An advanced protocol for intraoperative visualization of sinunasal structures: experiences from pituitary surgery

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OBJECTIVE

The transsphenoidal route to pituitary adenomas challenges surgeons because of the highly variable sinunasal anatomy. Orientation may be improved if the appropriate information is provided intraoperatively by image guidance. The authors developed an advanced image guidance protocol dedicated to sinunasal surgery that extracts information from multiple modalities and forms it into a single image that includes fine sinunasal structures and arteries.

The aim of this study was to compare the advantages of this novel image guidance protocol with the authors’ previous series, with emphasis on anatomical structures visualized and complication rate.

METHODS

This retrospective analysis comprised 200 patients who underwent surgery for pituitary adenoma via a transnasal transsphenoidal endoscopic approach. The authors’ standard image guidance protocol consisting of CT for solid bone, T1CEMRI for soft tissues, and MRA for the carotid artery was applied in 100 consecutive cases. The advanced image guidance protocol added a first-hit ray casting of the CT scan for visualization of fine sinunasal structures, and adjustments to the MRA to visualize the sphenopalatine artery (SPA) were applied in a subsequent 100 consecutive cases.

RESULTS

A patent sphenoid ostium—i.e., an ostium not covered by a mucosal layer—was visualized significantly more often by the advanced protocol than the standard protocol (89% vs 40%, p < 0.001) in primary surgeries. The SPA and its branches were only visualized by the advanced protocol (87% and 91% of cases in primary surgeries and reoperations, respectively) and not once by the standard protocol. The number of visualized complete and incomplete sphenoid septations matched significantly more commonly with the surgical view when using the advanced protocol than the standard protocol at primary operation (mean 1.9 vs 1.6, p < 0.001). However, in 25% of all cases a complex and not a simple sinus anatomy was present. In comparison with the intraoperative results, a complex sphenoid sinus anatomy was always detected by the advanced but not by the standard protocol (25% vs 8.5%, p = 0.001).

Furthermore, application of the advanced protocol reduced the cumulative rate of complications (25% vs 18% [standard vs advanced group]). Although an overall significant difference could not be determined (p = 0.228), a subgroup analysis of reoperations (35/200) revealed a significantly lower rate of complications in the advanced group (5% vs 30%, p = 0.028).

CONCLUSIONS

The data show that the advanced image guidance protocol could intraoperatively visualize the fine sinunasal sinus structures and small arteries with a high degree of detail. By improving intraoperative orientation, this may help to reduce the rate of complications in endoscopic transsphenoidal surgery, especially in reoperations.

ABBREVIATIONS GTR = gross-total resection; ICA = internal carotid artery; SPA = sphenopalatine artery; TOF = time-of-flight; T1CEMRI = T1-weighted contrast-enhanced MRI.

Article Information

Correspondence Engelbert Knosp: Medical University Vienna, Austria. engelbert.knosp@meduniwien.ac.at.

INCLUDE WHEN CITING Published online May 31, 2019; DOI: 10.3171/2019.3.JNS1985.

Disclosures S.W. is currently a consultant for Medtronic.

© AANS, except where prohibited by US copyright law.

Headings

Figures

  • View in gallery

    Visualization of SPAs and their branches (green arrows) by MRA on an axial advanced protocol image (left) and on a 3D reconstruction of CT and MRA images (right). Figure is available in color online only.

  • View in gallery

    A case of null cell adenoma with endosuprasellar extension and a visual field defect. A–E: Multiseptated sphenoid sinus with one horizontal, a doubled median vertical septum, and incomplete left oblique septum at the carotid protuberance (E, intraoperative view). The septations are displayed correctly by the advanced protocol (C, coronal; D, sagittal) but not by the standard protocol (A, coronal; B, sagittal). Figure is available in color online only.

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    A case of null cell adenoma with right-sided parasellar extension (Knosp grade 3B) and continuous enlargement. Surgery was performed with the standard protocol imaging guidance (A, coronal; B, sagittal) that did not visualize the Onodi cells and the two vertical septations (see advanced protocol: C, coronal; D, sagittal). The right vertical septum was not removed, impeding inspection of the inferior cavernous compartment. A recurrence was treated with Gamma Knife radiosurgery 3.5 years after the initial surgery (E, coronal; F, sagittal). Figure is available in color online only.

  • View in gallery

    Visualization of osseous covering of the ICA. Case of a young male operated on for microprolactinoma with dopamine agonist resistance. Besides the thin osseous sellar floor, the C3 segment of the right ICA does not show bony covering on advanced protocol (A, axial) and intraoperatively (B), important for anticipating when opening the sellar floor. Conversely, a patient is seen with a microadenoma with solid bone covering the ICA seen on image guidance (C, axial). Asterisks denote the uncovered ICA. CP = carotid protuberance; MS = median septum; SF = sellar floor. Figure is available in color online only.

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