Lasica Nebojsa, Parikh Kara A, Arnautović Kenan I
Clinic of Neurosurgery, University Clinical Center of Vojvodina, Novi Sad , Serbia.
Faculty of Medicine, University of Novi Sad, Novi Sad , Serbia.
Oper Neurosurg (Hagerstown). 2025 Apr 1;28(4):536-546. doi: 10.1227/ons.0000000000001344. Epub 2024 Sep 20.
Despite advances in cranial base techniques, surgery of the sellar and parasellar regions remains challenging because of complex neurovascular relationships. Lesions within this region frequently present with progressive visual deterioration caused by distortion and compression of the optic chiasm and nerves. In addition to the direct mass effect from mechanical forces acting on the optic apparatus, these lesions alter blood supply and reduce vascular perfusion, prompting surgical treatment to remove the lesion, alleviate compression, and improve blood flow to the optic nerve. We sought to describe a 2-stage, 4-by-4-step approach, broken down and described as a "four-by-four" technique for optic apparatus decompression and a wide approach to different sellar and parasellar lesions.
We describe the operative nuances and key anatomic points in the microsurgical removal of sellar and parasellar lesions. The technique is illustrated with examples of different cases with pre- and follow-up MRI imaging and a brief overview of visual outcomes.
The described technique has been demonstrated in various lesions in 5 patients. Patients presented with bilateral visual loss in 4 (80.0%) cases and with unilateral visual loss in 1 (20.0%) case. Improvement in visual function was noted in all cases, confirmed with visual acuity and visual field testing.
The transcranial approach ("from above") remains an important surgical option for patients with excellent exposure and visualization of the sellar and parasellar regions. It permits early access to the optic canal for careful microsurgical decompression and relaxation of the optic nerve to preserve and improve its microvascularization and ultimately vision.
The authors augmented the 2-stage, 4-by-4-step technique of decompression with elaborate illustrations of diverse sellar and parasellar lesions to demonstrate the versatility of this approach.
尽管颅底技术取得了进展，但由于复杂的神经血管关系，鞍区和鞍旁区域的手术仍然具有挑战性。该区域的病变常因视交叉和神经的扭曲及受压而导致进行性视力下降。除了作用于视觉器官的机械力产生的直接肿块效应外，这些病变还会改变血液供应并减少血管灌注，从而促使进行手术治疗以切除病变、减轻压迫并改善视神经的血流。我们试图描述一种两阶段、四乘四步骤的方法，将其分解并描述为用于视觉器官减压的“四乘四”技术以及针对不同鞍区和鞍旁病变的广泛方法。
我们描述了在显微手术切除鞍区和鞍旁病变时的手术细微差别和关键解剖要点。通过不同病例的术前和术后MRI成像示例以及视觉结果的简要概述来说明该技术。
所描述的技术已在5例患者的各种病变中得到验证。4例（80.0%）患者出现双侧视力丧失，1例（20.0%）患者出现单侧视力丧失。所有病例的视觉功能均有改善，通过视力和视野测试得到证实。
经颅入路（“从上方”）对于能够很好地暴露和观察鞍区和鞍旁区域的患者仍然是一种重要的手术选择。它允许早期进入视神经管进行仔细的显微减压并松解视神经，以保留并改善其微血管化，最终改善视力。
作者通过对各种鞍区和鞍旁病变的详细图示，扩充了两阶段、四乘四步骤的减压技术，以证明该方法的通用性。
