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07-OCTOBER-2018  SARA ABDEL-QADER SHABIB   25 YEARS  TUBERCULUM SELLA MENINGIOMA WITH SEVERE COMPRESSION BOTH OPTIC NERVES AND SUPRA-INTRA AND BILATERAL PARASELLAR EXTENSION AND INVOLVEMENT OF THE LEFT CAVERNOUS SINUS.

 
 

Anamnesis

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The patient was operated elsewhere for huge olfactory groove meningioma through subfrontal approach 6 years ago. At that time the MRI showed wide dural involvement reaching the left side of the tuberculum sella with involvement of the left cavernous sinus. The patient claim that she lost vision in her left eye for 15 years and there is paralysis of the left abducens nerve. The last 3 months, she started to notice rapid deterioration of the vision of the right eye. MRI of the brain performed 26-September-2018 showed tuberculum sella meningioma with MRA showing as be absent left A1 segment. The study was bad quality.

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On examination, the patient needs help to ambulate due to practical absence of vision. She has bilateral anosmia after performed first surgery. Complete blindness of the left eye with left abducens palsy. Can notice fingers at 10 cm by rotating the head to certain position. She has neuralgia like manifestations of the left V2 territory. She cannot look up with her left eye, denoting the involvement of the left III nerve. There is scar behind the hair line due to previous bifrontal approach, which seems that the anterior bony edge is relatively high.

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The patient was sent for investigations and MRI of the sella and both optic nerves with contrast showed tuberculum sella meningioma severely compressing the relatively short optic nerves, more the left. The pituitary stalk and chiasm are pushed behind the tumor mass. The left A1 segment is seen and not involved with the tumor. There is primary optic atrophy of the left optic fundus with total blindness of the left eye and seeing the fingers with certain position at 10 cm distance and profound scatoma right eye with small field of vision at the temporal upper half.     

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The old skin incision was refreshed and reflected to the face. The old bony flap was reflected to the right ear. It is defective and not suitable to approach the chiasmal region, for what another bone window was created to be flush with anterior fossa. The dura was opened parallel to the anterior lower edge of the bone defect. Sharp dissection of the anterior fossa to reach the chiasmal region. The tumor was seen between both optic nerves. The chiasma prefixa was the type of the chiasm. Drilling of the tuberculum sella to remove the bony part of the tumor and decrease the vascular supply of the meningioma. Piece meal resection of the tumor until the right optic nerve became free of tumor compression. Further intrasellar resection of the meningioma until the pituitary stalk and pituitary gland were noticed behind the tumor. There is left anterior clinoid tumor compressing the left ICA and left optic nerve. It was resected. The intrasellar part of the tumor is stuck and adherent to the left optic nerve. Sharp dissection and separation of tumor from the compressed left optic nerve. Radical resection of the tumor and no residual f the tumor to compress the left optic nerve. The pituitary gland and stalk were seen behind and the chiasm was hanging free. Both supraclinoid ICAs are free and all the time irrigation with Papaverine was applied to prevent possible arterial spasm. The tumor was separated totally from the left cavernous sinus. Strict hemostasis with water-tight closure of the dura.  Both bone flaps were sutured together and fixed in place,  Routine water-tight closure of the wound with ready Vac under the skin.

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Smooth postoperative recovery. She was sent to the ICU for 24 hours observation. The patient is claiming that the vision in the right eye improved and she can feel light in the left eye.

Comments  

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The patients is losing the vision of the right eye in addition to the totally lost vision of the left 15 years ago. Surgery is a must to rescue the pending bilateral blindness.

Follow Up  

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The at the same day after surgery, noticed slight improvement both optic nerves function, but the next day she lost vision in both. The day after she regained slight improvement of the vision of the right eye, but less than before surgery.

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The patient was admitted 30-October-2018 with nausea and vomiting and MRI of the brain (Fig-13 and 14) ruled out any intracranial problems. Lab investigations were normal and she was seen by gastroenterologist and endoscopy confirmed presence of hiatal hernia and ulcerative gastritis. She told us that after the first performed surgery, the same episode happened and for 3 months suffered from this situation. We stopped all medications and kept her in nexium twice daily and zofran 8 mg three times a day.

 

 

 

 

 

 

 

 

 

 

 

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Fig-1: Axial view with contrast.


Fig-2: The data as above with more cuts.


Fig:-3 Frontal view without contrast showing the pituitary stalk and chiasm pushed behind the tumor and the presence of the left A1 segment.


Fig:-4: Frontal view with contrast showing with wide extent of the tumor carpet.


Fig-5: Saggital view.


Fig-6: The right optic nerve after reconstructing the CT-scan using ORS Visual.


Fig-7: The optic chiasm and right ICA after total removal of the tumors. Notice that the tuberculum sella was drilled off to reach the intrasellar area due to chiasma prefixa variant.


Fig-8: MRI performed 6th postoperative day showing the free chiasma prefixa.


Fig-9: MRI Saggital view performed the 6th postoperative day showing the swollen pituitary gland and stalk.


Fig-10: The new created bone flap to obtain proper approach to the chiasmal region.


Fig-11: The bone defect after first surgery and the second due to drilling of the tuberculum sella to reach the sellar area due to chiasma prefixa.


Fig-12: It is now possible to see both optic nerves from behind after the performed surgery.


Fig-13: MRI performed 31-October-2018 showing some reduction of the distorted anatomy and disappearance of collection under the previous operation, ruling out progression of CSF leak.

Fig-14: same investigation with frontal T2W protocol.


 

Back Up!

Notice: Not all operative activities can be recorded due to lack of time.
Notice: Head injuries and very urgent surgeries are also escaped from the plan .

  

 

 

 

 

 

 

 

 

 

 

 

 

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