Tuberculum Sellae Meningiomas (TSMs) are benign tumors arising from the dura mater along the tuberculum sellae and planum sphenoidale — the bony structures at the front of the sella turcica, near the optic nerves and chiasm. Although usually slow-growing, their strategic location near critical visual and hormonal structures often leads to early visual symptoms. Surgical removal remains the gold standard of treatment, with excellent outcomes when performed using microsurgical or endoscopic skull base approaches.
Symptoms
Because of their proximity to the optic apparatus, early signs are often visual:
- Progressive loss of vision in one or both eyes (usually asymmetric)
- Loss of peripheral (temporal) vision
- Visual field defects (commonly bitemporal hemianopia)
- Blurred or double vision
- Headache and pressure behind the eyes
- Loss of smell (anosmia) if the tumor extends forward
- In larger lesions, endocrine symptoms (e.g., hormonal imbalance, menstrual irregularity) due to pituitary compression
Late-stage tumors can cause Cushing reflex (elevated blood pressure and pulse irregularity) or hydrocephalus if they obstruct cerebrospinal fluid pathways.
Diagnosis
- MRI Brain with Contrast: Reveals a well-defined, dural-based enhancing lesion at the tuberculum sellae or planum sphenoidale, often showing compression and elevation of the optic chiasm, hyperostosis of the sphenoid planum, and the typical ‘dural tail’ sign.
- CT Scan: Provides detail of bony involvement, useful for surgical planning and reconstruction.
- Endocrine Evaluation: Assesses pituitary function as tumors near the sella may affect hormone secretion (ACTH, TSH, prolactin, etc.).
- Visual Field Testing (Perimetry): Documents baseline visual loss and monitors recovery after surgery.
Treatment Options
1. Microsurgical Resection
The aim is complete tumor removal while preserving or improving vision. Approach selection depends on tumor size, extension, and surgeon expertise:
- Pterional / fronto-temporal approach: Excellent access to the optic canal and chiasm.
- Unilateral subfrontal approach: Suitable for small, midline lesions.
- Extended endoscopic endonasal approach (EEA): Minimally invasive route through the nasal cavity and sphenoid sinus — ideal for midline tumors without major lateral extension.
Modern microsurgical techniques utilize neuronavigation, intraoperative monitoring, and angled endoscopes to minimize manipulation of the optic nerves and hypothalamus.
2. Endoscopic Endonasal Surgery (EEA)
- Allows direct visualization of the optic apparatus and pituitary stalk from below.
- Offers early decompression of the optic nerves and avoids brain retraction.
- Skull base reconstruction with vascularized flaps minimizes the risk of CSF leakage.
- Particularly effective for smaller to moderate-sized midline tumors.
3. Radiotherapy / Radiosurgery
- Considered for residual or recurrent tumors, or in patients unfit for surgery.
- Stereotactic radiosurgery (Gamma Knife or LINAC) effectively controls tumor growth but does not remove mass effect.
- Used cautiously near the optic nerves to prevent radiation-induced injury.
Risks & Complications
- Temporary or permanent visual loss (risk minimized by gentle optic decompression)
- CSF leak (rare with proper skull base closure)
- Infection or meningitis
- Endocrine disturbances (temporary or permanent)
- Loss of smell if the tumor extends anteriorly
- Memory or behavioral changes (from frontal lobe manipulation — usually transient)
Multidisciplinary collaboration between neurosurgery, neuro-ophthalmology, and endocrinology ensures optimal recovery.
Recovery & Prognosis
- Hospital stay: typically 5–7 days
- Return to daily activity: within 4–6 weeks
- Vision improvement: occurs in up to 70–80% of patients postoperatively
- Recurrence rate: <10% after gross total resection
- Follow-up: MRI at 3 months, then annually for 5 years
Patients operated with modern skull base or endoscopic techniques often achieve excellent functional outcomes and durable tumor control.
Patient Advisory
Tuberculum Sellae Meningiomas require meticulous skull base surgical planning due to their close relationship with the optic nerves, pituitary gland, and major arteries. Every case is unique — surgical route and timing must be tailored to tumor size, visual function, and patient condition. Modern microsurgical and endoscopic methods enable safe and complete removal in experienced hands. Do not make medical decisions based solely on online information; always consult your neurosurgeon for individualized evaluation.