Internal carotid arterial shift after transsphenoidal surgery in pituitary adenomas with cavernous sinus invasion

Abstract

The intercarotid distance (ICD) between cavernous carotid arteries (CCAs) is an important factor for avoiding injury of the internal carotid artery during transsphenoidal surgery. The ICD between CCAs in pituitary adenoma patients is generally larger than in normal individuals. However, the movement of the CCA during transsphenoidal surgery is not known. The aim of this study is to measure the ICD between CCAs in pituitary adenoma patients before and after surgery. We reviewed 138 pituitary adenoma patients who were treated with resection via the transsphenoidal approach. The CCA diameter and the ICD between CCAs were measured from preoperative and postoperative MR images. The CCA diameter was similar at the preoperative and postoperative time points. On the other hand, the ICD between CCAs was shorter at postoperative time point (19.4 ± 4.5 mm) than at the preoperative time point (20.9 ± 4.9 mm) (P = 0.048). Above all, invasion type adenomas had more significant ICD change at the postoperative time point (23.8 ± 3.8 mm) than at the preoperative time point (21.6 ± 3.9 mm) (P = 0.008). Also in multivariate analysis, cavernous sinus invasion of adenoma was independently associated with ICD contraction >2 mm (P = 0.027). It is important to know the change in ICD between CCAs after transsphenoidal surgery, particularly for pituitary adenomas with cavernous sinus invasion. The position of the CCA should be known before and during transsphenoidal surgery, as well before and during the second operation to avoid vascular injuries.

Pituitary macroadenoma: analysis of intercarotid artery distance compared to controls

“…Our results reinforce the logically increase in the ICD with large pituitary tumors 2,4,6,21 , however we could not relate it to CSI as other authors did 4,5 . Interestingly, there was no statistical difference in the ICD2 when we compared the adenoma with the control group, but the ICD2 it was significantly higher in the giant subgroup when we compared to both, adenomas subgroup and control group ( Figure 6).…”

“…In another report Sasagawa et al compared the ICD at the cavernous carotid pre and postoperatively and demonstrated that in invasive pituitary adenomas the ICD tends to be reduced after surgery, probably because of disruption of supportive tissues that keep the carotid artery in place at this segment 5 . In contrast, in our study, the amount of patients with radiological signs of CSI did not differ between the adenoma and the giant subgroup, although the ICD2 was significantly higher in the giant subgroup.…”

“…Sasagawa et al 5 , were the only relating grade of resection with ICD. In their study gross total or subtotal resection was less achieved in patients with ICD lower than 25 mm, however, the aforementioned distance is still higher than the mean ICD found in ours and other studies, so we do not recommend that measurement as an obstacle to tumor resection 1,3,4,5,6,22,23,25,27,28,29 . In conclusion, apparently the ICD at the horizontal segment of the cavernous carotid tends to be wider in patients with giant pituitary adenomas.…”

“…In the transsphenoidal approach for pituitary adenomas, detailed preoperative planning with information regarding the sphenoid sinus, tumoral involvement of adjacent structures (cavernous sinus, suprasellar region, carotid arteries) and intercarotid distance (ICD) is critical. Despite that, there is little literature regarding the ICD at the parassellar region of the intracranial carotid arteries at its cavernous segment and its modifications due to the sellar pathologies, specially non-functioning pituitary adenomas 2,3,4,5,6 .Although vascular injuries have become less frequent over the years, with reports ranging from 0-3.8% 7,8,9,10,11,12,13,14,15,16,17,18,19,20 , it is still considered one of the most important complications in the transsphenoidal approaches due to its potential hazardous effects and difficult management. Taking this into consideration, it is crucial that every surgeon knows exactly the carotid artery position and its relation to the lesion.…”

“…In the transsphenoidal approach for pituitary adenomas, detailed preoperative planning with information regarding the sphenoid sinus, tumoral involvement of adjacent structures (cavernous sinus, suprasellar region, carotid arteries) and intercarotid distance (ICD) is critical. Despite that, there is little literature regarding the ICD at the parassellar region of the intracranial carotid arteries at its cavernous segment and its modifications due to the sellar pathologies, specially non-functioning pituitary adenomas 2,3,4,5,6 .…”