Surgical strategy to minimize dominant hemisphere retraction in an asymmetric giant tuberculum sellae meningioma with contralateral anterior cerebral artery positioning: A case report

Background: Large asymmetric tuberculum sellae meningiomas are technically demanding anterior skull base lesions because of their close relationships with the optic apparatus and the anterior cerebral artery–anterior communicating artery complex (ACA-AComA). Although tumor lateralization is commonly considered during approach selection, it may be insufficient as an isolated determinant in cases with contralateral vascular displacement and marked peritumoral edema involving the dominant frontal lobe. In selected complex cases, integrating vascular anatomy, edema distribution, and baseline functional vulnerability may help refine surgical planning. Case description: We report the case of a 44-year-old male patient with an asymmetric giant tuberculum sellae meningioma measuring 52 × 49 × 49 mm, associated with optic chiasm compression, contralateral displacement of the ACA-AComA complex, and pronounced peritumoral edema of the dominant left frontal lobe. Clinically, the patient presented with progressive visual deterioration and moderate frontal-executive cognitive impairment. Neuropsychological testing did not independently determine the surgical corridor, but complemented imaging by confirming baseline dominant frontal network vulnerability. Based on the combined assessment of vascular geometry, edema distribution, tumor size, and functional considerations, an extended bifrontal craniotomy was selected to allow early bilateral visualization of the anterior cerebral arteries and to reduce additional traction-related stress on the dominant edematous frontal lobe. Controlled cerebrospinal fluid management was performed using intraoperative ventricular drainage followed by postoperative lumbar drainage. Maximally safe near-total resection was achieved without vascular complications. A very thin adherent tumor layer was intentionally preserved along the densely adherent ACA-AComA region, with no radiographically appreciable residual enhancing tumor on early postoperative magnetic resonance imaging. Early postoperative mild frontal-executive worsening was observed, followed by recovery to baseline by 3 months, together with gradual improvement in visual function. Conclusion: This case illustrates that, in selected giant asymmetric tuberculum sellae meningiomas, surgical planning may benefit from explicit consideration of contralateral ACA-AComA displacement, dominant frontal edema, and preoperative frontal-executive vulnerability rather than tumor lateralization alone. The favorable postoperative course should be interpreted cautiously and should not be considered evidence of superiority of the bifrontal approach over unilateral transcranial or endoscopic routes. This report provides a hypothesis-generating example of functional–vascular surgical planning in a complex anterior skull base tumor.