Endoscopic endonasal transcavernous approach for invasive corticotroph pituitary adenoma

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.

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Endoscopic endonasal management of non-functioning pituitary adenomas with cavernous sinus invasion: a 10- year experience

Rhinology Journal ◽

10.4193/rhino14.309 ◽

2015 ◽

Vol 53 (4) ◽

pp. 308-316

Author(s):

F. Ferreli ◽

M. Turri-Zanoni ◽

F.R. Canevari ◽

P. Battaglia ◽

M. Bignami ◽

...

Keyword(s):

Cavernous Sinus ◽

Tumor Resection ◽

Mass Effect ◽

Extent Of Resection ◽

Tumor Control ◽

Endoscopic Endonasal ◽

Cavernous Sinus Invasion ◽

Visual Outcomes ◽

Contrast Enhanced ◽

Wait And See

Background: The management of Non-Functioning Pituitary Adenoma (NFPA) invading the cavernous sinus (CS) is currently a balancing act between the surgical decompression of neural structures, radiotherapy and a wait-and-see policy. Methods: We undertook a retrospective review of 56 cases of NFPA with CS invasion treated through an endoscopic endonasal approach (EEA) between 2000 and 2010. The Knosp classification was adopted to describe CS involvement using information from preoperative MRI and intraoperative findings. Extent of resection and surgical outcomes were evaluated on the basis of postoperative contrast-enhanced MRI. Endocrinological improvement and visual outcomes were assessed according to the most recent consensus criteria. Results: EEA was performed using direct para-septal, trans-ethmoidal-sphenoidal or trans-ethmoidal-pterygoidal-sphenoidal approach. Visual outcomes improved in 30 (81%) patients. Normalization or at least improvement of previous hypopituitarism was obtained in 55% of cases. A gross total resection was achieved in 30.3% of cases. The recurrence-free survival was 87.5%, with a mean follow-up of 61 months (range, 36-166 months). No major intraoperative or postoperative complications occurred. Discussion: EEA is a minimally-invasive, safe and effective procedure for the management of NFPA invading the CS. The extent of CS involvement was the main factor limiting the degree of tumor resection. The EEA was able to resolve the mass effect, preserving or restoring visual function, and obtaining adequate long-term tumor control.

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Microsurgical Resection of Recurrent Cavernous Sinus Hemangioma by Superior and Lateral Approach: 2-Dimensional Operative Video

Operative Neurosurgery ◽

10.1093/ons/opz313 ◽

2019 ◽

Vol 19 (2) ◽

pp. E165-E166

Author(s):

Qazi Zeeshan ◽

Juan P Carrasco Hernandez ◽

Michael K Moore ◽

Laligam N Sekhar

Keyword(s):

Optic Nerve ◽

Carotid Artery ◽

Cavernous Sinus ◽

Tumor Resection ◽

Cranial Nerves ◽

Brain Magnetic Resonance Imaging ◽

Mass Effect ◽

Lateral Approach ◽

Microsurgical Resection ◽

The Right

Abstract This video shows the technical nuances of microsurgical resection of recurrent cavernous sinus (CS) hemangioma by superior and lateral approach. A 77-yr-old woman presented with headache and difficulty in vision in right eye for 6 mo. She had previously undergone attempted resection of a right CS tumor in another hospital with partial removal, and the tumor had grown significantly. Neurological examination revealed proptosis, cranial nerve 3 palsy, and loss of vision in right eye (20/200). Left side visual acuity was 20/20. Brain magnetic resonance imaging (MRI) demonstrated a large CS mass with homogeneous enhancement, measuring 3.3 × 3.3 × 2.6 cm, extending into the suprasellar cistern with mass effect on the right optic nerve. It extended anteriorly to the region of the right orbital apex and abuted the basilar artery posteriorly. She underwent right frontotemporal craniotomy, posterolateral orbitotomy and anterior clinoidectomy as well as optic nerve decompression, and the CS tumor was removed by superior and lateral approach. An incision was made into the superior wall of the CS medial to the third nerve. On lateral aspect the tumor had extended outside the CS through the Parkinson's triangle. Posteriorly it extended through the clival dura. Anteriorly tumor encased the carotid artery and it was gradually dissected away. At the end of the operation, all of the cranial nerves were intact. Postoperative MRI showed near complete tumor resection with preservation of the internal carotid artery. At 6 mo follow-up her modified Rankin Scale was 1 and vision in left eye was normal. Informed consent was obtained from the patient prior to the surgery that included videotaping of the procedure and its distribution for educational purposes. All relevant patient identifiers have also been removed from the video and accompanying radiology slides.

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

Journal of Neurosurgery ◽

10.3171/2018.3.jns18596 ◽

2019 ◽

Vol 131 (1) ◽

pp. 122-130 ◽

Cited By ~ 6

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.

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Cavernous sinus compartments from the endoscopic endonasal approach: anatomical considerations and surgical relevance to adenoma surgery

Journal of Neurosurgery ◽

10.3171/2017.2.jns162214 ◽

2018 ◽

Vol 129 (2) ◽

pp. 430-441 ◽

Cited By ~ 13

Author(s):

Juan C. Fernandez-Miranda ◽

Nathan T. Zwagerman ◽

Kumar Abhinav ◽

Stefan Lieber ◽

Eric W. Wang ◽

...

Keyword(s):

Cavernous Sinus ◽

Cranial Nerves ◽

Spatial Relationship ◽

Abducens Nerve ◽

Human Head ◽

Residual Tumor ◽

Surgical Anatomy ◽

Endoscopic Endonasal Approach ◽

Endonasal Approach ◽

Endoscopic Endonasal

OBJECTIVETumors with cavernous sinus (CS) invasion represent a neurosurgical challenge. Increasing application of the endoscopic endonasal approach (EEA) requires a thorough understanding of the CS anatomy from an endonasal perspective. In this study, the authors aimed to develop a surgical anatomy–based classification of the CS and establish its utility for preoperative surgical planning and intraoperative guidance in adenoma surgery.METHODSTwenty-five colored silicon–injected human head specimens were used for endonasal and transcranial dissections of the CS. Pre- and postoperative MRI studies of 98 patients with pituitary adenoma with intraoperatively confirmed CS invasion were analyzed.RESULTSFour CS compartments are described based on their spatial relationship with the cavernous ICA: superior, posterior, inferior, and lateral. Each compartment has distinct boundaries and dural and neurovascular relationships: the superior compartment relates to the interclinoidal ligament and oculomotor nerve, the posterior compartment bears the gulfar segment of the abducens nerve and inferior hypophyseal artery, the inferior compartment contains the sympathetic nerve and distal cavernous abducens nerve, and the lateral compartment includes all cavernous cranial nerves and the inferolateral arterial trunk. Twenty-nine patients had a single compartment invaded, and 69 had multiple compartments involved. The most commonly invaded compartment was the superior (79 patients), followed by the posterior (n = 64), inferior (n = 45), and lateral (n = 23) compartments. Residual tumor rates by compartment were 79% in lateral, 17% in posterior, 14% in superior, and 11% in inferior.CONCLUSIONSThe anatomy-based classification presented here complements current imaging-based classifications and may help to identify involved compartments both preoperatively and intraoperatively.

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Endoscope-assisted contralateral transmaxillary approach to the clivus and the hypoglossal canal: technical case report

Journal of Neurosurgery ◽

10.3171/2018.1.jns171972 ◽

2019 ◽

Vol 130 (5) ◽

pp. 1609-1615 ◽

Cited By ~ 1

Author(s):

Eva Pamias-Portalatin ◽

Deependra Mahato ◽

Jordina Rincon-Torroella ◽

Tito Vivas-Buitrago ◽

Alfredo Quiñones-Hinojosa ◽

...

Keyword(s):

Tumor Resection ◽

Cranial Nerves ◽

Inferior Turbinate ◽

Residual Tumor ◽

Anatomical Location ◽

Endoscopic Endonasal ◽

Petroclival Region ◽

Proton Beam Radiotherapy ◽

Hypoglossal Canal ◽

The Right

Clival lesions are still considered surgically complex due to their anatomical location. Critical structures, such as the internal carotid arteries (ICAs), cavernous sinuses, cranial nerves, and brainstem, may be encased within the lesion. Although advances in endoscopic endonasal approaches have provided new routes to these lesions, exposure and resection of clival tumors through the endonasal route remain a technical challenge. Here, the authors report a left-sided endoscopic transmaxillary approach to access the right aspect of the clivus and the hypoglossal canal.A 35-year-old woman presented with progressive right 6th cranial nerve palsy. MRI revealed a contrast-enhancing right petroclival chondrosarcoma that involved Meckel’s cave and extended into the right hypoglossal canal. An endoscopic-contralateral-transmaxillary approach through a left sublabial incision was used to access the right petroclival region and right hypoglossal canal. A left maxillary osteoplastic flap was elevated to expose the left maxillary sinus. This was followed by a left medial maxillectomy, gaining access to the left posterior nasal cavity. The posterior third of the left inferior turbinate and nasal septum were removed to access the right side of the petroclival region. Near-total resection was achieved without any vascular or neurological complications. A thin shell of residual tumor was left behind due to involvement of vital structures, such as the ICA, and further treated with proton-beam radiotherapy.The endoscopic-contralateral-transmaxillary approach provides a direct surgical corridor and good lateral visualization of the skull base vasculature. This approach allows wide maneuverability around the ICA and hypoglossal canal, which, in this case, allowed maximal tumor resection with full preservation of neurological function.

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Transcavernous Approach for Gross Total Resection of a Dumbbell-Shaped Giant Trigeminal Schwannoma

Journal of Neurological Surgery Part B Skull Base ◽

10.1055/s-0041-1729995 ◽

2021 ◽

Author(s):

Sima Sayyahmelli ◽

Emel Avci ◽

Burak Ozaydin ◽

Mustafa K. Başkaya

Keyword(s):

Skull Base ◽

Cavernous Sinus ◽

Tumor Resection ◽

Mass Effect ◽

World Health ◽

Gross Total Resection ◽

Petrous Apex ◽

Total Resection ◽

Who Grade ◽

Trigeminal Schwannoma

AbstractTrigeminal schwannomas are rare nerve sheet tumors that represent the second most common intracranial site of occurrence after vestibular nerve origins. Microsurgical resection of giant dumbbell-shaped trigeminal schwannomas often requires complex skull base approaches. The extradural transcavernous approach is effective for the resection of these giant tumors involving the cavernous sinus.The patient is a 72-year-old man with headache, dizziness, imbalance, and cognitive decline. Neurological examination revealed left-sided sixth nerve palsy, a diminished corneal reflex, and wasting of temporalis muscle. Magnetic resonance imaging (MRI) showed a giant homogeneously enhancing dumbbell-shaped extra-axial mass centered within the left cavernous sinus, Meckel's cave, and the petrous apex, with extension to the cerebellopontine angle. There was a significant mass effect on the brain stem causing hydrocephalus. Computed tomography (CT) scan showed erosion of the petrous apex resulting in partial anterior autopetrosectomy (Figs. 1 and 2).The decision was made to proceed with tumor resection using a transcavernous approach. Gross total resection was achieved. The surgery and postoperative course were uneventful, and the patient woke up the same as in the preoperative period. MRI confirmed gross total resection of the tumor. The histopathology was a trigeminal schwannoma, World Health Organization (WHO) grade I. The patient continues to do well without any recurrence 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/TMK5363836M

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Extradural anterior clinoidectomy in surgical management of clinoidal meningiomas

The Egyptian Journal of Neurology Psychiatry and Neurosurgery ◽

10.1186/s41983-021-00336-x ◽

2021 ◽

Vol 57 (1) ◽

Author(s):

K. El-Bahy ◽

Ashraf M. Ibrahim ◽

Ibrahim Abdelmohsen ◽

Hatem A. Sabry

Keyword(s):

Cavernous Sinus ◽

Tumor Resection ◽

Visual Outcome ◽

Extent Of Resection ◽

Optic Canal ◽

Falciform Ligament ◽

Cavernous Sinus Invasion ◽

Anterior Clinoidectomy ◽

Microsurgical Techniques

Abstract Background Despite the recent advances in skull base surgery, microsurgical techniques, and neuroimaging, yet surgical resection of clinoidal meningiomas is still a major challenge. In this study, we present our institution experience in the surgical treatment of anterior clinoidal meningiomas highlighting the role of extradural anterior clinoidectomy in improving the visual outcome and the extent of tumor resection. This is a prospective observational study conducted on 33 consecutive patients with clinoidal meningiomas. The surgical approach utilized consisted of extradural anterior clinoidectomy, optic canal deroofing with falciform ligament opening in all patients. The primary outcome assessment was visual improvement and secondary outcomes were extent of tumor resection, recurrence, and postoperative complications. Results The study included 5 males and 28 females with mean age 49.48 ± 11.41 years. Preoperative visual deficit was present in 30 (90.9%) patients. Optic canal involvement was present in 24 (72.7%) patients, ICA encasement was in 16 (48.5%), and cavernous sinus invasion in 8 (24.2%). Vision improved in 21 patients (70%), while 6 patients (20%) had stationary course and 1 patient (3%) suffered postoperative new visual deterioration. Gross total resection was achieved in 24 patients (72.7%). The main factors precluding total removal were cavernous sinus involvement and ICA encasement. Mortality rate was 6.1%; mean follow-up period was 27 ± 13 months. Conclusions In this series, the use of extradural anterior clinoidectomy provided a favorable visual outcome and improved the extent of resection in clinoidal meningioma patients.

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