UNASSIGNED: Coexisting intracranial pathologies of distinct etiology which require intervention are rare. Only a handful of cases have been reported in the literature. The effects of each treatment option on both pathologies need to be considered during management. We describe the first report of the management of a patient with concurrent symptomatic tuberculum sellae meningioma (TSM) and idiopathic intracranial hypertension (IIH).
UNASSIGNED: A 58-year-old male presented with 2 weeks of vision loss and 3 months of headaches. He was found to have an inferior hemi-field deficit in the left eye and bilateral papilledema. Imaging studies revealed bilateral transverse sinus stenosis and a TSM abutting the left optic nerve. The opening pressure was 40 cmH2O. An expanded-endoscopic endonasal approach was performed for mass resection. Intraoperatively, a lumbar drain was placed to aid skull base repair integrity before definitive treatment was obtained. On postoperative day 9, a right transverse-sigmoid sinus stent was placed for IIH treatment. The patient was discharged the following day.
UNASSIGNED: Our management of this patient targeted the etiologies of each symptomatic pathology. Stenting provided treatment for the IIH and mass resection for the vision loss. Both the order and approaches to treatment were felt to maximize patient benefit while minimizing harm.

OBJECTIVE: This study compared the effectiveness of the endoscopic endonasal approach (EEA) with the conventional transcranial approach (TCA) for treating tuberculum sellae meningiomas (TSMs), aiming to identify the superior surgical method and the risk factors affecting outcomes.
METHODS: Patients treated for TSM from 1998 to 2023 at our institution were retrospectively analyzed, evaluating patient characteristics, tumor features, outcomes, and complications. A novel grading system for preoperative evaluation of TSMs was proposed.
RESULTS: Among 49 patients, 26 underwent EEA and 23 underwent TCA. The maximum diameters were comparable between the groups (mean 22 mm vs. 23 mm). Gross total resection rates were 62% for EEA and 70% for TCA, showing no significant difference. However, postsurgical visual improvement was significantly higher in the EEA group compared with the TCA group (77% vs. 44%; P = 0.020), with fewer complications in the EEA group (8% vs. 35%; P = 0.032).
CONCLUSIONS: EEA is a safe and effective treatment approach for small to medium TSMs, with outcomes comparable to TCA in terms of resection but superior in visual improvement and fewer complications. Selection of surgical approach should consider patient and tumor characteristics as well as surgeon experience.

Background/Objectives: Tuberculum sellae meningiomas (TSMs) constitute 5-10% of intracranial meningiomas, often causing visual impairment. Traditional microsurgical transcranial approaches (MTAs) have been effective, but the emergence of innovative surgical trajectories, such as endoscopic endonasal approaches (EEAs), has sparked debate. While EEAs offer advantages like reduced brain retraction, they are linked to higher cerebrospinal fluid leak (CSF leak) risk. This meta-analysis aims to comprehensively compare the efficacy and safety of EEAs and MTAs for the resection of TSMs, offering insights into their respective outcomes and complications. Methods: A comprehensive literature review of the databases PubMed, Ovid MEDLINE, and Ovid EMBASE was conducted for articles published on TSMs treated with either EEA or MTA until 2024. The systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. Meta-analysis was performed to estimate pooled event rates and assess heterogeneity. Fixed- and random-effects were used to assess 95% confidential intervals (CIs) of presenting symptoms, outcomes, and complications. Results: A total of 291 papers were initially identified, of which 18 studies spanning from 2000 to 2024 met the inclusion criteria. The exclusion of 180 articles was due to reasons such as irrelevance, non-reporting of selected results, systematic literature review or meta-analysis, and a lack of details on method/results. The 18 studies comprised a total sample of 1093 patients: 444 patients who underwent EEAs and 649 patients who underwent MTAs for TSMs. Gross total resection (GTR) rates ranged from 80.9% for EEAs to 79.8% for MTAs. The rate of visual improvement was 86.6% in the EEA group and 65.4% in the MTA group. The recurrence rate in the EEA group was 6.9%, while it was 5.1% in MTA group. The postoperative complications analyzed were CSF leak, infections, dysosmia, intracranial hemorrhage (ICH), and endocrine disorders. The rate of CSF leak was 9.8% in the EEA group and 2.1% in MTA group. The rate of infections in the EEA group was 5.7%, while it was 3.7% in the MTA group. The rate of dysosmia ranged from 10.3% for MTAs to 12.9% for EEAs. The rate of ICH in the EEA group was 0.9%, while that in the MTA group was 3.8%. The rate of endocrine disorders in the EEA group was 10.8%, while that in the MTA group was 10.2%. No significant difference was detected in the rate of GTR between the EEA and MTA groups (OR 1.15, 95% CI 0.7-0.95; p = 0.53), while a significant benefit in visual outcomes was shown in EEAs (OR 3.54, 95% CI 2.2-5.72; p < 0.01). There was no significant variation in the recurrence rate between EEA and MTA groups (OR 0.92, 95% CI 0.19-4.46; p = 0.89). While a considerably increased chance of CSF leak from EEAs was shown (OR 4.47, 95% CI 2.52-7.92; p < 0.01), no significant difference between EEA and MTA groups was detected in the rate of infections (OR 1.92, 95% CI 0.73-5.06; p = 0.15), the rate of dysosmia (OR 1.25, 95% CI 0.31-4.99; p = 0.71), the rate of ICH (OR 0.61, 95% CI 0.20-1.87; p = 0.33), and the rate of endocrine disorders (OR 1.16, 95% CI 0.69-1.95; p = 0.53). Conclusions: This meta-analysis suggests that both EEAs and MTAs are viable options for TSM resection, with distinct advantages and drawbacks. The EEAs demonstrate superior visual outcomes in selected cases while GTR and recurrence rates support the overall effectiveness of MTAs and EEAs. Endoscopic endonasal approaches had a higher chance of CSF leaks, but there are no appreciable variations in other complications. These results provide additional insights regarding patient outcomes in the intricate clinical setting of TSMs.

Tuberculum sellae meningiomas commonly present as bitemporal hemianopia and loss of visual acuity due to optic nerve compression. Two female patients (48 and 58 years old) presented with a small scotoma at the lower visual field center due to tuberculum sellae meningioma (25 and 10 mm, respectively). Despite the fact that their visual field defect was not very large, daily activities, including walking or reading were hindered. By the total removal of the tumors in both patients, the scotoma was cured and daily activities recovered. When patients exhibit visual deficits, especially in the lower center fields, surgical removal should be considered even if the tumors are small and visual deficits are limited because improvement of both vision and daily activities can be achieved.

BACKGROUND: Tuberculum sellae (TS) meningioma is one of the most frequent meningiomas of the anterior skull base. Herein we perform a review of the literature concerning the preferred surgical approaches to TS meningiomas; in addition, we describe two explicative cases, operated on by our group using different approaches, with the aim to critically revise surgical indications and contraindications.
METHODS: In October 2021, two female patients with tuberculum sellae meningioma were treated at the Policlinico Gemelli of Rome. The patients presented with visual deterioration. Surgery was performed using the fronto-temporal approach and transsphenoidal approach. The visual function before and after surgery was evaluated as the main outcome parameter of the surgical treatment of these tumors.
CONCLUSIONS: Tuberculum sellae meningioma can be safely resected using the transcranial approach and the transsphenoidal endoscopic approach with preservation and even improvement of visual function after surgery. The relationship of the tumor with the optic nerves, optic canal, and anterior cerebral artery complex are important issues that have to be considered when dealing with tuberculum sellae meningioma. Both transcranial and endonasal approaches, in experienced hands, can allow complete resection of the lesion.

OBJECTIVE: Tuberculum sellae meningiomas (TSMs) are typically in the proximity of the optic nerves and the optic chiasm, thus making the primary aim of surgery the enhancement or stabilization of the patients\' visual acuity. The authors therefore undertook a retrospective review of their 17-year experience with the pterional approach to ascertain the resection rate, neurological outcome, and visual outcome.
METHODS: Patients who underwent TSM surgery between September 2003 and December 2020 at the authors\' institution were retrospectively evaluated. Patient demographics, tumor characteristics, surgical parameters, postoperative visual outcomes, and complications were analyzed. Gross-total resection (GTR) and subtotal resection (STR) rates were assessed, along with the impact of surgical approach on visual outcomes.
RESULTS: A total of 71 patients with a mean age of 56.9 ± 14.3 years were enrolled in the study. The mean tumor volume was 10.2 ± 12.8 cm3. Postoperatively, 38.7% of patients experienced visual improvement, 45.2% had stable visual acuity, and 16.1% showed visual deterioration. Ipsilateral or contralateral surgical approaches were performed based on the side of the most affected visual acuity. No significant difference in postoperative visual outcomes was observed between the two approaches. GTR was achieved in 84.0% and STR in 16.0%. Minor complications occurred in 3 patients (4.2%), while major complications were found in 4 patients (5.6%). Seven patients (9.8%) showed recurrent tumor growth after 53 months. Progression-free survival after GTR was 123.9 ± 12.9 months, and it was 59.3 ± 13.2 months after STR.
CONCLUSIONS: This study highlighted the finding that TSMs can be successfully resected using a transcranial pterional approach with a low risk of complications and sufficient visual outcomes. Further studies with larger sample sizes are warranted to confirm these findings and optimize surgical strategies for TSM resection.