RESUMO
OBJECTIVE: The endoscopic endonasal transcavernous approach with interdural pituitary transposition provides surgical access to the posterior clinoids and interpeduncular cistern. Prior to posterior clinoidectomy, selective coagulation and transection of the inferior hypophyseal artery (IHA) is recommended to prevent uncontrolled tearing of the artery and its avulsion from the wall of the cavernous carotid artery. The authors' preliminary experience has shown that unilateral sacrifice of the IHA caused no permanent endocrine dysfunction. In this study, they investigated the pituitary function in the setting of bilateral sacrifice of IHAs and pituitary transposition. METHODS: All patients with normal preoperative pituitary function who underwent endoscopic endonasal bilateral posterior clinoidectomy with bilateral IHA sacrifice between March 2010 and December 2016 were included and retrospectively evaluated. All data regarding pituitary function were collected. The degree of pituitary gland manipulation was estimated based on tumor size on preoperative MRI. An angle between a line from the point where the gland meets the floor of the sella to the highest point of the tumor and the horizontal plane of the sellar floor, or access angle, was also measured. Posterior pituitary bright spots on pre- and postoperative T1-weighted MRI were also reported. RESULTS: Twenty patients had bilateral transcavernous posterior clinoidectomies with coagulation of both IHAs. There were 13 chordomas, 3 epidermoid cysts, 2 chondrosarcomas, 1 meningioma, and 1 hemangiopericytoma. The mean follow-up was 19 months (range 13-84 months). Two patients experienced transient diabetes insipidus (DI) requiring desmopressin, which resolved before hospital discharge. One patient (with chordoma) developed delayed permanent DI, and a second patient (with hemangiopericytoma) developed permanent DI and panhypopituitarism. The access angle was higher in the group with pituitary dysfunction (47.25° compared to 33.81°; p = 0.07). Posterior pituitary bright spots were preserved in 75% of cases with normal postoperative endocrine function. CONCLUSIONS: The endoscopic endonasal transcavernous approach to the interpeduncular cistern with pituitary transposition and bilateral sacrifice of the IHAs does not cause pituitary dysfunction in a majority of patients. When endocrine deficit occurs, it appears to be more likely to have been caused by surgical manipulation than loss of blood supply. This finding confirms clinically the crucial concept of interarterial anastomosis of pituitary vasculature proposed by anatomists.
RESUMO
BACKGROUND: Long-term outcome data for patients undergoing carotid endarterectomy (CEA) are lacking. As most of the published literature on CEA outcomes has been from high-volume providers, we wanted to investigate the outcomes of an average-volume cerebrovascular neurosurgeon. METHODS: We reviewed a single neurosurgeon's experience with CEA focusing on long-term outcomes. Most procedures (99.0%) were performed with primary closure of the arteriotomy. RESULTS: We studied 192 CEAs performed between 1998 and 2017, 77% for symptomatic disease. Two patients (1%) experienced immediate postoperative stroke. During an average follow-up of 53 months (range, 0-205 months), 2 more patients (1%) experienced ipsilateral carotid circulation stroke, and 5 patients (2.6%) experienced ipsilateral transient ischemic attacks. Five patients (2.6%) experienced contralateral transient ischemic attacks, and 6 (3.1%) experienced contralateral stroke. There were also 3 cases of (1.6%) hemorrhagic stroke and 6 cases (3.1%) of vertebrobasilar circulation stroke. The rate of ipsilateral stroke-free survival was 98.4% at 5 years post-CEA, 97.9% at 10 years post-CEA, and 97.9% at 15 years post-CEA. The rate of ipsilateral restenosis-free survival was 97.9% at 5 years post-CEA, 96.8% at 10 years post-CEA, and 96.8% at 15 years post-CEA. Six patients (3.1%) experienced restenosis >70% during follow-up. Two of these patients underwent carotid artery stenting. Almost all patients (>95%) were maintained on an antiplatelet medication and statin. CONCLUSIONS: In the hands of an average-volume cerebrovascular neurosurgeon, CEA can provide durable protection from recurrent stroke in the ipsilateral carotid distribution that extends beyond 15 years. Thus, this procedure should be considered the gold standard against which other revascularization modalities should be evaluated.
