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Deng S, Morisako H, Beniwal M, Sasaki T, Ikegami M, Ikeda S, Teranishi Y, Goto T. Usefulness of Opening the Diaphragma Sellae Before Transecting Interclinoidal Ligament for Endoscopic Endonasal Transoculomotor Triangle Approach: Technical Nuances and Surgical Outcomes. World Neurosurg 2024; 185:e731-e740. [PMID: 38428812 DOI: 10.1016/j.wneu.2024.02.120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Revised: 02/20/2024] [Accepted: 02/21/2024] [Indexed: 03/03/2024]
Abstract
OBJECTIVE Opening the oculomotor triangle (OT) and removing the posterior fossa lesion by endoscopic endonasal approach (EEA) is challenging for even an experienced endoscopic neurosurgeon. We summarize the treatment experience and technical nuances with EEA for resection of pituitary neuroendocrine tumors and cavernous sinus (CS) meningiomas invading through the OT. METHODS Between 2018 and 2022, 8 patients, comprising 5 with pituitary neuroendocrine tumors (3 with nonfunctioning and 2 with somatotroph tumors with increased levels of growth hormone) and 3 CS meningiomas, were treated using an endoscopic endonasal transoculomotor triangle approach. The critical surgical technique is continuously opening the diaphragma sellae from medial to lateral toward the interclinoidal ligament and transecting it to enlarge the OT. We evaluated preoperative tumor size, previous surgical history, preoperative symptoms, extent of tumor resection, histopathology, and postoperative complications for all patients. RESULTS The gross total resection (defined as complete removal) in 3 patients (38%), near-total resection (defined as >95% removal) in 4 patients (50%), and subtotal resection (defined as ≤90% removal) in 1 patient (12%) and gross total resection of tumor invading through the OT was achieved in all patients through pure EEA. Two of 3 patients with visual deficits in nonfunctioning pituitary neuroendocrine tumors improved, and the other remained stable postoperatively. One patient showed transient oculomotor nerve palsy. The growth hormone level of the 2 patients with somatotroph tumors declined to normal. For 3 patients with CS meningiomas, cranial nerve palsy improved in 2 patients, whereas the other patient developed increased facial numbness after surgery. CONCLUSIONS The endoscopic endonasal transoculomotor triangle approach is an efficient surgical option for tumors with CS invasion and OT penetration.
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Affiliation(s)
- Shengze Deng
- Department of Neurosurgery, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan; Department of Neurosurgery, The First Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang, China
| | - Hiroki Morisako
- Department of Neurosurgery, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan.
| | - Manish Beniwal
- Department of Neurosurgery, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan; Department of Neurosurgery, National Institute of Mental Health and Neurosciences, Bengaluru, India
| | - Tsuyoshi Sasaki
- Department of Neurosurgery, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | - Masaki Ikegami
- Department of Neurosurgery, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | - Shohei Ikeda
- Department of Neurosurgery, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | - Yuichi Teranishi
- Department of Otolaryngology and Head and Neck Surgery, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | - Takeo Goto
- Department of Neurosurgery, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
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Wu X, Liang L, Wu BW, Xie SH, Wu J, Wan XC, Din H, Zhan J, Xiao LM, Tang B, Hong T. Pituitary adenoma with oculomotor cistern extension: membranous anatomy and clinical application. Acta Neurochir (Wien) 2023; 165:2985-2993. [PMID: 37672094 DOI: 10.1007/s00701-023-05784-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Accepted: 08/25/2023] [Indexed: 09/07/2023]
Abstract
BACKGROUND The anatomical basis of pituitary adenomas (PAs) with oculomotor cistern (OC) extension as a growth corridor is overlooked in the literature. In this paper, the authors use the technique of epoxy sheet plastination to study the membranous structure of the OC and validate the results by retrospective analysis of patients with OC extension. METHODS Eighteen specimens were used to study the membranous anatomy surrounding the OC using the epoxy sheet plastination technique. Thirty-four patients with OC extension were retrospectively reviewed. RESULTS The OC consisted of two thin membranous layers. The inner layer was extended by the arachnoid layer from the posterior fossa, and the lateral layer consisted of the dura mater sinking from the roof of the cavernous sinus. The oculomotor nerve is more likely to displace with a superolateral trajectory due to the weakness of the posterior dura and the relatively large space in the medial and posterior trajectories, which is consistent with the intraoperative observations. Among the anatomical factors that affect the PA by OC extension, we found that the relative position of the internal carotid artery (ICA) and posterior clinoid process may lead to the narrowing of the OC. Of 34 cases, 28 patients achieved total resection. Among 24 preoperative patients with oculomotor nerve palsy, 16 cases were relieved to varying degrees postoperatively. There was no ICA injury or severe intracranial infection found in any of the patients. CONCLUSIONS Extension into the OC is influenced by two anatomical factors: a weak point in the dura in the posterior OC and a potential space beyond this region of the dura. Meticulous knowledge of the membranous anatomy in endoscopic endonasal surgery is required to safely and effectively resect PA with OC extension.
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Affiliation(s)
- Xiao Wu
- Department of Neurosurgery, the First Affiliated Hospital of Nanchang University, 17 Yong Wai Zheng Street, Nanchang, China
| | - Liang Liang
- Department of Anatomy, Anhui Medical University, NO. 81, Meishan Road, Shushan District, Hefei, Anhui, China
| | - Bo Wen Wu
- Department of Neurosurgery, the First Affiliated Hospital of Nanchang University, 17 Yong Wai Zheng Street, Nanchang, China
| | - Shen Hao Xie
- Department of Neurosurgery, the First Affiliated Hospital of Nanchang University, 17 Yong Wai Zheng Street, Nanchang, China
| | - Jie Wu
- Department of Neurosurgery, the First Affiliated Hospital of Nanchang University, 17 Yong Wai Zheng Street, Nanchang, China
| | - Xi Chen Wan
- Department of Neurosurgery, the First Affiliated Hospital of Nanchang University, 17 Yong Wai Zheng Street, Nanchang, China
| | - Han Din
- Department of Neurosurgery, the First Affiliated Hospital of Nanchang University, 17 Yong Wai Zheng Street, Nanchang, China
| | - Jie Zhan
- Department of Radiology, the First Affiliated Hospital of Nanchang University, 17 Yong Wai Zheng Street, Nanchang, China
| | - Li Min Xiao
- Department of Neurosurgery, the First Affiliated Hospital of Nanchang University, 17 Yong Wai Zheng Street, Nanchang, China
| | - Bin Tang
- Department of Neurosurgery, the First Affiliated Hospital of Nanchang University, 17 Yong Wai Zheng Street, Nanchang, China.
| | - Tao Hong
- Department of Neurosurgery, the First Affiliated Hospital of Nanchang University, 17 Yong Wai Zheng Street, Nanchang, China.
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Masuoka J, Yoshioka F, Inoue K, Furukawa T, Ito H, Ogata A, Nakahara Y, Abe T. Pituitary adenoma presenting as isolated oculomotor nerve palsy. Surg Neurol Int 2023; 14:305. [PMID: 37810282 PMCID: PMC10559479 DOI: 10.25259/sni_421_2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 08/09/2023] [Indexed: 10/10/2023] Open
Abstract
Background Isolated oculomotor nerve palsy is a relatively uncommon symptom of pituitary adenoma that usually occurs in association with pituitary apoplexy or cavernous sinus (CS) invasion. Case Description We report two cases of relatively small pituitary adenomas with neither apoplexy nor CS invasion presenting as isolated oculomotor nerve palsy. Both patients presented with gradually worsening diplopia, without headache or visual field defects. Magnetic resonance imaging (MRI) showed a pituitary tumor with no evidence of intratumoral hemorrhage. Computed tomography revealed a lateroposterior extension of the tumor with the erosion of the posterior clinoid process. Constructive interference in steady-state MRI revealed compression of the oculomotor nerve by the tumor at the oculomotor triangle. The patients underwent endoscopic transsphenoidal surgery, and the intraoperative findings showed that the tumors did not invade the CS. The tumors were completely resected, and the oculomotor palsies resolved fully. Conclusion These cases illustrate the need to consider isolated oculomotor nerve palsy as an initial manifestation of a relatively small pituitary adenoma with neither apoplexy nor CS invasion. Based on the characteristic radiological findings, early surgical treatment is recommended to preserve oculomotor function.
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Affiliation(s)
- Jun Masuoka
- Department of Neurosurgery, Saga University, Saga, Japan
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Serioli S, Buffoli B, Maroldi R, Mattogno P, Gaudino S, Lauretti L, Rezzani R, Olivi A, Fontanella MM, Rigante M, Doglietto F. The Oculomotor Cistern and Its Role in the Management of Pituitary Lesions: An Anatomical, Radiographic, and Clinical Scoping Review. World Neurosurg 2023; 172:12-19. [PMID: 36657712 DOI: 10.1016/j.wneu.2023.01.048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2022] [Revised: 01/12/2023] [Accepted: 01/13/2023] [Indexed: 01/17/2023]
Abstract
BACKGROUND The oculomotor cistern (OMC) is a cerebrospinal fluid space bound by meningeal layers that surrounds the oculomotor nerve as it crosses the oculomotor triangle to reach the lateral wall of the cavernous sinus at the level of the anterior clinoid process. Although several anatomical and radiological studies are available, its anatomy and relationship with pituitary adenomas (PAs) are still matter of discussion. OBJECTIVE The aim of the study is to provide an updated and focused overview of the OMC, highlighting the different perspectives and descriptions from anatomical, radiological, and clinical points of view. METHODS A scoping review was conducted up to 29th October 2022, according to PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews) criteria. PubMed, Web of Science, Scopus databases, and correlated citations were investigated. RESULTS Of the 562 records identified, 22 were included in the present analysis. There were 13, 5, and 4 anatomo-surgical, radiological, and clinical studies, respectively. Though there is general consensus on its definition, data are variable on different features of OMC. Defects or absence of dural layers adjacent to the oculomotor nerve were described in only 4 papers. The transition from meningeal to neural layers is still unclear. PAs with OMC involvement are poorly studied and have unique clinical characteristics. To date, 21 patients have been described; the reported prevalence of OMC involvement by PAs ranges from 4.1% to 14.6%. CONCLUSIONS Clarifying the OMC features with further systematic studies may not only broaden theoretical knowledge but also have implications on endoscopic transnasal pituitary surgery.
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Affiliation(s)
- Simona Serioli
- Division of Neurosurgery, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, Spedali Civili of Brescia, University of Brescia, Brescia, Italy.
| | - Barbara Buffoli
- Department of Clinical and Experimental Sciences, Section of Anatomy and Physiopathology, University of Brescia, Brescia, Italy
| | - Roberto Maroldi
- Division of Radiology, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Pierpaolo Mattogno
- Institute of Neurosurgery, "A. Gemelli" Hospital Foundation IRCCS, Catholic University of the Sacred Heart, Rome, Italy
| | - Simona Gaudino
- Department of Radiological Sciences, Institute of Radiology, "A. Gemelli" Hospital Foundation IRCCS, Catholic University of the Sacred Heart, Rome, Italy
| | - Liverana Lauretti
- Institute of Neurosurgery, "A. Gemelli" Hospital Foundation IRCCS, Catholic University of the Sacred Heart, Rome, Italy
| | - Rita Rezzani
- Department of Clinical and Experimental Sciences, Section of Anatomy and Physiopathology, University of Brescia, Brescia, Italy
| | - Alessandro Olivi
- Institute of Neurosurgery, "A. Gemelli" Hospital Foundation IRCCS, Catholic University of the Sacred Heart, Rome, Italy
| | - Marco Maria Fontanella
- Division of Neurosurgery, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, Spedali Civili of Brescia, University of Brescia, Brescia, Italy
| | - Mario Rigante
- Otorhinolaryngology and Head-Neck Surgery Unit, "A. Gemelli" Hospital Foundation IRCCS, Catholic University of the Sacred Heart, Rome, Italy
| | - Francesco Doglietto
- Institute of Neurosurgery, "A. Gemelli" Hospital Foundation IRCCS, Catholic University of the Sacred Heart, Rome, Italy
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5
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Huang J, Li M, Zeng Q, Xie L, He J, Chen G, Liang J, Li M, Feng Y. Automatic oculomotor nerve identification based on
data‐driven
fiber clustering. Hum Brain Mapp 2022; 43:2164-2180. [PMID: 35092135 PMCID: PMC8996358 DOI: 10.1002/hbm.25779] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Revised: 12/09/2021] [Accepted: 12/26/2021] [Indexed: 11/10/2022] Open
Abstract
The oculomotor nerve (OCN) is the main motor nerve innervating eye muscles and can be involved in multiple flammatory, compressive, or pathologies. The diffusion magnetic resonance imaging (dMRI) tractography is now widely used to describe the trajectory of the OCN. However, the complex cranial structure leads to difficulties in fiber orientation distribution (FOD) modeling, fiber tracking, and region of interest (ROI) selection. Currently, the identification of OCN relies on expert manual operation, resulting in challenges, such as the carries high clinical, time‐consuming, and labor costs. Thus, we propose a method that can automatically identify OCN from dMRI tractography. First, we choose the multi‐shell multi‐tissue constraint spherical deconvolution (MSMT‐CSD) FOD estimation model and deterministic tractography to describe the 3D trajectory of the OCN. Then, we rely on the well‐established computational pipeline and anatomical expertise to create a data‐driven OCN tractography atlas from 40 HCP data. We identify six clusters belonging to the OCN from the atlas, including the structures of three kinds of positional relationships (pass between, pass through, and go around) with the red nuclei and two kinds of positional relationships with medial longitudinal fasciculus. Finally, we apply the proposed OCN atlas to identify the OCN automatically from 40 new HCP subjects and two patients with brainstem cavernous malformation. In terms of spatial overlap and visualization, experiment results show that the automatically and manually identified OCN fibers are consistent. Our proposed OCN atlas provides an effective tool for identifying OCN by avoiding the traditional selection strategy of ROIs.
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Affiliation(s)
- Jiahao Huang
- Institute of Information Processing and Automation, College of Information Engineering, Zhejiang University of Technology Hangzhou China
- Zhejiang Provincial United Key Laboratory of Embedded Systems Hangzhou China
| | - Mengjun Li
- Department of Radiology, Second Xiangya Hospital Central South University Hunan China
- Department of Neurosurgery Capital Medical University Xuanwu Hospital Beijing China
| | - Qingrun Zeng
- Institute of Information Processing and Automation, College of Information Engineering, Zhejiang University of Technology Hangzhou China
- Zhejiang Provincial United Key Laboratory of Embedded Systems Hangzhou China
| | - Lei Xie
- Institute of Information Processing and Automation, College of Information Engineering, Zhejiang University of Technology Hangzhou China
- Zhejiang Provincial United Key Laboratory of Embedded Systems Hangzhou China
| | - Jianzhong He
- Institute of Information Processing and Automation, College of Information Engineering, Zhejiang University of Technology Hangzhou China
- Zhejiang Provincial United Key Laboratory of Embedded Systems Hangzhou China
| | - Ge Chen
- Department of Neurosurgery Capital Medical University Xuanwu Hospital Beijing China
| | - Jiantao Liang
- Department of Neurosurgery Capital Medical University Xuanwu Hospital Beijing China
| | - Mingchu Li
- Department of Neurosurgery Capital Medical University Xuanwu Hospital Beijing China
| | - Yuanjing Feng
- Institute of Information Processing and Automation, College of Information Engineering, Zhejiang University of Technology Hangzhou China
- Zhejiang Provincial United Key Laboratory of Embedded Systems Hangzhou China
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6
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Uozumi Y, Taniguchi M, Nakai T, Kimura H, Umehara T, Kohmura E. Comparative Evaluation of 3-Dimensional High Definition and 2-Dimensional 4-K Ultra-High Definition Endoscopy Systems in Endonasal Skull Base Surgery. Oper Neurosurg (Hagerstown) 2021; 19:281-287. [PMID: 31960059 DOI: 10.1093/ons/opz426] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2019] [Accepted: 12/01/2019] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND The differences between 3-dimensional (3D) high definition (HD) and 2-dimensional (2D) 4-K ultra-HD (4K) endoscopy and their respective advantages remain unclear. OBJECTIVE To evaluate the utility of these endoscopy systems in endonasal skull base surgery. METHODS Consecutive series of endoscopic endonasal surgeries performed after introduction of 3D/HD and 2D/4K systems (July 2017) were retrospectively evaluated. Sporadic cases treated with either system, or a conventional 2D standard definition (SD) system, during the rental period from March 2016 were also included. Objective comparisons between the systems were made for newly diagnosed Knosp grade 0 to 3 pituitary adenomas. Surgical procedures were divided into nasal, sphenoidal, and intradural phases, and the surgical procedural time was compared for each phase. The time required for and accuracy of suturing the sellar floor dura was also evaluated. RESULTS A total of 74 cases were treated with 3D/HD and/or 2D/4K, and 12 cases with 2D/SD. 3D/HD was advantageous in the nasal phase because of its intuitive depth perception. 2D/4K was advantageous in the intradural phase because of its superior image quality. Surgical time of the nasal phase with 3D/HD, and that of the intradural phase with 2D/4K, were significantly shorter than that with 2D/SD. The time required for and accuracy of sellar floor dural suturing showed a trend toward improving in the order of 2D/SD, 2D/4K, and 3D/HD. CONCLUSION 3D/HD and 2D/4K endoscopy systems have different advantages, which are useful in distinct surgical phases. Understanding the characteristics of endoscopy systems is important for selecting the most appropriate system for distinct surgical situations.
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Affiliation(s)
- Yoichi Uozumi
- Department of Neurosurgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Masaaki Taniguchi
- Department of Neurosurgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Tomoaki Nakai
- Department of Neurosurgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Hidehito Kimura
- Department of Neurosurgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Toru Umehara
- Department of Neurosurgery, Kobe University Graduate School of Medicine, Kobe, Japan.,Department of Neurosurgery, Osaka University Graduate School of Medicine, Suita, Japan
| | - Eiji Kohmura
- Department of Neurosurgery, Kobe University Graduate School of Medicine, Kobe, Japan
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7
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Umehara T, Taniguchi M, Akutsu N, Kimura H, Uozumi Y, Nakai T, Kishima H, Kohmura E. Anatomical variation of the internal carotid artery and its implication to the endoscopic endonasal translacerum approach. Head Neck 2021; 43:1535-1544. [PMID: 33502813 DOI: 10.1002/hed.26618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Revised: 10/09/2020] [Accepted: 01/14/2021] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND The endoscopic endonasal trans-lacerum approach (EETLA) is useful in handling skull base tumors around inferior petrous apex (IPA); however, its surgical corridor is exclusively a triangular space (supra-eustachian triangle [SET]), between the internal carotid artery (ICA) and eustachian tube. METHODS We investigated correlation between SET size and extent of resection around the IPA (lateral extent of resection [EOR]) through a retrospective analysis of 15 surgeries using EETLA. RESULTS Of 15 cases (9 chordomas, 4 chondrosarcomas, and 2 meningiomas), 20 sides of IPA were affected by the tumor. When being restricted to sides with severe lateral tumor extension beyond the midpoint of petrous ICA (10 sides), the SET size was significantly broader in the group with lateral EOR of ≥90% (p value = 0.019). CONCLUSIONS The SET size was a powerful index of tumor resectability in EETLA, especially in cases with severe tumor extension. The individual anatomical variations should be considered when determining EETLA application.
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Affiliation(s)
- Toru Umehara
- Department of Neurosurgery, Kobe University Graduate School of Medicine, Kobe, Hyogo, Japan.,Department of Neurosurgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Masaaki Taniguchi
- Department of Neurosurgery, Kobe University Graduate School of Medicine, Kobe, Hyogo, Japan
| | - Nobuyuki Akutsu
- Department of Neurosurgery, Hyogo Prefectural Kobe Children's Hospital, Kobe, Hyogo, Japan
| | - Hidehito Kimura
- Department of Neurosurgery, Kobe University Graduate School of Medicine, Kobe, Hyogo, Japan
| | - Yoichi Uozumi
- Department of Neurosurgery, Kobe University Graduate School of Medicine, Kobe, Hyogo, Japan
| | - Tomoaki Nakai
- Department of Neurosurgery, Kobe University Graduate School of Medicine, Kobe, Hyogo, Japan
| | - Haruhiko Kishima
- Department of Neurosurgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Eiji Kohmura
- Department of Neurosurgery, Kobe University Graduate School of Medicine, Kobe, Hyogo, Japan
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8
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Martinez-Perez R, Hardesty DA, Silveira-Bertazzo G, Carrau RL, Prevedello DM. Bony landmarks in the endoscopic endonasal transoculomotor approach. Neurosurg Rev 2021; 44:2717-2725. [PMID: 33389345 DOI: 10.1007/s10143-020-01458-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2020] [Revised: 10/30/2020] [Accepted: 12/08/2020] [Indexed: 10/22/2022]
Abstract
The endoscopic endonasal transoculomotor approach (EETA) has been recently described as a doorway to access the parapeduncular space and treat pituitary adenomas with oculomotor extension. Intraoperative identification of the oculomotor triangle endonasally is challenging and dissection can put the internal carotid artery (ICA) at risk. The aim of the present study is to find reliable landmarks that identify the oculomotor triangle (OCMT) during the EETA and protect the ICA from injury. Several lines were defined for calculations. Among them, one oblique line that extends from the inferior margin of the lateral orbital canal recess to the vidian canal was named the clinoid-to-vidian line (CVL), while a vertical line that extends over the most medial point of the paraclival ICA was titled the sagittal paraclival line (SPL). Anatomic relationships between the OCMT to these lines were assessed in 7 cadaveric heads. The intersecting point between the CVL and SPL is located within 2 mm of the center of the OCMT (mean 0.8 ± 0.5 mm), and 1.1 ± 0.8 mm medially and above the parasellar ICA. CVL and SPL are reliable landmarks during the EETA that can both protect the parasellar ICA and anatomically orientate to the blind spot that corresponds with the OCMT. We recommend starting dissection medial and superior to the CVL-SPL intersecting point, and carry the dissection laterally thereafter to avoid inadvertent injury of the ICA.
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Affiliation(s)
- Rafael Martinez-Perez
- Department of Neurological Surgery, University of Colorado, 12631 E 17th Ave, Aurora, CO, USA.
| | - Douglas A Hardesty
- Department of Neurological Surgery, The Ohio State University, Columbus, OH, 80045, USA.,Head and Neck Surgery, The Ohio State University Wexner Medical Center, 410 W. 10th Ave., N-1049 Doan Hall, Columbus, OH, 43210, USA
| | | | - Ricardo L Carrau
- Department of Neurological Surgery, The Ohio State University, Columbus, OH, 80045, USA.,Head and Neck Surgery, The Ohio State University Wexner Medical Center, 410 W. 10th Ave., N-1049 Doan Hall, Columbus, OH, 43210, USA
| | - Daniel M Prevedello
- Department of Neurological Surgery, The Ohio State University, Columbus, OH, 80045, USA. .,Head and Neck Surgery, The Ohio State University Wexner Medical Center, 410 W. 10th Ave., N-1049 Doan Hall, Columbus, OH, 43210, USA.
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9
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Serioli S, Doglietto F, Fiorindi A, Biroli A, Mattavelli D, Buffoli B, Ferrari M, Cornali C, Rodella L, Maroldi R, Gasparotti R, Nicolai P, Fontanella MM, Poliani PL. Pituitary Adenomas and Invasiveness from Anatomo-Surgical, Radiological, and Histological Perspectives: A Systematic Literature Review. Cancers (Basel) 2019; 11:E1936. [PMID: 31817110 PMCID: PMC6966643 DOI: 10.3390/cancers11121936] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Revised: 11/27/2019] [Accepted: 11/28/2019] [Indexed: 12/20/2022] Open
Abstract
Invasiveness in pituitary adenomas has been defined and investigated from multiple perspectives, with varying results when its predictive value is considered. A systematic literature review, following PRISMA guidelines, was performed, searching PubMed and Scopus databases with terms that included molecular markers, histological, radiological, anatomical and surgical data on invasiveness of pituitary adenomas. The results showed that differing views are still present for anatomical aspects of the sellar region that are relevant to the concept of invasiveness; radiological and histological diagnoses are still limited, but might improve in the future, especially if they are related to surgical findings, which have become more accurate thanks to the introduction of the endoscope. The aim is to achieve a correct distinction between truly invasive pituitary adenomas from those that, in contrast, present with extension in the parasellar area through natural pathways. At present, diagnosis of invasiveness should be based on a comprehensive analysis of radiological, intra-operative and histological findings.
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Affiliation(s)
- Simona Serioli
- Neurosurgery, Department of Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, 25123 Brescia, Italy; (S.S.); (A.F.); (A.B.); (C.C.); (M.M.F.)
| | - Francesco Doglietto
- Neurosurgery, Department of Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, 25123 Brescia, Italy; (S.S.); (A.F.); (A.B.); (C.C.); (M.M.F.)
- Neurosurgery, Spedali Civili Hospital, 25123 Brescia, Italy
| | - Alessandro Fiorindi
- Neurosurgery, Department of Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, 25123 Brescia, Italy; (S.S.); (A.F.); (A.B.); (C.C.); (M.M.F.)
| | - Antonio Biroli
- Neurosurgery, Department of Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, 25123 Brescia, Italy; (S.S.); (A.F.); (A.B.); (C.C.); (M.M.F.)
| | - Davide Mattavelli
- Otorhinolaryngology–Head and Neck Surgery, Department of Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, 25123 Brescia, Italy; (D.M.); (M.F.); (P.N.)
| | - Barbara Buffoli
- Section of Anatomy and Physiopathology, Department of Clinical and Experimental Sciences, University of Brescia, 25123 Brescia, Italy; (B.B.); (L.R.)
| | - Marco Ferrari
- Otorhinolaryngology–Head and Neck Surgery, Department of Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, 25123 Brescia, Italy; (D.M.); (M.F.); (P.N.)
| | - Claudio Cornali
- Neurosurgery, Department of Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, 25123 Brescia, Italy; (S.S.); (A.F.); (A.B.); (C.C.); (M.M.F.)
- Neurosurgery, Spedali Civili Hospital, 25123 Brescia, Italy
| | - Luigi Rodella
- Section of Anatomy and Physiopathology, Department of Clinical and Experimental Sciences, University of Brescia, 25123 Brescia, Italy; (B.B.); (L.R.)
| | - Roberto Maroldi
- Radiology, Department of Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, 25123 Brescia, Italy;
| | - Roberto Gasparotti
- Neuroradiology, Department of Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, 25123 Brescia, Italy;
| | - Piero Nicolai
- Otorhinolaryngology–Head and Neck Surgery, Department of Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, 25123 Brescia, Italy; (D.M.); (M.F.); (P.N.)
| | - Marco Maria Fontanella
- Neurosurgery, Department of Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, 25123 Brescia, Italy; (S.S.); (A.F.); (A.B.); (C.C.); (M.M.F.)
- Neurosurgery, Spedali Civili Hospital, 25123 Brescia, Italy
| | - Pietro Luigi Poliani
- Section of Pathology, Department of Molecular and Translational Medicine, University of Brescia, 25123 Brescia, Italy
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10
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Ikemura R, Tsutsumi S, Nonaka S, Okura H, Suzuki T, Ishii H. Intermittent oculomotor nerve paresis and hollow appearance on MRI manifested by pituitary adenoma. Radiol Case Rep 2019; 14:1368-1371. [PMID: 31528242 PMCID: PMC6742961 DOI: 10.1016/j.radcr.2019.08.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Revised: 08/16/2019] [Accepted: 08/22/2019] [Indexed: 11/17/2022] Open
Abstract
A 71-year-old man had sustained intermittent ptosis and double vision for 2 weeks. Neurological examination found unilateral oculomotor nerve (CN III) paresis manifesting as limitations of gaze, ptosis, and mydriasis. Neither headache nor any other cranial neuropathy was noted. Cerebral magnetic resonance imaging revealed a well-circumscribed mass in the pituitary fossa extending laterally into the left cavernous sinus. The segment of the left CN III lying in the oculomotor cistern was considerably compressed by the tumor. The cisternal segments of the left CN III showed an undescribed, “hollow” appearance. The left orbit and brainstem were intact. The patient underwent tumor resection via an endoscopic transsphenoidal approach. The tumor tissue was soft in consistency, involving xanthochromic fluid. The pathological diagnosis was pituitary adenoma accompanied with considerable hemorrhagic changes. The patent's ptosis and limitations of gaze showed remarkable improvements on postoperative day 1, with resolution of the hollow appearance of the affected CN III that was confirmed on day 3. We assumed that the intralesional bleeds and lateral tumor extension into the oculomotor cistern were associated with the intermittent paresis of the CN III as the sole presentation. A hollow appearance identified in the CN III might indicate a reversible dysfunction of the nerve that can anticipate an improvement by prompt surgical intervention.
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Affiliation(s)
- Ryogo Ikemura
- Department of Neurological Surgery, Juntendo University Urayasu Hospital, 2-1-1 Tomioka, Urayasu, Chiba 279-0021, Japan
| | - Satoshi Tsutsumi
- Department of Neurological Surgery, Juntendo University Urayasu Hospital, 2-1-1 Tomioka, Urayasu, Chiba 279-0021, Japan
| | - Senshu Nonaka
- Department of Neurological Surgery, Juntendo University Urayasu Hospital, 2-1-1 Tomioka, Urayasu, Chiba 279-0021, Japan
| | - Hidehiro Okura
- Department of Neurological Surgery, Juntendo University Urayasu Hospital, 2-1-1 Tomioka, Urayasu, Chiba 279-0021, Japan
| | - Takamoto Suzuki
- Department of Neurological Surgery, Juntendo University Urayasu Hospital, 2-1-1 Tomioka, Urayasu, Chiba 279-0021, Japan
| | - Hisato Ishii
- Department of Neurological Surgery, Juntendo University Urayasu Hospital, 2-1-1 Tomioka, Urayasu, Chiba 279-0021, Japan
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11
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Tosaka M, Shimizu T, Yoshimoto Y. Reply to letter "Pituitary tumors and oculomotor cistern". Acta Neurochir (Wien) 2019; 161:1707-1708. [PMID: 31154521 DOI: 10.1007/s00701-019-03963-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Revised: 05/21/2019] [Accepted: 05/24/2019] [Indexed: 11/28/2022]
Affiliation(s)
- Masahiko Tosaka
- Department of Neurosurgery, Gunma University Graduate School of Medicine, 3-39-22 Showa-machi, Maebashi, Gunma, 371-8511, Japan.
| | - Tatsuya Shimizu
- Department of Neurosurgery, Gunma University Graduate School of Medicine, 3-39-22 Showa-machi, Maebashi, Gunma, 371-8511, Japan
| | - Yuhei Yoshimoto
- Department of Neurosurgery, Gunma University Graduate School of Medicine, 3-39-22 Showa-machi, Maebashi, Gunma, 371-8511, Japan
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12
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Tosaka M, Shimizu T, Miyagishima T, Tanaka Y, Osawa T, Aihara M, Yamaguchi R, Yoshimoto Y. Combined supra-infrasellar approach to pituitary macroadenoma with oculomotor cistern extension: surgical strategy and experience. Acta Neurochir (Wien) 2019; 161:1025-1031. [PMID: 30863890 DOI: 10.1007/s00701-019-03869-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2018] [Accepted: 03/03/2019] [Indexed: 11/25/2022]
Abstract
BACKGROUND Oculomotor cistern extension (OMCE) of pituitary adenoma through the oculomotor triangle may be one of the major characteristics of multi-lobulated adenoma. The OMCE may be hard to remove only through the endonasal approach. METHOD We applied the simultaneous combined supra-infrasellar approach to remove pituitary adenoma with relatively large OMCE. Four (7.3%) of 55 consecutive patients with initially operated pituitary macroadenoma (> 10 mm) had OMCE. The combined supra-infrasellar approach was adopted in two cases with relatively large OMCE. RESULTS The simultaneous combined supra-infrasellar approach was performed with the transcranial microscopic transsylvian anterior temporal approach and the nasal endoscopic approach. The medial main mass was removed through the nasal side. The lateral OMCE was also removed through the nasal side by pushing the tumor in the sellar direction from the transcranial side. The oculomotor nerve was confirmed with electrical nerve stimulation. The main medial mass and the OMCE were mostly removed in both cases. Remnant tumor in the cavernous sinus was treated by gamma knife radiosurgery. Endoscopic transsphenoidal removal was performed in the other two cases with relatively small OMCE. CONCLUSIONS Pituitary macroadenomas with OMCE are a newly recognized form of progression with important implications for surgical strategy. The combined supra-infrasellar approach performed with the transcranial microscopic transsylvian anterior temporal approach using electrical nerve stimulation and the nasal endoscopic approach may be useful for this type of multi-lobulated pituitary adenoma.
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Affiliation(s)
- Masahiko Tosaka
- Department of Neurosurgery, Gunma University Graduate School of Medicine, 3-39-22 Showa-machi, Maebashi, Gunma, 371-8511, Japan.
| | - Tatsuya Shimizu
- Department of Neurosurgery, Gunma University Graduate School of Medicine, 3-39-22 Showa-machi, Maebashi, Gunma, 371-8511, Japan
| | - Takaaki Miyagishima
- Department of Neurosurgery, Gunma University Graduate School of Medicine, 3-39-22 Showa-machi, Maebashi, Gunma, 371-8511, Japan
| | - Yukitaka Tanaka
- Department of Neurosurgery, Gunma University Graduate School of Medicine, 3-39-22 Showa-machi, Maebashi, Gunma, 371-8511, Japan
| | - Tadashi Osawa
- Department of Neurosurgery, Gunma University Graduate School of Medicine, 3-39-22 Showa-machi, Maebashi, Gunma, 371-8511, Japan
| | - Masanori Aihara
- Department of Neurosurgery, Gunma University Graduate School of Medicine, 3-39-22 Showa-machi, Maebashi, Gunma, 371-8511, Japan
| | - Rei Yamaguchi
- Department of Neurosurgery, Gunma University Graduate School of Medicine, 3-39-22 Showa-machi, Maebashi, Gunma, 371-8511, Japan
| | - Yuhei Yoshimoto
- Department of Neurosurgery, Gunma University Graduate School of Medicine, 3-39-22 Showa-machi, Maebashi, Gunma, 371-8511, Japan
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