AL-MEFTY COLLECTION Diaphragm Sellae Meningioma: Distinct Clinical, Anatomic, and Surgical Considerations: 2-Dimensional Operative Video Ketan R. Bulsara, MD ∗ , Walid Ibn Essayed, MD ‡ , Emad Aboud, MD § , Ossama Al-Mefty, MD ‡ ∗ Division of Neurosurgery, University of Connecticut, Farmington, Connecticut, USA; ‡ Department of Neurosurgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA; § Arkansas Neurological Institute, Little Rock, Arkansas, USA Correspondence: Ossama Al-Mefty, MD, Department of Neurosurgery, Brigham and Women’s Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA. Email: almeftyossama@bwh.harvard.edu C  Congress of Neurological Surgeons 2021. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com Nestled in the parasellar region, surrounded by critical neurovascular structures, diaphragm sellae meningiomas although rare present distinct clinical, radiological, and surgical considerations. 1 - 3 Consequently, they present surgical challenges that could be overcome with technical nuances. The origin of this meningioma on the diaphragm creates a distorted anatomy, which must be compre- hended for the safe approach and resection. Three distinct subtypes of diaphragm sellae menin- giomas are described, each with distinctive clinical presen- tations and surgical treatment implications. 2 Type A origi- nates from the upper leaf of diaphragm sellae pushing the stalk posteriorly. It usually presents with unilateral visual loss. Type B originates from the upper leaf of the diaphragm sellae pushing the stalk anteriorly. It presents with few visual symptoms, but memory disturbance and hypopituitarism are common. Type C originates from the inferior leaf of the diaphragm sellae (intrasellar menin- gioma) presenting with bitemporal hemianopsia and hypopituitarism. Recognizing these variations in this rare tumor subtype is critical to minimizing potential adverse outcomes associated with operative treatment. The cranial approach has been the recommended route for these lesions with an exception of the intrasellar type. 1 , 3 In this article, we depict the pathological anatomy and demonstrate the surgical nuances in handling diaphragm sellae meningioma resection through a cranio-orbital approach 4 in a patient who had an unsuccessful trans- sphenoidal resection attempt. The patient consented for the procedure. Image at 1:38 from Al-Mefty O, Operative Atlas of Menin- giomas, C  LWW, 1997, with permission. Image at 8:56 from Kinjo et al, 2 Diaphragma sellae meningiomas, case reports, Neurosurgery, 1995, 36(6), 1082-1092, by permission of the Congress of Neurological Surgeons. KEY WORDS: Brain tumor, Cranio-orbital approach, Meningioma, Diaphragm sellae, Visual loss, Hypopituitarism, Cerebral arteries Operative Neurosurgery 0:1–2, 2021 https://doi.org/10.1093/ons/opab234 Received, February 23, 2021. Accepted, May 3, 2021. Watch now at https://academic.oup.com/ons/article-lookup/doi/10.1093/ons/opab234 OPERATIVE NEUROSURGERY VOLUME 0 | NUMBER 0 | 2021 | 1 Downloaded from https://academic.oup.com/ons/advance-article/doi/10.1093/ons/opab234/6309705 by guest on 26 June 2021