Name:
10.3171/2025.10.FOCVID25176_vid
Description:
10.3171/2025.10.FOCVID25176_vid
Thumbnail URL:
https://cadmoremediastorage.blob.core.windows.net/4a4437ff-98a0-4324-9256-34c53ee3cad0/videoscrubberimages/Scrubber_403.jpg
Duration:
T00H09M22S
Embed URL:
https://thejns.org/video/
Content URL:
https://cadmoreoriginalmedia.blob.core.windows.net/4a4437ff-98a0-4324-9256-34c53ee3cad0/14. 25-176.mp4?sv=2019-02-02&sr=c&sig=JcTGxapTvDtBGsm5LCH5rHh7kxGun%2Fy6qcR5HdxFiiI%3D&st=2026-04-05T05%3A29%3A55Z&se=2026-04-05T07%3A34%3A55Z&sp=r
Upload Date:
2026-04-05T05:34:55.3812146Z
Transcript:
Language: EN.
Segment:0 .
[MUSIC PLAYING]
SPEAKER: This video demonstrates endoscopic endonasal approach for tuberculous meningioma with optic canal involvement. Standard technique for optimal visual outcomes. A 35-year-old man presented with a chief complaint of progressive visual disturbance over a 5-month period. On neurological examination, visual acuity of the left eye was reduced to 0.7, with a temporary hemianopsia.
SPEAKER: The patient was otherwise neurologically intact and fully independent. The patient's past medical and family histories were unremarkable. Brain MRI demonstrated a vividly enhancing suprasellar mass, measuring 26 by 23 millimeters, consistent with a tuberculum sellae meningioma. The tumor, although located in the midline, was slightly displaced to the left, causing marked compression of the left optic nerve and extending into the left optic canal.
SPEAKER: Three-dimensional imaging was reconstructed to determine the optimal surgical corridor. The analysis indicated the endoscopic endonasal approach would permit safe resection, especially facilitating decompression of the left of the canal and removal of the tumor infiltrating this area. A patient was placed under general anesthesia, in the supine position, with the head elevated 10 degrees and rotated slightly towards the operator.
SPEAKER: The procedure was performed by a single surgeon using a robotic endoscope holder. A 4-millimeter endoscope with 0-, 30-, and 70-degree lenses was employed. Preoperative Stealth navigation guided the surgical corridor. And VEP monitoring was used throughout the procedure. The tumor was approached through a binostril endoscopic endonasal route.
SPEAKER: The sphenoid sinus was entered first and the sellar floor extending to the planum sphenoidale was exposed. On the bloodless field, this bony surface was carefully drilled. Once the dura overlying the tumor was identified, one of the advantages of this approach—meticulous coagulation of the tumor's feeding arteries, posterior ethmoidal arteries in this case—was employed.
SPEAKER: Subsequently, the dura is incised. At this stage, it is evident the tumor has already been adequately devascularized, which facilitates its descent into the surgical field. During tumor detachment, the initial step is to carefully identify the interface between the tumor and the preserved arachnoid membrane.
SPEAKER: The arachnoid of the anterior skull base was intact. A margin between the tumor and arachnoid was subsequently secured. We then proceed with internal decompression of the tumor. In cases where the tumor is soft, it often tends to spontaneously protrude into the extradural space during detachment and decompression. Once adequate internal decompression has been achieved, dissection can proceed between the tumor and the critical neurovascular structures.
SPEAKER: In this case, a favorable dissection plane was identified between the right optic nerve and the tumor, allowing dissection to be advanced toward the optic chiasm. Further, this section is carried out between the frontal lobe, the frontobasal artery, and the tumor. And portions that have been completely detached are removed.
SPEAKER: Dissection is once again advanced from the right optic nerve to the optic chiasm and pituitary stalk. Particular attention is given to identifying and preserving the right frontobasal artery, the A-com complex, and optic branch of the superior hypophyseal artery. Blunt dissection proved effective. However, as in conventional microsurgery, the use of endonasal scissors enables sharp dissection and facilitated optimal exposure.
SPEAKER: These meticulous steps, tumor removal is gradually advanced, eventually exposing the optic chiasm and the pituitary stalk. From the optic chiasm to the left optic canal, firm adhesion was encountered. The left optic canal was opened and infiltrating tumor was dissected carefully and removed to achieve adequate decompression of the left optic nerve, allowing complete removal of the infiltrating tumor within this region.
SPEAKER: This is a final view after complete tumor removal. Optic chiasm, optic nerves, and pituitary stalk are clearly preserved, with intact arachnoid planes and well-preserved perforating vessels. The left optic canal was also opened, and infiltrating tumor within the canal was completely removed. A Simpson grade I–equivalent resection has been achieved as a dural attachment and involved optic nerve were addressed, although, the full dural floor could not be directly visualized.
SPEAKER: Reconstruction was performed in a multilayered fashion. DuraGen was placed, followed by inlay and onlay fascia, with fat packing supported by a sinus balloon. The bony septum was repositioned, and the intranasal structures were completely restored to their original position, and the procedure was completed uneventfully. Postoperative MRI confirmed gross-total resection of the tumor.
SPEAKER: The postoperative course was uneventful, with no CSF leakage or other complications. Histopathological examination revealed a meningothelial meningioma with a Ki-67 index of 3%. Although the tumor extended partially beyond the left internal carotid artery, its soft consistency allowed sufficient internal decompression, enabling the capsule to infold and be mobilized medially.
SPEAKER: First, GTR was feasible, and such lateral extension does not always represent a contraindication for the endonasal route in selected soft tumors. Patient's visual acuity improved from 0.7 to 1.2, and preoperative visual field defects completely resolved by 5 months after surgery. In summary, the endoscopic endonasal approach enabled early devascularization, safe dissection, and complete removal of the tumor, with meticulous multilayer reconstruction, ensuring watertight closure.
SPEAKER: Gross-total resection was achieved without complications, and the patient experienced significant visual recovery via the EEA provides a higher chance of visual improvement, tailored selection between endonasal and transcranial routes remains essential depending on tumor location and vascular involvement. This case highlights that EEA is a safe and effective standard technique for midline anterior skull base meningiomas when combined with expert reconstruction.
SPEAKER:
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