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Expanded endoscopic endonasal approach for extending suprasellar and third ventricular lesions

Abstract

Background

Expanded endonasal approaches can provide direct access to the midline skull base from the anterior cranial fossa to the ventral foramen magnum. Surgical strategies of bone drilling, dural opening, and intradural dissection can determine the area of surgical exposure and instrument handling, affecting the safety of devascularizing/debulking suprasellar tumors.

Methods

We describe an expanded endoscopic endonasal approach for suprasellar lesions, with stepwise image-guided dissections highlighting surgical pearls and pitfalls to enhance surgical safety. This article presents transnasal intra-third-ventricular anatomy from trans-tuber cinereum, and trans-lamina terminalis approaches, comparing subchiasmatic and suprachiasmatic trajectories.

Conclusion

The rostral extension via endoscopic endonasal transsellar-transtubercular-transplanum approaches can provide a safe and feasible route for suprasellar lesions, in subchiasmatic, suprachiasmatic, and intraventricular regions.

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Abbreviations

EEEa:

Expanded endoscopic endonasal approaches

ICA:

Internal carotid artery

CR:

Clival recess

LOCR:

Lateral opticocarotid recess

MOCR:

Medial opticocarotid recess

MCP:

Middle clinoid process

LTR:

Lateral tubercular recess

LTC:

Lateral tubercular crest

DOA:

Distal osseous arch of the carotid sulcus

IGS:

Image guidance system

SSEP:

Somato-sensory evoked potential

SICS:

Superior intercavernous sinus

References

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Acknowledgments

We thank Andrei Koerbel MD and Leonardo Schmidt Bertazzo Silveira, MD (Department of Neurological Surgery, University of Joinville, SC, BR), Nyall R. London Jr, MD (Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland, USA) and Ruichun Li (Department of Neurological Surgery, the first affiliated hospital of Xi’an Jiaotong University, China) for their contribution to this project.

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Authors and Affiliations

Authors

Corresponding author

Correspondence to Daniel M. Prevedello.

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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.

Ethical approval

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

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 [5].

2. Intrasphenoid landmarks like LOCR, MCP, and the MOCR locating the paraclinoid and supraclinoid ICA are key landmarks [9].

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].

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 [2].

6. Multilayer reconstruction using collagen matrix and vascularized flap has been shown to significantly decrease the rates of postoperative CSF leak for the EEA [1].

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 [4].

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 [5].

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 [4].

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 [2].

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Silveira-Bertazzo, G., Manjila, S., Carrau, R.L. et al. Expanded endoscopic endonasal approach for extending suprasellar and third ventricular lesions. Acta Neurochir 162, 2403–2408 (2020). https://doi.org/10.1007/s00701-020-04368-9

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Keywords

  • Cranial base
  • Endonasal
  • Endoscopic
  • Suprasellar
  • Third ventricle
  • Transtuberculum
  • Transplanum