Najera Edinson, Snyderman Carl H, Fernandez-Miranda Juan C
Department of Neurological Surgery, UPMC Presbyterian, Pittsburgh, Pennsylvania, United States.
Department of Otolaryngology, University of Pittsburgh, Pittsburgh, Pennsylvania, United States.
J Neurol Surg B Skull Base. 2018 Apr;79(Suppl 3):S284. doi: 10.1055/s-0038-1625969. Epub 2018 Feb 20.
In this video, we describe the technical nuances of an endoscopic endonasal approach (EEA) for a complex macroadenoma with suprasellar and retrochiasmatic extension. The patient is a 51-year-old male with several years' history of progressive visual loss. Neuro-ophthalmology assessment revealed a profound visual loss with homonymous hemianopsia and left optic nerve atrophy. His pituitary hormonal profile was normal. The options for surgical approach included transcranial, endoscopic endonasal, or a combination of both. An EEA was the preferred surgical option, because it allows for early identification of the pituitary gland, and provides access to the suprasellar region including pre- and retrochiasmatic spaces, which facilitates tumor removal while minimizing manipulation of the optic apparatus. While most pituitary adenomas do not require extracapsular subarachnoidal dissection, there are complex adenomas with subarachnoidal invasion and multilobulated morphology, such as the one presented here, that require a combination of internal debulking, extracapsular and subarachnoidal dissection. The technique presented here allows for complete tumor resection, avoiding the risk of postoperative apoplexy of residual adenoma, and facilitates identification of perforating branches and neural structures that require meticulous preservation. Here, we also illustrate the proper management of reconstruction-related complications. Postoperative course was complicated with meningitis with necrotic nasoseptal flap and required surgical debridement, new inferior turbinate flap, fascia lata, lumbar drain, and 6-week antibiotic treatment. Imaging follow-up showed complete removal of tumor. The patient had significant improvement in visual fields and left visual acuity, and no postoperative hormonal dysfunction. The link to the video can be found at: https://youtu.be/9T5b167bVJA .
在本视频中，我们描述了一种针对具有鞍上和视交叉后扩展的复杂大腺瘤的鼻内镜经鼻入路（EEA）的技术细节。患者为一名51岁男性，有多年渐进性视力丧失病史。神经眼科评估显示严重视力丧失伴同向性偏盲和左侧视神经萎缩。其垂体激素水平正常。手术入路的选择包括经颅、鼻内镜经鼻或两者结合。EEA是首选的手术方式，因为它能够早期识别垂体，并可进入鞍上区域，包括视交叉前和视交叉后间隙，这有助于在尽量减少对视器操作的同时切除肿瘤。虽然大多数垂体腺瘤不需要进行囊外蛛网膜下腔分离，但存在一些具有蛛网膜下腔侵犯和多叶形态的复杂腺瘤，如此处所示的病例，需要结合瘤内减压、囊外和蛛网膜下腔分离。此处介绍的技术能够实现肿瘤的完全切除，避免残留腺瘤术后卒中的风险，并有助于识别需要精心保留的穿支和神经结构。在此，我们还展示了与重建相关并发症的恰当处理。术后过程出现了坏死鼻中隔瓣导致的脑膜炎，需要进行手术清创、新的下鼻甲瓣、阔筋膜、腰大池引流以及为期6周的抗生素治疗。影像学随访显示肿瘤完全切除。患者视野和左眼视力有显著改善，且无术后激素功能障碍。视频链接可在：https://youtu.be/9T5b167bVJA 找到。
