Endoscopic Orientation of Juxta-pituitary Carotid in Transsphenoidal Approaches: Critical Considerations for Clinical Applications

Abstract Introduction In sphenoid sinuses with ill-defined carotid bony landmarks, accidental injury of the internal carotid artery (ICA) remains one of the most challenging complications, which is particularly reported in the endoscopic endonasal transsphenoidal approaches (EETAs). Objectives To describe an anatomical model for the endoscopic orientation of the juxta-pituitary segment of the ICA in relation to the lateral opticocarotid recess (OCR) as a nearby bony landmark. Methods Dissection was performed progressively, simulating the EETA, in twenty fresh adult cadavers. After reducing the posterior and lateral walls of the sphenoid sinuses, various measurements were taken from both lateral OCRs to "contact points" on the juxta-pituitary segment of the ICA and lateral margins of the pituitary gland. Results The current results have enabled us to divide the region between the lateral OCRs into 3 compartments: 2 lateral parasellar compartments contain juxta-pituitary segments of the ICA with a mean width of 8 mm and a narrow range from 7 mm to 10 mm; and a central intercarotid sellar compartment represents the safe region for bone drilling, showing widely variable widths ranging from 9 mm to 20 mm. In all specimens, the variation in the width of the intercarotid compartment correlated with the distance between both lateral OCRs. Conclusion The present study improves surgeon awareness of the variations in the course of the ICA through the EETA along sphenoid sinuses with ill-defined bony landmarks. An appreciation of the measurements taken in the present study can help in operative training, and can also provide a base for future studies to confirm ICA courses associated with a higher risk of injury.

Current status of diagnosis and management of postoperative complications after endoscopic endonasal transsphenoidal approach to pituitary adenoma removal / 中国综合临床

Pituitary adenoma is one of the most common intracranial tumors, and most of them can be well removed by endoscopic transsphenoidal surgery. Pituitary adenoma is located in the sella, which can compress the pituitary and optic nerve, invade the sphenoid sinus and cavernous sinus, invade and grow in all directions, and affect the endocrine function at the same time. Endoscopic transsphenoidal pituitary adenoma resection (EETS) has the advantages of minimally invasive, close observation, panoramic view, high tumor resection rate and high preservation rate of normal pituitary function, but it can cause pituitary endocrine disorder, diabetes insipidus, electrolyte disorder, cerebrospinal fluid leakage, intracranial infection, cerebral nerve paralysis, tumor cavity, intracranial hemorrhage, rhinitis and other related complications. It affects the prognosis and quality of life of patients. The postoperative complications of EETS are not only related to the pathophysiological characteristics of pituitary adenoma, but also closely related to the depth of understanding of pathology and anatomy of pituitary adenoma, surgical skills, proficiency and clinical experience. Familiarity with endoscopic anatomy and fine surgical techniques, rich surgical experience, strict preoperative endocrine function evaluation, hormone replacement therapy, etc. can reduce the incidence of postoperative complications of EETS.

Evaluation and Current Clinical Progress of Invasiveness in Postoperative Residual Regrowth and Recurrence of Pituitary Adenoma / 肿瘤防治研究

Pituitary adenoma is one common type of intracranial tumors, accounting for about 10% of intracranial tumors. Although pituitary adenomas are benign tumors, the complete resection and recurrence prevention remain challengeable due to aggressive growth of tumor, limited equipment conditions and surgical techniques of the surgeon. The proportion of recurrent pituitary adenomas is rising year by year and the difficulty of treatment also increases. This article reviews the diagnosis and treatment of recurrent pituitary adenomas based on the summary data of invasive or recurrent pituitary adenomas cases in our center, including indication for the second transsphenoidal surgery, surgical techniques, and prevention and treatment of postoperative complications, to provide reference for clinicians in this field.

Glioma del nervio óptico en paciente adulto con presentación hemorrágica tratado mediante abordaje endoscópico transesfenoidal extendido / Optic nerve glioma in an adult patient with hemorrhagic presentation treated by an extended transsphenoidal endoscopic approach

El glioma del nervio óptico es una entidad de muy baja incidencia en pacientes adultos, lo cual impide tener suficiente información sobre historia natural y conducta terapéutica en este grupo etario. En el presente artículo comunicamos el caso de un paciente de 27 años de edad con compromiso agudo del nervio óptico izquierdo debido a hemorragia intra tumoral, forma de presentación muy poco común en este tipo de tumores. Se realizó la resección mediante un abordaje endoscópico transesfenoidal extendido, con preservación funcional de la vía óptica contralateral. La anatomía patológica confirmó astrocitoma pilocítico positivo para el rearreglo KIAA 1549-BRAF. y negativo para la mutación BRAF V600E. Teniendo en cuenta la histopatología y biología molecular en este caso, la estabilidad visual contralateral y la resección quirúrgica amplia, se decidió no realizar tratamiento adyuvante con radioterapia o quimioterapia. El objetivo de esta conducta fue evitar lesiones adicionales sobre el quiasma, nervio óptico contralateral y/o hipotálamo. Dada la escasa información existente en la literatura médica, el reporte de este caso podría contribuir con información adicional en el manejo y conducta terapéutica de este tipo de lesiones.

The optic nerve glioma is a very uncommon entity in adult patients, with little information about its natural history and therapeutical management. We report the case of a 27-year-old patient with acute involvement of the left optic nerve due to intratumoral hemorrhage, a very uncommon form of presentation in this type of tumor. Resection was performed using an extended transsphenoidal endoscopic approach, with functional preservation of the contralateral optic pathway. The histopathology confirmed positive pilocytic astrocytoma with KIAA 1549-BRAF rearrangement and without BRAF V600E mutation. Considering the histopathology and molecular biology, the contralateral visual stability and the wide surgical resection, it was decided not to perform further treatment. The purpose of this decision was to avoid additional damage to the chiasm, contralateral optic nerve and/or hypothalamus. Given the limited data available in medical literature, the report of this case could contribute with additional information on the management and therapeutic approach of this type of tumors

Efficacy and safety of pituitary adenomectomy purely endoscopically via a transsphenoidal approach in elderly patients / 中华老年医学杂志

Objective@#To investigate the clinical effect of surgical treatment of pituitary adenoma via neuroendoscopic-assisted transsphenoidal approach in elderly patients.@*Methods@#This was a prospective case-control study.Eighty-five patients with senile pituitary adenoma admitted to our hospital from May 2015 to February 2018 were consecutively enrolled in our study.Patients with pituitary adenoma were divided into the control group(n=42)undergoing conventional microsurgery and the observation group(n=43)receiving microsurgery via neuroendoscopic-assisted transsphenoidal approach.The effect of surgery, perioperative indexes(intraoperative blood loss, operation time, hospitalization time)and the serum level changes of prolactin(PRL), growth hormone(GH)and adrenocorticotropic hormone(ACTH)before and after surgery were recorded and compared between two groups.The incidences of complications in both groups and the dimensions of life quality(physical, cognitive, emotional, social activities)before and after surgery were calculated and assessed.@*Results@#The total effective rate was higher in the observation group(88.4%, 38/43)than in the control group(69.0%, 29/42)(P<0.05). The intraoperative blood loss, operation time and hospital days were less in the observation group than in the control group(P<0.05). No significant differences were found in serum levels of PRL, GH and ACTH between the two groups before and at 3 days after surgery(P>0.05). However, serum levels of PRL, GH and ACTH were deceased in both groups at 3 days after operation compared with before operation.The incidence of complications was lower in the observation group than in the control group(4.7% or 2/43 vs.21.4% or 9/42, P<0.05). The quality of life scores of the cognitive, role, physical, emotional and social dimensions were higher in the observation group than in the control group(P<0.01).@*Conclusions@#Neuroendoscopic-assisted transsphenoidal approach for surgical treatment of senile pituitary adenomas has less intraoperative blood loss, shorter operation time and lower complication rate, improves the endocrine hormone levels and the quality of life, and shortens the hospital stays.

Efficacy and safety of pituitary adenomectomy purely endoscopically via a transsphenoidal approach in elderly patients / 中华老年医学杂志

Objective To investigate the clinical effect of surgical treatment of pituitary adenoma via neuroendoscopic-assisted transsphenoidal approach in elderly patients.Methods This was a prospective case-control study.Eighty-five patients with senile pituitary adenoma admitted to our hospital from May 2015 to February 2018 were consecutively enrolled in our study.Patients with pituitary adenoma were divided into the control group(n=42)undergoing conventional microsurgery and the observation group(n=43)receiving microsurgery via neuroendoscopic-assisted transsphenoidal approach.The effect of surgery,perioperative indexes (intraoperative blood loss,operation time,hospitalization time) and the serum level changes of prolactin (PRL),growth hormone (GH) and adrenocorticotropic hormone(ACTH)before and after surgery were recorded and compared between two groups.The incidences of complications in both groups and the dimensions of life quality(physical,cognitive,emotional,social activities)before and after surgery were calculated and assessed.Results The total effective rate was higher in the observation group(88.4 ％,38/43)than in the control group (69.0 ％,29/42) (P ＜ 0.05).The intraoperative blood loss,operation time and hospital days were less in the observation group than in the control group(P＜0.05).No significant differences were found in serum levels of PRL,GH and ACTH between the two groups before and at 3 days after surgery (P＞0.05).However,serum levels of PRL,GH and ACTH were deceased in both groups at 3 days after operation compared with before operation.The incidence of complications was lower in the observation group than in the control group(4.7％ or 2/43 vs.21.4％ or 9/42,P＜0.05).The quality of life scores of the cognitive,role,physical,emotional and social dimensions were higher in the observation group than in the control group (P ＜ 0.01).Conclusions Neuroendoscopic-assisted transsphenoidal approach for surgical treatment of senile pituitary adenomas has less intraoperative blood loss,shorter operation time and lower complication rate,improves the endocrine hormone levels and the quality of life,and shortens the hospital stays.

Clinical efficacy of transsphenoidal approach under neuroendoscopy in treatment of different types of pituitary tumors / 局解手术学杂志

Objective To explore the best indication of neuroendoscopic surgery in patients with pituitary tumors by comparing the clinical effects of neuroendoscopic transsphenoidal surgery on patients with different types of pituitary tumors.MethodsA total of 92 patients with different types of pituitary adenoma received transsphenoidal approach under neuroendoscopy in our hospital from June 2016 to October2017 were selected, the surgical results were evaluated by comparing the postoperative hormone levels were normal or not and the tumor were resected or not.The patients were followed up, the physiological function (PF), physiological function (RP), emotional functions (RE) was determined by health measurement scale (SF-36) to evaluated the quality of life of patients.Results There were differences in clinical efficacy of neuroendoscopy for the treatment of different types of pituitary adenoma, the cure rate from high to low in turn was cortical hormone adenomas, growth hormone adenomas, prolactin adenomas, mixed adenoma, non-functional adenomas, the cure rate of functional pituitary adenoma was obviously higher than that of no functional pituitary adenoma, the difference was statistically significant (P＜0.05).At 6 months after surgery, SF-36 result showed that PF scores was (76.30±8.68), RP scores was (78.37±19.05), RE scores was (71.54±21.54), and at 12 months after surgery, PF scores was (87.20±9.24), RP scores was (78.66±15.18) and RE scores was (87.80±17.67), which were higher in patients with functional pituitary adenoma than those in patients with non-functional pituitary adenoma, the differences were significant (P＜0.05).ConclusionThe treatment of functional pituitary tumor by neuroendoscopic surgery, especially corticosteroid adenoma, has the best effect, and can significantly improve the quality of life of patients.

Clinical Usefulness of Trasseptal Transsphenoidal Approach for Pituitary Tumors with Septal Cartilage Removal and Replacement via Modified Killian Incision: Review of 42 Cases

BACKGROUND AND OBJECTIVES: The conventional transseptal transsphenoidal approach can inhibit visualization of the surgical field and may change the shape of external nose. We used the transseptal transsphenoidal technique to remove septal cartilage except the L strut via a modified Killian's incision and preserved the ‘key-stone area.’ The aim of this study was to verify the usefulness of this technique. SUBJECTS AND METHOD: Retrospective analysis was carried out on 42 pituitary tumor patients who received this technique by a single otolaryngologist from March 2005 to March 2012 at Kangbuk Samsung Hospital. RESULTS: The mean patient age at time of surgery was 52 years, and 41 cases were pituitary adenoma and 1 was Rathke's cleft cyst. Three patients had undergone prior surgery; of which 2 used a pterional approach and 1 a transsphenoidal approach. With regard to complication, there were 2 cases of CSF leakage and 5 cases of septal laceration. There were no cases of meningitis, deformity of external nose, septal perforation, anosmia, or sinusitis. In post operation follow up, 25 cases (59.5%) had no residual tumor, while 17 cases (40.5%) had residual tumor. CONCLUSION: This study reveals that transseptal transsphenoidal surgery with septal cartilage removal and a replacement technique for a pituitary tumor are effective, allow easy exposure, and result in a low complication rate.

Referencias anatómicas óseas en tomografía computada para el abordaje transesfenoidal a la base de cráneo / Anatomical bone landmarks in computed tomography for the transsphenoidal approach to the skull base

Objetivo: Aportar valores teóricos promedio de referencias anatómicas en tomografía computada con el fin de optimizar los abordajes transesfenoidales a la base de cráneo. Materiales y Métodos: Se desarrolló un diseño descriptivo, prospectivo, transversal y observacional de cien estudios de tomografía computada de macizo facial y base de cráneo. Mediante planillas de registro diseñadas ad Hoc, se confeccionó la base de datos considerando: sexo, edad, línea media, posición del rostrum esfenoidal y de la silla turca, posición de los ostium esfenoidales, presencia de las paredes óseas del seno esfenoidal, distancia entre las arterias carótidas internas y los nervios ópticos, neumatización de los recesos óptico-carotídeos, neumatización del seno esfenoidal, dimensiones del seno esfenoidal, número de tabiques intra-seno esfenoidal y su sitio de inserción posterior. Resultados: El rostrum esfenoidal es el mejor reparo de línea media para los abordajes transesfenoidales a la región selar. Los tabiques internos no deben considerarse como reparos de línea media seguros. Los ostium esfenoidales se localizan laterales a la línea media y conforman un sitio seguro para iniciar la apertura de la pared anterior del seno esfenoidal. Las paredes óseas laterales del seno esfenoidal no siempre están presentes a nivel de las prominencias carotídeas y ópticas. El canal de trabajo para abordar la silla turca está determinado por la distancia entre ambas arterias carótidas internas, siendo en promedio de 11,24 mm. Conclusión: La tomografía computada permite obtener un conocimiento de la anatomía del seno esfenoidal preciso para la planificación de un abordaje transesfenoidal a la silla turca o extendida a la base de cráneo.

Objective: To provide average theoretical values for anatomic references in computed tomography (CT) images and, thereby, improve the transsphenoidal approach to the skull base. Methods and Materials: A descriptive, prospective, cross-sectional, observational study was conducted of 100 CT evaluations of facial bones and the skull base. A database was created using ad hoc registration forms, entering data on patient gender and age, midline, position of the sphenoid rostrum, position of the sella, position of the sphenoid ostium, presence of the bony walls of the sphenoid sinus relative to the carotid and optic prominences, distance from the internal carotid arteries, distance between the optic nerves, pneumatization of the optic-carotid recesses, pneumatization of the sphenoid sinus, dimensions of the sphenoid sinus, and the number and posterior insertion sites of sphenoid septa. Results: The sphenoid rostrum was found to be the best midline reference for transsphenoidal approaches to the sellar region. Internal septa should not be considered safe midline references. The sphenoid ostium are located laterally to the midline, and are a safe site at which to initiate the opening of the anterior wall of the sphenoid sinus in the mid-caudal direction. The lateral bony walls of the sphenoid sinus are not always present at the carotid and optic prominence levels. The working channel to approach the sella is determined by the distance between the internal carotid arteries, the average distance being 11.24 mm. Conclusions: Computed tomography reveals the anatomy of the sphenoid sinus and sellar region and, thus, facilitates the trans-sphenoidal approach to the skull base.

Application of flexible laryngeal mask in transnaso-sphenoidal microsurgery for pituitary adenoma / 临床麻醉学杂志

Objective To observe the effect of flexible laryngeal mask (FLMA) in transnaso-sphenoidal microsurgery for pituitary adenoma on airway management and variation of stress response.Methods One hundred patients (71 males, 29 females, aged 18-65 years, BMI 21-28 kg/m2, ASA physical status Ⅰ or Ⅱ) undergoing transnaso-sphenoidal microsurgery for pituitary adenoma were randomly divided into two groups: the FLMA group (group F) and the reinforced endotracheal tube group (group T) using a random number table, 50 cases in each group.The plasma concentration of epinephrine and norepinephrine were measured before anesthesia induction (T0), at the time of inserting the FLMA or reinforced endotracheal tube (T1), 1 min (T2) and 5 min (T3) after insertion.The Berry scores of the preoperative and postoperative airway exposure by branchofiberoscope in group F were assessed.The time of removal of FLMA (endotracheal tube) and the occurrence of choking, laryngeal spasm, sore throat, hoarseness and other adverse reactions were recorded.Results The levels of epinephrine and norepinephrine were were significantly lower at T2 and T3 in group F than those in group T (P<0.05).There was no significant difference in airway Berry scores.The time of extubation was shorter in group F than that in group T [(9±3) min vs (17±6) min] (P<0.05).The incidence of choking (2% vs 22%) and sore throat (4% vs 30%) were significantly lower in group F than those in group T (P<0.05).Conclusion Compared with the reinforced endotracheal tube, FLMA can be applied safely and effectively to transnaso-sphenoidal microsurgery for pituitary adenoma, reduces stress respond associated with anesthesia and post-extubation complications, improves the recovery of patients.

Research on the effect of endoscopic single nostril transsphenoidal pituitary tumor resection / 局解手术学杂志

Objective To discussion the effect of endoscopic single nostril transsphenoidal pituitary tumor resection on improving clini-cal symptoms and related quality of life of patients. Methods Selected 114 cases of patients with pituitary tumors in our hospital from August 2013 to August 2015, and randomly divided them into the nasal endoscopic group and the microscopic group according to the random number table,with 57 patients in each group. Patients of the 2 groups were treated with nasal endoscopic and microscopic single nostril transsphenoi-dal pituitary tumor resection respectively. The operation situation,hormone decline,incidence of complications after surgery and SNOT-20 and VAS score of the two groups were compared. Results Operative time of nasal endoscopic group was significantly higher than that in the mi-croscopic group,whlie the blood loss,length of hospital stay in endoscopic group was significantly lower than the microscopic group,and the difference was statistically significant (P0. 05). One week after operation,cerebrospinal fluid cell count,cerebrospinal fluid protein,adrenocorticotropic hormone,serum chloride,sodium, growth hormone,and prolactin levels of the nasal endoscopic group were lower than the microscopic group (P<0. 05). The complication rate was 14. 9% in the nasal endoscopic group,which was obviously lower than 59. 6% in the microscopic group (P<0. 05). One week after operation,the SNOT-20 scores and VAS scores were increased in both of the two groups,but the microscopic group increased more significantly (P<0. 05). Conclusion Endoscopic single nostril transsphenoidal pituitary tumor resection surgery cost longer operation time,but it lead to less trauma and less postoperative complications,which may delay the decline of patients’ quality of life and promote the improvement of prognosis.

Endoscopic Endonasal Transsphenoidal Pituitary Tumors Approach: Nuances of Neurosurgical Technique / Abordagem endoscópica endonasal transesfenoidal para tumores hipofisários: detalhes da técnica neurocirúrgica

Pituitary tumors are responsible for 7 to 17% of all intracranial lesions. Over the past decade, advances in endoscopic microsurgical techniques have resulted in an increasingly aggressive endonasal approach to tumors of the midline skull base. We present our series emphasizing technical nuances of endoscopic endonasal transsphenoidal approach to treat pituitary adenomas.

Tumores hipofisários são responsáveis por 7 a 17% de todas as lesões intracranianas. Durante a última década, avanços nas técnicas microcirúrgicas endoscópicas resultaram no aumento de acessos endonasais agressivos para tumores de base de crânio de linha média. Apresentamos nossa série de casos, com ênfase nos detalhes técnicos do acesso endoscópico endonasal transesfenoidal para o tratamento de tumores da hipófise.

Endoscopic endonasal transsphenoidal surgery of symptomatic Rathke′s cleft cyst in sellar region / 重庆医学

Objective To explore the clinical characteristic of Rathke′s cleft cyst and assess the effect of endoscopic en-donasal transsphenoidal surgery .Methods A retrospective research was performed on 9 patients who underwent endoscopic en-donasal transsphenoidal surgery .Neural endoscopic surgery by single nostril transsphenoidal approach ,partial resection of the cyst wall with drainage of the intracystic contents was performed in all patients .Results Symptoms in all patients were resolved or alle-viated .No CSF rhinorrhea ,permanent diabetes insipidus and hypopituitarism happened .All patients were followed up for 4 to 12 months and no recurrence was found .Conclusion Endoscopic endonasal transsphenoidal surgery is a effective method for symptom-atic Rathke′s cleft cysts .

Neuro-endoscopic endonasal transsphenoidal surgery for the large pituitary adenoma:78 cases report / 中华显微外科杂志

Objective To summarize the experience of the simple neuroendoscopic endonasal transsphenoidal surgery for the large pituitary adenoma and discuss it's application value.Methods Seventy-eight cases of the large pituitary adenoma treated by simple neuroendoscopic endonasal transsphenoidal surgery from July,2011 to May,2014 were analyzed retrospectively.Tumors were resected using 0 and 30 degree endoscope after opening the same side of the anterior wall of the sphenoidal sinus and sellar bone using the abrasive drilling during operation.Results The tumor removal was total in 62 (79.49％),subtotal in 12 (15.38％),major in 3(3.85％) and part in 1 (1.28％).Seventy-one cases were followed up for 2 months to 2 years after operation and no recurrence was founded,the symptoms of headache disappeared in 49 cases;The vision of patients was improved in 47 cases,menstruation resumed in 12 cases;The acromegaly of patients reduced in 21 cases.Hormone level review of PRL returned to normal in 32 cases,GH returned to normal in 21 cases,ACTH returned to normal in 2 cases.Conclusion The endoscopic transsphenoidal surgery for large pituitary tumors is the safely,minimally invasive surgical techniques.With the development of endoscopic equipment constantly updated and the operational flexibility and comfort is improved ceaselessly,endoscopic transsphenoidal surgery for the sellar tumor will be carried out more widely.

Clinical Guidelines for the Diagnosis and Treatment of Cushing's Disease in Korea

Cushing's disease (CD) is a rare disorder characterized by the overproduction of adrenocorticotropic hormone due to a pituitary adenoma that ultimately stimulates excessive cortisol secretion from the adrenal glands. Prior to the detection of pituitary adenomas, various clinical signs of CD such as central obesity, moon face, hirsutism, and facial plethora are usually already present. Uncontrolled hypercortisolism is associated with metabolic, cardiovascular, and psychological disorders that result in increased mortality. Hence, the early detection and treatment of CD are not only important but mandatory. Because its clinical manifestations vary from patient to patient and are common in other obesity-related conditions, the precise diagnosis of CD can be problematic. Thus, the present set of guidelines was compiled by Korean experts in this field to assist clinicians with the screening, diagnoses, and treatment of patients with CD using currently available tests and treatment modalities.

Anatomic variations of sphenoid sinus pneumatization in a sample of Turkish population: MRI study / Variaciones anatómicas de la neumatización del seno esfenoidal en una muestra de población turca: estudio por resonancia magnética

There are a number of variations regarding morphometric anatomy and degree of pneumatization of the sphenoid sinus. In our study, we planned to examine and show the differences of pneumatization of the sphenoid sinus particularly to guide the neurosurgeon during transsphenoidal surgery. Sagittal T1-weighed spin-echo Magnetic Resonance Images (MRIs) of 616 adult individuals (406 women and 210 men) were analyzed, retrospectively. According to the collected data from our study, the most common type of the sphenoid sinus was the sellar type (83%; n=511) for the whole study group. Of the 616 individuals 16.6% (n=102) had presellar type and 0.5% (n=3) had conchal type of sphenoid sinus. Preoperative detailed detection of the anatomical characteristics of sphenoid sinus is essential. A thorough information obtained from studies of the regional anatomy and awareness of its variability can provide a safe and accurate transsphenoidal and extended endoscopic skull base approaches.

Existen variaciones respecto a la anatomía morfométrica y el grado de neumatización del seno esfenoidal. En nuestro estudio, se examinaron las diferencias de neumatización del seno esfenoidal, especialmente para guiar al neurocirujano durante la cirugía transesfenoidal. Fueron analizadas las imágenes sagitales T1-spin de resonancia magnética (RM) de 616 individuos adultos (406 mujeres y 210 hombres). De acuerdo con los datos obtenidos a partir de nuestro estudio, el tipo más común de seno esfenoidal fue el de silla turca (83%, n=511) para todo el grupo de estudio, 16,6% (n=102) corresponden al tipo presellar y 0,5% (n=3) al tipo conchal. Una detección preoperatoria detallada de las características anatómicas del seno esfenoidal es esencial. Información exhaustiva obtenida de los estudios de la anatomía y el conocimiento de su variabilidad regional puede proporcionar un abordaje endoscópico transesfenoidal extenso, seguro y preciso, de la base de cráneo.

Outcomes following Purely Endoscopic Endonasal Resection of Pituitary adenomas.

Background: The use of endoscope for the management of pituitary adenoma is not new. The better magnification and illumination provided by the endoscope gives better outcome than microscopic pituitary surgery. Objective: To find out the benefits of endoscope in relation to microscopic surgery. Materials and Methods: We performed 45 cases of pituitary adenoma surgery by endoscopic endonasal approach from July 2008 to July 2010. Results: Forty five cases underwent endoscopic transsphenoidal approach. Gross total removal was done in 35 cases and subtotal removal was done in 10 cases. Residual tumours were seen in 10 cases (22%) in postoperative follow-up MRI scan. Visual improvement was satisfactory, and hormonal improvement of functional adenoma was nice. Postoperative visual acuity and visual field were improved in 75% cases. There were 37% cases of temporary diabetes insipidus and about 4.5% cases of permanent diabetes insipidus. The average duration of follow-up was 20 months. One patient required reexploration to correct visual deterioration in the immediate postoperative period. There were 4.5% cases of CSF leak and 6.6% mortality. Mortality was due to electrolyte imbalance and improper management of infection and hydrocephalus. Conclusion: Endoscopic endonasal pituitary surgery now has become a gold standard surgery for most of the pituitary adenomas because of its better advantages in relation to microscopic surgery and less complications and less hospital stay.

Adenomas invasores, presentación de caso, revisión de la literatura y propuesta de clasificación según su extensión / Invasive adenomas, case report, literature review and proposal for classification according to their extensión

Los adenomas hipofisiarios invasores constituyen una patología de baja frecuencia dentro de los tumores del sistema nervioso central, su nombre hace referencia a aquellas lesiones que se extienden hacia estructuras adyacentes a la región selar y que en algunas ocasiones pueden alcanzar tamaños gigantes. Representan un importante reto quirúrgico considerando la posibilidad de daño de las estructuras comprometidas o rodeadas por el tumor. Son lesiones que se manifiestan de forma tardía y generalmente más por su efecto compresivo que por un compromiso hormonal secundario. Existen múltiples clasificaciones partiendo de la extensión del tumor, además de las que hacen referencia a las características histológicas. En este artículo se exponen los sistemas de clasificación así como algunos de los abordajes reportados en la literatura. Se muestra el caso de una de nuestras pacientes a quien se le diagnosticó tardíamente un adenoma invasor de gran tamaño, después de varios años de cursar con importantes alteraciones del comportamiento y quien posteriormente fue llevada a cirugía para resección del tumor por vía transcranial. Se expone la complejidad anatómica de la región selar y se propone un nuevo sistema de clasificación que contempla el compromiso diferencial de espacios y estructuras neurales y vasculares adyacentes a la región selar con el fin de guiar a los cirujanos sobre los procedimientos quirúrgicos más adecuados y disponibles en el momento.

Invasive pituitary adenomas constitute a low-frequency disease within the central nervous system tumors, the name refers to those lesions involving adjacent structures to the sellar region and who can reach giant sizes. The invasive adenomas represent a major challenge considering surgical morbidity due to the commitment of structures that may be involved given the extent of these lesions. These tumors usually are belatedly manifested and their manifestations are most often secondary to the compressive effect than hormonal involvement. There are multiple classifications based on the extent of the tumor, besides those that referring to the histologic features. This article shows a case of a patient who was diagnosed lately, with a big invasive adenoma who had had major behavioral disturbances in previous years and was subsequently taken to surgery for resection of the tumor. We present the anatomical complexity of the sellar region and we propose a new classification system to guide surgeons on the surgical procedure most suitable and available at the time.

Pituitary adenoma resection by single-nostril transsphenoidal approach / 中华显微外科杂志

Objective To summarize the experience of pituitary adenoma resection by single-nostril transsphenoidal approach and analyze the indications,intraoperative and postoperative common problems in order to improve the technique and quality of life.Methods Summarize the clinical data of 611 pituitary adenoma resections by single-nostril transsphenoidal approach from January 2005 to June 2010 retrospectively,reanalyze the choice of operative indications,analyze the bleeding during the operation and sums up the relevant pro cessing suggestions,and summarize the reasons and countermeasures of postoperative visual impairment.Results The tumors were totally removed in 538 cases,sub-resections in 59 cases,sub-totally removed in 14 cases,and no deaths.Eleven cases were poor gasification or concha sphenoid sinus in 11 totally removed patients.The bleeding came from diploe,emissarium,mucosa of sphenoid sinus,diploe,epidural space,dura matter of the sella turcica region,intercavernous sinuses,tumor or the tumor bed.The bleeding was controlled effectively with different approaches.There were 3 patients who underwent visual impairment,and the impairment was improved after treatment.Conclusion Following the correct operation principle,we can improve the rate of total resection; the single-nostril transsphenoidal approach is also suitable for the poor gasification; The prognosis can improve after deal with the intraoperative and postoperative common problems.

A Rathke's Cleft Cyst Presenting with Apoplexy

The occurrence of symptomatic pituitary hemorrhage into a Rathke's cleft cyst (RCC) is extremely rare. The author reports an interesting case of intra- and suprasellar RCC presented with features of pituitary apoplexy. This 62-year-old woman suffered acute headache, mental confusion, and partial hypopituitarism. The characteristics of the magnetic resonance imaging seemed most compatible with a hemorrhagic pituitary adenoma. Transsphenoidal drainage of the cyst contents confirmed the diagnosis of hemorrhagic RCC and resolved the symptoms. All published data on this rare clinical entity are extracted and reviewed.