Bilateral coagulation of inferior hypophyseal artery and pituitary transposition during endoscopic endonasal interdural posterior clinoidectomy: do they affect pituitary function?

OBJECTIVEThe endoscopic endonasal transcavernous approach with interdural pituitary transposition provides surgical access to the posterior clinoids and interpeduncular cistern. Prior to posterior clinoidectomy, selective coagulation and transection of the inferior hypophyseal artery (IHA) is recommended to prevent uncontrolled tearing of the artery and its avulsion from the wall of the cavernous carotid artery. The authors’ preliminary experience has shown that unilateral sacrifice of the IHA caused no permanent endocrine dysfunction. In this study, they investigated the pituitary function in the setting of bilateral sacrifice of IHAs and pituitary transposition.METHODSAll patients with normal preoperative pituitary function who underwent endoscopic endonasal bilateral posterior clinoidectomy with bilateral IHA sacrifice between March 2010 and December 2016 were included and retrospectively evaluated. All data regarding pituitary function were collected. The degree of pituitary gland manipulation was estimated based on tumor size on preoperative MRI. An angle between a line from the point where the gland meets the floor of the sella to the highest point of the tumor and the horizontal plane of the sellar floor, or access angle, was also measured. Posterior pituitary bright spots on pre- and postoperative T1-weighted MRI were also reported.RESULTSTwenty patients had bilateral transcavernous posterior clinoidectomies with coagulation of both IHAs. There were 13 chordomas, 3 epidermoid cysts, 2 chondrosarcomas, 1 meningioma, and 1 hemangiopericytoma. The mean follow-up was 19 months (range 13–84 months). Two patients experienced transient diabetes insipidus (DI) requiring desmopressin, which resolved before hospital discharge. One patient (with chordoma) developed delayed permanent DI, and a second patient (with hemangiopericytoma) developed permanent DI and panhypopituitarism. The access angle was higher in the group with pituitary dysfunction (47.25° compared to 33.81°; p = 0.07). Posterior pituitary bright spots were preserved in 75% of cases with normal postoperative endocrine function.CONCLUSIONSThe endoscopic endonasal transcavernous approach to the interpeduncular cistern with pituitary transposition and bilateral sacrifice of the IHAs does not cause pituitary dysfunction in a majority of patients. When endocrine deficit occurs, it appears to be more likely to have been caused by surgical manipulation than loss of blood supply. This finding confirms clinically the crucial concept of interarterial anastomosis of pituitary vasculature proposed by anatomists.

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

Operative Neurosurgery ◽

10.1227/01.neu.0000317374.30443.23 ◽

2008 ◽

Vol 62 (suppl_1) ◽

pp. ONS57-ONS74 ◽

Cited By ~ 51

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.

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Dual Endoscopic Endonasal Transphenoidal and Precaruncular Transorbital Approaches for Clipping of the Cavernous Carotid Artery-Enhanced Degrees of Freedom: A Cadaveric Cerebral Perfusion Simulation

Journal of Neurological Surgery Part B Skull Base ◽

10.1055/s-0036-1580076 ◽

2016 ◽

Vol 77 (S 01) ◽

Author(s):

Jeremy Ciporen ◽

Brandon Lucke-Wold ◽

Justin Cetas ◽

Aclan Dogan ◽

William Cameron

Keyword(s):

Carotid Artery ◽

Cerebral Perfusion ◽

Degrees Of Freedom ◽

Endoscopic Endonasal ◽

Cavernous Carotid Artery

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Endoscopic Endonasal Approaches to the Cavernous Sinus: Surgical Approaches

Neurosurgery ◽

10.1097/00006123-200108000-00017 ◽

2001 ◽

Vol 49 (2) ◽

pp. 354-362 ◽

Cited By ~ 11

Author(s):

Alessandra Alfieri ◽

Hae-Dong Jho

Keyword(s):

Cavernous Sinus ◽

Middle Turbinate ◽

Lateral Wall ◽

Surgical Instruments ◽

Surgical Approaches ◽

Lateral Nasal Wall ◽

Orbital Apex ◽

Superior Orbital Fissure ◽

Endoscopic Endonasal ◽

Surgical Access

Abstract OBJECTIVE After completion of an earlier endoscopic transsphenoidal anatomic study, we studied various endoscopic transsphenoidal approaches using cadaveric specimens to develop endoscopic endonasal surgical approaches to the cavernous sinus. METHODS Ten cavernous sinuses in five artery-injected adult cadaveric heads were studied with 0-, 30-, and 70-degree angled 4-mm rod-lens endoscopes. The extent of the surgical exposure, the skewed endoscopic anatomic view, and the maneuverability of surgical instruments through their relative operating spaces were studied after various endoscopic endonasal approaches via one nostril. RESULTS The paraseptal approach was used between the nasal septum and the middle turbinate and provided exposure at the anteromedial portion of the cavernous sinus. The contralateral paraseptal approach rendered a slightly more medial view at the cavernous sinus than did the ipsilateral approach. This approach offered limited surgical access to the lateral vertical compartment. The middle turbinectomy approach allowed surgical access to the lateral wall of the cavernous sinus, except for the superior orbital fissure and the orbital apex. The middle meatal approach, which was made between the middle turbinate and the lateral nasal wall, revealed the entire lateral vertical compartment of the cavernous sinus, including the orbital apex and the superior orbital fissure. However, its lateral tangential surgical trajectory and the absence of dedicated surgical tools limited the surgeon's surgical maneuverability. A combination of the middle turbinectomy and middle meatal approaches increased the operating space. CONCLUSION Various endoscopic endonasal surgical approaches to the cavernous sinus were studied using adult cadaveric head specimens.

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Posterior pituitary dysfunction following traumatic brain injury: review

Pituitary ◽

10.1007/s11102-018-0917-z ◽

2018 ◽

Vol 22 (3) ◽

pp. 296-304 ◽

Cited By ~ 9

Author(s):

Roxana Maria Tudor ◽

Christopher J. Thompson

Keyword(s):

Traumatic Brain Injury ◽

Brain Injury ◽

Posterior Pituitary ◽

Pituitary Dysfunction

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Rituximab treatment for isolated IgG4-related hypophysitis in a teenage female

Endocrinology Diabetes and Metabolism Case Reports ◽

10.1530/edm-18-0135 ◽

2018 ◽

Vol 2018 ◽

Cited By ~ 2

Author(s):

Danielle R Bullock ◽

Bradley S Miller ◽

H Brent Clark ◽

Patricia M Hobday

Keyword(s):

Endocrine Function ◽

List Type ◽

Pituitary Mass ◽

Related Disease ◽

Pituitary Dysfunction ◽

Igg4 Related Disease ◽

Pituitary Disease ◽

Appropriate Treatment ◽

Organ Systems ◽

Progression Of Disease

Summary IgG4-related hypophysitis is an important diagnostic consideration in patients with a pituitary mass or pituitary dysfunction and can initially present with headaches, visual field deficits and/or endocrine dysfunction. Isolated IgG4-related pituitary disease is rare, with most cases of IgG4-related disease involving additional organ systems. We report the case of a teenage female patient with isolated IgG4-related hypophysitis, diagnosed after initially presenting with headaches. Our patient had no presenting endocrinologic abnormalities. She was treated with surgical resection, prednisolone and rituximab with no further progression of disease and sustained normal endocrine function. This case, the youngest described patient with isolated IgG4-related hypophysitis and uniquely lacking endocrinologic abnormalities, adds to the limited reports of isolated pituitary disease. The use of rituximab for isolated pituitary disease has never been described. While IgG4-related hypophysitis has been increasingly recognized, substantial evidence concerning the appropriate treatment and follow-up of these patients is largely lacking. Learning points: IgG4-related hypophysitis most often occurs in the setting of additional organ involvement but can be an isolated finding. This diagnosis should therefore be considered in a patient presenting with pituitary abnormalities. Most patients with IgG4-related hypophysitis will have abnormal pituitary function, but normal functioning does not exclude this diagnosis. Corticosteroids have been the mainstay of therapy for IgG4-related disease, with other immunosuppressive regimens being reserved for refractory cases. Further research is needed to understand the effectiveness of corticosteroid-sparing regimens and whether there is utility in using these agents as first-line therapies.

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Management of Cerebrospinal Fluid Rhinorrhea in the Sphenoid Sinus Lateral Recess Through an Endoscopic Endonasal Transpterygoid Approach With Obliteration of the Lateral Recess

Ear Nose & Throat Journal ◽

10.1177/0145561320955140 ◽

2020 ◽

pp. 014556132095514

Author(s):

Chao He ◽

Hong-Tao Zhen

Keyword(s):

Cerebrospinal Fluid ◽

Sphenoid Sinus ◽

Surgical Repair ◽

Endoscopic Endonasal ◽

Simple Method ◽

Lateral Recess ◽

Cerebrospinal Fluid Rhinorrhea ◽

Surgical Access ◽

Skull Base Defect

Background: Cerebrospinal fluid rhinorrhea in the sphenoid sinus lateral recess is a rare occurrence and poses unique challenges due to limited surgical access for surgical repair. Objective: To report our experience of surgical repair of cerebrospinal fluid rhinorrhea in the sphenoid sinus lateral recess through an endoscopic endonasal transpterygoid approach with obliteration of the lateral recess. To evaluate the efficiency of this surgical procedure. Methods: A retrospective study. Twelve cases with cerebrospinal fluid rhinorrhea in the sphenoid sinus lateral recess were reviewed. Assisted by image-guided navigation, cerebrospinal fluid rhinorrhea was repaired through an endoscopic endonasal transpterygoid approach, with obliteration of the lateral recess. Complications and recurrence were recorded. Medical photographs were used. Results: This surgical approach provided a relatively spacious corridor to dissect the sphenoid sinus lateral recess and do postoperative surveillance. The repair area completely healed in 3 months after surgery. Cerebrospinal fluid rhinorrhea in the sphenoid sinus lateral recess was successfully repaired on the first attempt in all cases (100%). No main complications or recurrence was observed during a mean follow-up time of 40.3 months. Conclusion: The endoscopic endonasal transpterygoid approach gives appropriate access for the treatment of spontaneous cerebrospinal fluid rhinorrhea in the sphenoid sinus lateral recess. Multilayer reconstruction of a skull base defect with obliteration of the lateral recess is a reliable and simple method.

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Magnocellular Neurons and Posterior Pituitary Function

Comprehensive Physiology ◽

10.1002/cphy.c150053 ◽

2016 ◽

pp. 1701-1741 ◽

Cited By ~ 18

Author(s):

Colin H. Brown

Keyword(s):

Pituitary Function ◽

Posterior Pituitary ◽

Magnocellular Neurons

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Endocrine function and gland volume after endoscopic transsphenoidal surgery for nonfunctional pituitary macroadenomas

Journal of Neurosurgery ◽

10.3171/2018.5.jns181054 ◽

2019 ◽

Vol 131 (4) ◽

pp. 1142-1151 ◽

Cited By ~ 1

Author(s):

Maya Harary ◽

Aislyn C. DiRisio ◽

Hassan Y. Dawood ◽

John Kim ◽

Nayan Lamba ◽

...

Keyword(s):

Pituitary Gland ◽

Tumor Size ◽

Transsphenoidal Surgery ◽

Endocrine Function ◽

Pituitary Function ◽

Pituitary Hormone ◽

Tumor Diameter ◽

Endoscopic Transsphenoidal Surgery ◽

Gland Volume ◽

The Relationship

OBJECTIVELoss of pituitary function due to nonfunctional pituitary adenoma (NFPA) may be due to compression of the pituitary gland. It has been proposed that the size of the gland and relative perioperative gland expansion may relate to recovery of pituitary function, but the extent of this is unclear. This study aims to assess temporal changes in hormonal function after transsphenoidal resection of NFPA and the relationship between gland reexpansion and endocrine recovery.METHODSPatients who underwent endoscopic transsphenoidal surgery by a single surgeon for resection of a nonfunctional macroadenoma were selected for inclusion. Patients with prior pituitary surgery or radiosurgery were excluded. Patient characteristics and endocrine function were extracted by chart review. Volumetric segmentation of the pre- and postoperative (≥ 6 months) pituitary gland was performed using preoperative and long-term postoperative MR images. The relationship between endocrine function over time and clinical attributes, including gland volume, were examined.RESULTSOne hundred sixty eligible patients were identified, of whom 47.5% were female; 56.9% of patients had anterior pituitary hormone deficits preoperatively. The median tumor diameter and gland volume preoperatively were 22.5 mm (interquartile range [IQR] 18.0–28.8 mm) and 0.18 cm3 (IQR 0.13–0.28 cm3), respectively. In 55% of patients, endocrine function normalized or improved in their affected axes by median last clinical follow-up of 24.4 months (IQR 3.2–51.2 months). Older age, male sex, and larger tumor size were associated with likelihood of endocrine recovery. Median time to recovery of any axis was 12.2 months (IQR 2.5–23.9 months); hypothyroidism was the slowest axis to recover. Although the gland significantly reexpanded from preoperatively (0.18 cm3, IQR 0.13–0.28 cm3) to postoperatively (0.33 cm3, IQR 0.23–0.48 cm3; p < 0.001), there was no consistent association with improved endocrine function.CONCLUSIONSRecovery of endocrine function can occur several months and even years after surgery, with more than 50% of patients showing improved or normalized function. Tumor size, and not gland volume, was associated with preserved or recovered endocrine function.

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Surgical Outcomes of Endoscopic Endonasal Surgery in 29 Patients with Craniopharyngioma

Journal of Neurological Surgery Part B Skull Base ◽

10.1055/s-0040-1713108 ◽

2020 ◽

Author(s):

Arad Iranmehr ◽

Mostafa Esmaeilnia ◽

Khashayar Afshari ◽

Seyed Mousa Sadrehosseini ◽

Azin Tabari ◽

...

Keyword(s):

Tumor Resection ◽

Visual Outcome ◽

Extent Of Resection ◽

Csf Leak ◽

Endoscopic Endonasal Surgery ◽

Endonasal Surgery ◽

Endoscopic Endonasal ◽

Pituitary Dysfunction ◽

Before And After

Abstract Background Recently the endoscopic endonasal surgery (EES) has been introduced as a modality for the treatment of patients with craniopharyngiomas. In this study, we describe our initial experience in treatment of 29 patients with craniopharyngiomas using this approach. Methods Twenty-nine consecutive patients with craniopharyngiomas who had undergone EES in a 5-year period were studied retrospectively. Patients underwent preoperative and postoperative endocrinologic and ophthalmologic evaluations. Radiologic characteristics of tumors and extent of resection were determined. The recurrence and complications were evaluated. Results Pituitary and visual dysfunction were observed preoperatively in 89.7 and 86% of patients, respectively. After EES, visual outcome either showed an improvement or else remained unchanged in 92.3% of the cases; however, pituitary function remained unchanged and even got worsened in 34.6% of the cases. Prevalence of diabetes insipidus before and after surgery was 58.6 and 69.2%. The rate of gross total resection was 62%. Moreover, 86.2% of the tumors were almost totally resected (more than 95% of the tumor size resected). After surgery, cerebrospinal fluid (CSF) leak and meningitis occurred in four (13.8%) and two (6.9%) patients, respectively. Perioperative mortality was seen in two of the cases (6.9%). The mean follow-up was 25 months and tumor recurrence was discovered in four patients (15.3%). Conclusion The EES with the goal of maximal and safe tumor resection could be used for the treatment of most craniopharyngiomas. Although the rates of visual improvement and gross tumor resection are high, CSF leak, pituitary dysfunction, and meningitis are serious concerns.

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