Name:
10.3171/2025.10.FOCVID25166_vid
Description:
10.3171/2025.10.FOCVID25166_vid
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Duration:
T00H07M45S
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https://cadmoreoriginalmedia.blob.core.windows.net/3fd9bd51-d6c0-463c-87ee-6c88c125b4cd/9. 25-166.mp4?sv=2019-02-02&sr=c&sig=vRPctq4F%2BwAL%2BOOlwkpSTEykDX7FmPU2MsYgjH0DKRc%3D&st=2026-04-05T06%3A49%3A57Z&se=2026-04-05T08%3A54%3A57Z&sp=r
Upload Date:
2026-04-05T06:54:57.1744759Z
Transcript:
Language: EN.
Segment:0 .
[MUSIC PLAYING]
RAVI RANJAN: In this video, the authors
RAVI RANJAN: present paramedian tuberculum sellae meningioma tumor resection and optic canal unroofing via contralateral supraorbital approach. Tuberculoma and meningiomas arise from the tuberculum sella, the limbus sphenoidale, and the chiasmatic sulcus, and they cause visual symptoms because of pressure or sometimes tumor extension into the optic canals and optic canal hypertrophy.
RAVI RANJAN: There are several approaches available, and in some cases a contralateral transcranial approach may be advisable, especially if the tumor is asymmetric and is causing ipsilateral optic nerve compression. In this video, we show a case of contralateral supraorbital approach to an asymmetric tuberculum sellae meningioma. This patient was a 34-year-old lady who presented with irregular menstrual cycles for 6 months, painless progressive vision loss on the left side for 4 months, and headache for 4 months.
RAVI RANJAN: On examination, the vision on the left side was 3/60 with left-sided optic atrophy, whereas vision was 6/12 on the right side. There were no other neurological deficits or endocrinological deficits. Imaging shows an asymmetric suprasellar lesion located on the left side, medial to the optic nerve, with possible medial optic canal extension. The epicenter is on the left side, and we can see that the tumor is located in sagittal section in the tuberculum sellae area.
RAVI RANJAN: We planned the contralateral supraorbital approach because it would give us direct vision of the tumor. It will also give us direct access to the medial optic canal and a right-sided approach; a contralateral approach here would be from the nondominant side. Therefore, we took this patient for a contralateral supraorbital eyebrow approach. This was the position.
RAVI RANJAN: The head was rotated by around 10 to 15 degrees to the opposite side and slightly extended. We can see the marking of a lateral two-thirds eyebrow incision for supraorbital approach. We can see a supraorbital craniotomy has been done. The bony projections on the frontal skull base are drilled to make the trajectory flat. The dura is opened in a cruciate shape based on the frontal skull base.
RAVI RANJAN: By gradual creeping movements, the base of the brain is accessed and basal sylvian fissure is opened. As we let out some CSF, the brain becomes lax and the working space expands. Meticulous and sharp dissection of the retinal bands is essential to expose the structures. Here, we can see the ipsilateral internal carotid artery.
RAVI RANJAN: We see the first look of the tumor and the ipsilateral, that is right-sided, optic nerve. We can see the distance between the two. It is the opposite side, the left side. The base of the tumor is coagulated and divided. The tumor here can be seen as soft and moderately vascular.
RAVI RANJAN: With ultrasonic aspiration the tumor is decompressed and gradually we do the arachnoid dissection. And a layer of arachnoid is left over the optic nerve optic chiasm, which can be seen here. Preservation of this arachnoid is very important to preserve the blood supply to the optic apparatus. The base of the tumor is further divided until we are able to see the important structure that is the left-sided optic nerve.
RAVI RANJAN: Beneath here, the left-sided optic nerve is seen. And this is traditionally a blind spot of an anterolateral approach, the medial side of the optic nerve. And in a contralateral approach like this, we get a good view of this area. After debulking the tumor, it is very easy to roll the tumor and dissect the arachnoid. Preservation of this arachnoid is very, very important.
RAVI RANJAN: Here, we see that the tumor is being gently rolled off. We can see the left optic nerve very well now. Now, the bulk of the tumor has been removed, and we can see a portion of the tumor, which is where the tumor was based, just medial to the left optic nerve. This part of the tumor is gently dissected and brought into the surgical field and removed.
RAVI RANJAN: We can see the optic nerve. We can see the intraoptic space. We can see the Liliequist membrane here. Small tumor remnant is still visible, and it is very important to remove that by gradual, gentle and teasing movement with angled instruments like angled dissector that is being used here.
RAVI RANJAN: Now, we add a medial optic canal unroofing. This is the advantage of this approach. One can access the medial part of the contralateral optic canal under direct vision. Using a diamond burr, the optic canal is opened. And with upcutting rongeurs, the opening is further widened. It also gives us an opportunity to resect the involved infiltrated dura. Now, canal opening has given us access to this medial part of the tumor, which could otherwise not be accessed unless you open the optic canal.
RAVI RANJAN: The tumor is gently removed. And once all the tumor is removed, the dural base is coagulated with the angled bipolar forceps. The bony hypertrophy of the tuberculum sella is visible and it is drilled as much as possible, taking due care to prevent injury to the adjoining areas. This is at the end.
RAVI RANJAN: We can see that the tumor has been dissected. The middle optic canal has been drilled. The involved optic nerve is quite free. It looks healthy. We don't see any tumor inside the optic canal anymore. We can see the optic chiasm covered with a shining arachnoid.
RAVI RANJAN: We can see pituitary stalk and arachnoid covering it. And hemostasis was obtained. And following this, closure was performed by replacing the bone flap back. Postoperatively, the patient did not have any new onset endocrinological or neurological deficit.
RAVI RANJAN: At follow-up, the vision has improved to 6/60. And on the right side, it remains same. The patient remains functionally independent. The follow-up clinical photograph shows a good cosmetic outcome and good frontalis function. The posterior imaging shows the bony defect and the medial optic canal drilling that was performed. And MRI shows complete tumor resection, and we do not see any collateral damage on the frontal lobes.
RAVI RANJAN: So these are the references, and thank you for watching.
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