Giurintano Jonathan P, Gurrola Jose, Theodosopoulos Philip V, El-Sayed Ivan H
Otolaryngology - Head and Neck Surgery, MedStar Washington Hospital Center, Washington, USA.
Otolaryngology - Head and Neck Surgery, University of California, San Francisco, USA.
Cureus. 2021 Feb 25;13(2):e13547. doi: 10.7759/cureus.13547.
While the use of image-guided navigation is an excellent adjunct to the use of anatomical landmarks, dynamic changes that may occur in the position of critical structures are not accounted for during and after tumor resection. Unlike navigation, Doppler ultrasonography provides real-time imaging of the anterior skull base and can be used to accurately identify the location of vital structures during skull base surgery. A 56-year-old female initially presented with new onset left eye visual deficits. She previously underwent sublabial transsphenoidal subtotal resection of the tumor, confirmed as clival chordoma. She subsequently presented to our institution. She was treated with an expanded endonasal resection of the remaining chordoma followed by CyberKnife radiosurgery. Two years later, surveillance imaging identified tumor recurrence within the right clivus posterior to the carotid artery. Intraoperatively, in the previously operated irradiated skull base, the normal bony architecture of the sella was absent, resulting in the inability to distinguish the anterior genu of the internal carotid artery (ICA) from the adjacent tumor. Using Doppler ultrasonography, the course of the ICA was imaged in real time, allowing for safe, gross total tumor resection. In the setting of prior operation, radiation, or extensive disease, the normal bony architecture of the sella may be disrupted, placing the cavernous ICA at risk. We report what we believe is the first use of intraoperative ultrasound during the endoscopic endonasal approach in the setting of a previously operated, radiated sella.
虽然图像引导导航是利用解剖标志的出色辅助手段，但在肿瘤切除期间及之后，关键结构位置可能发生的动态变化并未得到考虑。与导航不同，多普勒超声能够对前颅底进行实时成像，可用于在颅底手术期间准确识别重要结构的位置。一名56岁女性最初出现新发左眼视力缺陷。她此前接受了经唇下入路经蝶窦肿瘤次全切除术，确诊为斜坡脊索瘤。随后她前来我院就诊。对残留的脊索瘤进行了扩大经鼻内镜切除术，随后进行了射波刀放射治疗。两年后，监测影像显示在颈动脉后方的右侧斜坡出现肿瘤复发。术中，在先前手术及放疗过的颅底区域，蝶鞍正常的骨质结构已不存在，导致无法将颈内动脉（ICA）的前膝部与相邻肿瘤区分开来。使用多普勒超声实时成像颈内动脉的走行，从而实现了安全的肿瘤全切。在先前有手术、放疗或病变广泛的情况下，蝶鞍正常的骨质结构可能遭到破坏，使海绵窦段颈内动脉面临风险。我们报告了我们认为是首次在先前手术及放疗过的蝶鞍情况下，在内镜经鼻入路手术中使用术中超声的情况。
