Diaphragma Sellae Research Articles

Prognostic factors in the surgical treatment of intracanalicular primary optic nerve sheath meningiomas.

Although meningiomas frequently involve the optic nerve, primary optic nerve sheath meningiomas (ONSMs) are rare, accounting for only 1% of all meningiomas. Given the high risk of vision loss with these tumors, surgical intervention is seldom considered, and radiation or observation is commonly applied. Here, the authors describe the visual outcomes for a series of patients who were treated with surgery aiming at maximal tumor resection and highlight their prognostic factors. The authors retrospectively analyzed the data for 8 patients with intracanalicular ONSMs who had been surgically treated by the senior author (O.A.) between 1998 and 2016. Meningiomas extending into the optic canal from the intracranial cavity (i.e., clinoid, sphenoid wing, tuberculum sellae, diaphragma sellae) were excluded. Diagnosis was based on ophthalmological, radiological, and intraoperative findings, which were confirmed by the typical histological findings. Preoperative, postoperative, and follow-up visual assessments were performed by neuro-ophthalmologists in all cases. The patients included 7 females and 1 male. The mean age at diagnosis was 45.1 years (range 25.0-70.0 years). Mean duration of follow-up was 38.9 months (range 3.0-88.0 months). All patients reported visual complaints, and all had objective evidence of optic nerve dysfunction. Their evaluation included visual field, visual acuity, funduscopy, and retinal fiber thickness. Total resection was obtained in 4 cases. Comparing preoperative and postoperative visual function revealed that 4 patients had improvement at the last follow-up, 1 patient had stable vision, and 3 patients had decreased function but none had total vision loss. All patients with good preoperative visual acuity maintained this status following surgical treatment. There was no surgical mortality or infection. Operative complications included binocular diplopia in 4 patients, which remitted spontaneously. Surgery can play a beneficial role in the primary treatment of ONSM, especially lesions located in the posterior third of the nerve. Total removal can be achieved with vision preservation or improvement, without major surgical complications, especially at early stages of the disease. Patients with good preoperative vision and CSF flow in the optic sheath have better chances of a favorable outcome than those with poor vision.

Tailored approach for the resection of planum sphenoidale meningiomas

Background and importance. Planum sphenoidale meningiomas are relatively rare tumours that can grow to a considerable size before determining noticeable symptoms. Modern imaging techniques can detect these tumours of varying size. Surgical resection of planum sphenoidale meningiomas can be performed by adapting the approach to the size of the tumour.Clinical presentation. A 56-year-old woman presented with a small (2 cm in diameter) planum sphenoidale meningioma that was resected through a frontal craniotomy performed with a 4,5 cm trephine at the level of the frontal sinus. The second case is that of a 55-year-old woman that presented with a large planum sphenoidale meningioma (5,6 cm in the antero-posterior plane and 5,5 cm cranio-caudally) extending to the tuberculum sellae and sellar diaphragm, reaching the anterior wall of the third ventricle. In this case, a bifrontal craniotomy was performed with frontal sinus cranialization and resection of falx cerebri, achieving a Simpson II resection. Both cases presented a favourable postoperative evolution, without any deficits and an excellent cosmetic result.Conclusion. The approach for tumours of the anterior skull base must be tailored to the size of the tumour. A minimally invasive approach through the frontal sinus should not be avoided in cases with small tumours.

Sellar Diaphragm Reconstruction with Tachosil During Endoscopic Endonasal Surgery: Technical Note.

This report introduces a new closure technique for the management of intraoperative cerebrospinal fluid (CSF) leakage during endoscopic endonasal surgery. The procedure is based on the combination of a traditional autologous tissue flap with a heterologous fibrin graft (TachoSil). We performed a retrospective analysis on 121 patients with pituitary adenomas treated in our center by the senior neurosurgeon (author V.R.B) in the previous 4 years. Only one patient (0.8%) developed a CSF leakage and no adverse events were found related to the use of TachoSil. Compared with other techniques used previously, sellar diaphragm reconstruction with TachoSil seems to be an effective and inexpensive alternative.

Contribution of Intrasellar Pressure Elevation to Headache Manifestation in Pituitary Adenoma Evaluated With Intraoperative Pressure Measurement.

Headache frequently occurs in patients with pituitary adenoma and is reported in large as well as small adenomas. However, the exact mechanism of headache derived from pituitary adenoma remains unknown. To evaluate the contribution of intrasellar pressure (ISP) to headache manifestation by using intraoperative ISP measurement. The records of 108 patients who had first-time transsphenoidal surgery for pituitary adenoma were reviewed retrospectively. Measurement of intraoperative ISP was undergone using intracranial pressure monitoring sensors and compared with radiological assessment. Among 30 patients with headache, 29 (96.7%) presented with significant headache (Headache Impact Score-6, 50 or greater). Intraoperative ISP measurement was conducted successfully in all cases, and revealed higher ISP in patients with headache (35.6 ± 9.2 mm Hg) than in those without headache (15.8 ± 5.2 mm Hg). The ISP reduction after sella floor decompression was greater in patients with headache than that in patients without headache. In patients with headache, the frequency of invasion into the cavernous sinus or sphenoid sinus was significantly lower, and the diameter of the foramen at the diaphragm sellae was narrower. In addition, intratumoral cyst or hematoma was more common in patients with headache. Postoperatively, headache was either diminished or improved in 28 patients (93.3%). Headache in patients with pituitary adenomas associated with ISP elevation, results from compromised dural integrity at the sella and intratumoral hemorrhage. The increased stretch force of the sella dura may be a notable etiology of headache in patients with pituitary adenoma.

The diaphragma sellae, diaphragm opening, and subdiaphragmatic cistern: an anatomical study using magnetic resonance imaging.

Few studies have explored the detailed morphology of the diaphragma sellae (DS), diaphragm opening (DO) or stoma, and subdiaphragmatic cistern (SDC) using neuroimages. The aim of the present study was to characterize these structures using magnetic resonance imaging. Thin-sliced, sagittal and coronal T2-weighted imaging was performed for a total of 84 outpatients. The DS, DO, SDC, and relevant structures were consistently delineated in all patients. In 66% of patients, all three structures appeared to be highly variable, and were classifiable as six distinct morphological types. In 4% of patients, the DS presented as a complete sheet lacking a discernible DO. In addition, 30% of the patients presented with undiscernible SDCs. In the coronal sections of 11% of patients, the pituitary glands extended laterally, reaching or extending beyond the center line on the sectional image of the cavernous internal carotid artery. Thin-sliced, sagittal, and coronal T2-weighted sequences are useful for delineating the DS, DO, and SDC. Morphological variation of these structures among individuals may considerably influence the direction of pituitary tumor expansion.

Anatomical Risk Factors for Intraoperative Cerebrospinal Fluid Leaks During Transsphenoidal Surgery for Pituitary Adenomas

Cerebrospinal fluid (CSF) fistulas are among the most clinically important and frequent complications of transsphenoidal surgery for pituitary adenomas. Between the adenoma and the CSF, a "barrier" exists that consists of ≤3 elements. These, from cephalad to caudad, are the arachnoid, dura mater (sellar diaphragm), and pituitary glandular tissue. The objective of the present study was to determine whether the presence or absence of any of these 3 anatomical elements would be associated with the development of an intraoperative CSF fistula. From November 2016 to June 2018, 40 patients with pituitary adenomas underwent surgery, by transsphenoidal endonasal access, under a microscope. All procedures were filmed in 3 dimensions. The intraoperative findings and preoperative magnetic resonance images were analyzed and compared. The patients who had developed a fistula were compared against those who had not. In 20 patients, glandular tissue was identified between the tumor and subarachnoid space. In 13, dura mater was evident, and in 7, only the arachnoid was noted. An intraoperative CSF fistula occurred in 6 patients, all of whom had the arachnoid as the only barrier. The presence of a fistula was significantly more likely statistically for patients with an arachnoid-only barrier than for those with any other barrier composition (P < 0.001). The anatomical architecture forming the roof of the pituitary fossa is an important determinant of intraoperative CSF fistula risk. When the barrier consists of only the arachnoid, the risk will be significantly greater than when the barrier contains additional elements. Preoperative magnetic resonance imaging would be useful to determine the type of the existing barrier.

The application of nasoseptal \u201crescue\u201d flap technique inendoscopic transsphenoidal pituitary adenoma resection

To explore the reliability and superiority of nasoseptal “rescue” flaptechnique in neuroendoscopic transnasal pituitary adenoma resection. Retrospectiveclinical analysis of 113 cases of endoscopic transsphenoid pituitary adenomaresection with the application of nasoseptal “rescue” flap technology. Thereliability and the superiority of the technique were evaluated according to theduration of nasal cavity and sphenoid sinus stage, the incidence of postoperativeanosmia, and cerebrospinal rhinorrhea. The duration of nasal and sphenoid sinusstage was 15–30 min, averaging 24 min. There were 27 cases of intro-operativecerebrospinal fluid leakage, including 24 cases of low-flow cerebrospinal fluid leakand 3 cases of high-flow cerebrospinal fluid leak. Twenty-three cases were convertedfrom nasoseptal “rescue” flap to nasal septum flap. There were 17 cases ofpostoperative olfactory decline or disappearance, 1 case of epistaxis and 1 case ofcerebrospinal rhinorrhea. The application of nasoseptal “rescue” flap technique canproceed sellar floor reconstruction when the diaphragma sellae rupture occurs duringthe operation. There is no obvious increase of the duration of sphenoid sinus andnasal stage and the rate of postoperative olfactory loss. This technique can be usedas a conventional technique for endoscopic transsphenoid pituitary adenomaresection.

THE PTERIONAL APPROACH IN A CASE OF PLANUM SPHENOIDALE MENINGIOMA

Meningiomas represent almost 15 percent of primary brain tumors and are the most common non-glial primary brain tumor. Parasellar meningiomas represent 5–10 percent of all intracranial meningiomas. They may arise from the diaphragma sella, tuberculum sellae, planum sphenoidale, medial lesser wing of sphenoid, anterior clinoid, clivus, and cavernous sinus (Smith 2005). Planum sphenoidale meningiomas are located anterior to and in proximity to the olfactory groove. For an optimal postoperative outcome planum, sphenoidale meningiomas must be diagnosed early, and the operative procedures performed promptly and with utmost care. Ideally, management is intended to preserve and improve vision and consists of total resection with no injury to the neighboring vital structures. We report the case of a 64-year-old woman who presented with progressive visual disturbance, impairment of visual acuity, visual field defects and diffuse headache. Gadolinium-enhanced T1-weighted MR images showed a well-defined, suprasellar solid mass, measuring 30/35/40 mm. The lesion was hyperintense on T1-weighted imaging with homogenous enhancement and a broad dural attachment to the planum sphenoidale. The planum sphenoidale meningioma was successfully resected using a left pterional approach. The intraoperative and postoperative courses were uneventful with a total recovery. Improvement of visual acuity was noted and the postoperative computer-tomography investigation showed total surgical removal with no residual tumor.

Degrees of Diaphragma Sellae Descent during Transsphenoidal Pituitary Adenoma Resection: Predictive Factors and Effect on Outcome

This study is aimed to classify degrees of diaphragma sellae (DS) descent into sella turcica according to the surgical field block caused by the descent and to construct predictive imaging criteria for the degree of descent, and in addition, to determine whether there is any correlation between the degree of DS descent and the operative outcome (in the form of cerebrospinal fluid leak and/or presence of residual tumor). Totally, 72 patients were enrolled in our study. Their clinical and radiological data as well as the high definition videos of operations were retrospectively reviewed. The degree of DS descent during the operation was classified into five degrees according to surgical field block caused by the descent. We investigated the correlation between these five degrees and the clinical findings, radiological findings as well as the surgical outcomes. We found that the most important determining factors of DS descent degree were the volume and the height of the tumor portion above diaphragma opening. On the other hand, the total tumor volume, the maximum tumor height and the morphological pattern according to Wilson's system (modified from Hardy) had no statistically significant correlation with DS degree of descent. Presence of residual tumor on postoperative magnetic resonance images was significantly correlated with Wilson's classification and with supradiaphragmatic tumor height. On the other hand, cerebrospinal fluid leak showed no statistically significant difference between variable degrees of DS descent. Volumetric data of the tumor portion above the diaphragma opening are more important than morphological data for prediction of surgical field block caused by descended DS. While DS prolapse significantly increases the difficulty of the operative procedure, residual tumor presence is mainly dependent on morphological classification, especially cavernous sinus invasion.

Prognosis of Hormonal Deficits in Empty Sella Syndrome Using Neuroimaging.

Aim:We have evaluated the anatomic measurements on sellar area of patients who were radiologically diagnosed with empty sella to determine the relation between the amount of pressure on the adenohypophysis and hormonal imbalances.Materials and Methods:Sixty-one cases were diagnosed with empty sella and had hormone tests and hypophysis magnetic resonance (MR). The cases were categorized into two groups – patients with hypophyseal hormone anomaly and patients without hormone anomaly. We have measured interclinoid distance, anteroposterior distance from the anterior diaphragm sella to the pituitary stalk, depth of the sella turcica, craniocaudal distance of the optic chiasm from the diaphragm sella, the heights of the right and left adenohypophysis, subcutaneous fat thickness measured orthogonal to the coronal suture and posteriorly at the level of C2–C3 for two groups on hypophysis and cranial MR imaging MRI.Results:Twenty-five hormone-positive cases (40.9%) (hormone test were abnormal) and 36 hormone-negative cases (59.1%) (hormone tests were normal) were included in the study. The most common hormone abnormality was thyroid-stimulating hormone, T3 and T4 deficiency in 12 cases (48%) and increase in prolactin level in 7 cases (28%). Right adenohypophysis height was 1.54 ± 0.840 mm for the 1st group, and 1.96 ± 0.83 mm for the 2nd group. The left adenohypophysis height was 1.66 ± 0.80 mm for the 1st group, and 1.94 ± 0.94 mm for the 2nd group. It was found out that the thickness at right and left side in the hormone-positive group diminished significantly.Conclusion:Adenohypophysis height and distance between stalk and optic nerve were good determiner for hormone defect.

Complications Associated With Transsphenoidal Pituitary Surgery: Review of the Literature.

Complications Associated With Transsphenoidal Pituitary Surgery: Review of the Literature.

Endoscopic extrapseudocapsular resection of pituitary adenoma using bilateral endonasal approach

Objective To explore our surgical experience and clinical outcome of endoscopic extrapseudocapsular resection of pituitary adenoma using bilateral endonasal approach. Methods A retrospective review of clinical data of 254 patients who were treated for pituitary adenoma by endoscopic surgery using bilateral endonasal approach within the time frame of January 2015-December 2016 at Department of Neurosurgery, First Affiliated Hospital of Nanchang University. The patients who experienced extrapseudocapsular resection were selected for general evaluation of surgical outcome and follow-up results. Results A total of 133 cases underwent endoscopic endonasal extrapseudocapsular resection. Among those, 124 (93.2%) cases achieved gross total resection and subtotal resection was achieved in 9 (6.8%) cases. Postoperative improvement of vision and visual field occurred in 61 (84.7%) cases and 42 (73.7%) cases achieved postoperative remission of headache. Among 62 non-functional pituitary adenomas with normal preoperative pituitary function, 42 (67.7%) cases preserved normal pituitary function after operation and the other 20 (32.3%) cases developed partial hypopituitarism. Out of 23 non-functional pituitary adenomas with preoperative partial hypopituitarism, postoperative improvement was reported in 10 (43.5%) cases, persistent hypopituitarism in 10 (43.5%) cases and aggravation in 3 (13.0%) cases. Overall, 44 (91.7%) cases showed biochemical remission in endocrine-active pituitary adenomas after operation. Intraoperative rupture of sellar diaphragm was noted in 52 (39.1%) cases, postoperative CSF (cerebrospinal fluid) leakage in 6 (4.5%) cases, and transient diabetes insipidus (DI) in 27 (20.3%) cases. No death occurred during the follow-up period. Tumor recurrence occurred in 3 (2.4%) cases during the follow-up period lasting for 23.6±7.0 months. Conclusions Endoscopic extrapseudocapsular resection of pituitary adenoma using bilateral endonasal approach could achieve high rate of gross total resection and low rate of tumor recurrence, effectively alleviate the patients’ clinical symptoms, increase surgical remission rate in endocrine-active adenomas with less complications. Key words: Pituitary neoplasms; Natural orifice endoscopic surgery; Pseudocapsular; Transsphenoidal surgery

The application of nasoseptal " rescue" flap technique in endoscopic transsphenoidal pituitary adenoma resection

Objective To explore the reliability and superiority of nasoseptal flap technique in neuroendoscopic transnasal resection of pituitary adenoma. Methods A retrospective clinical analysis was conducted about 113 cases of endoscopic transsphenoidal pituitary adenoma resection with the application of nasoseptal flap technology in Department of Neurosurgery , Qilu Hospital of Shandong University from January 2016 to March 2017. The reliability and superiority of the technique were evaluated based on the duration of nasal cavity and sphenoid sinus stage, the incidence of post-operative anosmia and cerebrospinal rhinorrhea. Results The duration of nasal and sphenoid sinus stage was 15-30 minutes, averaging 24.0±4.5 minutes. There were 27 (23.9%) cases of intraoperative cerebrospinal fluid leakage including 24 cases of low flow cerebrospinal fluid leak and 3 cases of high flow cerebrospinal fluid leak. Twenty-three cases were converted from nasoseptal flap to nasal septum flap. The patients were followed up for 3-15 months, averaging 8.0±4.3 months. There were 17 cases(15.0%) of postoperative olfactory decline or disappearance, 1 case(0.9%) of epistaxis and 1 case(0.9%) of cerebrospinal rhinorrhea. Conclusions The application of nasoseptal flap technique could facilitate sellar floor reconstruction in case of intraoperative rupture of diaphragma sellae. There seems to be no increase of the duration of sphenoid sinus and nasal stage. Key words: Pituitary neoplasms; Natural orifice endoscopic surgery; Transphenoidal; Nasoseptal rescue flap; Nasal septum flap

Early diagnosis Gorlin-Goltz syndrome: A Rare Case Report

Gorlin-Goltz syndrome, is an uncommon, autosomal dominant inherited disorder, which is characterized by numerous basal cell carcinoma (known as nevoid basal cell carcinoma syndrome (NBCCS)). The common manifestations include multiple odontogenic keratocysts in the jaws are usually one of the first manifestations of the syndrome, macrocephaly, frontal boosing, multiple basal cell nevi on the skin with an early age onset, palmar pits, bifid or splayed ribs, high arched palate, calcified diaphragm sellae.

Anatomical Considerations of the Endonasal Transsphenoidal Approach

The sellar contents are separated from the sphenoidal sinus by a tiny sheath of bone that compris es the sellar floor, making the transsphenoidal approach the most used surgical route to intrasellar lesions. The transsphenoidal approach can be initiated in three different ways: 1) cutting the mucosa over the alveolar part of maxilla (sublabial transsphenoidal), 2) cutting along the anterior nasal mucosa adjacent to the columella (transeptal transsphenoidal), and 3) cutting the mucosa over the sphenoidal rostrum (endonasal transsphenoidal). Each cavernous sinus has four dural walls. The lateral, superior and posterior walls are composed of endosteal and periosteal dura leaflets. Unlike the other dural walls, the medial wall is formed of a single, thin dural sheath, an anatomical fact that help explains the lateral expansion of a pituitary adenoma. In the center, the diaphragm sellae has an opening through which the infundibulum courses, linking the pituitary gland to the floor of the third ventricle. The morphology of this opening is quite variable among individuals. On average, the anteroposterior distance of the diaphragm opening was 7.26 mm + 1.99 mm, varying from 3.4 mm up to 10.7 mm. The lateral distance of the diaphragm opening was 7.33 mm + 2.79 mm, varying from 2.8 mm up to 14.1 mm.

Resection of a Retrochiasmatic Craniopharyngioma by Combined Modified Orbital Craniotomy and Transnasal Endoscopic Techniques.

A 20-year-old patient presented with hydrocephalus but intact vision and hormone function. The MRI showed a large seller, suprasellar and third ventricular mass. We chose a combined approach utilizing the translyvian, lamina terminals route, with a possible interhemispheric approach. But, we also utilized a transnasal endoscopic approach for the tumor that remained below the diaphragma sellae. The patient did well, with complete tumor resection via a staged approach, but did require hormone replacement. The link to the video can be found at: https://youtu.be/yzpfOxzI4cQ .

Endoscopic Endonasal Transplanum-Transtuberculum Sellae Approach for the Resection of a Diaphragma Sellae Meningioma.

The endoscopic endonasal approach (EEA) provides a direct access to diaphragma sellae meningiomas. We present a case of a 56-year-old-female with an incidentally diagnosed sellar/suprasellar lesion with no hormonal deficit; thus, she opted for conservative management initially. During her annual follow-up appointment with her ophthalmologist, it was noticed that the patient had right eye peripheral deficit on formal visual field testing. Magnetic resonance imaging (MRI) revealed an enlargement of the sellar/suprasellar mass, causing displacement of the optic chiasm. A transplanum–transtuberculum EEA was performed. Gross-total removal was achieved and closure was done in a multilayer fashion using a collagen matrix, nasoseptal flap. Histopathological examination confirmed a meningioma WHO grade I. There were no intra- or postoperative complications. At 4-year-follow-up, the patient has stable vision and MRI brain showed no recurrence. The link to the video can be found at: https://youtu.be/xY8T9hotlDs .

Rathke’s Cleft Cyst Presenting Synchronously with a Diaphragma Sellae Meningioma

Rathke’s Cleft Cyst Presenting Synchronously with a Diaphragma Sellae Meningioma

The posterior nasoseptal flap: A novel technique for closure after endoscopic transsphenoidal resection of pituitary adenomas

Background:While effective for the repair of large skull base defects, the Hadad-Bassagasteguy nasoseptal flap increases operative time and can result in a several-week period of postoperative crusting during re-mucosalization of the denuded nasal septum. Endoscopic transsphenoidal surgery for pituitary adenoma resection is generally not associated with large dural defects and high-flow cerebrospinal fluid (CSF) leaks requiring extensive reconstruction. Here, we present the posterior nasoseptal flap as a novel technique for closure of skull defects following endoscopic resection of pituitary adenomas. This flap is raised in all surgeries during the transnasal exposure using septal mucoperiosteum that would otherwise be discarded during the posterior septectomy performed in binostril approaches.Methods:We present a retrospective, consecutive case series of 43 patients undergoing endoscopic transsphenoidal resection of a pituitary adenoma followed by posterior nasoseptal flap placement and closure. Main outcome measures were extent of resection and postoperative CSF leak.Results:The mean extent of resection was 97.16 ± 1.03%. Radiographic measurement showed flap length to be adequate. While a defect in the diaphragma sellae and CSF leak were identified in 21 patients during surgery, postoperative CSF leak occurred in only one patient.Conclusions:The posterior nasoseptal flap provides adequate coverage of the surgical defect and is nearly always successful in preventing postoperative CSF leak following endoscopic transsphenoidal resection of pituitary adenomas. The flap is raised from mucoperiosteum lining the posterior nasal septum, which is otherwise resected during posterior septectomy. Because the anterior septal cartilage is not denuded, raising such flaps avoids the postoperative morbidity associated with the larger Hadad-Bassagasteguy nasoseptal flap.

Diaphragma sellae: Anatomical and surgical implication in surgery for pituitary adenomas – Highlighting contributions by Goel

Diaphragma sellae: Anatomical and surgical implication in surgery for pituitary adenomas – Highlighting contributions by Goel