Clinical Applicability of the Sellar Barrier Concept in Patients with Pituitary Apoplexy: Is It Possible?

There is evidence of association between sellar barrier thickness and intraoperative cerebrospinal fluid (CSF) leakage, impacting the postoperative prognosis of the patients. The aim of this study is to analyze the clinical applicability of the sellar barrier concept in a series of operated patients with pituitary apoplexy (PA). A retrospective study was conducted including 47 patients diagnosed with PA who underwent surgical treatment through a transsphenoidal approach. Brain magnetic resonance imaging (MRI) of the patients were evaluated and classified utilizing the following criteria: strong barrier (greater than 1 mm), weak barrier (less than 1 mm), and mixed barrier (less than 1 mm in one area and greater than 1 mm in another). The association between sellar barrier types and CSF leakage was analyzed, both pre- and intraoperatively. The preoperative MRI classification identified 10 (21.28%) patients presenting a weak sellar barrier, 20 patients (42.55%) with a mixed sellar barrier, and 17 patients (36.17%) exhibiting a strong sellar barrier. Preoperative weak and strong sellar barrier subtypes were associated with weak (p ≤ 0.001) and strong (p = 0.009) intraoperative sellar barriers, respectively. Strong intraoperative sellar barrier subtypes reduced the odds of CSF leakage by 86% (p = 0.01). A correlation between preoperative imaging and intraoperative findings in the setting of pituitary apoplexy has been observed.

Usefulness of endonasal flaps and grafts in skull base surgery. Consensus document

INTRODUCTION

Skull base reconstruction is one of the greatest challenges extended endonasal endoscopic surgery. Many grafts and flaps from the endonasal fossa have been demonstrated to be useful in the control of complications such a cerebrospinal fluid leaks. Review and analysis of these resources are necessary in skull base recontruction to improve outcomes.

OBJECTIVES

The target is to create a consensus document on the use of different endonasal flaps and grafts in the skull base surgery.

MATERIAL AND METHODS

Literature review of the most relevant free grafts and vascularized flaps from the endonasal fossa. Analysis using the Delphi method on the use of the different endonasal resources for endoscopic repair of skull base defects.

RESULTS

We obtained two results: 1) A selection of the most representative flaps and grafts from the endonasal fossa, describing origin, surface and indications, based on a literature review. 2) A consensus document, using Delphi methodology, with general considerations (2), recommendations (10) and limitations (6) of the different endonasal flaps and grafts.

CONCLUSIONS

We present the first consensus document in the field of extended endonasal endoscopic surgery using the Delphi method as a working tool. We highlight the usefulness of the nasoseptal flap together with other endonasal flaps and grafts for skull base reconstruction.

The Quadrangular Space, Endonasal Access to the Meckel Cave: Technical Considerations and Clinical Series

OBJECTIVE

An anteromedial corridor via an expanded endoscopic endonasal approach to the Meckel cave (MC) was described more than a decade ago. However, few clinical series or endoscopic endonasal technical contributions exist concerning this type of approach to this complex region.

METHODS

We present a detailed description of the surgical technique for this approach reviewing the original technique and adding clarifying conceptual notions. We conducted a multicenter retrospective study selecting patients who underwent endonasal endoscopic surgery for lesions exclusively limited to the MC in the past 6 years. Intraoperative and postoperative complications were analyzed. The study of 10 cadaveric specimens provides additional information.

RESULTS

We performed a fully endoscopic anteromedial corridor to the MC in 18 patients. The most prevalent pathologic finding was schwannoma of the V nerve in 4 patients. Sixth cranial nerve palsy (13 patients) and trigeminal dysfunction (10 patients) were the predominant preoperative clinical signs. There were no remarkable intraoperative complications. Corneal keratopathy caused by dry eye syndrome affected 3 patients and V2 residual neuralgia appeared postoperatively in 2 patients. Six patients recovered from sixth cranial nerve palsy, and 2 showed improvement in preoperatively referred facial pain.

CONCLUSIONS

The front door to the MC via the endonasal anteromedial corridor could be a good option. Understanding of the anatomy and the concept of the quadrangular space is crucial to performing this technique safely, which has few complications in experienced hands. Recovery from sixth nerve palsy is possible with this approach. Corneal keratopathy in these patients is a potential complication.

Sex Hormone Receptor Expression in Craniopharyngiomas and Association with Tumor Aggressiveness Characteristics

Craniopharyngiomas (CPs) are rare tumors of the sellar and suprasellar regions of embryonic origin. The primary treatment for CPs is surgery but it is often unsuccessful. Although CPs are considered benign tumors, they display a relatively high recurrence rate that might compromise quality of life. Previous studies have reported that CPs express sex hormone receptors, including estrogen and progesterone receptors. Here, we systematically analyzed estrogen receptor α (ERα) and progesterone receptor (PR) expression by immunohistochemistry in a well-characterized series of patients with CP (n = 41) and analyzed their potential association with tumor aggressiveness features. A substantial proportion of CPs displayed a marked expression of PR. However, most CPs expressed low levels of ERα. No major association between PR and ERα expression and clinical aggressiveness features was observed in CPs. Additionally, in our series, β-catenin accumulation was not related to tumor recurrence.

Usefulness of endonasal flaps and grafts in skull base surgery. Consensus document

INTRODUCTION

Skull base reconstruction is one of the greatest challenges extended endonasal endoscopic surgery. Many grafts and flaps from the endonasal fossa have been demonstrated to be useful in the control of complications such a cerebrospinal fluid leaks. Review and analysis of these resources are necessary in skull base recontruction to improve outcomes.

OBJECTIVES

The target is to create a consensus document on the use of different endonasal flaps and grafts in the skull base surgery.

MATERIAL AND METHODS

Literature review of the most relevant free grafts and vascularized flaps from the endonasal fossa. Analysis using the Delphi method on the use of the different endonasal resources for endoscopic repair of skull base defects.

RESULTS

We obtained two results: 1) A selection of the most representative flaps and grafts from the endonasal fossa, describing origin, surface and indications, based on a literature review. 2) A consensus document, using Delphi methodology, with general considerations (2), recommendations (10) and limitations (6) of the different endonasal flaps and grafts.

CONCLUSIONS

We present the first consensus document in the field of extended endonasal endoscopic surgery using the Delphi method as a working tool. We highlight the usefulness of the nasoseptal flap together with other endonasal flaps and grafts for skull base reconstruction.

Basilar Artery Injury During Endonasal Surgery: Stepwise to Control Bleeding

BACKGROUND

Intraoperative injury during endoscopic endonasal surgery of the carotid artery has been previously described in the literature. However, the accidental damage of the basilar artery in such scenario is not defined.

OBJECTIVE

To define the protocol of action for massive bleeding from an artery in the posterior fossa.

METHODS

The reported patient was diagnosed with a partially calcified clival chordoma featured by a huge intradural component. An endoscopic endonasal transpterygoid transclival approach was selected for the treatment of this tumor. During the surgical procedure, the basilar artery injury was injured, causing intense bleeding. We present and discuss the surgical maneuvers that could save a patient's life after this dramatic complication.

RESULTS

Different techniques were performed in order to control the massive bleeding, including injection of hemotastic matrix with thrombin (Floseal©), bipolar coagulation, and vessel reconstruction by means of a vascular clip. Finally, an autologous muscle graft reinforced with an overlying fibrin sealant patch (Tachosil©) was chosen and was an effective technique. Afterwards, the patient was treated with a flow diverter device to occlude an iatrogenic pseudoaneurysm. A monoplegia of the right upper limb was the only remarkable sequel 6 mo after surgery.

CONCLUSION

The muscle graft together with the coordinated action with interventional neuroradiology for the reconstruction of the vessel are possibly the best options to try to preserve the neurological function. In such a scenario, the assumption of potential ischemic events prevails over the intraoperative death of the patient.

Refining the anatomic boundaries of the endoscopic endonasal transpterygoid approach: the "VELPPHA area" concept

OBJECTIVE

The endoscopic endonasal transpterygoid route has been widely evaluated in cadavers, and it is currently used during surgery for specific diseases involving the lateral skull base. Identification of the petrous segment of the internal carotid artery (ICA) is a key step during this approach, and the vidian nerve (VN) has been described as a principal landmark for safe endonasal localization of the petrous ICA at the level of the foramen lacerum. However, the relationship of the VN to the ICA at this level is complex as well as variable and has not been described in the pertinent literature. Accordingly, the authors undertook this purely anatomical study to detail and quantify the peri-lacerum anatomy as seen via an endoscopic endonasal transpterygoid pathway.

METHODS

Eight human anatomical specimens (16 sides) were dissected endonasally under direct endoscopic visualization. Anatomical landmarks of the VN and the posterior end of the vidian canal (VC) during the endoscopic endonasal transpterygoid approach were described, quantitative anatomical data were compiled, and a schematic classification of the most relevant structures encountered was proposed.

RESULTS

The endoscopic endonasal transpterygoid approach was used to describe the different anatomical structures surrounding the anterior genu of the petrous ICA. Five key anatomical structures were identified and described: the VN, the eustachian tube, the foramen lacerum, the petroclival fissure, and the pharyngobasilar fascia. These structures were specifically quantified and summarized in a schematic acronym-VELPPHA-to describe the area. The VELPPHA area is a dense fibrocartilaginous space around the inferior compartment of the foramen lacerum that can be reached by following the VC posteriorly; this area represents the posterior limits of the transpterygoid approach and, of utmost importance, no neurovascular structures were observed through the VELPPHA area in this study, indicating that it should be a safe zone for surgery in the posterior end of the endoscopic endonasal transpterygoid approach.

CONCLUSIONS

The VELPPHA area represents the posterior limits of the endoscopic endonasal transpterygoid approach. Early identification of this area can enhance the safety of the endoscopic endonasal transpterygoid approach expanded to the lateral aspect of the skull base, especially when treating patients with poorly pneumatized sphenoid sinuses.

Transcavernous sinus pituitary gland transposition: how I do it

BACKGROUND

Pituitary transposition preserving gland function is possible when approaching superior clival region tumors. Clinical experience along with detailed anatomical knowledge makes this technique safe and effective.

METHOD

We present a step by step description of our technique based on the most recent anatomical references to get a pituitary transposition through the different compartments of the cavernous sinus. By this technique, we achieve minor gland manipulation and a better surgical view of this area. We support this technique with an anatomical analysis on cadaveric specimens and clarifying dissection images.

CONCLUSIONS

Transcavernous sinus pituitary gland transposition is an easily feasible technique and allows gland shifting preserving pituitary function.

Surgical Outcome and Treatment of Thyrotropin-Secreting Pituitary Tumors in a Tertiary Referral Center

OBJECTIVE

Thyrotropin (TSH)-secreting pituitary tumors are rare and typically present with hyperthyroidism. Here we report the diagnosis, treatment, and surgical outcomes in a series of patients with TSH-secreting pituitary tumors in a tertiary referral center.

METHODS

Descriptive retrospective study that included all patients with TSH-secreting pituitary tumors who underwent transsphenoidal surgery in the endocrinology and nutrition unit of the Virgen del Rocío University Hospital (Seville, Spain) between 2004 and 2016.

RESULTS

The mean age at diagnosis was 42.8 ± 17 years. The mean time from onset of symptoms to diagnosis was 13 ± 10 months. Four patients displayed symptoms indicating hyperthyroidism (1 suffered from tachycardia); 3 patients showed symptoms because of mass effect (visual impairment and headache) and 3 patients were diagnosed based on incidental findings after routine blood tests (high free thyroxine levels). Eight patients had macroadenomas, and 2 patients had microadenomas. Five patients underwent conventional pituitary surgery, and 5 patients underwent expanded endoscopic transsphenoidal surgery. Six patients achieved cure after surgery. The other patients received radiotherapy and/or treatment with somatostatin analogs. Analysis of somatostatin receptor (SSTR) expression by immunohistochemistry could be performed in 6 tumors.

CONCLUSIONS

Our results confirm the clinical and hormonal heterogeneity caused by TSH-secreting pituitary adenomas. Surgery is considered the first choice of treatment for these tumors. We observed surgical cure rates similar to those reported in recent published series. SSTR2 and SSTR3 are highly expressed in TSH-secreting pituitary adenomas. Our results suggest that somatostatin analog treatment may be also helpful in the treatment of TSH-secreting pituitary adenomas.

Endoscopic endonasal superomedial orbitectomy: How far is safe and possible?

OBJECTIVES

During the endoscopic endonasal approach (EEA) to the anterior cranial base, the lateral boundaries are the lamina papyracea (medial orbital walls) bilaterally but further extension in the coronal plane is possible by performing a superomedial orbitectomy. The aims of this study are to describe the technique of the endoscopic endonasal transethmoidal supraorbital approach to the anterior cranial base and to calculate the extension in the coronal plane added with the superomedial orbitectomy.

METHODS

Thirty superomedial orbitectomies via EEA were completed in 15 fresh-frozen heads. After finishing the procedure, a bifrontal craniotomy with removal of both frontal lobes was performed in order to measure the width of the supraorbital EEA in the coronal plane. We divided the anterior cranial base into five zones related to distinct anatomical segments: sinusal zone, post-sinusal zone, anterior ethmoidal, inter-ethmoidal zone, and posterior ethmoidal zone. Measurements of each segment of the anterior cranial base were taken.

RESULTS

In all specimens, it was possible to perform a superomedial orbitectomy without excessive retraction of the orbital contents. The inter-ethmoidal zone is the segment where the lateral extension was widest. The mean total width in this area was 45.4 mm. The superomedial orbitectomy added a mean of 8 mm on each side to the total anterior skull base exposure.

CONCLUSION

The endoscopic endonasal superomedial orbitectomy added important extension in the coronal plane during an EEA to the anterior cranial base. The inter-ethmoidal zone has shown the greatest lateral extension.

LEVEL OF EVIDENCE

N/A Laryngoscope, 130:1151-1157, 2020.

Optic Nerve Atrophy Due to Long-Standing Compression by Planum Sphenoidale Meningioma

PURPOSE

In this study we report an uncommon endoscopic endonasal image of an atrophic optic nerve as seen after surgical removal of a suprasellar meningioma. The peculiarity of this case is the long-lasting underestimated ocular symptomatology of the patient who reported a 15-year history of impairment of vision on her left eye.

METHODS

A 51-year-old woman was admitted to our hospital complaining of a 15-year history of impairment of vision on her left eye. After making serendipitously the diagnosis of a suprasellar mass, we performed endoscopic endonasal surgery.

RESULTS

The tumor was reached from below and removed safely, without manipulation of the optic pathways. At the end of tumor removal, the impressive left optic nerve atrophy due to enduring local tumor compression was visualized.

CONCLUSIONS

To the best of our knowledge, no endoscopic endonasal image with such features has been provided in the pertinent literature. Possibly, this contribution will help identify damaged optic nerves during endoscopic endonasal surgery.

How I do it? Cranial setup for cranial settling

BACKGROUND

Expanded endonasal endoscopic techniques allow us to treat several pathologies related to the odontoid process and craniocervical junction. Cases such as giant basilar invagination represent a surgical challenge.

METHODS

The authors provide technical nuances and describe how to complete an endoscopic endonasal odontoidectomy and release the craniocervical junction with the aim of restoring a correct sagittal balance in cases with giant basilar invagination. The study of cadaveric specimens adds clarifying dissections.

CONCLUSIONS

Endonasal endoscopic odontoidectomy and craniocervical junction joint release allow the treatment of irreducible basilar invagination and restoration of better sagittal balance before posterior cervical occipitocervical fusion.

Endoscopic radical hypophysectomy: how I do it

BACKGROUND

Total hypophysectomy it is a classical procedure that currently has many indications especially in patients with Cushing syndrome without good endocrine control. Expanded endonasal endoscopic techniques grant us an alternative standpoint to the classic trans-sphenoidal microscopic approach and a comprehensive assessment of the process METHOD: The author provides technical nuances and describe step by step the radical endoscopic hypophysectomy. The study of cadaveric specimens adds clarifying dissections.

CONCLUSIONS

Radical hypophysectomy is an easily replicable and safe procedure. The most important morbidity is the intraoperative cerebrospinal fluid (CSF) leakage, which is inherent to this technique and can be successfully prevented with a pedicled nasoseptal flap reconstruction.

Basiespinal Cerebrospinal Fluid Leak as a Complication After Adenoidectomy: Case Report and Literature Review

BACKGROUND

Adenoidectomy is one of the most common procedures in the field of pediatric otolaryngology. Postoperative bleeding is one of the most frequent complications (0.4%). In turn, cerebrospinal fluid fistula is a very uncommon but critical complication in this type of surgery.

METHODS

We report the case of a 3-year-old patient who underwent adenoidectomy and presented a cerebrospinal fluid leak associated with pneumocephalus and meningitis.

RESULTS

The solution provided was a suture in layers of the fistula tract, reinforced with basipharyngeal vascularized and rotation random flap of mucosa, and a free graft of muscle, through a transoral endoscopic approach.

CONCLUSIONS

Cerebrospinal fluid leak as a complication after adenoidectomy is exceedingly rare. These pharyngospinal fistulae are determined by the anatomic features associated with intraoperative hemorrhagic complications, and it is essential that we take them into account when facing postoperative complications in the follow-up. The use of vascularized flaps based on the irrigation of the ascending pharyngeal artery with endoscopic techniques offers low-morbidity solutions, which are more efficient than traditional methods.