scholarly journals REMOVING A RETROSELLAR PITUITARY ADENOMA VIA THE ENDOSCOPIC ENDONASAL TRANSSPHENOIDAL TRANSCAVERNOUS APPROACH

2019 ◽  
Vol 21 (2) ◽  
pp. 39-44
Author(s):  
О. I. Sharipov ◽  
M. A. Kutin ◽  
P. L. Kalinin
Keyword(s):  
Pituitary Adenoma ◽  
Carotid Artery ◽  
Internal Carotid Artery ◽  
Cavernous Sinus ◽  
Internal Carotid ◽  
Sella Turcica ◽  
Posterior Cranial Fossa ◽  
Anatomical Landmarks ◽  
Endoscopic Endonasal ◽  
Cranial Fossa

The study objective is to describe the removal of the pituitary adenoma from the posterior cranial fossa through endoscopic transsphenoidal trans-cavernous approach, when the main surgical corridor was the tumor-intact cavernous sinus. Materials and methods. A 55-year-old male patient with endosupraretrosellar endocrine-inactive pituitary adenoma was admitted to N.N. Burdenko Research Center of Neurosurgery. The patient had earlier undergone two surgeries for pituitary adenoma. Using the endoscopic endonasal transsphenoidal approach, we found that these surgeries resulted in the formation of scar-altered adipose tissue in the sphenoid sinus and partly in the sella turcica; anatomical landmarks indicating the midline and the location of the internal carotid arteries were absent. We formed an access to both retro- and suprasellar portions of the tumor between the sella turcica and cavernous segment of the internal carotid artery (through the cavernous sinus); then we dissected anterior and posterior walls of the sinus and revealed a soft capsule-free pituitary adenoma, which was completely removed by a vacuum aspirator. The skull base defect was repaired using the multilayer technique with autologous tissues. Results. After surgery, neurological status and visual functions did not change. In the postoperative period, we observed no oculomotor disorders, pituitary insufficiency, diabetes insipidus, or nasal liquorrhea. Follow-up computed tomography scans revealed no signs of intracranial complications or obvious residual tumor tissue. Magnetic resonance imaging 4 month postoperatively demonstrated small laterosellar fragments of the tumor in the sella turcica. The patient was further followed up. Conclusion. Cavernous sinus is a natural anatomical corridor providing access to the structures of the posterior cranial fossa and interpeduncular cistern. The main risk (damage to the cavernous segment of the internal carotid artery) can be minimized by using intraoperative dopplerography and visual control of all manipulations.

The So-Called Cavernous Sinus: A Review of the Controversy and Its Implications for Neurosurgeons

Neurosurgery ◽  
1982 ◽  
Vol 11 (5) ◽  
pp. 712-717 ◽  
Author(s):  
John N. Taptas
Keyword(s):  
Carotid Artery ◽  
Internal Carotid Artery ◽  
Cavernous Sinus ◽  
Internal Carotid ◽  
Cranial Nerves ◽  
Sella Turcica ◽  
Middle Cranial Fossa ◽  
Cranial Fossa ◽  
Base Of The Skull ◽  
Extradural Space

Abstract The so-called cavernous sinus is a venous pathway, an irregular network of veins that is part of the extradural venous network of the base of the skull, not a trabeculated venous channel. This venous pathway, the internal carotid artery, and the oculomotor cranial nerves cross the medial portion of the middle cranial fossa in an extradural space formed on each side of the sella turcica by the diverging aspects of a dural fold. In this space the venous pathway has only neighborhood relations with the internal carotid artery and the cranial nerves. The space itself must be distinguished from the vascular and nervous elements that it contains. The revision of the anatomy of this region has not only theoretical interest but also important clinical implications.

scholarly journals Endoscopic transnasal transmaxillary approach to the upper parapharyngeal space and the skull base

2019 ◽  
Vol 277 (3) ◽  
pp. 801-807
Author(s):  
Quan Liu ◽  
Huan Wang ◽  
Weidong Zhao ◽  
Xiaole Song ◽  
Xicai Sun ◽  
...  
Keyword(s):  
Carotid Artery ◽  
Internal Carotid Artery ◽  
Skull Base ◽  
Internal Carotid ◽  
Parapharyngeal Space ◽  
Middle Cranial Fossa ◽  
Anatomical Landmarks ◽  
Endoscopic Endonasal ◽  
Cranial Fossa ◽  
Optimal Approach

Abstract Purpose Treatment of tumors arising in the upper parapharyngeal space (PPS) or the floor of the middle cranial fossa is challenging. This study aims to present anatomical landmarks for a combined endoscopic transnasal and anterior transmaxillary approach to the upper PPS and the floor of the middle cranial fossa and to further evaluate their clinical application. Methods Dissection of the upper PPS using a combined endoscopic endonasal transpterygoid and anterior transmaxillary approach was performed in six cadaveric heads. Surgical landmarks associated with the approach were defined. The defined approach was applied in patients with tumors involving the upper PPS. Results The medial pterygoid muscle, tensor veli palatini muscle and levator veli palatini muscle were key landmarks of the approach into the upper PPS. The lateral pterygoid plate, foramen ovale and mandibular nerve were important anatomical landmarks for exposing the parapharyngeal segment of the internal carotid artery through a combined endoscopic transnasal and anterior transmaxillary approach. The combined approach provided a better view of the upper PPS and middle skull base, allowing for effective bimanual techniques and bleeding control. Application of the anterior transmaxillary approach also provided a better view of the inferior limits of the upper PPS and facilitated control of the internal carotid artery. Conclusions Improving the knowledge of the endoscopic anatomy of the upper PPS allowed us to achieve an optimal approach to tumors arising in the upper PPS. The combined endoscopic transnasal and anterior transmaxillary approach is a minimally invasive alternative approach to the upper PPS.

Paratrigeminal, Paraclival, Precavernous, or All of the Above? A Circumferential Anatomical Study of the C3-C4 Transitional Segment of the Internal Carotid Artery

2017 ◽  
Vol 14 (4) ◽  
pp. 432-440 ◽  
Author(s):  
Eleonora Marcati ◽  
Norberto Andaluz ◽  
Sebastien C Froelich ◽  
Lee A Zimmer ◽  
James L Leach ◽  
...  
Keyword(s):  
Carotid Artery ◽  
Internal Carotid Artery ◽  
Cavernous Sinus ◽  
Internal Carotid ◽  
Anatomical Study ◽  
Posterior Longitudinal Ligament ◽  
Petrous Apex ◽  
Meckel’S Cave ◽  
Endoscopic Endonasal ◽  
Meckel's Cave

Abstract BACKGROUND Although the term paraclival carotid pervades recent skull base literature, no clear consensus exists regarding boundaries or anatomical segments. OBJECTIVE To reconcile various internal carotid artery (ICA) nomenclatures for transcranial and endoscopic-endonasal perspectives, we reexamined the transition between lacerum (C3) and cavernous (C4) segments using a C1-C7 segments schema. In this cadaveric study, we obtained a 360°-circumferential view integrating histological, microsurgical, endoscopic, and neuroradiological analyses of this C3-C4 region and identified a distinct transitional segment. METHODS In 13 adult, silicone-injected, formalin-fixed cadaveric heads (26 sides), transcranial-extradural-subtemporal and endoscopic-endonasal CT­guided dissections were performed. A quadrilateral area was noted medial to Meckel's cave between cranial nerve VI, anterolateral and posterolateral borders of the lateral-paratrigeminal aspect of the precavernous ICA, and posterior longitudinal ligament. Endoscopically, a medial-paraclival aspect was defined. Anatomical correlations were made with histological and neuroradiological slides. RESULTS We identified a distinct precavernous C3-C4 transitional segment. In 18 (69%) specimens, venous channels were absent at the quadrilateral area, on the paratrigeminal border of the precavernous ICA. A trigeminal membrane, seen consistently on the superior border of V2, defined the lateral aspect of the cavernous sinus floor. The medial aspect of the precavernous ICA corresponded with the paraclival ICA. CONCLUSION Our study revealing the juncture of 2 complementary borders of the ICA, endoscopic endonasal (paraclival) and transcranial (paratrigeminal), reconciles various nomenclature. A precavernous segment may clarify controversies about the paraclival ICA and support the concept of a “safe door” for lesions involving Meckel's cave, cavernous sinus, and petrous apex.

scholarly journals Microsurgical anatomy of the arterial compartment of the cavernous sinus: analysis of 24 cavernous sinus

2005 ◽  
Vol 63 (2a) ◽  
pp. 259-264 ◽  
Author(s):  
Gustavo Isolan ◽  
Evandro de Oliveira ◽  
João Paulo Mattos
Keyword(s):  
Carotid Artery ◽  
Internal Carotid Artery ◽  
Cavernous Sinus ◽  
Internal Carotid ◽  
Sella Turcica ◽  
Microsurgical Anatomy ◽  
Isolated Artery ◽  
Anatomy Knowledge ◽  
Tentorial Artery ◽  
Meningohypophyseal Trunk

The cavernous sinus is a complex compartment situated in both sides of the sella turcica, being its microsurgical anatomy knowledge of fundamental importance when consider to approach surgically. We studied the arterial microanatomy of 24 cavernous sinus at the microsurgical laboratory, considering that in all the internal carotid artery were filled with colored latex. The meningohypophyseal trunk was present in 18 cases (75%) with its origin in intracavernous portion of the internal carotid artery. In relation to the 18 presented cases with meningohypophyseal trunk, 14 (77.7%) had a trifurcate and 4 (23.3%) had a bifurcate pattern. The tentorial artery was present in all. Its origin was observed, arising from the meningohypophyseal trunk in 17 (70.8%) and as an isolated artery in some extension of the intracavernous portion in 7 (29.1%). An accessory tentorial artery was found in one specimen. The dorsal meningeal artery was present in 22 cases (91.6%). Its origin was in the meningohypophyseal trunk in 17 cases (77.2%), arising from internal carotid artery in 4 cases (18.1%) and from inferior hypophyseal artery in one case (4.1%).The inferior hypophyseal artery was present in all cases, having its origin at the meningohypophyseal trunk in 16 cases (66.6%). In the remaining 8 cases (33.3%) the artery was found arising alone from the intracavernous portion also. The artery of the inferior cavernous sinus or inferolateral trunk was present in all cases and had its origin from internal carotid artery in its intracavernous segment. The McConnell's artery was not found in any cavernous sinus.

scholarly journals Ultrasound Doppler examination in the surgical treatment of pituitary adenomas with cavernous sinus extension

2021 ◽  
Vol 27 (1) ◽  
pp. 29-33
Author(s):  
Ruslan V. Aksyonov ◽  
Orest I. Palamar ◽  
Andrii P. Huk ◽  
Dmytro I. Okonskyi ◽  
Dmytro S. Teslenko
Keyword(s):  
Surgical Treatment ◽  
Carotid Artery ◽  
Internal Carotid Artery ◽  
Doppler Ultrasound ◽  
Cavernous Sinus ◽  
Pituitary Adenomas ◽  
Internal Carotid ◽  
Gross Total Resection ◽  
Total Resection ◽  
Endoscopic Endonasal

Objective: To determine the effectiveness of intraoperative Doppler ultrasound in the surgical treatment of pituitary adenomas with invasive parasellar growth into the cavernous sinus Knosp 3 and Knosp 4. Material and Methods. During 2009–2017, 71 patients with pituitary adenomas (PA) with extension into the cavernous sinus Knosp 3 and Knosp 4 were retrospectively reviewed. According to the size PA were divided into pituitary macroadenomas, (from 10 to 40 mm) in 45 (63.4%) patients, and giant PA (over 40 mm) – in 26 (36.6%) patients. Cavernous sinus invasion Knosp 3 and 4 was identified in 47 (66.2%) and 24 (33.8%) patients respectively. Non-secreting PA - 43 (60.5%) patients and hormone-secreting PA - 28 patients (39.4%). Endoscopic endonasal trassphenoidal (EET) approach was used in all cases. Laterally expanded EET (LEEET) approach was used in 29 cases. Intraoperative Doppler ultrasound (IDUS) was used in 36 (51%) cases. Results. Intraoperative Doppler ultrasound was used in cases of Knosp 3 extension in 23 (32.4%) cases and in Knosp 4 - in 13 (18.3%) cases. Gross total resection, including extension into the cavernous sinus using IDUS was achieved in 22 (62.7%) patients. In cases where IDUS was not used, gross total resection was achieved in 19 (52.7%) cases. In cases where the IDUS was not used, recurrence rate was 7.3%, with IDUS - 5%. Biochemical remission was achieved in 22 (78.6%) cases. Liquorrhea nasalis after surgery was observed in 6 (8.4%) cases, meningoencephalitis - in 1 (1.4%) case, oculomotor palsy -3 (4.2%) cases. Conclusions. Intraoperative Doppler ultrasound is an informative method that provides safe resection of pituitary adenomas with cavernous sinus extension with a low level of possible postoperative complications. Parasellar extension of Pituitary adenomas into the cavernous sinus Knosp 4 significantly reduces the possibility of gross total resection. However, the use of intraoperative ultrasound makes it possible to determine safe boundaries for manipulation both medially and laterally from the internal carotid artery, increasing the level of radicality and the duration of clinical remission. Intraoperative Doppler ultrasound during endoscopic endonasal transsphenoidal surgery of pituitary adenomas with parasellar extension allows to identify the internal carotid artery in the tumor stroma with the existing changed skull base anatomy. Dura incision under intraoperative Doppler ultrasound reduces the risk of internal carotid artery injury.

scholarly journals The surgical management of pituitary apoplexy with occluded internal carotid artery and hidden intracranial aneurysm: illustrative case

2021 ◽  
Vol 2 (5) ◽  
Author(s):  
Jian-Dong Zhu ◽  
Sungel Xie ◽  
Ling Xu ◽  
Ming-Xiang Xie ◽  
Shun-Wu Xiao
Keyword(s):  
Pituitary Adenoma ◽  
Carotid Artery ◽  
Internal Carotid Artery ◽  
Intracranial Aneurysm ◽  
Internal Carotid ◽  
Pituitary Apoplexy ◽  
Illustrative Case ◽  
Bleeding Events ◽  
Endoscopic Endonasal ◽  
Aneurysm Embolization

BACKGROUND Approximately 0.6% to 12% of cases of pituitary adenoma are complicated by apoplexy, and nearly 6% of pituitary adenomas are comorbid aneurysms. Occlusion of the internal carotid artery (ICA) with hidden intracranial aneurysm due to compression by an apoplectic pituitary adenoma is extremely rare; thus, the surgical strategy is also unknown. OBSERVATIONS The authors reported the case of a 48-year-old man with a large pituitary adenoma with coexisting ICA occlusion. After endoscopic transnasal surgery, repeated computed tomography angiography (CTA) demonstrated reperfusion of the left ICA but with a new-found aneurysm in the left posterior communicating artery; thus, interventional aneurysm embolization was performed. With stable recovery and improved neurological condition, the patient was discharged for rehabilitation training. LESSONS For patients with pituitary apoplexy accompanied by a rapid decrease of neurological conditions, emergency decompression through endoscopic endonasal transsphenoidal resection can achieve satisfactory results. However, with occlusion of the ICA by enlarged pituitary adenoma or pituitary apoplexy, a hidden but rare intracranial aneurysm may be considered when patients are at high risk of such vascular disease as aneurysm, and gentle intraoperative manipulations are required. Performing CTA or digital subtraction angiography before and after surgery can effectively reduce the missed diagnosis of comorbidity and thus avoid life-threatening bleeding events from the accidental rupture of an aneurysm.

Endoscopic Transnasal Approach to the Cavernous Sinus versus Transcranial Route: Anatomic Study

2005 ◽  
Vol 56 (suppl_4) ◽  
pp. ONS-379-ONS-389 ◽  
Author(s):  
Luigi Maria Cavallo ◽  
Paolo Cappabianca ◽  
Renato Galzio ◽  
Giorgio Iaconetta ◽  
Enrico de Divitiis ◽  
...  
Keyword(s):  
Carotid Artery ◽  
Internal Carotid Artery ◽  
Cavernous Sinus ◽  
Internal Carotid ◽  
Middle Cranial Fossa ◽  
Anatomic Landmarks ◽  
Transnasal Approach ◽  
Endoscopic Transnasal Approach ◽  
Cranial Fossa ◽  
Triangular Area

Abstract OBJECTIVE: The aim of the present study was to compare the anatomy of the cavernous sinus via an endoscopic transnasal route with the anatomy of the same region explored by the transcranial route. The purpose was to identify and correlate the corresponding anatomic landmarks both through the endoscopic transnasal transsphenoidal and the microscopic transcranial views. METHODS: Five fresh injected heads (10 specimens) were dissected by the endoscopic transnasal and microsurgical transcranial approaches. A comparison of different microsurgical corridors of the cavernous sinus with the corresponding endoscopic transnasal ones was performed. RESULTS: Through the endoscopic transnasal approach, it is possible to explore only some of the parasellar and middle cranial fossa subregions. Because of the complex multilevel architecture of the cavernous sinus, there is not always a correspondence between the surgical corridors bounded through the transcranial route and those exposed through the endoscopic transnasal approach. Nevertheless, some surgical corridors specific to the endoscopic transnasal route are evident: a C-shaped corridor is identifiable medial to the “intracavernous” internal carotid artery, whereas a wider triangular area is delineable lateral to the internal carotid artery; inside the latter, three more surgical corridors (a superior triangular space, a superior quadrangular space, and an inferior quadrangular space) can be described. CONCLUSION: Different surgical corridors can be defined during the endoscopic transnasal approach to the anteroinferior portion of the cavernous sinus, as already established for the transcranial route as well. Knowledge of these could be useful in decreasing morbidity and mortality during surgery in this region, these approaches being reserved to experienced transsphenoidal surgeons only.

BILATERAL INTERNAL CAROTID ARTERY ANEURYSM SIMULATING PITUITARY APOPLEXY

Neurosurgery ◽  
2009 ◽  
Vol 65 (6) ◽  
pp. E1202-E1202 ◽  
Author(s):  
Alberto Torres ◽  
Ruben Dammers ◽  
Ali F. Krisht
Keyword(s):  
Breast Cancer ◽  
Pituitary Adenoma ◽  
Carotid Artery ◽  
Internal Carotid Artery ◽  
Internal Carotid ◽  
Pituitary Apoplexy ◽  
Sella Turcica ◽  
Metastatic Breast ◽  
Artery Aneurysm ◽  
Vascular Lesion

Abstract OBJECTIVE Intracavernous internal carotid artery (ICA) aneurysms can extend into the sella and simulate pituitary adenomas. However, they are rarely associated with pituitary apoplexy. We present a rare case of bilateral intracavernous ICA aneurysms simulating a sellar mass with the clinical picture of a pituitary apoplexy. CLINICAL PRESENTATION An 82-year-old woman presented with a classic case of pituitary apoplexy with a history of headache, nausea, vomiting, and diplopia. She was found to have an intrasellar mass simulating a large and invasive pituitary adenoma. The patient had a medical history positive for breast cancer. INTERVENTION Because of the presentation with apoplexy and the possibility of metastatic breast cancer or pituitary adenoma, the patient was explored transsphenoidally to obtain pathological verification and possibly resect the tumor. Unusual intraoperative findings led to a microDoppler evaluation, suggesting a vascular lesion. Intraoperatively, an angiogram confirmed the presence of bilateral ICA giant aneurysms involving the ICA intracavernous component extending into the sella turcica. The patient refused further treatment. CONCLUSION The present case indicates that an intrasellar ICA aneurysm can be misdiagnosed as a macroadenoma and even present through pituitary apoplexy. When treating intrasellar masses with the slightest suspicion of a nonpituitary origin, further workup should be considered. The possibility of a vascular lesion simulating a pituitary adenoma should always be considered by neurosurgeons and ear, nose, and throat surgeons operating in the sellar region.

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