Tuberculum sellae meningiomas represent 5% 10%

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1 J Neurosurg 115: , 2011 Bilateral subfrontal approach for tuberculum sellae meningiomas in long-term postoperative visual outcome Clinical article Isao Chokyu, M.D., Takeo Goto, M.D., Kenichi Ishibashi, M.D., Takashi Nagata, M.D., and Kenji Ohata, M.D., Ph.D. Department of Neurosurgery, Osaka City University Graduate School of Medicine, Osaka, Japan Object. Various surgical approaches, such as uni- and bifrontal, frontolateral, and pterional approaches, have been advocated for tuberculum sellae meningiomas. The authors retrospectively reviewed the effectiveness of a bilateral subfrontal approach for tuberculum sellae meningiomas with special attention to ophthalmological outcomes and complications. Methods. Between 1993 and 2009, 34 patients underwent surgery for removal of tuberculum sellae meningiomas at Osaka City University. Tumor size ranged from 14 to 45 mm. Thirty-two of 34 patients presented with visual disturbances before the surgery. The visual functions in all patients were assessed using a visual impairment score (VIS) before and after surgery. Postoperative visual examination was performed 2 weeks after surgery. Long-term follow-up examinations were conducted 1 year after surgery. Results. Radical resection (Simpson Grades I and II) was accomplished in 27 patients, and subtotal or partial resection (Simpson Grades III and IV) was achieved in 7. There was no deterioration in postoperative visual outcome. Twenty-nine (90.6%) of 32 patients showed improved VIS compared with preoperative VIS. The average VIS was 38.1 preoperatively, 23.5 in the short-term postoperative period, and 21.8 in the long-term postoperative period. In the short-term postoperative period, the visual function in 6 patients normalized, and visual problems persisted in the remaining 26. Six (23%) of 26 patients showed further improvement in VIS during the long-term follow-up period, and no patient exhibited a worsened VIS during this time. One patient complained of hyposmia after surgery, but there was no indication of related complications such as CSF leakage or frontal brain contusion. Conclusions. The bilateral subfrontal approach was previously avoided because of the relatively high rate of complications in earlier surgical series of tuberculum sellae meningiomas. However, after developments in microsurgical techniques in recent years, the bilateral subfrontal approach can now provide satisfactory visual outcomes with minimal postoperative complications. Careful preservation of the blood supply to optic apparatus and early unroofing of the optic canal using a bilateral subfrontal approach led to further improvement in long-term postoperative visual outcome. (DOI: / JNS101812) Key Words tuberculum sellae meningioma skull base bilateral subfrontal approach long-term postoperative visual outcome oncology Abbreviations used in this paper: ICA = internal carotid artery; VIS = visual impairment score. Tuberculum sellae meningiomas represent 5% 10% of intracranial meningiomas. 1,8 Complete removal is the optimal goal to prevent recurrence. However, treating this tumor is still challenging because of the high risk of visual pathway involvement and internal carotid artery (ICA) encasement and cavernous sinus infiltration. Various surgical approaches have been advocated to resect tuberculum sellae meningiomas. The unilateral or bilateral subfrontal approach was often selected in earlier microsurgical cases. 2,24,25 The advantage of this approach is that it provides a wide and direct view of both optic nerves, the ICA, and the anterior cerebral artery. However, the bilateral subfrontal approach has several disadvantages, including the possibility of opening the frontal sinus and the risk of CSF leakage, meningitis, olfactory nerve damage, and venous infarction due to occlusion of the superior sagittal sinus. 18 For these complications, the bilateral subfrontal approach tends to be used with hesitation for the treatment of tuberculum sellae meningiomas in recent surgical series, compared with the pterional or frontolateral approach that has been adopted with the development of microsurgical techniques. 9,11 Indeed, the pterional approach provides a frontolateral view through the carotid cistern and preserves the olfactory nerves. However, most reports on the pterional approach have demonstrated that 10% 15% of patients exhibit deterioration in visual functions after surgery. It remains unclear 802 J Neurosurg / Volume 115 / October 2011

2 Tuberculum sellae meningioma whether the pterional approach may later be associated with significant visual improvement. 3,9,15,18,20 Recently, although extended transsphenoidal surgery has become an alternative surgical option for suprasellar meningiomas, the benefits of the transsphenoidal approach have yet to be established. We performed surgery in 34 patients with tuberculum sellae meningiomas using a bilateral subfrontal approach and modified surgical techniques to address previously reported complications. Our results from the bilateral subfrontal approach in the era of advanced microsurgery are presented, focusing on tumor control, long-term visual function, and complications to offer an alternative surgical option for these tumors. Methods We undertook a retrospective review of the neurosurgical database at the Osaka City University. Between January 1993 and December 2009, a total of 34 patients were diagnosed with tuberculum sellae meningiomas after surgery. All meningiomas included in this study were benign. A careful review of clinical records and radiological analysis was made. The mean patient age was 55.7 years (range years), and the male-to-female ratio was 5:29. All patients were evaluated by an ophthalmologist before and after surgery. The quality of vision depends on visual acuity as well as visual fields. The ophthalmological findings of visual acuity and visual fields were analyzed according to the guidelines of the German Ophthalmological Society (Fig. 1). We adopted the visual impairment score (VIS) that is based on 2 tables, one representing visual acuity and the other any visual field defect, each combining the findings for the 2 eyes. Visual analysis was performed before and after surgery in all patients. Short-term postoperative visual examination was performed 2 weeks after surgery. Long-term postoperative examinations were recommended 1 year after surgery. 9 For the definition of long-term results, we evaluated visual function yearly after surgery in 11 of 27 patients who had undergone total tumor excision. However, these patients did not exhibit further improvement after the 1-year follow-up visit. Moreover, none of the 27 patients experienced subjective improvement of his or her vision after that 1-year period. Therefore, we defined visual results at 1 year after surgery as long-term results in cases in which total tumor removal occurred. When some remnants of the tumor were left behind, ophthalmological studies were conducted at every 1-year interval, and the latest results were defined as long-term results. Preoperative imaging studies included MR imaging in all patients; conventional angiography was performed if needed. The mean tumor size was 24.3 mm (range mm). Patients were monitored with annual MR imaging studies until death. The mean follow-up period was 95.8 months (range months). Surgical Techniques Excision was performed via a bilateral subfrontal J Neurosurg / Volume 115 / October 2011 approach in all patients. Using this approach, the patient was placed supine with the head secured in a Mayfield headholder. The skin was cut behind the frontal hairline from zygoma to zygoma. The scalp and pericranial flaps were reflected anteriorly in a single layer. Four bur holes were made at the bilateral superior margin of the orbital rim, and 2 were made in the posterior parasagittal region. After bifrontal craniotomy, a unilateral orbital bur hole on the dominant side of the tumor was made to gain a wider inferosuperior viewing trajectory with reduced brain retraction. In cases of lateral tumor extension, a temporal craniotomy was added (Fig. 2). Moreover, if the tumor was large enough to encase the anterior communicating artery and the anterior cerebral artery, the bilateral subfrontal approach combined with an interhemispheric fissure approach was selected to prevent excessive brain retraction. The baseline of the craniotomy involved the tables of the frontal sinuses, and the mucous membranes were removed completely. The dura mater was cut in a W- shaped fashion. Under microscopic view, the olfactory nerve on the tumor-dominant side was intentionally cut for the later procedure to open the optic canal. However, the contralateral olfactory nerve should be dissected from the olfactory bulb to the olfactory trigone to protect it and prevent it from being avulsed during tumor resection. When the tumor did not show obvious invasion into the optic canal, both olfactory tracts were preserved using meticulous dissection technique. Then, the superior sagittal sinus was ligated at the lowest part and the falx was transected to obtain a wide surgical field for tumor resection. Following the initial internal decompression of the tumor, the lesion was carefully dissected from the surrounding critical structures. The optic apparatus is the structure most at risk and requires the most attention. The arterial supply from the ICA to the optic pathway was especially well visualized from the contralateral side through the subfrontal space (Fig. 3). The technique to preserve these perforators was to peel them off the tumor surface, keeping the arachnoid plane. The inferior surface of each optic nerve and chiasm could be visualized from the dominant side of the tumor extension (Fig. 4). On the dominant side of the tumor extension, the optic canal was completely unroofed and examined for tumor invasion. The contralateral optic canal was partially opened on the medial side to preserve the olfactory nerve just over the optic canal (Fig. 5). Involved anterior cerebral arteries and their perforators were carefully dissected through the interhemispheric fissure approach. Adaption of the interhemispheric fissure approach to large tumors decreased the subfrontal brain retraction. Small parts of the tumor should be left behind if they are strongly adherent to the vessels. After watertight closure of the dura mater, the frontal sinus was simply covered over using plenty of fibrin glue soaked abdominal fat. The fat was pinched with the frontal bone flap to prevent CSF leakage (Fig. 6). Frontal pericranial and galeal flaps were not used to avoid postoperative skin atrophy that could cause cosmetic problems. The extent of tumor resection was classified accord- 803

3 I. Chokyu et al. Fig. 1. Tables of visual acuity and visual field defects used for calculation of the visual impairment score. The marked numbers provide an example of the calculation made in a patient with a visual acuity of 0.4 in the left eye and 0.2 in the right eye, together with a bitemporal visual field defect. Therefore, the numbers 35 and 22 total 57. This number shows the VIS, which reaches 100 as a maximum. Reprinted with permission from Fahlbusch R, Schott W: J Neurosurg 96: , ing to the Simpson classification. 23 The Simpson classification is as follows: Grade I, total tumor resection with excision of infiltrated dura; Grade II, total tumor resection and coagulation of dural attachments; Grade III, gross-total tumor resection without excising dural attachments or extradural attachments; and Grade IV, subtotal tumor resection. Results The clinical data in our series are summarized in Table 1, and detailed visual function results are demonstrated in Table 2. Visual failure was the most common initial symptom in tuberculum sellae meningiomas and was present in most of the cases. In the bilateral subfrontal approach, the tumor under either optic nerve could be directly confirmed from the contralateral side, so the perforators from the ICA to the optic nerve could be carefully preserved under direct viewing through a microscope. Radical resection (Simpson Grades I and II) was accomplished in 27 patients, and subtotal or partial resection (Simpson Grades III and IV) was achieved in 7. In Case 7, the tumor was so hard that it adhered to the anterior communicating artery perforators; therefore, these portions were left behind (Simpson Grade IV). In Case 24, the tumor was also hard and adhered to the C 2 portion of the ICA, and therefore these portions were left behind (Simpson Grade III). In Case 12, the tumor strongly adhered to the inferior part of the optic chiasm and could not be removed (Simpson Grade IV). In Case 11, a partial removal was performed because of cavernous sinus invasion. The mean follow-up period was 95.8 months. Three patients experienced additional tumor progression after surgery; one of these patients underwent Gamma Knife surgery for the recurrent tumor around the ICA with some distance to the optic pathway. The other 2 patients are closely observed at each 6-month interval to plan additional surgery when they present with visual deterio- Fig. 2. Schema of the bilateral subfrontal approach. After bifrontal craniotomy (light gray area), a unilateral orbital bur on the dominant side of the tumor is removed to get a wider inferosuperior viewing trajectory with reduced brain retraction. In cases of lateral extension of the tumor, a temporal craniotomy is added (dark gray area). 804 J Neurosurg / Volume 115 / October 2011

4 Tuberculum sellae meningioma Fig. 3. The arterial supply from the ICA to the optic pathway is well visualized from the contralateral side through the subfrontal space and could be carefully preserved. ration. However, they have not shown any neurological signs of visual deterioration. Visual Outcome All but 2 patients had preoperative visual disturbances (Tables 1 and 2). There was no deterioration in visual function during the postoperative course. Of 32 patients with preoperative visual disturbance, 28 (87.5%) showed improved VIS in the short-term postoperative period. The other 4 patients did not show improvement. One patient (Case 11) had been blind in both eyes (VIS 100) when she underwent surgery, and another 2 patients (Cases 18 and 32) had visual symptoms lasting longer than 72 months. In the short-term postoperative period, visual function normalized in 6 patients and visual problems persisted in the remaining 26 patients. Six (23%) of 26 patients showed further improvement in VIS during the long-term follow-up period. No patient s VIS worsened in the long-term period. Finally, 29 (90.6%) of 32 patients Fig. 5. The contralateral optic canal is partially opened at the medial side to preserve the olfactory nerve just over the optic canal. had an improved VIS compared with their preoperative VIS. The average VIS was 38.1 preoperatively, 23.5 in the short-term postoperative period, and 21.8 in the long-term postoperative period (Table 1). Complications The olfactory nerve was sacrificed unilaterally in 20 patients, but, interestingly, only 1 patient experienced hyposmia in daily life, even in cases in which unilateral anosmia was detected by physical examination. Cerebrospinal fluid leakage was completely prevented by our procedure of covering the frontal sinus with plenty of fat tissue. Evidence of brain contusion and venous infarction was assessed on the basis of postoperative MR images and the patient s clinical symptoms. Magnetic resonance imaging signs of brain contusion and venous infarction that caused some neurological symptoms were defined as brain contusion and venous infarction. Based on these criteria, no patient had venous infarction or brain contusion. Meningitis occurred in 1 patient, which was cured with intravenous antibiotic injections for 1 week. Discussion Fig. 4. Intraoperative photograph. The inferior surface of each optic nerve and chiasm could be visualized from the dominant side of the tumor extension. J Neurosurg / Volume 115 / October 2011 Tuberculum sellae meningiomas can be resected through several approaches: bilateral subfrontal, frontolateral, and pterional (Table 3). In macrosurgery, the frontal approach has often been used. Jallo and Benjamin12 reported that the pterional approach decreased the risk of injury to the anterior visual pathway and the anterior cerebral circulation arteries in tuberculum sellae meningiomas. Since then, with the development of microsurgical techniques, many authors have reported that the pterional approach is suitable for tumors of the suprasellar region.3,9,10,12,18 20,22 Jallo and Benjamin12 demonstrated that the pterional approach has 2 advantages. First, it minimizes injury to the olfactory nerves. Second, the risk of CSF leakage or infection from the frontal sinus is low. However, it has also been reported that the undersurface of the ipsilateral optic nerve and chiasm are not as well 805

5 I. Chokyu et al. Fig. 6. The frontal sinus is simply covered over using plenty of fibrin glue soaked abdominal fat. A: Precraniotomy. B: Removal of the mucosa of the frontal sinus. C: The fat is pinched with the frontal bone flap to prevent CSF leakage. TABLE 1: Summary of clinical data Case No. Age (yrs), Sex Preop Duration of Visual Symptoms (mos) Size (mm) Simpson Grade VIS Preop Short-Term Postop Long-Term Postop Follow-Up (mos) Complications 1 63, F II , M I , M 8 30 II , F IV , F 7 22 II , F 6 20 I , F 3 30 IV , F 3 23 II , F 3 15 I , F II , F IV , F IV , F 2 25 I , F 2 23 II , F II , F II , F 6 22 II hyposmia 18 65, F I , F 3 30 I , F I , M 3 25 I , F 3 20 II , F 5 17 I , F III , F 2 23 I , F 1 14 I , M I , F 3 15 II , F 5 30 II meningitis 30 36, F 1 25 II , M IV , F III , F 9 20 I , F 3 19 I mean J Neurosurg / Volume 115 / October 2011

6 Tuberculum sellae meningioma TABLE 2: Preoperative and short-term and long-term postoperative visual acuity and visual field results* Preop Short-Term Postop Long-Term Postop Case No. Visual Acuity (rt/lt) Visual Field (rt/lt) Visual Acuity (rt/lt) Visual Field (rt/lt) Visual Acuity (rt/lt) Visual Field (rt/lt) 1 0/0.8 0/1.2 0/ / / / / / / /0.5 0/0.8 0/ / / / / / / / / / / / / / / / /0 0/0.1 0/ / /0 1.5/0 12 0/0 0.8/ / / / / / / / /0 0.8/0 0.8/ / / / / / / /0 1.0/0 1.0/ / / / / / / / / / /0/6 1.0/ / /0.6 0/0.9 0/ /0 1.5/0 1.5/ / / / / / / /0 1.5/0 1.5/ / / / / / /0.2 (continued) J Neurosurg / Volume 115 / October

7 I. Chokyu et al. TABLE 2: Preoperative and short-term and long-term postoperative visual acuity and visual field results (continued)* Preop Short-Term Postop Long-Term Postop Case No. Visual Acuity (rt/lt) Visual Field (rt/lt) Visual Acuity (rt/lt) Visual Field (rt/lt) Visual Acuity (rt/lt) Visual Field (rt/lt) / / / /0 0.1/0 0.1/ /0 1.2/0 1.2/ / / / / / /1.0 * Please refer to Fig. 1 for an explanation of the visual acuity and visual field measurements. visualized as in the subfrontal approach. Because of this disadvantage, 10% 20% of patients in whom a pterional approach is undertaken may experience visual deterioration after surgery. 3,9,17,18,20 In contrast, surgical results using a bilateral subfrontal approach to tuberculum sellae meningiomas have not been published since The surgical outcome of the bilateral subfrontal approach using the more recent microsurgical techniques should be reported to offer an alternative surgical option for these tumors. Visual Outcome Visual outcome is the most crucial issue to consider in the surgical treatment for tuberculum sellae meningiomas. There have been many reports detailing visual outcomes after surgery. The results of recently reported studies are summarized in Table 3. 2,3,12,18,20 Cushing and Eisenhardt 6 first reported a 50% visual improvement rate in In later microsurgical series, the improvement rates ranged from 41.7% to as high as 91%. However, 10% 30% of patients have been reported to show worsened visual function after surgery, even in recent reports. 7,9,10,12,13 In our study, visual functions as evaluated by VIS improved in 90.6% of the patients and did not deteriorate in any patient even in the long-term period, and 23% had more favorable improvement between the short- and long-term periods. This satisfactory result might be offered with careful preservation of the blood supply to the optic apparatus and early unroofing of the optic canal. The key to preserving visual function is to minimize direct manipulation of the optic nerves and avoid injury to the blood supply to the optic apparatus. 4,7 Anatomically, the inferior surfaces of the optic nerve and optic chiasm receive their blood supply from the superior hypophysial arteries or small perforators that originate from the medial wall of the ICA. By using a bilateral subfrontal approach, the inferior surface of the optic nerve, which cannot be well visualized via the ipsilateral pterional approach, is clearly visualized under the microscope using a contralateral trajectory, and the perforators can be carefully preserved. 3,9,12,18,20 The inferior surface of the optic apparatus can also be well visualized via an endoscopic extended transsphenoidal approach, but it cannot be applied in all cases, particularly those with large and hard tumors. Endoscope-assisted unilateral subfrontal approaches have a great potential to be the optimal way to visualize the undersurface of both optic nerves. Refinement of surgical instruments of the neuroendoscope will allow us to obtain satisfactory surgical results. Early unroofing of the optic canal might contribute to the improvement in visual function. 15 In the subfrontal approach, the preserved olfactory nerve just covers over the optic canal and interferes with optic canal drilling. Therefore, wide optic canal unroofing was completed by sacrificing the olfactory nerve unilaterally on the dominant side of the tumor extension into the optic canal. Of course, surgical difficulties for removing tuberculum sellae meningiomas are significantly influenced by TABLE 3: Recent studies showing visual outcomes in patients with tuberculum sellae or diaphragm meningiomas Visual Function (%) Authors & Year Surgical Approach Improved Unchanged Deteriorated Fahlbusch & Schott, 2002 pterional Goel et al., 2002 unilat subfrontal Pamir et al., 2005 pterional Schick & Hassler, 2005 pterional Park et al., 2006 frontolat Mathiesen & Kihlström, 2006 pterional Nakamura et al., 2006 pterional, bilat subfrontal, frontolat present study bilat subfrontal J Neurosurg / Volume 115 / October 2011

8 Tuberculum sellae meningioma the size of the tumor, existence of a calcified part, and adherence to the optic nerve. However, a bilateral subfrontal approach is one of the applicable approaches to any condition of tuberculum sellae meningiomas and can offer satisfactory results concerning visual function. Complications Olfactory damage is recognized as one of the disadvantages of a bilateral subfrontal approach to tumor. Nakamura et al. 18 pointed out that injury to the olfactory nerves was more frequently reported in cases resected via bifrontal craniotomy. Nevertheless, this complication is not specific to a bifrontal approach and, indeed, a frontotemporal approach in the series of Nakamura et al. caused hyposmia in 2 of 30 cases. In our study, the unilateral olfactory nerve was transected in 20 patients to accomplish a wide unroofing of the optic canal. The contralateral olfactory nerve was carefully dissected to the olfactory trigone to prevent hyposmia. One side effect of unilateral transection of the olfactory nerve was detected as unilateral anosmia on physical examination. However, the fact that only 1 patient complained of hyposmia in postoperative daily life even after sacrifice of the unilateral olfactory nerve is quite important to neurosurgeons dealing with this tumor. Unilateral olfactory function could be more reliably preserved using advanced microsurgical techniques developed in recent years. The occurrence of CSF leakage from the frontal sinus is also considered a disadvantage of the bilateral subfrontal approach. 12 However, the infection rate was less than 2% in early reports. 21 In our surgical series, postoperative CSF leakage was not encountered because we covered the frontal sinus with plenty of fat tissue without the use of a pericranial flap. The fat tissue changed to thin membranous fibrous tissue over the course of the follow-up (Fig. 7). Repair of the skull base using auto fat graft has been well known in transsphenoidal surgeries and sometimes has been used in spinal and posterior fossa surgeries. 5 In addition, the frontal sinus was classically obliterated with free fat tissues in the field of otolaryngology. 14,16,26 The effect of sealing the dural defect and preventing CSF leakage was as good as that with vascularized flap. 5 The results of obliterating the frontal sinus were also satisfactory in the cases of frontal mucoceles. 14,16,26 Long-term results of frontal sinus obliteration using fat graft have been observed on MR images. In most reports, fat tissues reduced their volume and changed to something similar to a fibrous tissue during longer follow-up periods. 14,16,26 Our procedure of frontal sinus repair using plenty of auto fat graft is a modification of these techniques, which produced sufficient results to prevent CSF leakage and frontal sinus infections. 5,14,16,26 In cases with malignant pathology that requires additional radiation treatment, the vascularized flap technique should be recommended to prevent infections. On the contrary, in cases with benign pathology, our procedure is technically quite simple and shows satisfactory long-term results. This procedure does not use a frontal pericranial flap, so it also allows for a good cosmetic appearance of the forehead, preventing skin and bone atrophy caused by loss of vascularized anterior pericranium. 6 J Neurosurg / Volume 115 / October 2011 Fig. 7. Sagittal T2-weighted MR image showing that the fat tissues have reduced their volume and changed to something resembling a fibrous tissue (arrow) during the long-term follow-up period. The incidences of postoperative brain edema and venous infarction were considerably higher in patients who had undergone a bifrontal craniotomy. 18 However, most bifrontal surgeries were performed prior to the development of improved surgical techniques and were often applied to larger tumors compared with the pterional approach. 18 Our procedure transecting the superior sagittal sinus at the bottom of the frontal base and cutting the falx at the lowest part enabled preservation of the cortical bridging veins at the frontal lobe. Moreover, additional interhemispheric approaches reduced excessive frontal lobe retraction if the tumor was relatively large in size and involved anterior cerebral arteries and their perforators. The risk of brain edema and venous infarction in the bilateral subfrontal approach is not so serious with recent advances of microsurgical techniques. Conclusions The bilateral subfrontal approach has been avoided due to the relatively high complication rate in the earlier surgical series of tuberculum sellae meningiomas. However, in recent years, with the development of microsurgical techniques, a bilateral subfrontal approach, occasionally combined with an interhemispheric approach, can be advantageous, providing satisfactory visual outcomes and minimizing postoperative complications such as CSF leakage, anosmia, and frontal brain contusion. Careful preservation of the blood supply to the optic apparatus and early unroofing of the optic canal using a bilateral subfrontal approach led to further improvement in longterm postoperative visual outcome. Of course, we do not intend that the bilateral subfrontal approach is the best approach to the tumor in this small study. However, we 809

9 I. Chokyu et al. can suggest that the bilateral subfrontal approach in recent years has acceptable surgical results compared with other approaches. Disclosure The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper. Author contributions to the study and manuscript preparation include the following. Conception and design: Chokyu, Goto, Ohata. Acquisition of data: Chokyu, Goto, Ishibashi. Analysis and interpretation of data: Chokyu. Drafting the article: Nagata. Study supervision: Ohata. References 1. Al-Mefty O, Smith RR: Tuberculum sellae meningiomas, in Al-Mefty O (ed): Meningiomas. New York: Raven Press, 1991, pp Arai H, Sato K, Okuda, Miyajima M, Hishii M, Nakanishi H, et al: Transcranial transsphenoidal approach for tuberculum sellae meningiomas. Acta Neurochir (Wien) 142: , Benjamin V, Russell SM: The microsurgical nuances of resecting tuberculum sellae meningiomas. Neurosurgery 56 (2 Suppl): , Bergland R: The arterial supply of the human optic chiasm. J Neurosurg 31: , Black P: Cerebrospinal fluid leaks following spinal or posterior fossa surgery: use of fat grafts for prevention and repair. Neurosurg Focus 9(1):e4, Casiano RR, Cooper J: Anterior table free bone graft technique for frontal sinus obliteration. Otolaryngol Head Neck Surg 106: , Chicani CF, Miller NR: Visual outcome in surgically treated suprasellar meningiomas. J Neuroophthalmol 23:3 10, Cushing H, Eisenhardt L: Meningiomas. Their Classification, Regional Behaviour, Life History, and Surgical End Results. Springfield, IL: Charles C Thomas, 1938, pp Fahlbusch R, Schott 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: , Goel A, Muzumdar D, Desai KI: Tuberculum sellae meningioma: a report on management on the basis of a surgical experience with 70 patients. Neurosurgery 51: , Gökalp HZ, Arasil E, Kanpolat Y, Balim T: Meningiomas of the tuberculum sella. Neurosurg Rev 16: , Jallo GI, Benjamin V: Tuberculum sellae meningiomas: microsurgical anatomy and surgical technique. Neurosurgery 51: , Klink DF, Sampath P, Miller NR, Brem H, Long DM: Longterm visual outcome after nonradical microsurgery in patients with parasellar and cavernous sinus meningiomas. Am J Ophthalmol 130:689, Loevner LA, Yousem DM, Lanza DC, Kennedy DW, Goldberg AN: MR evaluation of frontal sinus osteoplastic flaps with autogenous fat grafts. AJNR Am J Neuroradiol 16: , Mathiesen T, Kihlström L: Visual outcome of tuberculum sellae meningiomas after extradural optic nerve decompression. Neurosurgery 59: , Mendians AE, Marks SC: Outcome of frontal sinus obliteration. Laryngoscope 109: , Moore KR, Harnsberger HR, Shelton C, Davidson HC: Leave me alone lesions of the petrous apex. AJNR Am J Neuroradiol 19: , Nakamura M, Roser F, Struck M, Vorkapic P, Samii M: Tuberculum sellae meningiomas: clinical outcome considering different surgical approaches. Neurosurgery 59: , Pamir MN, Ozduman K, Belirgen M, Kilic T, Ozek MM: Outcome determinants of pterional surgery for tuberculum sellae meningiomas. Acta Neurochir (Wien) 147: , Park CK, Jung HW, Yang SY, Seol HJ, Paek SH, Kim DG: Surgically treated tuberculum sellae and diaphragm sellae meningiomas: the importance of short-term visual outcome. Neurosurgery 59: , Ray BS: Intracranial hypophysectomy. J Neurosurg 28: , Schick U, Hassler W: Surgical management of tuberculum sellae meningiomas: involvement of the optic canal and visual outcome. J Neurol Neurosurg Psychiatry 76: , Simpson D: The recurrence of intracranial meningiomas after surgical treatment. J Neurol Neurosurg Psychiatry 20:22 39, Solero CL, Giombini S, Morello G: Suprasellar and olfactory meningiomas. Report on a series of 153 personal cases. Acta Neurochir (Wien) 67: , Symon L, Rosenstein J: Surgical management of suprasellar meningioma. Part 1: The influence of tumor size, duration of symptoms, and microsurgery on surgical outcome in 101 consecutive cases. J Neurosurg 61: , Weber R, Draf W, Keerl R, Kahle G, Schinzel S, Thomann S, et al: Osteoplastic frontal sinus surgery with fat obliteration: technique and long-term results using magnetic resonance imaging in 82 operations. Laryngoscope 110: , 2000 Manuscript submitted November 2, Accepted May 31, Portions of this work were presented in abstract form at the 69th Annual Meeting of the Japan Neurosurgical Society, Fukuoka, Japan, October 28, Please include this information when citing this paper: published online July 8, 2011; DOI: / JNS Address correspondence to: Isao Chokyu, M.D., Department of Neurosurgery, Osaka City University Graduate School of Medicine, Asahi-machi, Abeno-ku, Osaka , Japan. chokyui@med.osaka-cu.ac.jp. 810 J Neurosurg / Volume 115 / October 2011