Endoscopic endonasal transcavernous posterior clinoidectomy with interdural pituitary transposition

Fernández-Miranda, Juan C.; Gardner, Paul A.; Rastelli, Milton M.; Peris-Celda, María; Koutourousiou, Maria; Peace, David A.; Snyderman, Carl H.; Rhoton, Albert L.

doi:10.3171/2014.3.jns131865

Cited by 99 publications

(89 citation statements)

References 13 publications

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“…Recently Fernandez-Miranda et al 13 introduced a variant of endoscopic endonasal transcavernous posterior clinoidectomy with interdural pituitary transposition that works through a lateral corridor within the cavernous sinus. This required meticulous dissection of the interdural plane separating the cavernous sinus and lateral mobilization of the ICA in order to expose the posterior clinoid and dorsum sellae.…”

Section: Limits Of Endoscopic Visualization Of the Cavernous Sinusmentioning

confidence: 99%

Pituitary macroadenomas with oculomotor cistern extension and tracking: implications for surgical management

Hoang¹,

Tran²,

Herde

et al. 2016

JNS

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T reaTmenT management strategies for pituitary macroadenomas depend on numerous factors that guide the determination of medical management, surgical approach, and/or adjuvant therapeutic options. Maximal resection and adequate decompression of the neurological structures is the paradigm of care for symptomatic pituitary macroadenomas, with the exception of medically responsive prolactinomas.Since its inception by Schloffer in 1907 and then refinement and popularization by Hirsch, Guiot, and Hardy, the transsphenoidal approach has become the preferred route to the sella because of its relative safety profile. 9,14,16,17 The transcranial route still plays an important role in providing access to the sella in 1% to 4% of pituitary macroadenomas where direct visualization and accessibility via the transsphenoidal approach are limited. 38A transcranial approach should be considered in the surgical management of pituitary adenomas that display constriction at the diaphragma sellae, parasellar extension or inaccessible suprasellar extension off the midline, tumors of fibrous consistency with large suprasellar extension, and in patients with an active sinus infection or a coexisting adjacent aneurysm. Other cases that should be approached transcranially include those patients with ectatic intrasellar carotid arteries, 40 retrosellar extension, brain invasion with edema, involvement or vasospasm of the arteries of the circle of Willis, or encasement of the optic apparatus or invasion of the optic foramina. obJective Oculomotor cistern extension of pituitary adenomas is an overlooked feature within the literature. In this study, 7 cases of pituitary macroadenoma with oculomotor cistern extension and tracking are highlighted, and the implications of surgical and medical management are discussed. methods The records of patients diagnosed with pituitary macroadenomas who underwent resection and in whom preoperative pituitary protocol MRI scans were available for review were retrospectively reviewed. The patient and tumor characteristics were reviewed along with the operative outcomes and complications. results Seven patients (4.1%) with oculomotor cistern extension and tracking were identified in a cohort of 170 patients with pituitary macroadenoma. The most common presenting symptoms were visual deficit (6 patients; 86%), apoplexy (3 patients; 43%), and oculomotor nerve palsy (3 patients; 43%). Lone oculomotor nerve palsy was seen in 2 patients without apoplexy and 1 patient with an apoplectic event. Gross-total resection was achieved via a microscopic endonasal transsphenoidal approach with or without endoscopic aid to the sella in 14%, near-total resection in 29%, and subtotal resection in 57% of patients in the data set. coNclusioNs Pituitary adenoma extension along the oculomotor cistern is uncommon; however, preoperatively recognizing such extension should play an important role in the surgeon's operative considerations and postoperative clinical management because this extension can limit gross-total resection using t...

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Section: Limits Of Endoscopic Visualization Of the Cavernous Sinusmentioning

confidence: 99%

Pituitary macroadenomas with oculomotor cistern extension and tracking: implications for surgical management

Hoang¹,

Tran²,

Herde

et al. 2016

JNS

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“…Removal of the bone overlying the cavernous ICA, medial opticocarotid recess and middle clinoid allows for better manipulation of the paraclinoidal segment 42 and dural rings and a transtuberculum/transplanum approach will expose the supraclinoidal segment and potentially the anterior communicating artery complex 43 . 16 . Even with this addition, full access requires that the apex be low-lying (at or below the dorsum sellae).…”

Section: Endoscopic Endonasal Anatomy Of the Internal Carotid Artery mentioning

confidence: 95%

“…The approach was extended with an extradural left-sided posterior clinoidectomy via interdural pituitary transposition 16 as well as extension to the left medial jugular tubercle 17 . The dura was opened in a Y-shaped fashion starting in the mid clivus and the aneurysm with its calcified and atherosclerotic neck could be identified and carefully dissected free from the left posterior cerebral and superior cerebellar arteries as well as the perforating branches and oculomotor nerve (FIGURE 2A).…”

Section: Surgical Proceduresmentioning

confidence: 99%

Endoscopic Endonasal Clipping of Intracranial Aneurysms: Surgical Technique and Results

et al. 2015

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“…The surgical technique and application for an endoscopic endonasal, purely extradural posterior clinoidectomy was originally described in a seminal publication by the Pittsburgh group led by Amin Kassam in 2005. 1 This publication literally states: "Subsellar extradural removal of the posterior clinoid and dorsum sellae … the posterior clinoid and dorsum sellae can also be removed via a completely extrasellar approach.… The pituitary, with dura mater intact, is elevated superiorly.… The dura over the sella is not opened.… With the pituitary gland elevated, the dorsum sellae and posterior clinoid can be drilled using a 1-mm diamond bit or a rongeur...." In 2012, the Cornell group provided a more complete description of the surgical anatomy for the extradural posterior clinoidectomy technique by performing dissections in 5 anatomical specimens. 3 Continued clinical experience by the Pittsburgh group resulted in further refinement of the technique to provide a balance of optimal exposure with preservation of pituitary function, as documented in subsequent publications: the intradural pituitary transposition and posterior clinoidectomy by Kassam et al in 2008, 2 and then the interdural transcavernous posterior clinoidectomy described in the article under discussion.…”

Section: Responsementioning

confidence: 99%

Letter to the Editor: Endoscopic endonasal posterior clinoidectomy

Silva

Attia²,

Schwartz³

2015

JNS

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endoscopic endonasal posterior clinoidectomy TO THE EDITOR: We read with interest the article by Fernandez-Miranda et al. 1 regarding a new technique for performing endoscopic endonasal posterior clinoidectomy (Fernandez-Miranda JC, Gardner PA, Rastelli MM Jr, et al: Endoscopic endonasal transcavernous posterior clinoidectomy with interdural pituitary transposition. Technical note. J Neurosurg 121:91-99, July 2014).The authors described an innovative surgical technique performed through the cavernous sinus, with an interdural dissection taking advantage of the natural corridor provided by the separation of the inner and outer dural layers at the lateral margin of the sellae. This corridor provides access to the posterior clinoid process, making the endoscopic endonasal posterior clinoidectomy a safe and effective procedure. The approach was performed in 12 patients (6 with chordomas, 5 with petroclival meningiomas, and 1 with an epidermoid tumor), with great clinical results and no permanent hypopituitarism, diabetes insipidus, or neurovascular injuries. The impeccable quality of the anatomical dissections together with the detailed description of the surgical approach helps the reader to understand the complex anatomy of this region seen from the endoscopic endonasal view. The authors are to be congratulated on the excellent quality of the study and the clinical results.In contrast to the Pittsburgh group's experience, we have described a purely extradural posterior clinoidectomy. 2 We have performed this approach safely in dozens of patients and have formed the opinion that in the majority of cases a purely extradural approach is sufficient to achieve an adequate posterior clinoidectomy. In those cases in which the extradural approach is not sufficient we have used the interdural approach, as described expertly in this article. Hence, we use the interdural approach more selectively, as needed, and it is possible to convert easily from the extradural to the interdural approach. Overall, it is our opinion that an extradural approach is safer because the dura mater can serve as a natural protector against neurovascular injury. There is also the option of working both above and below the pituitary gland to reach the interpeduncular fossa and retroinfundibular area, thereby avoiding damage to the pituitary gland and its blood supply. 3 Making an analogy to the transcranial anterior clinoidectomy, which can be performed intra-or extradurally, there are probably indications for both inter-and extradural posterior clinoidectomy. Ultimately, the idea is to avoid a complete pituitary transposition, which often causes hypopituitarism.Modern skull base neurosurgery is based on tailoring the approach for each patient. Thus, the new technique described by the authors is an important addition to skull base surgery, but in our opinion should be reserved for those posterior clinoids that cannot be removed extradurally, rather than being the default operation in all cases.

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Endoscopic endonasal transcavernous posterior clinoidectomy with interdural pituitary transposition

Cited by 99 publications

References 13 publications

Pituitary macroadenomas with oculomotor cistern extension and tracking: implications for surgical management

Pituitary macroadenomas with oculomotor cistern extension and tracking: implications for surgical management

Endoscopic Endonasal Clipping of Intracranial Aneurysms: Surgical Technique and Results

Letter to the Editor: Endoscopic endonasal posterior clinoidectomy

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