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Pailler JI, Villalonga JF, Ries-Centeno T, Saenz A, Baldoncini M, Pipolo DO, Cárdenas Ruiz-Valdepeñas E, Kaen A, Hirtler L, Roytowski D, Solari D, Cervio A, Campero A. Clinical Applicability of the Sellar Barrier Concept in Patients with Pituitary Apoplexy: Is It Possible? LIFE (BASEL, SWITZERLAND) 2023; 13:life13010158. [PMID: 36676107 PMCID: PMC9861876 DOI: 10.3390/life13010158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Revised: 12/30/2022] [Accepted: 01/03/2023] [Indexed: 01/06/2023]
Abstract
There is evidence of association between sellar barrier thickness and intraoperative cerebrospinal fluid (CSF) leakage, impacting the postoperative prognosis of the patients. The aim of this study is to analyze the clinical applicability of the sellar barrier concept in a series of operated patients with pituitary apoplexy (PA). A retrospective study was conducted including 47 patients diagnosed with PA who underwent surgical treatment through a transsphenoidal approach. Brain magnetic resonance imaging (MRI) of the patients were evaluated and classified utilizing the following criteria: strong barrier (greater than 1 mm), weak barrier (less than 1 mm), and mixed barrier (less than 1 mm in one area and greater than 1 mm in another). The association between sellar barrier types and CSF leakage was analyzed, both pre- and intraoperatively. The preoperative MRI classification identified 10 (21.28%) patients presenting a weak sellar barrier, 20 patients (42.55%) with a mixed sellar barrier, and 17 patients (36.17%) exhibiting a strong sellar barrier. Preoperative weak and strong sellar barrier subtypes were associated with weak (p ≤ 0.001) and strong (p = 0.009) intraoperative sellar barriers, respectively. Strong intraoperative sellar barrier subtypes reduced the odds of CSF leakage by 86% (p = 0.01). A correlation between preoperative imaging and intraoperative findings in the setting of pituitary apoplexy has been observed.
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Affiliation(s)
- José Ignacio Pailler
- LINT, Facultad de Medicina, Universidad Nacional de Tucumán, San Miguel de Tucumán 4000, Argentina
| | - Juan Francisco Villalonga
- LINT, Facultad de Medicina, Universidad Nacional de Tucumán, San Miguel de Tucumán 4000, Argentina
- Correspondence:
| | | | - Amparo Saenz
- LINT, Facultad de Medicina, Universidad Nacional de Tucumán, San Miguel de Tucumán 4000, Argentina
| | - Matías Baldoncini
- LINT, Facultad de Medicina, Universidad Nacional de Tucumán, San Miguel de Tucumán 4000, Argentina
| | - Derek Orlando Pipolo
- LINT, Facultad de Medicina, Universidad Nacional de Tucumán, San Miguel de Tucumán 4000, Argentina
| | | | - Ariel Kaen
- Hospital Virgen del Rocío, 41013 Sevilla, Spain
| | - Lena Hirtler
- Endoscopic Laboratory of Anatomy Center, Medical University of Vienna, 1090 Vienna, Austria
| | - David Roytowski
- Department of Neurosurgery, University of Cape Town, Cape Town 7701, South Africa
| | - Domenico Solari
- Division of Neurosurgery, Department of Neurosciences, Reproductive and Odontostomatological Sciences, Universita’ degli Studi di Napoli Federico II, 80131 Naples, Italy
| | - Andrés Cervio
- Departamento de Neurocirugía, FLENI, Buenos Aires 1625, Argentina
| | - Alvaro Campero
- LINT, Facultad de Medicina, Universidad Nacional de Tucumán, San Miguel de Tucumán 4000, Argentina
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Villalonga JF, Solari D, Cavallo LM, Cappabianca P, Prevedello DM, Carrau R, Martinez-Perez R, Hardesty D, Fuchssteiner C, Saenz A, Abbritti RV, Valencia-Ramos C, Kaen A, Bernat AL, Cardenas E, Hirtler L, Gomez-Amador JL, Liu J, Froelich S, Cervio A, Campero A. The sellar barrier on preoperative imaging predicts intraoperative cerebrospinal fluid leak: a prospective multicenter cohort study. Pituitary 2021; 24:27-37. [PMID: 32918661 DOI: 10.1007/s11102-020-01082-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/05/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND The type of sellar barrier observed between a pituitary tumor and cerebrospinal fluid (CSF) on preoperative magnetic resonance imaging (MRI) may predict intraoperative CSF leak during endonasal pituitary surgery. This is the first multicentric prospective cohort trial to study the sellar barrier concept and CSF leak rate during endoscopic pituitary surgery. METHODS This multi-center, international study enrolled patients operated for pituitary adenomas via fully endoscopic endonasal surgery over a period of 4 months. The independent variable was the subtype of sellar barrier observed on preoperative MRI (strong, mixed or weak); the dependent variable was the presence of an intraoperative CSF leak. The primary goal was to determine the association between a particular type of sellar barrier and the risk of intraoperative CSF leak. Appropriate statistical methods were then applied for data analysis. RESULTS Over the study period, 310 patients underwent endoscopic endonasal surgery for pituitary tumor. Preoperative imaging revealed a weak sellar barrier in 73 (23.55%), a mixed sellar barrier in 75 (24.19%), and a strong sellar barrier in 162 (52.26%) patients. The overall rate of intraoperative CSF leak among all patients was 69 (22.26%). A strong sellar-type barrier was associated with significantly reduced rate of intraoperative CSF leak (RR = 0.08; 95% CI 0.03-0.19; p < 0.0001), while a weak sellar barrier associated with higher rates of CSF leak (RR = 8.54; 95% CI 5.4-13.5; p < 0.0001). CONCLUSIONS The preoperative MRI of pituitary patients can suggest intraoperative CSF leak rates, utilizing the concept of the sellar barrier. Patients with a weak sellar barrier carry a higher risk for an intraoperative CSF leak, whereas a strong sellar barrier on MRI seems to mitigate intraoperative CSF leak. We propose that preoperatively assessment of the sellar barrier can prepare surgeons for intraoperative CSF leak repair.
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Affiliation(s)
- Juan F Villalonga
- LINT, Facultad de Medicina, Universidad Nacional de Tucumán, Lamadrid 875, San Miguel de Tucumán, Tucumán, Argentina.
| | - Domenico Solari
- Division of Neurosurgery, Department of Neurosciences, Reproductive and Odontostomatological Sciences, Università degli Studi di Napoli Federico II, Naples, Italy
| | - Luigi M Cavallo
- Division of Neurosurgery, Department of Neurosciences, Reproductive and Odontostomatological Sciences, Università degli Studi di Napoli Federico II, Naples, Italy
| | - Paolo Cappabianca
- Division of Neurosurgery, Department of Neurosciences, Reproductive and Odontostomatological Sciences, Università degli Studi di Napoli Federico II, Naples, Italy
| | - Daniel M Prevedello
- Department of Neurological Surgery, Wexner Medical Center, The Ohio State University, Columbus, OH, USA
| | - Ricardo Carrau
- Department of Neurological Surgery, Wexner Medical Center, The Ohio State University, Columbus, OH, USA
| | - Rafael Martinez-Perez
- Department of Neurological Surgery, Wexner Medical Center, The Ohio State University, Columbus, OH, USA
| | - Douglas Hardesty
- Department of Neurological Surgery, Wexner Medical Center, The Ohio State University, Columbus, OH, USA
| | - Christoph Fuchssteiner
- Division of Anatomy, Center for Anatomy and Cell Biology, Medical University of Vienna, Vienna, Austria
| | - Amparo Saenz
- LINT, Facultad de Medicina, Universidad Nacional de Tucumán, Lamadrid 875, San Miguel de Tucumán, Tucumán, Argentina
| | | | | | - Ariel Kaen
- Hospital Virgen del Rocío, Sevilla, Spain
| | - Anne-Laure Bernat
- Lariboisière University Hospital - Assistance Publique, Paris, France
| | | | - Lena Hirtler
- Division of Anatomy, Center for Anatomy and Cell Biology, Medical University of Vienna, Vienna, Austria
| | | | - James Liu
- Rutgers New Jersey Medical School, Newark, NY, USA
| | | | | | - Alvaro Campero
- LINT, Facultad de Medicina, Universidad Nacional de Tucumán, Lamadrid 875, San Miguel de Tucumán, Tucumán, Argentina
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Gutierrez WR, Bennion DM, Walsh JE, Owen SR. Vascular pedicled flaps for skull base defect reconstruction. Laryngoscope Investig Otolaryngol 2020; 5:1029-1038. [PMID: 33364390 PMCID: PMC7752068 DOI: 10.1002/lio2.471] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Accepted: 09/28/2020] [Indexed: 01/18/2023] Open
Abstract
OBJECTIVE Techniques for reconstruction of skull base defects have advanced greatly since the introduction of the vascular pedicled nasoseptal flap in 2006. The objective of this review is to assess the current state of the field by examining both intranasal and extranasal techniques of vascular pedicled skull base defect repair, their indications and success rates, and novel techniques that are currently under investigation. METHODS A review of the literature describing the use of vascular pedicled flaps in skull base defect reconstruction was conducted using PubMed and Google Scholar. RESULTS The nasoseptal flap remains the most widely used vascular pedicled flap for endoscopic repair of skull base defects. Its ease of harvest, wide arch of rotation, and high success rates make it a popular choice among surgeons. Several variations including a "rescue" nasopseptal flap have been developed. Other less commonly used pedicled intranasal flaps include the middle turbinate flap and the posterior pedicled inferior turbinate flap. Additionally, several novel vascular pedicled flaps have been developed and tested in small cohorts of patients. Extranasal flaps such as the pericranial flap and the temporoparietal fascia flap are used less frequently than intranasal flaps. However, they remain valuable options for reconstruction in certain situations. CONCLUSION Advancements continue to be made in the field of skull base defect reconstruction using vascular pedicled flaps. Though the nasoseptal flap remains the most widely utilized option, additional intranasal techniques continue to be developed and tested to optimize surgical outcomes and patient care. LEVEL OF EVIDENCE NA.
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Affiliation(s)
- Wade R. Gutierrez
- Medical Scientist Training ProgramUniversity of Iowa Carver College of MedicineIowa CityIowaUSA
| | - Douglas M. Bennion
- Department of Otolaryngology–Head and Neck SurgeryUniversity of Iowa Hospitals and ClinicsIowa CityIowaUSA
| | - Jarrett E. Walsh
- Department of Otolaryngology–Head and Neck SurgeryUniversity of Iowa Hospitals and ClinicsIowa CityIowaUSA
| | - Scott R. Owen
- Department of Otolaryngology–Head and Neck SurgeryUniversity of Iowa Hospitals and ClinicsIowa CityIowaUSA
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