Endoscopic endonasal transcavernous posterior clinoidectomy with interdural pituitary transposition

2014 ◽  
Vol 121 (1) ◽  
pp. 91-99 ◽  
Author(s):  
Juan C. Fernandez-Miranda ◽  
Paul A. Gardner ◽  
Milton M. Rastelli ◽  
Maria Peris-Celda ◽  
Maria Koutourousiou ◽  
...  
Keyword(s):  
Pituitary Gland ◽  
Cavernous Sinus ◽  
Venous Drainage ◽  
Surgical Anatomy ◽  
Medial Wall ◽  
Endoscopic Endonasal ◽  
Interpeduncular Cistern ◽  
Working Space ◽  
Petroclival Meningiomas ◽  
Extradural Approach

Object The object of this paper was to describe the surgical anatomy and technical nuances of the endonasal transcavernous posterior clinoidectomy approach with interdural pituitary transposition and to report the clinical outcome of this technical modification. Methods The surgical anatomy of the proposed approach was studied in 10 colored silicon-injected anatomical specimens. The medical records of 12 patients that underwent removal of the posterior clinoid(s) with this technique were reviewed. Results The natural anatomical corridor provided by the cavernous sinus is used to get access to the posterior clinoid by mobilizing the pituitary gland in an interdural fashion. The medial wall of the cavernous sinus is preserved intact and attached to the gland during its medial and superior mobilization. This provides protection to the gland, allowing for preservation of its venous drainage pathways. The inferior hypophyseal artery is transected to facilitate the manipulation of the medial wall of the cavernous sinus and pituitary gland. This approach was successfully performed in all patients, including 6 with chordomas, 5 with petroclival meningiomas, and 1 with an epidermoid tumor. No patient in this series had neurovascular injury related to the posterior clinoidectomy. There were no instances of permanent hypopituitarism or diabetes insipidus. Conclusions The authors introduce a surgical variant of the endoscopic endonasal posterior clinoidectomy approach that does not require intradural pituitary transposition and is more effective than the purely extradural approach. The endoscopic endonasal transcavernous approach facilitates the removal of prominent posterior clinoids increasing the working space at the lateral recess of the interpeduncular cistern, while preserving the pituitary function.

scholarly journals The medial wall of the cavernous sinus. Part 1: Surgical anatomy, ligaments, and surgical technique for its mobilization and/or resection

2019 ◽  
Vol 131 (1) ◽  
pp. 122-130 ◽  
Author(s):  
Huy Q. Truong ◽  
Stefan Lieber ◽  
Edinson Najera ◽  
Joao T. Alves-Belo ◽  
Paul A. Gardner ◽  
...  
Keyword(s):  
Cavernous Sinus ◽  
Single Layer ◽  
Lateral Wall ◽  
Anterior Wall ◽  
Surgical Anatomy ◽  
Medial Wall ◽  
Vertical Segment ◽  
Anterior Clinoid Process ◽  
Endoscopic Endonasal

OBJECTIVEThe medial wall of the cavernous sinus (CS) is often invaded by pituitary adenomas. Surgical mobilization and/or removal of the medial wall remains a challenge.METHODSEndoscopic endonasal dissection was performed in 20 human cadaver heads. The configuration of the medial wall, its relationship to the internal carotid artery (ICA), and the ligamentous connections in between them were investigated in 40 CSs.RESULTSThe medial wall of the CS was confirmed to be an intact single layer of dura that is distinct from the capsule of the pituitary gland and the periosteal layer that forms the anterior wall of the CS. In 32.5% of hemispheres, the medial wall was indented by and/or well adhered to the cavernous ICA. The authors identified multiple ligamentous fibers that anchored the medial wall to other walls of the CS and/or to specific ICA segments. These parasellar ligaments were classified into 4 groups: 1) caroticoclinoid ligament, spanning from the medial wall and the middle clinoid toward the clinoid ICA segment and anterior clinoid process; 2) superior parasellar ligament, connecting the medial wall to the horizontal cavernous ICA and/or lateral wall of the CS; 3) inferior parasellar ligament, bridging the medial wall to the anterior wall of the CS or anterior surface of the short vertical segment of the cavernous ICA; and 4) posterior parasellar ligament, which anchors the medial wall to the short vertical segment of the cavernous ICA and/or the posterior carotid sulcus. The caroticoclinoid ligament and inferior parasellar ligament were present in most CSs (97.7% and 95%, respectively), while the superior and posterior parasellar ligaments were identified in approximately half of the CSs (57.5% and 45%, respectively). The caroticoclinoid ligament was the strongest and largest ligament, and it was typically assembled as a group of ligaments with a fan-like arrangement. The inferior parasellar ligament was the first to be encountered after opening the anterior wall of the CS during an interdural transcavernous approach.CONCLUSIONSThe authors introduce a classification of the parasellar ligaments and their role in anchoring the medial wall of the CS. These ligaments should be identified and transected to safely mobilize the medial wall away from the cavernous ICA during a transcavernous approach and for safe and complete resection of adenomas that selectively invade the medial wall.

Endoscopic Endonasal Pituitary Transposition for a Transdorsum Sellae Approach to the Interpeduncular Cistern

2008 ◽  
Vol 62 (suppl_1) ◽  
pp. ONS57-ONS74 ◽  
Author(s):  
Amin B. Kassam ◽  
Daniel M. Prevedello ◽  
Ajith Thomas ◽  
Paul Gardner ◽  
Arlan Mintz ◽  
...  
Keyword(s):  
Pituitary Gland ◽  
Diabetes Insipidus ◽  
Medical Center ◽  
Pituitary Function ◽  
Total Resection ◽  
Endoscopic Endonasal ◽  
Interpeduncular Cistern ◽  
Petroclival Meningiomas ◽  
Expanded Endonasal Approach ◽  
Function Preservation

Abstract Objective: The interpeduncular cistern, including the retroinfundibular area, is one of the most challenging regions to approach surgically. The pituitary gland and the infundibu-lum guard the region when an endonasal route is undertaken. Superior transposition of the pituitary gland and infundibulum is described as a functional means to access this complex region through a fully endoscopic, completely transnasal route. Methods: Ten consecutive patients in whom a pituitary transposition was performed during an expanded endonasal approach at the University of Pittsburgh Medical Center for resection of retroinfundibular lesions were reviewed. The series consisted of seven men and three women with a mean age of 44.4 years. Pathology consisted of four craniopharyngiomas, four chordomas, and two petroclival meningiomas. Results: Five patients (50%) underwent total resection of the tumor, three patients (30%) underwent near total resection (>95% removal), and two patients (20%) had partial resection of petroclival meningiomas with the goal of optic apparatus decompression. All four patients with visual deficits recovered their vision completely. There was no neurological deterioration. Eight patients had normal pituitary function preoperatively, seven of whom (87.5%) had confirmed function preservation postoperatively, with one of these patients experiencing transient diabetes insipidus. The remaining patient with a hypothalamic craniopharyngioma underwent complete resection with obligatory panhypopituitarism and diabetes insipidus. Conclusion: Endoscopic endonasal transposition of the pituitary gland and its stalk can provide a valuable corridor to the retroinfundibular space and interpeduncular cistern with pituitary function preservation in the majority of patients. This approach should only be pursued once significant experience with endoscopic endonasal approaches has been acquired.

The Medial Wall of the Cavernous Sinus: Microsurgical Anatomy

Neurosurgery ◽  
2004 ◽  
Vol 55 (1) ◽  
pp. 179-190 ◽  
Author(s):  
Alexandre Yasuda ◽  
Alvaro Campero ◽  
Carolina Martins ◽  
Albert L. Rhoton ◽  
Guilherme C. Ribas
Keyword(s):  
Pituitary Gland ◽  
Cavernous Sinus ◽  
Thin Sheet ◽  
Single Layer ◽  
Lateral Wall ◽  
The Body ◽  
Medial Wall ◽  
Microsurgical Anatomy ◽  
Pituitary Fossa ◽  
Adjacent Structures

Abstract OBJECTIVE: This study was conducted to clarify the boundaries, relationships, and components of the medial wall of the cavernous sinus (CS). METHODS: Forty CSs, examined under ×3 to ×40 magnification, were dissected from lateral to medial in a stepwise fashion to expose the medial wall. Four CSs were dissected starting from the midline to lateral. RESULTS: The medial wall of the CS has two parts: sellar and sphenoidal. The sellar part is a thin sheet that separates the pituitary fossa from the venous spaces in the CS. This part, although thin, provided a barrier without perforations or defects in all cadaveric specimens studied. The sphenoidal part is formed by the dura lining the carotid sulcus on the body of the sphenoid bone. In all of the cadaveric specimens, the medial wall seemed to be formed by a single layer of dura that could not be separated easily into two layers as could the lateral wall. The intracavernous carotid was determined to be in direct contact with the pituitary gland, being separated from it by only the thin sellar part of the medial wall in 52.5% of cases. In 39 of 40 CSs, the venous plexus and spaces in the CS extended into the narrow space between the intracavernous carotid and the dura lining the carotid sulcus, which forms the sphenoidal part of the medial wall. The lateral surface of the pituitary gland was divided axially into superior, middle and inferior thirds. The intracavernous carotid coursed lateral to some part of all the superior, middle, and inferior thirds in 27.5% of the CSs, along the inferior and middle thirds in 32.5%, along only the inferior third in 35%, and below the level of the gland and sellar floor in 5%. In 18 of the 40 CSs, the pituitary gland displaced the sellar part of the medial wall laterally and rested against the intracavernous carotid, and in 6 there was a tongue-like lateral protrusion of the gland that extended around a portion of the wall of the intracavernous carotid. No defects were observed in the sellar part of the medial wall, even in the presence of these protrusions. CONCLUSION: The CS has an identifiable medial wall that separates the CS from the sella and capsule of the pituitary gland. The medial wall has two segments, sellar and sphenoidal, and is formed by just one layer of dura that cannot be separated into two layers as can the lateral wall of the CS. In this study, the relationships between the medial wall and adjacent structures demonstrated a marked variability.

scholarly journals Endoscopic endonasal transoculomotor triangle approach for adenomas invading the parapeduncular space: surgical anatomy, technical nuances, and case series

2019 ◽  
Vol 130 (4) ◽  
pp. 1304-1314 ◽  
Author(s):  
Cristian Ferrareze Nunes ◽  
Stefan Lieber ◽  
Huy Q. Truong ◽  
Georgios Zenonos ◽  
Eric W. Wang ◽  
...  
Keyword(s):  
Cavernous Sinus ◽  
Case Series ◽  
Surgical Anatomy ◽  
Oculomotor Nerve ◽  
Oculomotor Nerve Palsy ◽  
Tumor Extension ◽  
Endoscopic Endonasal ◽  
Transcranial Approach ◽  
Surgical Corridor ◽  
Dural Opening

OBJECTIVEPituitary adenomas may extend into the parapeduncular space by invading through the roof of the cavernous sinus. Currently, a transcranial approach is the preferred choice, with or without the combination of an endonasal approach. In this paper the authors present a novel surgical approach that takes advantage of the natural corridor provided by the tumor to further open the oculomotor triangle and resect tumor extension into the parapeduncular space.METHODSSix injected specimens were used to demonstrate in detail the surgical anatomy related to the approach. Four cases in which the proposed approach was used were retrospectively reviewed.RESULTSFrom a technical perspective, the first step involves accessing the superior compartment of the cavernous sinus. The interclinoid ligament should be identified and the dura forming the oculomotor triangle exposed. The oculomotor dural opening may be then extended posteriorly toward the posterior petroclinoidal ligament and inferolaterally toward the anterior petroclinoidal ligament. The oculomotor nerve should then be identified; in this series it was displaced superomedially in all 4 cases. The posterior communicating artery should also be identified to avoid its injury. In all 4 cases, the tumor invading the parapeduncular space was completely removed. There were no vascular injuries and only 1 patient had a partial oculomotor nerve palsy that completely resolved in 2 weeks.CONCLUSIONSThe endoscopic endonasal transoculomotor approach is an original alternative for removal of tumor extension into the parapeduncular space in a single procedure. The surgical corridor is increased by opening the dura of the oculomotor triangle and by working below and lateral to the cisternal segment of the oculomotor nerve.

scholarly journals Endoscopic endonasal transcavernous approach for invasive corticotroph pituitary adenoma

2020 ◽  
Vol 2 (2) ◽  
pp. V2
Author(s):  
Ming-Ying Lan ◽  
Wei-Hsin Wang
Keyword(s):  
Cavernous Sinus ◽  
Diagnostic Tests ◽  
Tumor Resection ◽  
Cranial Nerves ◽  
Surgical Anatomy ◽  
Total Resection ◽  
Endoscopic Endonasal ◽  
Cavernous Sinus Invasion ◽  
The Right

This is a 37-year-old woman who presented with weight gain, a moon-shaped face, and muscle weakness for 4 months. Cushing’s disease was confirmed after a series of diagnostic tests. MRI demonstrated a pituitary macroadenoma with right cavernous sinus invasion and encasement of the right ICA. An endoscopic endonasal approach was performed, and gross-total resection could be achieved without injury of the cranial nerves. The Cushing’s syndrome improved gradually after the surgery. Histopathology revealed a corticotroph adenoma. In this surgical video, we demonstrate the strategies of tumor resection according to a surgical anatomy-based classification of the cavernous sinus from an endonasal perspective.The video can be found here: https://youtu.be/aNXFRdGfjpI.

scholarly journals Expanded endonasal approach: fully endoscopic, completely transnasal approach to the middle third of the clivus, petrous bone, middle cranial fossa, and infratemporal fossa

2005 ◽  
Vol 19 (1) ◽  
pp. 1-10 ◽  
Author(s):  
Amin B. Kassam ◽  
Paul Gardner ◽  
Carl Snyderman ◽  
Arlan Mintz ◽  
Ricardo Carrau
Keyword(s):  
Skull Base ◽  
Cavernous Sinus ◽  
Infratemporal Fossa ◽  
Surgical Anatomy ◽  
Illustrative Case ◽  
Endonasal Approach ◽  
Transnasal Approach ◽  
Endoscopic Endonasal ◽  
Expanded Endonasal Approach ◽  
Neurovascular Structures

Object The middle third of the clivus and the region around the petrous internal carotid artery (ICA) is a difficult area of the skull base in terms of access. This is a deep area rich with critical neurovascular structures, which is often host to typical skull base diseases. Expanded endoscopic endonasal approaches offer a potential option for accessing this difficult region. The objective of this paper was to establish the clinical feasibility of gaining access to the paraclival space in the region of the middle third of the clivus, to provide a practical modular and clinically applicable classification, and to describe the relevant critical surgical anatomy for each module. Methods The anatomical organization of the region around the petrous ICA, cavernous sinus, and middle clivus is presented, with approaches divided into zones. In an accompanying paper in this issue by Cavallo, et al., the anatomy of the pterygopalatine fossa is presented; this was observed through cadaveric dissection for which an expanded endonasal approach was used. In the current paper the authors translate the aforementioned anatomical study to provide a clinically applicable categorization of the endonasal approach to the region around the petrous ICA. A series of zones inferior and superior to the petrous ICA are described, with an illustrative case presented for each region. Conclusions The expanded endonasal approach is a feasible approach to the middle third of the clivus, petrous ICA, cavernous sinus, and medial infratemporal fossa in cases in which the lesion is located centrally, with neurovascular structures displaced laterally.

scholarly journals The Medial Wall of the Cavernous Sinus: Surgical Anatomy, Ligaments, and Surgical Application

2018 ◽  
Vol 79 (S 01) ◽  
pp. S1-S188
Author(s):  
Huy Truong ◽  
Edinson Najera ◽  
Joao Belo ◽  
Eric Wang ◽  
Carl Snyderman ◽  
...  
Keyword(s):  
Cavernous Sinus ◽  
Surgical Anatomy ◽  
Medial Wall ◽  
Surgical Application

scholarly journals Surgical Anatomy of the Medial Wall of the Cavernous Sinus and Technical Nuances for its Surgical Resection

2017 ◽  
Vol 78 (S 01) ◽  
pp. S1-S156
Author(s):  
Stefan Lieber ◽  
Maximiliano Nunez ◽  
Cristian Nunes ◽  
Eric Wang ◽  
Carl Snyderman ◽  
...  
Keyword(s):  
Surgical Resection ◽  
Cavernous Sinus ◽  
Surgical Anatomy ◽  
Medial Wall

Endoscopic Endonasal Cavernous Sinus Surgery: An Anatomic Study

Neurosurgery ◽  
2001 ◽  
Vol 48 (4) ◽  
pp. 827-837 ◽  
Author(s):  
Alessandra Alfieri ◽  
Hae-Dong Jho
Keyword(s):  
Carotid Artery ◽  
Cavernous Sinus ◽  
Posterior Wall ◽  
Surgical Anatomy ◽  
Sinus Surgery ◽  
Endoscopic Endonasal ◽  
Sphenoidal Sinus ◽  
Optic Strut ◽  
Anatomic Basis ◽  
Planum Sphenoidale

Abstract OBJECTIVE The endoscopic surgical anatomy of the cavernous sinus was studied to establish an anatomic basis for endoscopic endonasal cavernous sinus surgery. METHODS Five adult cadaveric heads were studied with 0-, 30-, and 70-degree 4-mm rod-lens endoscopes. The posterior wall of the sphenoidal sinus was approached via a paraseptal, middle turbinectomy, or middle meatal approach. RESULTS The posterior bony wall of the sphenoidal sinus is subdivided into five vertical compartments: midline, bilateral paramedian, and bilateral lateral. The midline vertical compartment consists of the planum sphenoidale, tuberculum sellae, sella, and clival indentation. The paramedian vertical compartment is composed of the medial third of the optic canal and the carotid artery protuberance. The lateral vertical compartment contains four bony protuberances (optic, cavernous sinus apex, maxillary, and mandibular) and three depressions (carotico-optic, ophthalmomaxillary [V1–V2], and maxillomandibular [V2–V3]). The three depressions form anatomic triangles at the lateral vertical compartment: the optic strut triangle, which is bordered by the optic nerve, carotid artery, and oculomotor nerve (IIIrd cranial nerve); the V1–V2 triangle; and the V2–V3 triangle. The internal carotid artery at the posterior wall of the sphenoidal sinus can be subdivided into two main segments: the parasellar and the paraclival. The vidian canal is a landmark that leads to the foramen lacerum, the mandibular nerve, and the pterygopalatine fossa. CONCLUSION Endoscopic anatomy of the cavernous sinus has been studied via an endonasal route in cadaveric specimens to provide an anatomic basis for endoscopic endonasal cavernous sinus surgery.

Endoscopic Endonasal Approach to the Lateral Wall of the Cavernous Sinus: A Cadaveric Feasibility Study

2018 ◽  
Vol 127 (12) ◽  
pp. 903-911 ◽  
Author(s):  
Sameh M. Amin ◽  
Hesham Fathy ◽  
Ahmed Hussein ◽  
Mohamed Kamel ◽  
Ahmed Hegazy ◽  
...  
Keyword(s):  
Feasibility Study ◽  
Cavernous Sinus ◽  
Cranial Nerves ◽  
Lateral Wall ◽  
Middle Cranial Fossa ◽  
Endonasal Approach ◽  
Endoscopic Endonasal ◽  
Maxillary Nerve ◽  
Bony Landmarks ◽  
Extradural Approach

Objective: A transcranial extradural approach to the middle cranial fossa (MCF) requires separation of the dural layers of the lateral wall of the cavernous sinus. The authors tested the feasibility of an endonasal approach for this separation. Methods: A cadaveric feasibility study was conducted on the sides of 14 dry skulls and 10 fresh cadaveric heads. An endonasal, transsphenoidal, transpterygoid approach was taken to the MCF. The maxillary struts and medial greater wing of the sphenoid below the superior orbital fissure were drilled with transposition of the maxillary nerve. The lateral cavernous dural layers were split at the maxillary nerve with separation of the temporal lobe dura and exposure of the MCF bony base. The integrity of the cranial nerves and inner and outer dural layers of the lateral cavernous wall was checked. Different measurements of bony landmarks were obtained. Results: The integrity of the dural layers of the lateral cavernous wall and the cranial nerves were preserved in 10 heads. The mean area of the bony corridor was 4.68 ± 0.97 cm2, the V2-to-V3 distance was 15.21 ± 3.36 mm medially and 18.21 ± 3.45 mm laterally, and the vidian canal length was 13.01 ± 3.06 mm. Conclusions: Endonasal endoscopic separation of the lateral cavernous dural layers is feasible without crossing the motor cranial nerves, allowing better exposure of the MCF.

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