Two Routes, One Goal: Early Optic Nerve Decompression from Above and Below in Minimal Access Tuberculum Sellae Meningioma Surgery.

Early optic nerve decompression in tuberculum sellae meningiomas is critical for visual preservation, as postoperative visual dysfunction is primarily attributable to manipulation-induced ischemia, independent of the surgical approach. This video demonstrates this principle through both endoscopic endonasal and transcranial routes. The extended endoscopic endonasal approach(EEEA) provides direct access to the inferomedial optic canal, lateral and medial opticocarotid recesses(LOCR/MOCR), paraclival internal carotid artery, and limbus chiasmaticus, permitting 270° optic canal unroofing and controlled inferomedial optic sheath fenestration. The transcranial corridor enables extradural-intradural falciform ligament division, medial optic canal drilling under direct visualization, and superior-lateral optic sheath decompression. Extended endonasal endoscopy is optimal for inferomedial optic canal invasion, providing direct access to the preforaminal-canalicular corridor. However, the transcranial route remains indicated for tumors with supradiaphragmatic extension, a prefixed chiasm, or complex vascular encasement involving the A1-ACom-ICA segments. Early optic nerve decompression, whether performed endonasally or transcranially, remains a key determinant of postoperative visual outcome in tuberculum sellae meningioma surgery.