Conflict of interest
This study was performed at ALT-VISION at The Ohio State University. This laboratory receives educational support from the following companies: Carl Zeiss Microscopy, Intuitive Surgical Corp., KLS Martin Corp., Karl Storz Endoscopy, Leica Microsystems, Medtronic Corp., Stryker Corp., and Vycor Medical. Dr. Prevedello is a consultant for Stryker Corp., Medtronic Corp., and Integra; he has received an honorarium from Mizuho and royalties from KLS- Martin. N. London holds stock in Navigen Pharmaceuticals currently of no value and was a consultant for Cooltech Inc., both of which are unrelated to this manuscript. Ricardo L. Carrau is a consultant for Medtronic Corp.
All procedures performed in studies involving human participants were in accordance with the ethical standards of the Ohio State University Wexner Medical Center institutional research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.
Informed consent was obtained from all individual participants included in the study
A summary of 10 key points
1. SSEP and cranial nerve electromyography help assess intraoperative cranial nerve and brainstem function .
2. Intrasphenoid landmarks like LOCR, MCP, and the MOCR locating the paraclinoid and supraclinoid ICA are key landmarks .
3. Navigation using high-resolution CT-angiography fused with MR images can help avoid neurovascular injury and help concurrent evaluation of osseous, vascular, and soft tissue anatomy .
4. Bone removal overlying the carotid artery when necessary is done by drilling with 4- or 3-mm coarse diamond drills until the bone is thin enough to be elevated with the Kerrison or other dissectors.
5. Cavernous sinus bleeding can be controlled by the elevation of the head end of the table and the local application of hemostatic agents .
6. Multilayer reconstruction using collagen matrix and vascularized flap has been shown to significantly decrease the rates of postoperative CSF leak for the EEA .
7. An endonasal approach can avoid brain retraction and major neurovascular manipulation while removing lesions extending to the interpeduncular fossa or into the third ventricle .
8. The bone removal over MOCR is crucial to expose the lateral aspect of the suprasellar space where the superior hypophyseal arteries should be protected. This focal point outlining the transition between extradural (paraclinoid)–intradural (supraclinoid) segments is a prominent ICA landmark in EEA for suprasellar lesions .
9. During intradural dissections, the earliest visualization and preservation of the ophthalmic artery, pituitary infundibulum, superior hypophyseal arteries, and perforators are advocated, the latter can be achieved by avoiding bipolar coagulation and blind dissections .
10. Pre- and postoperative hormone deficits should be timely managed by the endocrinology team (diabetes insipidus and hypopituitarism) and other surgical complications carefully monitored by the ICU/neurosurgical team .