1
|
Serioli S, Plou P, Leonel LCPC, Graepel S, Buffoli B, Rezzani R, Fontanella MM, Poliani PL, Doglietto F, Link MJ, Pinheiro-Neto CD, Peris-Celda M. The "candy wrapper" of the pituitary gland: a road map to the parasellar ligaments and the medial wall of the cavernous sinus. Acta Neurochir (Wien) 2023; 165:3431-3444. [PMID: 37594638 DOI: 10.1007/s00701-023-05736-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2023] [Accepted: 07/24/2023] [Indexed: 08/19/2023]
Abstract
PURPOSE The anatomy of the medial wall of the cavernous sinus (MWCS) and parasellar ligaments (PLs) has acquired increasing importance in endoscopic endonasal (EE) surgery of the cavernous sinus (CS), including resection of the MWCS in functioning pituitary adenomas (FPAs). Although anatomical studies have been published, it represents a debated topic due to their complex morphology. The aim is to offer a description of the PLs that originate from the MWCS and reach the lateral wall of the cavernous sinus (LWCS), proposing the "candy wrapper" model. The relationships between the neurovascular structures and histomorphological aspects were investigated. METHODS Forty-two CSs from twenty-one human heads were studied. Eleven specimens were used for EE dissection; five underwent a microscopic dissection. Five specimens were used for histomorphological analysis. RESULTS Two groups of PLs with a fan-shaped appearance were encountered. The anterior group included the periosteal ligament (55% sides) and the carotico-clinoid complex (100% sides), formed by the anterior horizontal and the carotico-clinoid ligaments. The posterior group was formed by the posterior horizontal (78% sides), and the inferior hypophyseal ligament (34% sides). The periosteal ligament originated inferiorly from the MWCS, reaching the periosteal dura. The anterior horizontal ligament was divided in a superior and inferior branch. The superior one continued as the carotid-oculomotor membrane, and the inferior branch reached the CN VI. The carotico-clinoid ligament between the middle and anterior clinoid was ossified in 3 sides. The posterior horizontal ligament was related to the posterior genu and ended at the LWCS. The inferior hypophyseal ligament followed the homonym artery. The ligaments related to the ICA form part of the adventitia. CONCLUSION The "candy wrapper" model adds further details to the previous descriptions of the PLs. Understanding this complex anatomy is essential for safe CS surgery, including MWCS resection for FPAs.
Collapse
Affiliation(s)
- Simona Serioli
- Division of Neurosurgery, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
- Rhoton Neurosurgery and Otolaryngology Surgical Anatomy Program, Mayo Clinic, Rochester, MN, USA
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Pedro Plou
- Rhoton Neurosurgery and Otolaryngology Surgical Anatomy Program, Mayo Clinic, Rochester, MN, USA
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, USA
- Neurosurgery Department, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Luciano C P C Leonel
- Rhoton Neurosurgery and Otolaryngology Surgical Anatomy Program, Mayo Clinic, Rochester, MN, USA
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Stephen Graepel
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Barbara Buffoli
- Section of Anatomy and Physiopathology, Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Rita Rezzani
- Section of Anatomy and Physiopathology, Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Marco Maria Fontanella
- Division of Neurosurgery, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Pietro Luigi Poliani
- Vita-Salute San Raffaele University and Pathology Unit, IRCCS San Raffaele, Milan, Italy
| | - Francesco Doglietto
- Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
- Catholic University School of Medicine, Rome, Italy
| | - Michael J Link
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, USA
- Department of Otolaryngology/Head and Neck Surgery, Mayo Clinic, Rochester, MN, USA
| | - Carlos D Pinheiro-Neto
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, USA
- Department of Otolaryngology/Head and Neck Surgery, Mayo Clinic, Rochester, MN, USA
| | - Maria Peris-Celda
- Rhoton Neurosurgery and Otolaryngology Surgical Anatomy Program, Mayo Clinic, Rochester, MN, USA.
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, USA.
- Department of Otolaryngology/Head and Neck Surgery, Mayo Clinic, Rochester, MN, USA.
| |
Collapse
|
2
|
Locatelli D, Karligkiotis A, Turri-Zanoni M, Canevari FR, Pozzi F, Castelnuovo P. Endoscopic Endonasal Approaches for Treatment of Craniovertebral Junction Tumours. Acta Neurochir Suppl 2019; 125:209-24. [PMID: 30610324 DOI: 10.1007/978-3-319-62515-7_30] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Tumours involving the craniovertebral junction (CVJ) are challenging because of their local invasiveness and high recurrence rates, as well as their proximity to critical neurovascular structures and the difficulty of reconstructing the resulting skull base defect at this site. Several surgical techniques are currently available to access these lesions, including the far lateral, extreme lateral, direct lateral, transcervical, transoral and transnasal approaches. In this paper, application of the endoscopic endonasal approach (EEA) in the treatment of CVJ tumours is analysed. The indications, contraindications, preoperative workup, step-by-step surgical technique, skull base reconstruction options and postoperative management are described. The advantages and limitations of the EEA are also discussed. Finally, a systematic review of the literature is provided to elucidate the levels of evidence supporting the use of the EEA in this field. Employment of this approach to the CVJ has contributed to high success rates in achieving gross total resection of tumours and improvement in neurological symptoms. Intraoperative and postoperative complication rates are acceptable, with cerebrospinal fluid leakage being the major concern (with a 17-25% incidence). Moreover, in comparison with traditional approaches to the CVJ, the EEA provides lower rates of postoperative dysphagia and respiratory complications. Use of the EEA for treatment of CVJ tumours appears to be a rational alternative to the conventional transoral, transcranial and transcervical approaches in selected cases. Multidisciplinary teamwork including different specialists-such as medical and radiation oncologists, radiologists, otorhinolaryngologists and neurosurgeons-is strongly recommended for the purpose of offering the best treatment strategy for the patient.
Collapse
|