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

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.

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Intraoperative Doppler ultrasound of the cavernous part of the internal carotid artery in endoscopic transsphenoidal removal of the laterosellar tumors

Russian journal of neurosurgery ◽

10.17650/1683-3295-2019-21-1-27-34 ◽

2019 ◽

Vol 21 (1) ◽

pp. 27-34

Author(s):

O. I. Sharipov ◽

D. V. Fomichev ◽

M. A. Kutin ◽

P. L. Kalinin

Keyword(s):

Carotid Artery ◽

Internal Carotid Artery ◽

Doppler Ultrasound ◽

Cavernous Sinus ◽

Dura Mater ◽

Pituitary Adenomas ◽

Internal Carotid ◽

Blue Color ◽

Study Objective ◽

Invasive Method

The study objective is to describe the technique of intraoperative Doppler ultrasound (DU) of brain arteries and to determine the indications for its use during endoscopic transsphenoidal operations. Materials and methods. The study included 100 patients with skull base tumors (pituitary adenomas, trigeminal schwannomas, chordomas), operated via standard or extended transsphenoid endoscopic approaches. For DU, the location of the internal carotid artery (ICA) relative to the surface of the tumor or dura mater was determined as a red and/or blue color of the monitor screen in the M-mode window, accompanied by a characteristic sound signal. Results. DU was used to remove pituitary adenomas in 95 cases, trigeminal schwannomas in 3 cases, chordomas in 2 cases. Intraoperative DU helped to locate the ICA during removal of the laterosellar part of the tumor in all observations. In none of the cases presented were no injuries to the ICA. Сonclusion. DU is an effective and non-invasive method for detecting ICA during endoscopic operations which contributes to the safe disposal of laterosellar tumors. Adequate use of the method does not carry well-known and potential risks. DU should be performed when the tumor is removed from the cavernous sinus or its projection via the lateral extended transsphenoidal endoscopic access (to determine the safe boundaries of the dura mater section in the cavernous sinus projection).

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Transcavernous Resection of a Giant Extensive Chondrosarcoma with Endoscopic Assistance

Journal of Neurological Surgery Part B Skull Base ◽

10.1055/s-0041-1727124 ◽

2021 ◽

Author(s):

Walid Elshamy ◽

Burcak Soylemez ◽

Sima Sayyahmelli ◽

Nese Keser ◽

Mustafa K. Baskaya

Keyword(s):

Carotid Artery ◽

Internal Carotid Artery ◽

Skull Base ◽

Internal Carotid ◽

Gross Total Resection ◽

Petrous Apex ◽

Left Internal Carotid Artery ◽

Total Resection ◽

Complete Occlusion ◽

Grade Ii

AbstractChondrosarcomas are one of the major malignant neoplasms which occur at the skull base. These tumors are locally invasive. Gross total resection of chondrosarcomas is associated with longer progression-free survival rates. The patient is a 55-year-old man with a history of dysphagia, left eye dryness, hearing loss, and left-sided facial pain. Magnetic resonance imaging (MRI) showed a giant heterogeneously enhancing left-sided skull base mass within the cavernous sinus and the petrous apex with extension into the sphenoid bone, clivus, and the cerebellopontine angle, with associated displacement of the brainstem (Fig. 1). An endoscopic endonasal biopsy revealed a grade-II chondrosarcoma. The patient was then referred for surgical resection. Computed tomography (CT) scan and CT angiogram of the head and neck showed a left-sided skull base mass, partial destruction of the petrous apex, and complete or near-complete occlusion of the left internal carotid artery. Digital subtraction angiography confirmed complete occlusion of the left internal carotid artery with cortical, vertebrobasilar, and leptomeningeal collateral development. The decision was made to proceed with a left-sided transcavernous approach with possible petrous apex drilling. During surgery, minimal petrous apex drilling was necessary due to autopetrosectomy by the tumor. Endoscopy was used to assist achieving gross total resection (Fig. 2). Surgery and postoperative course were uneventful. MRI confirmed gross total resection of the tumor. The histopathology was a grade-II chondrosarcoma. The patient received proton therapy and continues to do well without recurrence at 4-year follow-up. This video demonstrates steps of the combined microsurgical skull base approaches for resection of these challenging tumors.The link to the video can be found at: https://youtu.be/WlmCP_-i57s.

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Identification of the internal carotid artery at the superior part of the cavernous sinus during endoscopic endonasal cavernous sinus tumor surgery

Acta Neurochirurgica ◽

10.1007/s00701-013-1986-4 ◽

2014 ◽

Vol 156 (3) ◽

pp. 475-479 ◽

Cited By ~ 4

Author(s):

Fuminari Komatsu ◽

Masami Shimoda ◽

Shinri Oda ◽

Masaaki Imai ◽

Hideaki Shigematsu ◽

...

Keyword(s):

Carotid Artery ◽

Internal Carotid Artery ◽

Cavernous Sinus ◽

Internal Carotid ◽

Tumor Surgery ◽

Endoscopic Endonasal ◽

Superior Part ◽

Sinus Tumor ◽

Cavernous Sinus Tumor

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

Operative Neurosurgery ◽

10.1093/ons/opx121 ◽

2017 ◽

Vol 14 (4) ◽

pp. 432-440 ◽

Cited By ~ 2

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.

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Endoscopic Endonasal Removal of Pituitary Adenomas with Paraclival Internal Carotid Artery Invasion

ORL ◽

10.1159/000276876 ◽

2010 ◽

Vol 72 (1) ◽

pp. 28-37 ◽

Cited By ~ 2

Author(s):

Qiuhang Zhang ◽

Haili Lv ◽

Ge Chen ◽

Hongchuan Guo

Keyword(s):

Carotid Artery ◽

Internal Carotid Artery ◽

Pituitary Adenomas ◽

Internal Carotid ◽

Endoscopic Endonasal

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

Russian journal of neurosurgery ◽

10.17650/1683-3295-2019-21-2-39-44 ◽

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.

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Tumors Invading the Cavernous Sinus That Cause Internal Carotid Artery Compression Are Rarely Pituitary Adenomas

10.1210/endo-meetings.2011.part2.p5.p1-435 ◽

2011 ◽

pp. P1-435-P1-435

Author(s):

Mark E Molitch ◽

Laura Cowen ◽

Raymond Stadiem ◽

Alexander Uihlein ◽

Michelle Naidich ◽

...

Keyword(s):

Carotid Artery ◽

Internal Carotid Artery ◽

Cavernous Sinus ◽

Pituitary Adenomas ◽

Internal Carotid ◽

Carotid Artery Compression

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Orbitopterional Approach for the Resection of a Suprasellar Craniopharyngioma: Adapting the Strategy to the Microsurgical and Pathologic Anatomy

Journal of Neurological Surgery Part B Skull Base ◽

10.1055/s-0038-1623525 ◽

2018 ◽

Vol 79 (S 03) ◽

pp. S239-S240

Author(s):

Vincent Nguyen ◽

Jaafar Basma ◽

Paul Klimo ◽

Jeffrey Sorenson ◽

L. Michael

Keyword(s):

Optic Nerve ◽

Carotid Artery ◽

Internal Carotid Artery ◽

Internal Carotid ◽

Senior Author ◽

Gross Total Resection ◽

Microsurgical Anatomy ◽

Pathological Anatomy ◽

Total Resection ◽

Suprasellar Region

Objectives To describe the orbitopterional approach for the resection of a suprasellar craniopharyngioma with emphasis on the microsurgical and pathological anatomy of such lesions. Design After completing the orbitopterional craniotomy in one piece including a supraorbital ridge osteotomy, the Sylvian fissure was split in a distal to proximal direction. The ipsilateral optic nerve and internal carotid artery were identified. Establishing a corridor to the tumor through both the opticocarotid and optic cisterns allowed for a wide angle of attack. Using both corridors, a microsurgical gross total resection was achieved. A radical resection required transection of the stalk at the level of the hypothalamus. Photographs of the region are borrowed from Dr Rhoton's laboratory to illustrate the microsurgical anatomy. Understanding the cisternal and topographic relationships of the optic nerve, optic chiasm, and internal carotid artery is critical to achieving gross total resection while preserving normal anatomy. Participants The surgery was performed by the senior author assisted by Dr. Jaafar Basma. The video was edited by Dr. Vincent Nguyen. Outcome Measures Outcome was assessed with extent of resection and postoperative visual function. Results A gross total resection of the tumor was achieved. The patient had resolution of her bitemporal hemianopsia. She had diabetes insipidus with normal anterior pituitary function. Conclusions Understanding the microsurgical anatomy of the suprasellar region and the pathological anatomy of craniopharyngiomas is necessary to achieve a good resection of these tumors. The orbitopterional approach provides the appropriate access for such endeavor.The link to the video can be found at: https://youtu.be/Be6dtYIGqfs.

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