Starnoni Daniele, Cossu Giulia, Messerer Mahmoud, Daniel Roy Thomas
Department of Neurosurgery, Centre Hospitalier Universitaire Vaudois, Switzerland.
University of Lausanne (UniL), Lausanne, Switzerland.
J Neurol Surg B Skull Base. 2021 May 11;83(Suppl 3):e630-e631. doi: 10.1055/s-0041-1727119. eCollection 2022 Aug.
Surgical treatment of functional pituitary adenomas is as rule performed by transsphenoidal approach. However, when then lesion invades the parasellar structures and the cavernous sinus, the transsphenoidal removal of these adenomas is usually incomplete. In this video, we present the technical nuances of a transcavernous approach to the anterio-medial triangle for the resection of a residual functional pituitary adenoma. The patient is a 40-year-old male who was diagnosed with growth hormone secreting pituitary macroadenoma. He underwent two transsphenoidal resections in 2013 and 2016 with a small residue in the left cavernous sinus. Subsequently, due to a failure of biochemical remission despite medical management, a transcranial transcavernous surgery was performed. Brain magnetic resonance imaging showed a mass in the roof of the left cavernous sinus, located at the level of the anteromedial triangle, adherent to the clinoidal segment of the internal carotid artery (ICA). The computed tomographic scan showed an osteolysis of the inferior surface of the anterior clinoidal process. After performing an extended pterional craniotomy and an extradural clinoidectomy, the cleavage plane is extended between the temporal dura and the inner layer of the lateral wall of the cavernous sinus. Intraoperative Doppler and stimulation are used to localize the clinoidal segment of the ICA and the third cranial nerve, delimiting the anteromedial triangle. The lesion is progressively dissected and removed. An optic neuropexy with the previously harvested fat is performed in case of a complementary radio surgical treatment. The patient had an uneventful postoperative course and showed a biochemical remission at the 3-month follow-up. The link to the video can be found at: https://youtu.be/oHfugVtU-Nc .
功能性垂体腺瘤的手术治疗通常采用经蝶窦入路。然而，当病变侵犯鞍旁结构和海绵窦时，经蝶窦切除这些腺瘤通常并不彻底。在本视频中，我们展示了经海绵窦入路至前内侧三角切除残留功能性垂体腺瘤的技术细节。患者为一名40岁男性，诊断为分泌生长激素的垂体大腺瘤。他在2013年和2016年接受了两次经蝶窦切除术，左侧海绵窦内仍有少量残留。随后，尽管进行了药物治疗，但生化缓解未成功，遂进行了经颅经海绵窦手术。脑部磁共振成像显示左侧海绵窦顶部有一肿块，位于前内侧三角水平，与颈内动脉（ICA）床突段粘连。计算机断层扫描显示前床突下表面骨质溶解。在进行扩大翼点开颅和硬膜外床突切除术之后，在颞叶硬膜和海绵窦外侧壁内层之间扩展分离平面。术中使用多普勒和电刺激来定位ICA的床突段和第三脑神经，划定前内侧三角。逐步分离并切除病变。如果需要辅助放射外科治疗，则用先前采集的脂肪进行视神经固定术。患者术后过程顺利，在3个月随访时显示生化缓解。视频链接可在：https://youtu.be/oHfugVtU-Nc 找到。
