Extended Transsphenoidal Approach Research Articles

Amygdalohippocampectomy via the Lateral Extended Transsphenoidal Endoscopic Approach Through the Pterygopalatine Fossa: An Anatomic Study.

The lateral extended transsphenoidal endoscopic approach (LETEA) is used to remove tumors located lateral to the cavernous segment of the internal carotid artery under direct visual control and provides access to Meckel cave, pterygopalatine fossa, medial part of the middle cranial fossa, and orbit. We describe an extended transsphenoidal approach to the amygdalohippocampectomy through the pterygopalatine fossa. The LETEA to the middle cranial fossa through the pterygopalatine fossa was studied on 3 injected human cadavers at the Burdenko Neurosurgery Institute in Moscow, Russia. LETEA and trepanation of the greater wing of the sphenoid bone allow access to the medial part of the middle cranial fossa. Medial segments of the temporal lobe (hippocampus and amygdala) and the temporal pole were removed under guidance of the 45° angled endoscope. LETEA through the pterygopalatine fossa is minimally invasive and provides direct access to the temporal pole and medial part of the temporal lobe. This approach may reduce risk of neurologic deficit and help to avoid cosmetic defects in the frontotemporal region associated with injury to temporal muscle and facial nerve injury as can occur during transcranial approaches. Disadvantages that limit application of LETEA include risk of cerebrospinal fluid leak and skills needed for manipulation in a narrow and deep surgical field with angled 30° and 45° endoscopes.

Progress and Achievements of Endoscopic Endonasal Transsphenoidal Surgery

For the past 11 years we gained a great experience in treating over 5,000 patients by endoscopic endonasal transsphenoidal approach. The majority of patients had pituitary adenomas (p.a.) (85%). The other tumors were represented by different pathologies: craniopharyngiomas (more 500 pts), chordomas, meningiomas, gliomas, cancers, arachnoid cysts etc. Use of endoscopic technique permitted us to considerably broaden indications for transsphenoidal surgery. In particular, this approach allowed removal of p.a. with a small-size sella, adenomas with different secondary nodes, p.a. with a narrow neck between their superior and basal parts, and giant pituitary tumors (over 60 mm). Introduction of endoscopic technologies into daily practice permitted to evacuate tumors via anterior extended transsphenoidal approach which earlier could be hardly accessed by a transcranial approach: suprasellar and intraventricular craniopharyngiomas, anterior scull base meningiomas, chiasmal and III ventricular gliomas and other suprasellar tumors. Lateral extended transsphenoidal approach allows safety removal tumors invading cavernous sinus (especially when medial displacement internal carotid artery)—p.a., chordomas, trigeminal and oculomotors nerves schwannomas. Via posterior extended transsphenoidal approach is available the removal clivus chordomas invading in posterior fossae, clivus meningiomas, some ventral brainstem tumors, clipping aneurism of Basilar artery. A modified method was used for a multilayer hermetic closure using auto- and allotransplant of major postoperative skull base defects and prevention of postoperative CSF leakage.

The ventral route to intracranial aneurysm: from the origin towards modern transsphenoidal surgery. An historical review and current perspective.

A review of the main studies that have explored the use of the ventral pathway for treatment of intracranial aneurysms,including the recent reported extended transsphenoidal approaches. A comprehensive literature review was performed using the PubMed database. We recovered 48 cases of cerebral aneurysms, approached via the transcervical-transclival, transoral-transclival, transfacial-transclival ventral pathways and the extended transsphenoidal route. The overall rates of complications and surgical success were evaluated and compared for both traditional ventral and transsphenoidal approaches. For traditional routes, the overall complications and surgical success rates were 74% (26/35) and 87% (13115), respectively.For extended transsphenoidal approaches were 44% (4/9) and 78% (7 /9), respectively. Our paper is a reconnaissance of what has been done via "the anterior route" and a notification of the existence of this "surgical window': Present and future of cerebral aneurysm treatment is represented by the endovascular technique. A few selected cases in specialized centers, where transsphenoidal approaches with the aid of the endoscope are routinely performed,may be treated with such techniques alone or in combination with other different procedures. Further studies in large numbers of patients will be required to validate the full benefit of this approach.

The ventral route to intracranial aneurysm: from the origin towards modern transsphenoidal surgery. An historical review and current perspective

A review of the main studies that have explored the use of the ventral pathway for treatment of intracranial aneurysms,including the recent reported extended transsphenoidal approaches. A comprehensive literature review was performed using the PubMed database. We recovered 48 cases of cerebral aneurysms, approached via the transcervical-transclival, transoral-transclival, transfacial-transclival ventral pathways and the extended transsphenoidal route. The overall rates of complications and surgical success were evaluated and compared for both traditional ventral and transsphenoidal approaches. For traditional routes, the overall complications and surgical success rates were 74% (26/35) and 87% (13115), respectively.For extended transsphenoidal approaches were 44% (4/9) and 78% (7 /9), respectively. Our paper is a reconnaissance of what has been done via "the anterior route" and a notification of the existence of this "surgical window': Present and future of cerebral aneurysm treatment is represented by the endovascular technique. A few selected cases in specialized centers, where transsphenoidal approaches with the aid of the endoscope are routinely performed,may be treated with such techniques alone or in combination with other different procedures. Further studies in large numbers of patients will be required to validate the full benefit of this approach.

Indication and Limitations of Endoscopic Extended Transsphenoidal Surgery for Craniopharyngioma

The transsphenoidal approach has been utilized in intrasellar craniopharyngioma surgeries. However, the advent of endoscopic extended transsphenoidal approach (EETSA) has expanded its indication to suprasellar craniopharyngiomas. We compared the indication and limitations of EETSA to those of uni-lateral basal interhemispheric approach (UBIHA), which presents similar indications for surgery. We analyzed 30 patients with tumors located below the foramen of Monro and the lateral boundary extending slightly beyond the internal carotid artery (UBIHA: N = 18; EETSA: N = 12). Postoperative magnetic resonance imaging (MRI) revealed gross total resection in 10 patients in the EETSA group (83.3%) and 12 in the UBIHA group (66.7%). Postoperative MRI in the EETSA group revealed residual tumor at the cavernous sinus in one patient, at the prepontine in one; in the UBIHA group, residual tumors were located in the retrochiasmatic area in two patients, infundibulum-hypothalamus in one, on the stalk in one, and in the intrasellar region in two. No intergroup differences were observed in the preservation of pituitary function and postoperative improvement of visual function. The extent of resection was better with EETSA than with UBIHA. EETSA is considered the first-line therapy because the distance between the optic chiasm and the superior border of the pituitary is large; the lateral extension does not go beyond the internal carotid artery; and the tumor does not extend inferiorly beyond the posterior clinoid process. However, in patients showing poorly developed sphenoid sinuses or pituitary stalks anterior to the tumor, surgery is difficult regardless of the selection criteria.

Extended Endonasal Solo Endoscopic Approach for the Resection of Craniopharyngiomas

Background: Extended endonasal solo endoscopic approach for the non-pituitary lesions of the sellar and suprasellar regions are not new in the field of neurosurgery. Following endoscopic surgical approach of the pituitary adenoma, endoscopic neurosurgeon is eager to develop the skill for non-pituitary sellar & suprasellar lesions. Common sellar & suprasellar lesions are pituitary adenoma, craniopharyngioma, tuberculumselle meningioma and suprasellar germinoma.
 Objective: Traditional transsphenoidal approach gives exposure to the pituitary fossa, whereas extended approach provides exposure to the optic nerve, chiasm, acom complex and basal frontal lobe ,mammillary body, mid brain and laterally to the cavernous sinuses.
 Material & method: From November 2007 to March 2012, 12 cases of done by extended endonasal solo endoscopic approach among 12 cases of craniopharyngiomas. Patient’s history, clinical findings, pre-operative and post-operative visual acuity, visual field and radiological data were collected and analyzed. All patients underwent solo endoscopic extended transsphenoidal approach with or without nasoseptal flap technique for closure. Most of the patients were given lumbar drain as a treatment for CSF leak.
 Result: All patients were of age group of 10 to 60 years. Male were 8 (66.67%), female were 4 (33.33%) in number. Gross total removals were done in 7 cases out of 12 (58.33%) craniopharyngiomas and subtotal removal done in 5 (41.67%) cases. Visual acuity and field of vision were improved in all cases of craniopharyngiomas. One case (8.33%) of craniopharyngioma had prolong period of unconsciousness probably from hypothalamic disturbance. CSF leak developed in 2 (16.67%) cases. Patients with craniopharyngioma were required thyroxin and cortisol for replacement. Permanent diabetes insipidus developed in 5 cases (41.67%). Three patients required permanent CSF diversion via a ventriculoperitoneal shunt after documentation of postoperative HCP. There was one case of chemical meningitis, and two cases confirmed bacterial infections. Craniopharyngioma can be successfully resected via a purely endoscopic, endonasal approach. Craniopharyngioma have a higher rate of perioperative hydrocephalus and postoperative CSF leak compared with other tumor types in the same area.
 Conclusion: Extended transsphenoidal approach is an excellent alternative of skull base approach for the removal of most of the craniopharyngioma.The endoscopic endonasal route provides a good exposure, especially of the sub-chiasmatic and retro-chiasmatic areas, as well as of the stalk– infundibulum axis and the third ventricle chamber. It gives better visualization, improved postoperative visual outcome for less manipulation and low complication then craniotomy. However CSF leak and diabetes insipidus is common known complications which have to be manage promptly and appropriately.
 Bangladesh Journal of Neuroscience 2013; Vol. 29 (2) : 108-114

Outcome of endoscopy-assisted microscopic extended transsphenoidal surgery for suprasellar adult craniopharyngiomas.

Craniopharyngiomas are difficult to treat. The extended transsphenoidal approach has recently been described in several small series. We describe the usefulness of microscopy-assisted angled endoscopy for visualizing vital structures such as tumor attachment or tumor invasion to the pituitary stalk to achieve confident radical tumor removal. Between 2006 and 2010, 15 patients underwent the microscopy-assisted extended transsphenoidal approach for resection of entirely suprasellar craniopharyngiomas. Fourteen patients had the transinfundibular type, and one had the transinfundibular type with extension to the third ventricle. We observed color change within the pituitary stalk by endoscopy. The pituitary stalk was cut intentionally in 10 patients because of suspected tumor invasion surrounding the stalk. Total removal was accomplished in nine patients. Pathological specimens from the pituitary stalk showed tumor invasion spreading over the surface of the pituitary stalk, shown by a discolored pituitary stalk, and this was essential for confident radical tumor removal. Even after stalk resection, postoperative diabetes insipidus was minimal when a bright signal on T1 in the posterior lobe was not observed with preoperative magnetic resonance imaging. Confident radical tumor removal is possible with the introduction of the endoscopy-assisted microscopic extended transsphenoidal approach.

Endoscopic, Endonasal Resection of Craniopharyngiomas

The endoscopic, endonasal, extended transsphenoidal approach is a minimal-access technique for managing craniopharyngiomas. Outcome measures such as return to employment and body mass index (BMI) have not been reported and are necessary for comparison with open transcranial approaches. Most prior reports of the endoscopic, endonasal approach have reported unacceptably high cerebrospinal fluid (CSF) leak rates. To assess the outcome of endoscopic, endonasal surgery in a consecutive series of craniopharyngiomas with special attention to extent of resection, CSF leak, return to employment, and BMI. Twenty-six surgeries were performed on 24 patients at Weill Cornell Medical College-New York Presbyterian Hospital. Five patients had recurrent lesions. Gross-total resection (GTR) was attempted in 21 surgeries. Indications for intended subtotal resection were advanced age, medical comorbidities, preservation of pituitary function, and hypothalamic invasion. Mean tumor diameter was 2.9 cm. GTR (18 surgeries) or near-total (>95%) resection (2 surgeries) was achieved in 95% when GTR was the goal. Seven patients received postoperative radiation therapy. Mean follow-up was 35 months with no recurrences in GTR cases and stable disease in all patients at last follow-up. Vision improved in 77%. Diabetes insipidus and panhypopituitarism developed in 42% and 38%, respectively. A more than 9% increase in BMI occurred in 39%; 69% returned to their preoperative profession/schooling. The postoperative CSF leak rate was 3.8%. Minimal-access, endoscopic, endonasal surgery for craniopharyngioma can achieve high rates of GTR with low rates of CSF leak. Return to employment and obesity rates are comparable to microscope-assisted transcranial and transsphenoidal reports.

Endoscopic management of craniopharyngiomas

Craniopharyngiomas are deep-seated anterior skull base lesions that are challenging to treat because of their location and locally aggressive behavior. In recent years, the endoscopic, endonasal technique has been developed for craniopharyngioma surgery to overcome the limitations of previously established microscope-based transcranial and transsphenoidal approaches. The endoscopic, endonasal technique provides a direct path to the tumor with panoramic visualization. Through the transsphenoidal surgical corridor, the endoscopic skull base surgeon can target the craniopharyngioma tumor located within the sella, suprasellar cistern, third ventricle, and prepontine cistern. The initial outcome data from endoscopic, endonasal case series in terms of extent of resection, vision improvement, and hypothalamic-pituitary dysfunction have been encouraging, although further follow-up of treated patients and analysis of outcomes are needed. We describe our technique for treating craniopharyngiomas via a fully endoscopic, endonasal, extended transsphenoidal approach. Craniopharyngiomas are deep-seated anterior skull base lesions that are challenging to treat because of their location and locally aggressive behavior. In recent years, the endoscopic, endonasal technique has been developed for craniopharyngioma surgery to overcome the limitations of previously established microscope-based transcranial and transsphenoidal approaches. The endoscopic, endonasal technique provides a direct path to the tumor with panoramic visualization. Through the transsphenoidal surgical corridor, the endoscopic skull base surgeon can target the craniopharyngioma tumor located within the sella, suprasellar cistern, third ventricle, and prepontine cistern. The initial outcome data from endoscopic, endonasal case series in terms of extent of resection, vision improvement, and hypothalamic-pituitary dysfunction have been encouraging, although further follow-up of treated patients and analysis of outcomes are needed. We describe our technique for treating craniopharyngiomas via a fully endoscopic, endonasal, extended transsphenoidal approach.

Pneumatization of the sphenoid sinus in Chinese: the differences from Caucasian and its application in the extended transsphenoidal approach

In recent years, the transsphenoidal approach has been extensively used surgically to treat parasellar, suprasellar, clival, and even petrous lesions. Extended pneumatization of the sphenoid sinus (SS) is considered an indispensable element for the extended transsphenoidal (ETS) approach. Because most anatomical studies of the ETS approach use Caucasian subjects, the present study aims to clarify the pneumatic extension types in Chinese individuals as well as any differences from those in Caucasians and analyze these differences with respect to the application of the ETS approach. A total of 200 computed tomography (CT) images of SSs and 18 adult cadaveric heads were selected for observation and measurement. The conchal, presellar, and sellar types comprised 6, 28.5, and 65.5% of subjects, respectively; according to the extra extension, the prevalence of the lateral, clival, lesser wing, and combined extension sinus types was 11.4, 21.4, 0.8, and 48.1% of subjects, respectively. The percentages of pneumatization of the anterior and posterior clinoid processes, pterygoid process, and optic strut were 5.0, 1.0, 22.3, and 7.0%, respectively. Onodi cells were observed in 61.1% of the sides of the cadaveric heads, including 30.6% with good pneumatization with identifiable optical or ICA bulges. These features were related to poor lateral and clival gasification in Chinese compared with Caucasians, which might make extended surgery more dangerous. However, the anterior pneumatization, especially the higher presentation of Onodi cells, ensures that the anterior ETS approach can be performed safely in Chinese patients. In general, measurements showing smaller sinus volumes and thicker bones with identifiable bone landmarks that are hard to find compared with those in Caucasians suggest increased surgical risks in the Chinese population. In this situation, carefully analysis of presurgical CT and magnetic resonance imaging scans is important. Furthermore, in the ETS approach, the use of stricter intraoperative technological devices such as neuronavigation and ultrasound Doppler is advisable.

The microscopic extended transsphenoidal approach for the treatment of clival chordomas

Objective To evaluate the application of microscopic extended transsphenoidal approach in surgery for clival chordomas. Methods Nine patients with clival chordomas were managed by microscopic extended transsphenoidal approach from August 2007 to March 2008 with the assistance of neuro-navigation. Among those, 3-D stereoscopic virtual reality images of 4 cases were reconstructed successfully,which could identify the relationship between the tumors and surrounding structures and conduced to the operations. Results Total removal was achieved in 3 cases,which was confirmed by the imaging-scopy after the operations, subtotal removal in 6 cases. Because of the invasion of the subdural space by the tumor,CSF leakage occurred in 2 cases after the tumors were removed, which was cured by the reconstruction of the cranial base with the fat tissue and albumin gel. Conclusion The microscopic extended trans spbenoidal approach is a viable, minimally invasive alternative for surgical treatment of clival tumors. By this approach, the clivus including the anterior skull base and cavernous sinus can be exposed conveniently. Key words: Transsphenoidal approach; Clival chordoma; Microsurgical operation

Outcomes following endoscopic, expanded endonasal resection of suprasellar craniopharyngiomas: a case series

Craniopharyngiomas are challenging tumors that most frequently occur in the sellar or suprasellar regions. Microscopic transsphenoidal resections with various extensions and variations have been performed with good results. The addition of the endoscope as well as the further expansion of the standard and extended transsphenoidal approaches has not been well evaluated for the treatment of this pathological entity. The authors performed a retrospective review of all patients who underwent a purely endoscopic, expanded endonasal approach (EEA) for the resection of craniopharyngiomas at their institution between June 1999 and February 2006. Endocrine and ophthalmological outcomes, extent of resection, and complications were evaluated. Sixteen patients underwent endoscopic EEA for the resection of craniopharyngiomas. Five patients (31%) presented with recurrent disease. Complete resection was planned in 11 of the 16 patients. Three elderly patients with vision loss underwent planned debulking, 1 patient with vision loss and a moderate-sized tumor had express wishes for debulking, and 1 patient had a separate, third ventricular nodule that was not resected. Of those in whom complete resection was planned, 91% underwent near-total (2/11) or gross-total (8/11) resection. No patient who underwent gross-total resection suffered a recurrence. The mean follow-up period was 34 months. Of the 14 patients who presented with vision loss, 93% had improvement or complete recovery and 1 patient's condition remained stable. No patient experienced visual worsening. Eighteen percent of patients (without preexisting hypopituitarism) developed panhypopituitarism and 8% developed permanent diabetes insipidus. There were no cases of new obesity. The postoperative cerebrospinal fluid leak rate was 58%. All leaks were resolved, and there were no cases of bacterial meningitis. There was 1 vascular injury (posterior cerebral artery perforator branch) resulting in the only new neurological deficit. No patient died. Endoscopic EEA for the resection of craniopharyngiomas provides acceptable results and holds the potential to improve outcomes.

Development of Trans-sphenoidal Surgery—A New Approach for Cavernous Sinus Tumors

Introduction: For less invasive removal of the tumors in the cavernous sinus, we have developed an extended trans-sphenoidal approach. The cranial nerves run along the lateral wall of the cavernous sinus, while there are no cranial nerves adjacent to the medial and inferior walls of the cavernous sinus. Therefore, the surgical risk of injury to these cranial nerves could be decreased via the trans-sphenoidal approach than via the conventional transcranial approach.