scholarly journals Microsurgical Resection of Tuberculum Sellae Meningioma via Pterional Craniotomy with Extradural Anterior Clinoidectomy and Optic Unroofing

2018 ◽  
Vol 79 (S 02) ◽  
pp. S218-S218 ◽  
Author(s):  
Ihsan Dogan ◽  
Melih Ucer ◽  
Mustafa Başkaya
Keyword(s):  
Carotid Artery ◽  
Internal Carotid Artery ◽  
Internal Carotid ◽  
Visual Field Examination ◽  
Who Grade ◽  
Tuberculum Sellae Meningioma ◽  
Pterional Craniotomy ◽  
Anterior Clinoidectomy ◽  
Microsurgical Resection ◽  
Tuberculum Sellae

AbstractMicrosurgical treatment of suprasellar tumors, in particular tuberculum sellae meningiomas, poses significant challenge. These tumors are surrounded by vital neurovascular structures, such as optic apparatus, pituitary stalk, internal carotid artery and its branches, and anterior cerebral arteries. In large and complex cases, early identification and decompression of these structures may facilitate safer dissection and resection. Therefore, extradural anterior clinoidectomy with optic unroofing facilitates the internal carotid artery exposure and optic nerve decompression. In this video, we describe a 37-year-old female patient who presented with new onset of severe headaches. On visual examination, she was found to have bitemporal visual defects. MRI scan of the head showed a large, approximately 3 cm suprasellar tumor consistent with tuberculum sellae meningioma. She underwent surgical resection via pterional craniotomy with extradural anterior clinoidectomy and optic unroofing. Microsurgical gross total resection was achieved and histopathology was WHO grade II meningioma. She had an uneventful postoperative course and visual field examination improved significantly. In this video, surgical technique in performing extradural anterior clinoidectomy and optic unroofing and steps of microsurgical resection are demonstrated.The link to the video can be found at: https://youtu.be/oPZ8NTyvxJc.

scholarly journals Modified One-Piece Extended Transbasal Approach for Endoscopic-Assisted Microsurgical Resection of Tuberculum Sellae Meningioma: Operative Video and Technical Nuances

2017 ◽  
Vol 79 (S 02) ◽  
pp. S213-S214 ◽  
Author(s):  
James Liu ◽  
Kentaro Watanabe
Keyword(s):  
Optic Nerve ◽  
Carotid Artery ◽  
Internal Carotid Artery ◽  
Internal Carotid ◽  
Falciform Ligament ◽  
Tuberculum Sellae Meningioma ◽  
Nerve Decompression ◽  
Optic Nerve Decompression ◽  
Microsurgical Resection ◽  
Tuberculum Sellae

AbstractThe optimal approach for surgical resection of tuberculum sellae meningiomas remains controversial. Approach selection is largely based on a variety of factors, such as tumor size, extent and location relative to the optic canal and internal carotid artery, the presence of vascular encasement, and surgeon's preference. In this operative video manuscript, the authors demonstrate the importance of an open transcranial approach when the tumor extends lateral to the optic nerve over the internal carotid artery into the opticocarotid triangle, which is a difficult region to safely access with a purely endoscopic endonasal approach. We present a case of an endoscopic-assisted microsurgical resection of a tuberculum sellae meningioma using a modified one-piece extended transbasal approach in a patient with unilateral visual loss. The approach allows both interhemispheric and subfrontal routes to the suprasellar region. Early optic nerve decompression and division of the falciform ligament is critical to optimize visual outcomes. This video atlas demonstrates the operative technique and surgical nuances of the skull base approach, optic nerve decompression, tumor-arachnoid dissection, and safe handling of the neurovascular structures. A gross total resection was achieved and the patient had restoration of normal vision with normal pituitary function. In summary, the modified one-piece extended transbasal approach with endoscopic assistance is an important strategy in the armamentarium for surgical management of tuberculum sellae meningiomas.The link to the video can be found at: https://www.youtube.com/watch?v=jKNtRzMSFVE.

Endoscopic endonasal approach for a tuberculum sellae meningioma

2012 ◽  
Vol 32 (Suppl1) ◽  
pp. E8 ◽  
Author(s):  
Juan C. Fernandez-Miranda ◽  
Carlos D. Pinheiro-Neto ◽  
Paul A. Gardner ◽  
Carl H. Snyderman
Keyword(s):  
Optic Nerve ◽  
Carotid Artery ◽  
Internal Carotid Artery ◽  
Internal Carotid ◽  
Optic Canal ◽  
Csf Leak ◽  
Endoscopic Endonasal ◽  
Tuberculum Sellae Meningioma ◽  
Tuberculum Sellae

The authors present the technical and anatomical nuances needed to perform an endoscopic endonasal removal of a tuberculum sellae meningioma. The patient is a 47-year-old female with headaches and an incidental finding of a small tuberculum sellae meningioma with no vascular encasement, no optic canal invasion, but mild inferior to superior compression of the cisternal segment of the left optic nerve. Neuroophthalmology assessment revealed no visual defects. Treatment options included clinical observation with imaging follow-up studies, radiosurgery, and resection. The patient elected to undergo surgical removal and an endonasal endoscopic approach was the preferred surgical option. Preoperative radiological studies showed the presence of an osseous ring between the left middle and anterior clinoids, the so-called carotico-clinoidal ring. The surgical implications of this finding and its management are illustrated. The surgical anatomy of the suprasellar region is reviewed, including concepts such as the chiasmatic sulcus and limbus sphenoidale, medial and lateral optico-carotid recesses, and the paraclinoidal and supraclinoidal segments of the internal carotid artery. Emphasis is made in the importance of exposing the distal dural ring of the internal carotid artery and the precanalicular segment of the optic nerve for adequate intradural dissection. The endonasal route allows for early coagulation of the tumor meningeal supply and extensive resection of dural attachments, and importantly, provides an inferior to superior access to the infrachiasmatic region that facilitates complete tumor removal without any manipulation of the optic nerve. The lateral limit of dural removal is formed by the distal dural ring, which is gently coagulated after the tumor is resected. A 45° scope is used to inspect for any residual tumor, in particular at the entrance of the optic nerve into the optic canal and at the most anterior margin of the exposure (limbus sphenoidale). The steps for reconstruction are detailed and include intradural placement of dural substitute and extradural placement of the nasoseptal flap. The nuances for proper harvesting, positioning, and reinforcement of the flap are described. No lumbar drain was used. The patient had an uneventful recovery with no CSF leak or any other complications. Imaging follow-up at 6 months showed complete removal of the tumor. The patient had no sinonasal or neurological symptoms, and olfaction was fully preserved. The video can be found here: http://youtu.be/kkuV-yyEHMg.

scholarly journals Role of Extradural Clinoidectomy and Optic Unroofing in Resection of an Anterior Clinoidal Meningioma with Encasement of the Internal Carotid Artery and Its Branches

2021 ◽  
Author(s):  
Sima Sayyahmelli ◽  
Zhaoliang Sun ◽  
Emel Avci ◽  
Mustafa K. Başkaya
Keyword(s):  
Carotid Artery ◽  
Internal Carotid Artery ◽  
Skull Base ◽  
Vision Loss ◽  
Internal Carotid ◽  
Extent Of Resection ◽  
World Health ◽  
Who Grade ◽  
The Right ◽  
Supraclinoid Internal Carotid Artery

AbstractAnterior clinoidal meningiomas (ACMs) remain a major neurosurgical challenge. The skull base techniques, including extradural clinoidectomy and optic unroofing performed at the early stage of surgery, provide advantages for improving the extent of resection, and thereby enhancing overall outcome, and particularly visual function. Additionally, when the anterior clinoidal meningiomas encase neurovascular structures, particularly the supraclinoid internal carotid artery and its branches, this further increases morbidity and decreases the extent of resection. Although it might be possible to remove the tumor from the artery wall despite complete encasement or narrowing, the decision of whether the tumor can be safely separated from the arterial wall ultimately must be made intraoperatively.The patient is a 75-year-old woman with right-sided progressive vision loss. In the neurological examination, she only had light perception in the right eye without any visual acuity or peripheral loss in the left eye. MRI showed a homogeneously enhancing right-sided anterior clinoidal mass with encasing and narrowing of the supraclinoid internal carotid artery (ICA). Computed tomography (CT) angiography showed a mild narrowing of the right supraclinoid ICA with associated a 360-degree encasement. The decision was made to proceed using a pterional approach with extradural anterior clinoidectomy and optic unroofing. The surgery and postoperative course were uneventful. MRI confirmed gross total resection (Figs. 1 and 2). The histopathology was a meningothelial meningioma, World Health Organization (WHO) grade I. The patient continues to do well without any recurrence and has shown improved vision at 15-month follow-up.This video demonstrates important steps of the microsurgical skull base techniques for resection of these challenging tumors.The link to the video can be found at https://youtu.be/vt3o1c2o8Z0

The Minipterional Craniotomy for Anterior Circulation Aneurysms: Initial Experience With 72 Patients

2014 ◽  
Vol 10 (2) ◽  
pp. 200-207 ◽  
Author(s):  
Justin M. Caplan ◽  
Kyriakos Papadimitriou ◽  
Wuyang Yang ◽  
Geoffrey P. Colby ◽  
Alexander L. Coon ◽  
...  
Keyword(s):  
Carotid Artery ◽  
Internal Carotid Artery ◽  
Middle Cerebral Artery ◽  
Cerebral Artery ◽  
Internal Carotid ◽  
Average Length ◽  
Temporalis Muscle ◽  
Anterior Circulation ◽  
Pterional Craniotomy ◽  
Anterior Circulation Aneurysms

Abstract BACKGROUND: The pterional craniotomy is well established for microsurgical clipping of most anterior circulation aneurysms. The incision and temporalis muscle dissection impacts postoperative recovery and cosmetic outcomes. The minipterional (MPT) craniotomy offers similar microsurgical corridors, with a substantially shorter incision, less muscle dissection, and a smaller craniotomy flap. OBJECTIVE: To report our experience with the MPT craniotomy in select unruptured anterior circulation aneurysms. METHODS: From January 2009 to July 2013, 82 unruptured aneurysms were treated in 72 patients, with 74 MPT craniotomies. Seven patients had multiple aneurysms treated with a single MPT craniotomy. The average patient age was 56 years (range: 24-87). Aneurysms were located along the middle cerebral artery (n = 36), posterior communicating (n = 22), paraophthalmic (n = 22), choroidal (n = 1), and dorsal ICA segments (n = 1). The MPT craniotomy utilized an incision just posterior to the hairline and a single myocutaneous flap. RESULTS: The average aneurysm size was 5.45 mm (range: 1-14). There were no instances of compromised operative corridors requiring craniotomy extension. Three significant early postoperative complications included epidural and subdural hematomas requiring evacuation, and a middle cerebral artery infarction. Average length of hospitalization was 3.96 days (range: 2-20). Two patients required reoperation for wound infections. Average follow-up was 421 days (range: 5-1618). Minimal to no temporalis muscle wasting was noted in 96% of patients. CONCLUSION: The MPT craniotomy is a worthwhile alternative to the standard pterional craniotomy. There were no instances of suboptimal operative corridors and clip applications when the MPT craniotomy was utilized in the treatment of unruptured middle cerebral artery and supraclinoid internal carotid artery aneurysms proximal to the terminal internal carotid artery bifurcation.

Quantitative Analysis of Variable Extent of Anterior Clinoidectomy With Intradural and Extradural Approaches

2015 ◽  
Vol 11 (1) ◽  
pp. 147-161 ◽  
Author(s):  
Manjul Tripathi ◽  
Rama Chandra Deo ◽  
Natesan Damodaran ◽  
Ashish Suri ◽  
Vinkle Srivastav ◽  
...  
Keyword(s):  
Optic Nerve ◽  
Carotid Artery ◽  
Internal Carotid Artery ◽  
Laser Scanning ◽  
Internal Carotid ◽  
Volumetric Analysis ◽  
Surgical Approaches ◽  
Anterior Clinoid Process ◽  
Anterior Clinoidectomy ◽  
Bony Landmarks

Abstract BACKGROUND Drilling of the anterior clinoid process (ACP) is an integral component of surgical approaches for central and paracentral skull base lesions. The technique to drill ACP has evolved from pure intradural to extradural and combined techniques. OBJECTIVE To describe the computerized morphometric evaluation of exposure of optic nerve and internal carotid artery with proposed tailored intradural (IDAC) and complete extradural (EDAC) anterior clinoidectomy. METHODS We describe a morphometric subdivision of ACP into 4 quadrangles and 1 triangle on the basis of fixed bony landmarks. Computerized volumetric analysis with 3-dimensional laser scanning of dry-drilled bones for respective tailored IDAC and EDAC was performed. Both approaches were compared for the area and length of the optic nerve and internal carotid artery. Five cadaver heads were dissected on alternate sides with intradural and extradural techniques to evaluate exposure, surgical freedom, and angulation of approach. RESULTS Complete anterior clinoidectomy provides a 2.5-times larger area and 2.7-times larger volume of ACP. Complete clinoidectomy deroofed the optic nerve to an equal extent as by proposed the partial tailored clinoidectomy approach. Tailored IDAC exposes only the distal dural ring, whereas complete EDAC exposes both the proximal and distal dural rings with complete exposure of the carotid cave. CONCLUSION Quantitative comparative evaluation provides details of exposure and surgical ease with both techniques. We promote hybrid/EDAC technique for vascular pathologies because of better anatomic orientation. Extradural clinoidectomy is the preferred technique for midline cranial neoplasia. An awareness of different variations of clinoidectomy can prevent dependency on any particular approach and facilitate flexibility.

The “Yo-Yo” Technique to Prevent Cerebrospinal Fluid Rhinorrhea after Anterior Clinoidectomy for Proximal Internal Carotid Artery Aneurysms

2006 ◽  
Vol 59 (suppl_1) ◽  
pp. ONS-101-ONS-107 ◽  
Author(s):  
John H. Chi ◽  
Michael Sughrue ◽  
Sandeep Kunwar ◽  
Michael T. Lawton
Keyword(s):  
Cerebrospinal Fluid ◽  
Carotid Artery ◽  
Internal Carotid Artery ◽  
Sphenoid Sinus ◽  
Internal Carotid ◽  
Anterior Clinoid Process ◽  
Csf Rhinorrhea ◽  
Anterior Clinoidectomy ◽  
Optic Strut ◽  
Proximal Internal Carotid Artery

Abstract OBJECTIVE: Resection of the anterior clinoid process is important for the exposure of aneurysms on clinoidal and supraclinoidal segments of the internal carotid artery. Cerebrospinal fluid (CSF) rhinorrhea can complicate anterior clinoidectomy when the optic strut is pneumatized and its removal communicates the subarachnoid space with the sphenoid sinus. We present a technique for repairing this defect and preventing CSF rhinorrhea. METHODS: A suture is secured around a strip of temporalis muscle, which is then pushed through the opening in the optic strut completely into the sphenoid sinus. The ends of suture that trail the muscle are used to retract the muscle from the sphenoid sinus back into the optic strut. The suture is trimmed and the repair is covered with sealant or fibrin glue. RESULTS: During an 8-year period in which 127 patients with proximal internal carotid artery aneurysms that required anterior clinoidectomy were treated, pneumatized optic struts were encountered in 14 patients (11%). Four patients were treated with the “yo-yo” technique, none of whom experienced CSF rhinorrhea. Before using this technique, 10 patients were managed with standard packing techniques (wax, muscle, and gel foam) and four of these patients subsequently experienced CSF rhinorrhea (40%). In these four patients, all required reoperation with either craniotomy and packing with pericranium (one patient), Couldwell-Luc procedure (one patient), or endoscopic transnasal obliteration of the sphenoid sinus with fat (two patients). CONCLUSION: The “yo-yo” technique of tightly wedging a muscle plug into the optic strut proved to be simple, fast, and effective, preventing CSF rhinorrhea in all patients in whom it was applied. Although experience with this technique is limited, reversing the direction of packing and pulling muscle from the sphenoid sinus into the optic strut eliminated a complication that occurred in 40% of patients with standard packing techniques.

The “No-drill” Technique of Anterior Clinoidectomy: A Cranial Base Approach To The Paraclinoid And Parasellar Region

2009 ◽  
Vol 64 (suppl_1) ◽  
pp. ONS96-ONS106 ◽  
Author(s):  
Dongwoo John Chang
Keyword(s):  
Carotid Artery ◽  
Internal Carotid Artery ◽  
Internal Carotid ◽  
Cranial Base ◽  
Optic Canal ◽  
Anterior Clinoid Process ◽  
Anterior Clinoidectomy ◽  
Computed Tomographic ◽  
Optic Strut ◽  
Neurovascular Structures

Abstract Introduction: A high-speed power-drilling technique of anterior clinoidectomy has been advocated in all publications on paraclinoid region surgery. The entire shaft of the power drill is exposed in the operative field; thus, all neurovascular structures in proximity to any portion of the full length of the rotating drill bit are at risk for direct mechanical and/or thermal injury. Ultrasonic bone removal has recently been developed to mitigate the potential complications of the traditional power-drilling technique of anterior clinoidectomy. However, ultrasound-related cranial neuropathies are recognized complications of its use, as well as the increased cost of device acquisition and maintenance. Methods: A retrospective review of a cerebrovascular/cranial base fellowship-trained neurosurgeon's 45 consecutive cases of anterior clinoidectomy using the “no-drill” technique is presented. Clinical indications have been primarily small to giant aneurysms of the proximal internal carotid artery; however, in addition to ophthalmic segment aneurysms, selected internal carotid artery-posterior communicating artery aneurysms and internal carotid artery bifurcation aneurysms, and other large/giant/complex anterior circulation aneurysms, this surgical series of “no-drill” anterior clinoidectomy includes tuberculum sellae meningiomas, clinoidal meningiomas, cavernous sinus lesions, pituitary macroadenomas with significant suprasellar extension, other perichiasmal lesions (sarcoid), and fibrous dysplasia. A bony opening is made in the mid- to posterior orbital roof after the initial pterional craniotomy. Periorbita is dissected off the bone from inside the orbital compartment. Subsequent piecemeal resection of the medial sphenoid wing, anterior clinoid process, optic canal roof, and optic strut is performed with bone rongeurs of various sizes via the bony window made in the orbital roof. Results: No power drilling was used in this surgical series of anterior clinoidectomies. Optimal microsurgical exposure was obtained in all cases to facilitate complete aneurysm clippings and lesionectomies. There were no cases of direct injury to surrounding neurovascular structures from the use of the “no-drill” technique. The surgical technique is presented with illustrative clinical cases and intraoperative photographs, demonstrating the range of applications in anterior and central cranial base neurosurgery. Conclusion: Power drilling is generally not necessary for removal of the anterior clinoid process, optic canal roof, and optic strut. Rigorous study of preoperative computed tomographic scans/computed tomographic angiography scans, magnetic resonance imaging scans, and angiograms is essential to identify important anatomic relationships between the anterior clinoid process, optic strut, optic canal roof, and neighboring neurovascular structures. The “no-drill” technique eliminates the risks of direct power-drilling mechanical/ thermal injury and the risks of ultrasound-associated cranial neuropathies. The “no-drill” technique provides a direct, time-efficient, and efficacious approach to the paraclinoid/ parasellar/pericavernous area, using a simplified mechanical route.This technique is applicable to any neurosurgical diagnosis and approach in which anterior clinoidectomy is necessary. It is arguably the gentlest and most efficient method for exposing the paracli-noid/parasellar/pericavernous region.

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