Background: Although there are several surgical approaches for the treatment of tuberculum sellae (TS) meningiomas, clear indications for non–large TS meningiomas are still lacking. Methods: Our case series included 20 patients with TS meningiomas (<3 cm). We classified the tumors into 3 groups based on their radiologic relationship with the optic chiasm: type I, tumor with intact optic chiasm; type II, tumor with superiorly deviated optic chiasm; and type III, tumor with posteriorly deviated optic chiasm. Clinical outcomes, radiologic findings, and surgical approaches for the removal of each tumor type were retrospectively reviewed. Results: Resections using a pterional approach, interhemispheric approach, and an endoscopic endonasal approach were performed in three groups of 6, 7, and 7 patients. The rate of total tumor resection was equivalent across approaches, whereas postoperative visual dysfunction was observed in 1 patient (7.69%) undergoing a transcranial approach. Our evaluation of the sphenoid sinus shape across radiographs revealed that the patterns of bony wall elongation attached to these tumors significantly differed among tumor types, indicating that tumor origin and growth direction might affect the patterns of optic chiasm deviation. In addition, selective elongation of the TS provided a favorable surgical corridor for an endoscopic endonasal approach, especially in type II tumors. These results indicate that this tumor classification influenced surgical approach selection for non–large TS meningiomas. Conclusions: The aim of surgery is maximal tumor resection without causing visual dysfunction. The classification proposed here may predict surgical risk associated with meningioma resection and further inform the selection of a surgical approach.
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