The changing sella: internal carotid artery shift during transsphenoidal pituitary surgery

Serra, Carlo; Maldaner, Nicolai; Muscas, Giovanni; Staartjes, Victor E.; Pangalu, Athina; Holzmann, David; Soyka, Michael; Schmid, Christoph; Regli, Luca

doi:10.1007/s11102-017-0830-x

Cited by 12 publications

(5 citation statements)

References 18 publications

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“…This is consistent with prior reports investigating ICD contraction, finding that it was not well predicted by tumor size/volume. 11,12 Despite this, Δ-ICD is evidently contingent upon the prior existence of tumor sufficient to expand the sella before it can "relax" and contract. However, Δ-ICD and volume are different physical measurements, not merely surrogates for each other.…”

Section: Discussionmentioning

confidence: 99%

“…Previous work has shown that following transsphenoidal resection of pituitary adenoma, there is an intra-and postoperative reduction in the ICD in 26 to 52% of cases. 11,12 Larger contraction was not associated with greater preoperative tumor size. Another group noted that Knosp grade 13 3 and 4 tumors (i.e.…”

Section: Introductionmentioning

confidence: 91%

“…tumors extending at least beyond the lateral margin of the cavernous internal carotid artery [ICA]) were associated with large postoperative ICD contraction (> 2 mm). 11 However this has not been replicated elsewhere, 12 and may have been related to inclusion of microadenoma with necessarily low Knosp grade and mechanical implausibility to widen the sella.…”

Section: Introductionmentioning

confidence: 98%

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Sellar Remodeling after Surgery for Nonfunctioning Pituitary Adenoma: Intercarotid Distance as a Predictor of Recurrence.

Raghu

Flower

Statham

et al. 2019

J Neurol Surg B Skull Base

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Introduction As they grow, pituitary adenoma can remodel the sella turcica and alter anatomical relationships with adjacent structures. The intercarotid distance (ICD) at the level of the sella is a measure of sella width. The purpose of this study was to (1) assess how ICD changes after transsphenoidal surgery and (2) explore whether the extent of ICD change is associated with tumor recurrence. Methods A retrospective analysis of preoperative and postoperative coronal magnetic resonance imaging (MRI) scans was carried out by two independent assessors on patients who underwent transsphenoidal surgery for nonfunctioning pituitary macroadenomas. Preoperative tumor volume and any change in ICD following surgery were recorded and compared between groups. Logistic regression models of recurrence were generated. Results In 36 of 42 patients, ICD fell after surgery (mean = 1.8 mm) and six cases were static. At time of follow-up (mean = 77 months), 25 had not required further intervention and 17 had undergone second surgery or radiosurgery. In patients in whom no further intervention has yet been necessary, the postoperative reduction in ICD was significantly smaller than in those who required repeat intervention (1.1 vs. 2.7 mm respectively, p < 0.01). ICD decrease was weakly correlated with tumor volume (r = 0.35). ICD decrease was a significant predictor of recurrence (odds ratio [OR] = 3.15; 95% confidence interval [CI]: 1.44–6.87), largely independent of tumor volume. Conclusion For most patients, ICD falls following surgical excision of a nonfunctioning pituitary macroadenoma. A greater reduction in ICD postsurgery appears to predict recurrence. Change in ICD shows promise as a radiographic tool for prognosticating clinical course after surgery.

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 91%

Section: Introductionmentioning

confidence: 98%

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Sellar Remodeling after Surgery for Nonfunctioning Pituitary Adenoma: Intercarotid Distance as a Predictor of Recurrence.

Raghu

Flower

Statham

et al. 2019

J Neurol Surg B Skull Base

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“…One may speculate that this might be favored by the systematic use of 3T iMRI, which allows for excellent intraoperative assessment of the EOR 30 and of intra-and perisellar anatomical structures. 31,34 It is possible that the use of 3T iMRI compensates for the partially reduced view created by the mononostril approach. The intraoperative accurate volumetric assessment of the EOR and the precise view of intra-and perisellar anatomy provided by the 3T iMRI give the surgeon immediate feedback on the results of surgery.…”

Section: Technical Nuances In Tssmentioning

confidence: 99%

Assessing the surgical outcome of the “chopsticks” technique in endoscopic transsphenoidal adenoma surgery

Serra

Staartjes

Maldaner

et al. 2020

Neurosurgical Focus

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OBJECTIVEThe “chopsticks” technique is a 3-instrument, 2-hand mononostril technique that has been recently introduced in endoscopic neurosurgery. It allows a dynamic surgical view controlled by one surgeon only while keeping bimanual dissection. Being a mononostril approach, it requires manipulation of the mucosa of one nasal cavity only. The rationale of the technique is to reduce nasal morbidity without compromising surgical results and complication rates. There are, however, no data available on its results in endoscopic surgery (transsphenoidal surgery [TSS]) for pituitary adenoma.METHODSThe authors performed a cohort analysis of prospectively collected data on 144 patients (156 operations) undergoing TSS using the chopsticks technique with 3T intraoperative MRI. All patients had at least 3 months of postoperative neurosurgical, endocrinological, and rhinological follow-up (Sino-Nasal Outcome Test–20 [SNOT-20] and Sniffin’ Sticks). The surgical technique is described, and the achieved gross-total resection (GTR) and extent of resection (EOR) together with patients’ clinical outcomes and complications are descriptively reported.RESULTSOn 3-month postoperative MRI, GTR was achieved in 71.2% of patients with a mean EOR of 96.7%. GTR was the surgical goal in 122 of 156 cases and was achieved in 106 of 122 (86.9%), with a mean EOR of 98.7% (median 100%, range 49%–100%). There was no surgical mortality. At a median follow-up of 15 months (range 3–70 months), there was 1 permanent neurological deficit. As of the last available follow-up, 11.5% of patients had a new pituitary single-axis deficit, whereas 26.3% had improvement in endocrinological function. Three patients had new postoperative hyposmia. One patient had severe impairment of sinonasal function (SNOT-20 score > 40). The operation resulted in endocrine remission in 81.1% of patients with secreting adenomas.CONCLUSIONSThis study shows that the chopsticks technique confers resection and morbidity results that compare favorably with literature reports of TSS. This technique permits a single surgeon to perform effective endoscopic bimanual dissection through a single nostril, reducing manipulation of healthy tissue and thereby possibly minimizing surgical morbidity.

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“…The smallest distance between the 2 horizontal C 4 segments of the internal carotid arteries was defined as the intercarotid distance (ICD), and tumor diameters in 3 axes were obtained on coronal sections. 3,21 Table 1 provides an explanation of the most important concepts in machine learning-based outcome prediction. Extended methods and model specifications can be found in Appendix 1.…”

Section: Outcome Measuresmentioning

confidence: 99%

Utility of deep neural networks in predicting gross-total resection after transsphenoidal surgery for pituitary adenoma: a pilot study

Staartjes

Serra

Muscas

et al. 2018

Neurosurgical Focus

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OBJECTIVEGross-total resection (GTR) is often the primary surgical goal in transsphenoidal surgery for pituitary adenoma. Existing classifications are effective at predicting GTR but are often hampered by limited discriminatory ability in moderate cases and by poor interrater agreement. Deep learning, a subset of machine learning, has recently established itself as highly effective in forecasting medical outcomes. In this pilot study, the authors aimed to evaluate the utility of using deep learning to predict GTR after transsphenoidal surgery for pituitary adenoma.METHODSData from a prospective registry were used. The authors trained a deep neural network to predict GTR from 16 preoperatively available radiological and procedural variables. Class imbalance adjustment, cross-validation, and random dropout were applied to prevent overfitting and ensure robustness of the predictive model. The authors subsequently compared the deep learning model to a conventional logistic regression model and to the Knosp classification as a gold standard.RESULTSOverall, 140 patients who underwent endoscopic transsphenoidal surgery were included. GTR was achieved in 95 patients (68%), with a mean extent of resection of 96.8% ± 10.6%. Intraoperative high-field MRI was used in 116 (83%) procedures. The deep learning model achieved excellent area under the curve (AUC; 0.96), accuracy (91%), sensitivity (94%), and specificity (89%). This represents an improvement in comparison with the Knosp classification (AUC: 0.87, accuracy: 81%, sensitivity: 92%, specificity: 70%) and a statistically significant improvement in comparison with logistic regression (AUC: 0.86, accuracy: 82%, sensitivity: 81%, specificity: 83%) (all p < 0.001).CONCLUSIONSIn this pilot study, the authors demonstrated the utility of applying deep learning to preoperatively predict the likelihood of GTR with excellent performance. Further training and validation in a prospective multicentric cohort will enable the development of an easy-to-use interface for use in clinical practice.

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The changing sella: internal carotid artery shift during transsphenoidal pituitary surgery

Abstract: We have demonstrated a uniform narrowing in ICD at different levels of the ICA during and after TSS adenoma resection. Surgeons should be aware of this change since it determines the width of the surgical corridor and can thus influence the ease of surgery.

Cited by 12 publications

References 18 publications

Sellar Remodeling after Surgery for Nonfunctioning Pituitary Adenoma: Intercarotid Distance as a Predictor of Recurrence.

Sellar Remodeling after Surgery for Nonfunctioning Pituitary Adenoma: Intercarotid Distance as a Predictor of Recurrence.

Assessing the surgical outcome of the “chopsticks” technique in endoscopic transsphenoidal adenoma surgery

Utility of deep neural networks in predicting gross-total resection after transsphenoidal surgery for pituitary adenoma: a pilot study

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