in recent series [10] up to 67% have been reported in old series [10] [28]. Series with no fatalities have been reported during the last two decades with advance of technique and facilities and modern neuroanesthesia [10]. Death has been reported to depend on the size of the tumor [4] [17] [20] [32]. Brihaye and Brihaye-Van Geertruyden [7] reported higher mortality rates in patients with tumors exceeding 3 cm in diameter (7.1% - 44%). In our series mortality rate is about (5.9%); there was one male patient who died as he developed post-operative status epilepticus and cardiac arrest.

Suprasellar meningiomas usually present with visual deterioration, including decreased visual acuity and/or visual field defects due to affection of the optic nerves and optic chiasm. In addition, they may encase major blood vessels, thus compromising the possibility for total resection. So one of the main aims of surgery is to relief the optic apparatus compression, allowing for visual recovery [25] [34]. Improvement in vision has been reported in 40% to 80% of patients undergoing surgery [6] [10] [25] [33] [34]. No change in visual status has been reported in 18% to 40%, whereas worsened vision has been reported in 17% to 20% [10] [26]. In this series there were 17 patients diagnosed with tuberculum sellae meningiomas who underwent surgical removal over a 4-year period. The mean follow-up duration was 12 months. Visual acuity improved in 8 patients (47%), remained unchanged in 7 patients (41%), and worsened in one patient (5.9%) of patients.

A review of old the literature, there is a stress on that complete tumor resection should not be achieved at the cost of increased rates of morbidity, especially the risk of visual deterioration and hypothalamic dysfunction [9] [24] but in recent microsurgical series, there were high rates of complete tumor resection ranged from 35% to 100%. The extent of tumor resection has improved with the advent of modern microsurgery [1] [5] [17].

In our series, there was only 3 patients patients (18%) in whom there was subtotal resection of a meningioma was achieved, residual tumor in the two cases were related to either the carotid artery or anterior cerebral artery that were very adherent to these vessels, for which a more aggressive dissection and resection was judged to be injurious. The third case subtotal resction was considered due to a calcified portion of the lesion extending toward the brainstem that could not be removed. The percentage of Gross total resection in this series is about 82%.