Surgical implementation and efficacy of endoscopic endonasal extradural posterior clinoidectomy

Restricted access

OBJECTIVE

The endoscopic endonasal approach (EEA) for skull base tumors has become an important topic in recent years, but its use, merits, and demerits are still being debated. Herein, the authors describe the nuances and efficacy of the endoscopic endonasal extradural posterior clinoidectomy for maximal tumor exposure.

METHODS

The surgical technique included extradural posterior clinoidectomy following lateral retraction of the paraclival internal carotid artery and extradural pituitary transposition. In cases with prominent posterior clinoid process, a midline sellar dura cut was added to facilitate extradural exposure. Forty-four consecutive patients, in whom this technique was performed between 2016 and 2018 at Osaka City University Hospital, were reviewed. The pathology included 19 craniopharyngiomas, 7 chordomas, 6 meningiomas, 6 pituitary adenomas, 4 chondrosarcomas, and 2 miscellaneous. Utilization and effectiveness of this approach were further demonstrated with neuroimaging.

RESULTS

Extradural posterior clinoidectomies were successfully applied in all patients without permanent neurovascular injury and with better maneuverability and greater resection rate of the tumors. Four patients experienced transient postoperative abducens nerve paresis, and 1 patient experienced transient postoperative oculomotor nerve paresis; however, the patients with deficits recovered within 3 months. On radiological examination, the surgical field was 2.2 times wider in cases with bilateral posterior clinoidectomy than in cases without posterior clinoidectomy.

CONCLUSIONS

The extended EEA with extradural posterior clinoidectomy creates an extra working space and allows adequate accessibility with safe surgical maneuverability to remove tumors that extend behind the posterior clinoid and dorsum sellae.

ABBREVIATIONS DI = diabetes insipidus; EEA = endoscopic endonasal approach; GTR = gross-total resection; ICA = internal carotid artery; IHA = inferior hypophyseal artery; OF = operative field; PCP = posterior clinoid process; POF = prospective operative field; STR = subtotal resection.

Article Information

Correspondence Takeo Goto: Osaka City University Graduate School of Medicine, Osaka, Japan. gotot@med.osaka-cu.ac.jp.

INCLUDE WHEN CITING Published online May 3, 2019; DOI: 10.3171/2019.2.JNS183278.

Disclosures The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

© AANS, except where prohibited by US copyright law.

Headings

Figures

  • View in gallery

    Endoscopic view from after sphenoidectomy to after posterior clinoidectomy. A: Drilling out the sellar floor until it is eggshell thin. B: Exposure of the tuberculum sellae and the medial part of the optic canal. C: Exposure of the anterior and inferior dural walls of the cavernous sinus on both sides. D: Identification of the paraclival internal carotid artery and upper clivus. E: Upper clivectomy and exposure of the paraclival internal carotid artery. F: Removal of bony structures covering the cavernous sinus around the foramen lacerum. G: Drilling out the upper clivus to expose the dura mater behind the clivus. H: Exposure of the lateral attachment of the PCP and dorsum sellae. I: Drilling out the proximal part of the PCP. J: Detachment of the PCP from the attachments. K: Removal of the PCP. L: After posterior clinoidectomy. M: Cutting the dura on the sellar floor. N: Exposure of the larger PCP with upper elevation of the dura mater of the sellar floor and pituitary gland. O: Drilling out the proximal portion of the PCP with lateral retraction of the paraclival internal carotid artery. P: Removal of the proximal PCP. Q: Removal of the top of the PCP. R: Lateral side of the interpeduncular cistern and identification of the oculomotor nerve, posterior communicating artery, and posterior cerebral artery. S: Detachment of the tumor from the oculomotor nerve and posterior communicating artery with straight surgical instruments. T: Opening the wide view of the prepontine cistern. ACS = anterior dural wall of the cavernous sinus; DS = dorsum sellae; ICS = inferior dural wall of cavernous sinus; OC = optic canal; P com = posterior communicating artery; PCA = posterior cerebral artery; PCICA = paraclival internal carotid artery; PCP = posterior clinoid process; PG = pituitary gland; SF = sellar floor; UC = upper clivus; III = oculomotor nerve. Figure is available in color online only.

  • View in gallery

    The schema of the operative view and radiological evaluation. A: A simplified figure before posterior clinoidectomy. B: A simplified figure after posterior clinoidectomy. C: Fusion image of CT and MRI. ac = anterior clinoid; BA = basilar artery; ICA = internal carotid artery; OF = operative field; pc, PC = posterior clinoid; PCA = posterior cerebral artery; PCP = posterior clinoid process; POF = prospective operative field; SCA = superior cerebellar artery; II = optic nerve; III = oculomotor nerve. Panels A and B copyright Alhusain Nagm. Published with permission. Figure is available in color online only.

  • View in gallery

    The schema of posterior clinoidectomy for a large posterior clinoid process and the coronal view around the sella turcica. A: Drilling out the proximal part of the PCP with lateral retraction of the paraclival internal carotid artery and epidural upper elevation of the pituitary gland. Removal of the PCP and dissection around the dura mater, interclinoid, and posterior clinoid ligament. B: Cutting the dura on the midline of the sellar floor after exposure of the paraclival internal carotid artery. Drilling out the proximal part of the PCP with lateral retraction of the paraclival internal carotid artery and further epidural upper elevation of the sellar floor with the pituitary gland. Removal of the PCP and dissection of the surrounding dura mater and the interclinoid and posterior clinoid ligaments. C: Epidural upper elevation of the pituitary gland without visualization of PCPs. D: After drilling out the inferior dural wall of the cavernous sinus, epidural upper elevation of the pituitary gland with visualization of the normal size PCP or proximal view of a large PCP. E: After drilling out the inferior dural wall of the cavernous sinus and cutting the sellar dura, upper elevation of the pituitary gland with visualization of the large PCP via the epidural tract. ICS = inferior dural wall of cavernous sinus; PCICA = paraclival internal carotid artery; PCP = posterior clinoid process; PG = pituitary gland; SF = sellar floor. Copyright Alhusain Nagm. Published with permission. Figure is available in color online only.

References

  • 1

    Dolenc VVSkrap MSustersic JSkrbec MMorina A: A transcavernous-transsellar approach to the basilar tip aneurysms. Br J Neurosurg 1:2512591987

  • 2

    Essayed WISingh HLapadula GAlmodovar-Mercado GJAnand VKSchwartz TH: Endoscopic endonasal approach to the ventral brainstem: anatomical feasibility and surgical limitations. J Neurosurg 127:113911462017

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 3

    Fernandez-Miranda JCGardner PARastelli MM JrPeris-Celda MKoutourousiou MPeace D: Endoscopic endonasal transcavernous posterior clinoidectomy with interdural pituitary transposition. J Neurosurg 121:91992014

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 4

    Fernandez-Miranda JCTormenti MLatorre FGardner PSnyderman C: Endoscopic endonasal middle clinoidectomy: anatomic, radiological, and technical note. Neurosurgery 71 (2 Suppl Operative):ons233ons2392012

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 5

    Kasemsiri PCarrau RLDitzel Filho LFPrevedello DMOtto BAOld M: Advantages and limitations of endoscopic endonasal approaches to the skull base. World Neurosurg 82 (6 Suppl):S12S212014

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 6

    Kassam ABGardner PASnyderman CHCarrau RLMintz AHPrevedello DM: Expanded endonasal approach, a fully endoscopic transnasal approach for the resection of midline suprasellar craniopharyngiomas: a new classification based on the infundibulum. J Neurosurg 108:7157282008

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 7

    Kassam ABPrevedello DMThomas AGardner PMintz ASnyderman C: Endoscopic endonasal pituitary transposition for a transdorsum sellae approach to the interpeduncular cistern. Neurosurgery 62 (3 Suppl 1):57742008

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 8

    Kassam ABVescan ADCarrau RLPrevedello DMGardner PMintz AH: Expanded endonasal approach: vidian canal as a landmark to the petrous internal carotid artery. J Neurosurg 108:1771832008

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 9

    Koutourousiou MGardner PAFernandez-Miranda JCPaluzzi AWang EWSnyderman CH: Endoscopic endonasal surgery for giant pituitary adenomas: advantages and limitations. J Neurosurg 118:6216312013

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 10

    Koutourousiou MGardner PATormenti MJHenry SLStefko STKassam AB: Endoscopic endonasal approach for resection of cranial base chordomas: outcomes and learning curve. Neurosurgery 71:614252012

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 11

    Krisht AF: Transcavernous approach to diseases of the anterior upper third of the posterior fossa. Neurosurg Focus 19(2):E22005

  • 12

    Mesquita Filho PMDitzel Filho LFPrevedello DMMartinez CAFiore MEDolci RL: Endoscopic endonasal surgical management of chondrosarcomas with cerebellopontine angle extension. Neurosurg Focus 37(4):E132014

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 13

    Messerer MCossu GPasche PIkonomidis CSimon CPralong E: Extended endoscopic endonasal approach to clival and paraclival tumors: indications and limits. Neurochirurgie 62:1361452016

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 14

    Ozveren MFUchida KAiso SKawase T: Meningovenous structures of the petroclival region: clinical importance for surgery and intravascular surgery. Neurosurgery 50:8298372002

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 15

    Paluzzi AFernandez-Miranda JCPinheiro-Neto CAlcocer-Barradas VLopez-Alvarez BGardner P: Endoscopic endonasal infrasellar approach to the sellar and suprasellar regions: technical note. Skull Base 21:3353422011

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 16

    Silva DAttia MSchwartz TH: Endoscopic endonasal posterior clinoidectomy. J Neurosurg 122:4784792015

  • 17

    Truong HQBorghei-Razavi HNajera EIgami Nakassa ACWang EWSnyderman CH: Bilateral coagulation of inferior hypophyseal artery and pituitary transposition during endoscopic endonasal interdural posterior clinoidectomy: do they affect pituitary function? J Neurosurg [epub ahead of print July 1 2018. DOI: 10.3171/2018.2.JNS173126]

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 18

    Umansky FElidan JValarezo A: Dorello’s canal: a microanatomical study. J Neurosurg 75:2942981991

  • 19

    Umansky FValarezo AElidan J: The microsurgical anatomy of the abducens nerve in its intracranial course. Laryngoscope 102:128512921992

  • 20

    Wang AJZaidi HALaws ED Jr: History of endonasal skull base surgery. J Neurosurg Sci 60:4414532016

TrendMD

Metrics

Metrics

All Time Past Year Past 30 Days
Abstract Views 695 695 120
Full Text Views 129 129 38
PDF Downloads 143 143 34
EPUB Downloads 0 0 0

PubMed

Google Scholar