Lateral nasal wall flap for endoscopic reconstruction of the skull base: anatomical study and clinical series.

BACKGROUND: The lateral nasal wall (LNW) flap provides vascularized endonasal reconstruction primarily in revision surgery. Although the harvesting technique and reconstructive surface have been reported, the arterial supply to the LNW flap and its clinical implications is not well defined. This study presents anatomical dissections to clarify the vascular supply to this flap, and the associated clinical outcomes from this reconstructive technique. METHODS: The course and branching pattern of the sphenopalatine artery (SPA) to the LNW were studied in 6 vascular latex-injected heads (11 LNW flaps total). Patients undergoing an LNW flap since 2008 were identified and the underlying pathology, indication, flap viability, and clinical outcomes were retrospectively analyzed. RESULTS: The inferior turbinate artery arises from the LNW artery and divides into 2 branches at the most posterior aspect of the inferior turbinate bone. A smaller-caliber superficial branch travels anteriorly and branches to the LNW. A larger dominant branch travels into the inferior meatus and tangentially supplies the nasal floor. Twenty-four patients with sellar or posterior cranial fossa (PCF) defects were reconstructed with an LNW flap. Postoperative contrast enhancement of the LWN flap was identified in 95.5% of cases. Postoperative cerebrospinal fluid (CSF) leaks were identified in 6 cases. CONCLUSION: Blood supply to the nasal floor by the dominant inferior meatus branch is more robust than the supply to the anterior LNW by the superficial arterial branch. The LNW flap is the preferred vascularized reconstructive option to the PCF and sella in the absence of a nasoseptal flap (NSF).

A case of right internal carotid agenesis with associated transcavernous anastomosis revealed by transient ischemic attack.

Agenesis of the internal carotid artery (ICA) is a rare congenital vascular disorder of the cerebral circulation. CT scan of the skull base disclosing complete absence of the bony carotid canal helps to differentiate an agenesis from aplasia or hypoplasia. Although most of the patients remain asymptomatic (thanks to the sufficient collateral circulation provided by the circle of Willis) cerebral infarcts, transient ischemic attacks or intracranial aneurysms have been rarely described in association with agenesis of the ICA. Most often, the vascular territory of the involved ICA is supplied by the contralateral carotid artery and from the vertebrobasilar circulation through the anterior and posterior communicating arteries, respectively. However, collateral supply can also be provided thanks to a transcavernous anastomosis, an aberrant vascular communication between the cavernous portions of the ICAs coursing through the sella turcica. We report here the case of a 55-year-old man with right carotid agenesis and associated transcavernous anastomosis revealed by transient ischemic attack. Embryogenesis, imaging findings, possibilities of collateral circulation and potential complications have also been discussed.

Persistence of intrasellar trigeminal artery and simultaneous pituitary adenoma: description of two cases and their importance for the differential diagnosis of sellar lesions.

Persistent trigeminal artery (PTA) is the most frequent embryonic communication between the carotid and vertebrobasilar systems. However, hormonal changes or the association of PTA with other sellar lesions, such as pituitary adenomas, are extremely rare. The aim of the present study was to report two patients with intrasellar PTA and simultaneous pituitary adenoma in order to emphasize the importance of differential diagnoses for sellar lesions. Case 1. A female patient, 41 years old, was admitted with a history of chronic headache (> 20 years). Pituitary magnetic resonance imaging (MRI) showed a rounded lesion in the left portion of the pituitary gland suggestive of adenoma (most likely clinically non-functioning adenoma). In addition to this lesion, the MRI demonstrated ecstasy of the right internal carotid artery and imaging suggestive of an intrasellar artery that was subsequently confirmed by an angio-MRI of the cerebral vessels as PTA. Case 2. A female patient, 42 years old, was admitted with a history of amenorrhea and galactorrhea in 1994. Laboratorial investigation revealed hyperprolactinemia. Pituitary MRI showed a small hyposignal area in the anterior portion of pituitary gland suggestive of a microadenoma initiated by a dopaminergic agonist. Upon follow-up, aside from the first lesion, the MRI showed a well delineated rounded lesion inside the pituitary gland, similar to a vessel. Angio-MRI confirmed a left primitive PTA. Failure to recognize these anomalous vessels within the sella might lead to serious complications during transsphenoidal surgery. Therefore, although their occurrence is uncommon, a working knowledge of vascular lesions in the sella turcica or pituitary gland is important for the differential diagnosis of pituitary lesions, especially pituitary adenomas.

Persistence of intrasellar trigeminal artery and simultaneous pituitary adenoma: description of two cases and their importance for the differential diagnosis of sellar lesions / Persistência da artéria trigeminal intrasselar e simultâneo adenoma de hipófise: descrição de dois casos e importância para o diagnóstico diferencial das lesões selares

Persistent trigeminal artery (PTA) is the most frequent embryonic communication between the carotid and vertebrobasilar systems. However, hormonal changes or the association of PTA with other sellar lesions, such as pituitary adenomas, are extremely rare. The aim of the present study was to report two patients with intrasellar PTA and simultaneous pituitary adenoma in order to emphasize the importance of differential diagnoses for sellar lesions. Case 1. A female patient, 41 years old, was admitted with a history of chronic headache (> 20 years). Pituitary magnetic resonance imaging (MRI) showed a rounded lesion in the left portion of the pituitary gland suggestive of adenoma (most likely clinically non-functioning adenoma). In addition to this lesion, the MRI demonstrated ecstasy of the right internal carotid artery and imaging suggestive of an intrasellar artery that was subsequently confirmed by an angio-MRI of the cerebral vessels as PTA. Case 2. A female patient, 42 years old, was admitted with a history of amenorrhea and galactorrhea in 1994. Laboratorial investigation revealed hyperprolactinemia. Pituitary MRI showed a small hyposignal area in the anterior portion of pituitary gland suggestive of a microadenoma initiated by a dopaminergic agonist. Upon follow-up, aside from the first lesion, the MRI showed a well delineated rounded lesion inside the pituitary gland, similar to a vessel. Angio-MRI confirmed a left primitive PTA. Failure to recognize these anomalous vessels within the sella might lead to serious complications during transsphenoidal surgery. Therefore, although their occurrence is uncommon, a working knowledge of vascular lesions in the sella turcica or pituitary gland is important for the differential diagnosis of pituitary lesions, especially pituitary adenomas.

Persistência da artéria trigeminal (PAT) é a comunicação embrionária mais frequente entre os sistemas carotídeo e vertebrobasilar. No entanto, alterações hormonais ou associação de PAT com outras lesões selares, como adenomas hipofisários, são extremamente raros. O objetivo do presente estudo foi relatar dois pacientes com PAT intrasselar e concomitante adenoma hipofisário e enfatizar a importância para o diagnóstico diferencial de lesões selares. Caso 1. Paciente do sexo feminino, 41 anos, admitida com história de cefaleia crônica (> 20 anos). Ressonância magnética (RM) de hipófise mostrou imagem arredondada na porção esquerda da glândula sugestiva de adenoma (provavelmente adenoma clinicamente não funcionante). Adicionalmente, a RM demonstrou ectasia da artéria carótida interna direita e imagem sugestiva de artéria intrasselar, posteriormente confirmada por angio-RM dos vasos cerebrais como PAT. Caso 2. Paciente do sexo feminino, 42 anos, admitida com história de amenorreia e galactorreia em 1994. A investigação laboratorial revelou hiperprolactinemia. RM de hipófise mostrou pequena área de hipossinal na porção anterior da glândula sugestiva de microadenoma, sendo iniciado agonista dopaminérgico. Na evolução, além da primeira lesão, a RM mostrou uma imagem arredondada bem delimitada dentro da glândula pituitária semelhante a vaso sanguíneo. Angio-RM confirmou PAT primitiva esquerda. A falta de reconhecimento de tais vasos anômalos dentro da sela túrcica pode levar a sérias complicações durante a cirurgia transesfenoidal. Portanto, apesar de sua ocorrência não ser comum, o conhecimento de lesões vasculares dentro da sela túrcica ou glândula hipofisária é importante para o diagnóstico diferencial de lesões da hipófise, especialmente com adenomas hipofisários.

Sphenoid and subdural hemorrhage as a presenting sign of ruptured clinoid aneurysm.

BACKGROUND: Aneurysm rupture presenting as an isolated or pure subdural hematoma (SDH) without subarachnoid hemorrhage is an extremely rare radiographic presentation. We present a case of a ruptured internal carotid artery aneurysm with a pure SDH and concurrent sphenoid sinus hemorrhage. METHODS: Case report and review of the literature. RESULTS: We describe a case of a 48-year-old right-handed woman found comatose brought by emergency medical services to an outside hospital. A non-contrast head CT scan demonstrated bilateral acute SDHs without evidence of intraparenchymal or subarachnoid hemorrhage. A CT angiogram of the head showed a focal hyperdensity in the distal left internal carotid artery (ICA) and was confirmed by conventional cerebral angiography to be a 7-mm left supraclinoid ICA aneurysm. On repeat CT scan a new hemorrhage was seen in the sphenoid sinus indicating a re-bleeding. The aneurysm was treated with coil embolization and complete occlusion was confirmed with subsequent angiograms. The patient had an eventful hospital course complicated by a Takotsubo cardiomyopathy and pulmonary edema. She was medically treated with successful recovery of her cardiopulmonary function. She remained markedly disabled and was transferred to an inpatient rehabilitation center for continued convalescence. CONCLUSIONS: Acute subdural hematoma may be due to a ruptured clinoid carotid aneurysm. Acute hemorrhage into the sphenoid sinus can be an important clue.

Osteochondroma of the sella turcica presenting with intratumoral hemorrhage.

A 29-year-old man presented with a primary sellar turcica osteochondroma manifesting as intratumoral hemorrhage mimicking pituitary apoplexy. The patient suffered sudden onset of headache concomitant with vision loss in the left eye. Radiography and computed tomography detected destruction and calcification of the sellar turcica. Magnetic resonance imaging revealed a heterogeneously enhanced suprasellar mass that had elevated and compressed the optic chiasm. The preoperative diagnosis was hemorrhagic pituitary adenoma, craniopharyngioma, meningioma, or chordoma based on the signal heterogeneity of the lesion. To relieve the symptoms and make a definitive diagnosis, surgical removal via a basal interhemispheric approach was carried out. The tumor was not totally removed because of tight adhesion to the pituitary stalk, but postoperative ophthalmological examination revealed improvement of the visual disturbance. The histological diagnosis was osteochondroma based on the presence of mature chondrocytes and osteomatous tissue. Osteochondroma should be included in the differential diagnosis of tumors with acute hemorrhage in the sella turcica.

Complications of transsphenoidal surgery in patients with pituitary adenoma: experience at a single centre.

OBJECTIVE: This paper reports the complications of transsphenoidal surgery for pituitary adenomas in a series of 1240 consecutive patients operated at our Institute between 1990 and 2004 (first operations) and indicate the clinical characteristics of patients which affected surgical morbidity and mortality. METHODS: According to tumour type, there were 420 (33.9%) non-functioning pituitary adenomas (NFPA), 349 (28.1%) GH-secreting, 288 (23.2%) ACTH-secreting, 155 (12.5%) prolactin (PRL)-secreting, and 28 (2.3%) TSH-secreting adenomas. The mean age of patients was 43.7 +/- 0.4 yr and 122 patients (9.9%) were 65 yr or older; the female/male ratio was 1.5/1. There were 370 (29.8%) microadenomas and 870 (70.2%) macroadenomas of which 54 (4.4%) were giant adenomas. RESULTS: The series mortality was 0.2%, the medical morbidity 1.9%, and the surgical morbidity 3.5%. Medical complications were significantly more frequent in patients older than 65 yr (4.9 vs. 1.4%; p = 0.009) and in patients with giant adenomas (5.6 vs. 1.6%; p = 0.03). Multivariate analysis showed that both variables were independently associated with a higher morbidity rate. The surgical morbidity was increased in giant adenomas (15 vs. 3%; p = 0.0001), in NFPA (6.2 vs. 2.1% in secreting adenomas; p = 0.0002) and in patients older than 65 yr (6.6 vs. 3.1%; p = 0.05). Multivariate analysis showed that only giant size was independently associated with an increased surgical morbidity rate. CONCLUSIONS: In our experience, the size of the adenoma was a risk factor for medical and surgery related complications and age over 65 yr for medical complications alone.

The post-haemorrhagic vasopressin release into the blood.

The aim of the present study was to compare the influence of the renin-angiotensin and sympathetic system in the process of post-haemorrhagic vasopressin release. A dialysis of the venous blood from the sella turcica region was performed in male rats under anaesthesia. The animals were divided into eight experimental groups: 1). control; 2). bleeding; 3). 20 days after superior cervical ganglionectomy; 4). 20 days after superior cervical ganglionectomy and bleeding; 5). injection of captopril; 6). injection of captopril and bleeding; 7). 20 days after superior cervical ganglionectomy and injection of captopril; 8). 20 days after superior cervical ganglionectomy, injection of captopril and bleeding. The content of vasopressin in dialysates was determined by radioimmunoassay. In control rats the release of vasopressin into dialysates was constant during 180 min of the experiment. Bleeding, as well as, superior cervical ganglionectomy caused an increase in vasopressin release. Captopril did not change vasopressin release in comparison to control group. Furthermore, vasopressin release after both, bleeding and sympathetic denervation performed simultaneously was significantly abolished. We conclude that renin-angiotensin, as well as, sympathetic nervous system are involved in the increased post-haemorrhagic vasopressin release.

Intrasellar latrogenic carotid pseudoaneurysm: endovascular treatment with a polytetrafluoroethylene-covered stent.

This case illustrates successful treatment of a large postoperative intrasellar pseudoaneurysm with a polytetrafluoroethylene (PTFE)-covered stent. The advantages and potential disadvantages of this novel method of treatment are discussed. A previously healthy 59-year-old man underwent transsphenoidal operative treatment for hypophyseal macroadenoma, complicated by bleeding. On the 17th postoperative day the patient had profuse arterial bleeding from his nose requiring posterior tamponade. Subsequent angiography of the left internal carotid artery (ICA) revealed a large pseudoaneurysm located intrasellarly, with the orifice in the anteromedial wall in the ophthalmic segment of the ICA. Surgical treatment of the pseudoaneurysm was considered very risky. A 12-mm PTFE-covered stent (JoMed, Ulestraten, Netherlands), manually compressed on a PTCA-balloon (Maxxum 4.5/13 mm, Boston Scientific, Ireland) was endovascularly delivered covering the orifice of the pseudoaneurysm. Control angiography immediately after the intervention and one year later revealed no flow into the pseudoaneurysm and the ICA was fully patent. In conclusion, deployment of a PTFE-covered stent proved to be feasible and successful in the treatment of an intrasellar iatrogenic ICA pseudoaneurysm. Adequate anticoagulative treatment after the procedure is essential to prevent thrombotic complications.

Increase in vasopressin concentration and cardiodepressant activity in the blood dialysates from the sella turcica during acute hypoxia.

OBJECTIVE: It was previously observed that infusion of angiotensin II, hypertonic saline and N-methyl-D-aspartic acid (NMDA) causes an increase in vasopressin and cardiodepressant factor release from the posterior pituitary lobe into the blood (Goraca 1998). The aim of present study was to investigate if the cardiodepressant factor and vasopressin are simultaneously released from the pituitary into the blood dialysate during acute hypoxia. METHODS: The samples of dialysates of venous blood outflowing from the vicinity of cavernous sinus of the sella turcica were collected in anaesthetized rats. 30-min hypoxia was obtained by increasing the respiratory dead space. The concentration of vasopressin in blood dialysate was determined by radioimmunoassay, and cardiodepressant activity on spontaneously discharging pacemaker tissue of the right auricle of the right heart atrium. RESULTS: Acute hypoxia caused simultaneously an increase in cardiodepressant activity and vasopressin concentration in the blood dialysate outflowing from the vicinity of cavernous sinus of the sella turcica. CONCLUSIONS: These data suggest that cardiodepressant factor released together with vasopressin from the posterior pituitary lobe decrease the heart contraction rate and improves coronary circulation affected by vasopressin release.

Vascular complications of transsphenoidal surgery.

Vascular complication of transsphenoidal surgery can lead to mortality and serious morbidity. In a series of 3,061 transsphenoidal operations for pituitary disease, 24 such complications were encountered, seven of which were fatal. The anatomic substrate for such complications is discussed, along with technical aspects of surgery and other methods for the avoidance of vascular complications.

Intrasellar vascular malformation mimicking a pituitary macroadenoma.

We report the case of a 61-year-old man with an unusual intrasellar vascular malformation, who presented with symptoms of hypopituitarism and whose neuroradiologic evaluation mimicked a pituitary macroadenoma. The histopathologic and radiologic findings are discussed. This rare lesion should be considered in the diagnosis of a sellar mass lesion.

The increase in the cardiodepressant activity and vasopressin concentration in the sella turcica venous blood during vagal afferents stimulation or after angiotensin II infusion.

It has previously been demonstrated that the cardiodepressant activity is present in the bovine hypothalamic extract and in the fluid incubating the posterior pituitary lobe "in situ". The present study was an attempt to reveal if the cardiodepressant factor and vasopressin were simultaneously released from the pituitary into blood. The samples of venous blood flowing from the sella turcica and, for comparison, from the posterior paw were collected in anaesthetized rats. Blood from the sella turcica was collected with a fine cannula inserted into the internal maxillary vein. The concentration of vasopressin in blood plasma was determined by radioimmunoassay and cardiodepressant activity--using a biological test on a spontaneously discharged pacemaker tissue of the right auricle of the right heart atrium. Stimulation of the central ends of the cut vagus nerves or intra-arterial infusion of angiotensin II simultaneously caused an increase in the cardiodepressant activity and vasopressin concentration in the sella turcica venous blood. The cardiodepressant activity and vasopressin concentration was also enhanced to some degree in blood outflowing from the posterior paw. Present results indicate that both vasopressin and the cardiodepressant factor are released into blood from the posterior pituitary lobe.

Increase in oxytocin and vasopressin concentration in the blood outflowing from sella turcica region after superior cervical ganglion stimulation in rat.

The aim of the study was to investigate whether the stimulation of the superior cervical ganglion influences the oxytocin and vasopressin release into the blood in condition of the of the sella turcica integrity. The experiments were performed on male rats under urethane-chloralose anaesthesia. Four 0.7 ml samples of the blood from the sella turcica region flowing through a tube inserted in the maxillary interna vein were collected in the 30, 35, 60 and 90 min of the experiments. The animals were divided into three groups: 1) control, 2) after the exposition of superior cervical ganglion. 3) after the collection of the 1-st sample of the blood the superior cervical ganglion was electrically stimulated for 30 min with trains of pulses. Vasopressin (AVP) and oxytocin (OXY) were determined in the blood plasma by radioimmunoassay. Stimulation of the superior cervical ganglion evoked an significant increase of AVP and OXY release into the blood. The increase of AVP release occurred after 30 min longer latency than the increase of OXY release.

[The parasellar osteo-dural chamber and the vascular and neural elements that traverse it. An anatomical concept that would replace the cavernous sinus of classical anatomy]. / La loge ostéo-durale parasellaire et les éléments vasculaires et nerveux qui la traversent. Une conception anatomique qui doit remplacer celle du sinus caverneux des classiques.

On each side of the sella turcica, because of the existence of vascular and nervous elements, the two aspects of the parasellar segment of the tentorium cerebelli diverge and with the wall of the sphenoid bone form an extradural lodge. In this space are included a venous pathway (the cavernous sinus of the classics), the internal carotid artery and the three oculo-motor cranial nerves. The venous pathway is a plexus of small sized veins, mainly draining the orbital blood, and has neighborhood relations with the carotid. The morphology of the region and the relations of the internal carotid artery and the cranial nerves with the dura propria are the result of the embryonnic development of the brain and the formation of the anterior and middle cerebral fossae. In the parasellar space the cranial nerves have a dural sheath as well as a leptomeningeal one. Nerves III and IV are very close to the lateral wall explaining its multilayered aspect. The internal carotid artery, extradural in its parasellar segment, at the level of the anterior clinoid process, is involved by dura propria to become intradural (the artery does not pierce the dura). Because of the adhesion of the dura propria to the intracranial periosteum the artery is attached to the bone whereas in its extradural and intradural segments it has some mobility. Recent studies have confirmed and completed this topographical concept, first presented in 1949, allowing successful approaches to vascular and tumorous lesions considered inoperable.

Intrasellar persistent trigeminal artery associated with a pituitary adenoma. Case report.

The case of a patient with Cushing's disease and a pituitary macroadenoma, who also had a persistent trigeminal artery coursing through the sella turcica on preoperative imaging studies, is presented. The patient was treated by transsphenoidal resection of the tumor.

Magnetic resonance imaging of the cavernous sinus.

The magnetic resonance (MR) appearance of the cavernous sinus was studied by correlating the MR images of normal volunteers and cryomicrotomic sections from six cadavers. In addition, MR images of patients with parasellar masses were compared with corresponding intravenously enhanced computed tomographic (CT) scans. The MR appearance of the cranial nerves in the cavernous sinuses is demonstrated, as well as MR signs of a parasellar mass, including obliteration of intracavernous venous spaces, displacement of the intracavernous internal carotid artery, and bulging of the lateral wall of the cavernous sinus. MR proved to be more effective than CT in delineating the parts of the cavernous sinus.