Outcome of Visual Functions in Surgery for Meningiomas of the Jugum Sphenoidale and Tuberculum Sellae
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Outcome of Visual Functions in Surgery for Meningiomas of the Jugum Sphenoidale and Tuberculum Sellae, WALID M. ABD EL-RAHMAN, ABD EL-WAHAB M. IBRAHIM, MOHAMMED T. HOSNY, HATEM I. BADR, MOHAMMED A. EL-METWALY MATTAR and EZZAT A. ABD EL-AZIM
Abstract
Background: Jugum sphenoidale and tuberculum sellae meningiomas represent nearly up to ten percent of cranial meningioma cases, presenting mostly by chiasmal syndrome; adult primary optic atrophy with bitemporal field affection. Challenges faced are intra-optic canal neoplasm extension and its vicinity to ± jeopardizing the crucial basal neurovascular architecture.
Objective: Is to make evidence that the innovative ma-neuver of early cold bone drilling unroofing of the optic canal and tailoring an aggressive skull base unlocking aiming at gentle wise removal of extended tumor portion from the interior of the optic canal before removal of the gross tumor is superior to late execution of the same maneuver after removal of the gross tumor, in minimizing surgical insults of the endangered nervus opticus achieving a better promising outcome of visual functions. Nimodipine dripped topically intraoperatively aiming at neutralizing result bias made by vasa nervosa vasospasm from surgical manipulations.
Patients and Methods: It is a prospective study in which 50 candidate patients for surgery were selected and included in the study, from the cases presenting to Neurosurgery Departments of the Chief Military Hospitals (Maadi, Interna-tional Medical Center, Galaa, and Kobri El-Kobba Military Hospitals) and Mansoura Teaching Hospital at Mansoura University. The study was done during a three years period starting from 2014 and all the selected patients are managed through microsurgical resection of meningioma of the tuber-culum sellae or Planum sphenoidale via a pterional approach. The cases are divided to 20pts in the early group in which the patients underwent early unlocking of the basis cranii in the form of optic canal unroofing, tailored anterior clinoidectomy, and opening of the falciform ligament and optic sheath before dissection of the gross tumor, and 20 pts in the late group in which the same maneuver is done but after dissection of the gross tumor, and 10pts in the none group in which no canal extension is done in some cases and intentional incomplete bony resection as appropriate in the others). Post-operative care, neurological, radiological, laboratory, and ophthalmological assessment are done in early post-operative and re-evaluation after 2 and 4 months later were scheduled.
Results: The study revealed 70% visual acuity improve-ments in the early group in comparison with 30% improvement in the late group, the visual deterioration was 10% and 20% in the early and late groups respectively, but in the none group stabilization of visual functions achieved in 70% and deteri-oration in 30%. We noticed that in cases chosen for application of topical intraoperative Nimodipine irrigation in the field of surgery in the form of half cases in each of the three groups: There was 48% of visual acuity improvement in the half of study cases who the Nimotop used with in comparison to 32% in the other half of study cases who the Nimotop was not used with.
Conclusion: The early optic canal unroofing accompanied by skull base unlocking in the form of tailored anterior clinoidectomy, cutting the falciform ligament, and opening the nervus opticus sheath, using cold ultrasonic bone drilling, with the concurrent use of intraoperative field irrigation with Nimodipine for microsurgical removal of the optic canal extension of the jugum sphenoidale and tuberculum sellae meningiomas before attacking the gross tumor, is superior for late execution of the same maneuver after removal of the gross tumor in preserving and improving the outcome of visual functions.