fig4

Figure 4. A 46-year-old woman presented with severe left eye vision loss and progressively worsening right eye vision, with a right inferior field cut. She also had amenorrhea with mild hyperprolactinemia, presumably from stalk effect. Pre-operative imaging demonstrates a large tuberculum sella meningioma with a severely displaced optic apparatus and left optic canal invasion (red arrow), but no arterial encasement or lateral extension beyond the supraclinoid ICAs. The pituitary infundibulum is displaced posteriorly. An endoscopic transtuberculum approach was performed with a gross total resection achieved. A sellar fat graft and well-vascularized nasoseptal flap is seen overlying a bony buttress (posterior nasal septum graft; blue arrow) reinforced with nasal packing (“M”). The pituitary gland and infundibulum enhance normally. The patient demonstrated marked improvement in visual acuity and visual fields and her menses returned with normalization of serum prolactin.