Abstract
Transsphenoidal resection of the sellar and suprasellar lesions, whether microscopic or endoscopic, has been traditionally limited by tumors extending laterally to the carotid artery and cavernous sinus. Extended endoscopic or transmaxillary approaches may be warranted depending on these tumor extensions. We describe the use of an intraoperative Valsalva maneuver as a surgical adjunct to the transsphenoidal approach to improve the extent of resection for a favorable outcome. The patient was a 65-year-old woman who underwent resection of a giant pituitary tumor that extended laterally to the cavernous sinus to occupy a volume within the middle fossa. It was the senior author's impression that the lateral cavernous wall was intact at the time of surgery although this is difficult to determine definitively. After a transsphenoidal intrasellar resection of the intrasellar tumor, side-angled endoscopic visualization enabled identification of the breach in the medial cavernous wall where the tumor had invaded the cavernous sinus and ultimately grown into the middle fossa. A Valsalva maneuver was then applied, and the tumor was extruded from the cavernous sinus lateral to the carotid. The significant tumor was removed under direct visualization of the abducens nerve, which was well preserved. Postoperative imaging showed a sufficient extent of resection, and there were no postoperative complications. An intraoperative Valsalva maneuver can be a potentially useful technique for extending tumor resection in cases with a soft tumor and visualization of the opening within the cavernous sinus wall.
Highlights
Surgical management of sellar and suprasellar lesions, including large pituitary tumors, which have cavernous and middle fossa extension may be problematic
We describe the use of an intraoperative Valsalva maneuver as a surgical adjunct to the transsphenoidal approach to improve the extent of resection for a favorable outcome
Transcranial surgery has been used in pituitary adenomas that are thought to be difficult to resect via the transsphenoidal approach because of retrosellar, retrochiasmatic, subfrontal, or temporal extension; the transsphenoidal approach is the preferred method when feasible because there is a higher likelihood of preserving normal pituitary and visual function with less morbidity [1,2,3,4,5,6]
Summary
Surgical management of sellar and suprasellar lesions, including large pituitary tumors, which have cavernous and middle fossa extension may be problematic. The authors report a case of a patient who underwent resection of a large pituitary adenoma with tumor encasement of the internal carotid arteries bilaterally and lateral extension to the left middle fossa. With the use of a 45° endoscope, the hole in the medial cavernous wall was identified within the anterior loop of the cavernous carotid Careful dissection in this area enabled visualization of the abducens nerve lateral to the carotid. Pituitary laboratory tests done on postoperative day 2 indicated a cortisol level of 27.2 μg/dL and a prolactin level of 5.7 ng/mL (within normal limits) She was restarted on her previous dosage of levothyroxine. The patient's scan at three years was concerning for stable to slight interval growth in the tumor; she has been scheduled for stereotactic radiosurgery in the near future
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