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Open access

The infundibulochiasmatic angle and the favorability of an endoscopic endonasal approach in type IV craniopharyngioma: illustrative case

Guilherme Finger, Maria Jose C Ruiz, Eman H Salem, Matthew D Marquardt, Kyle C Wu, Lucas P Carlstrom, Ricardo L Carrau, Luciano M Prevedello, and Daniel M Prevedello

BACKGROUND

Lesions located in the floor of the third ventricle are among the most difficult to access in neurosurgery. The neurovascular structures can limit transcranial exposure, whereas tumor extension into the third ventricle can limit visualization and access. The midline transsphenoidal route is an alternative approach to tumor invading the third ventricle if the tumor is localized at its anterior half and a working space between the optic apparatus and the pituitary infundibulum exists. The authors introduce the “infundibulochiasmatic angle,” a valuable measurement supporting the feasibility of the translamina terminalis endoscopic endonasal approach (EEA) for resection of type IV craniopharyngiomas.

OBSERVATIONS

Due to a favorable infundibulochiasmatic angle measurement on preoperative magnetic resonance imaging (MRI), an endoscopic endonasal transsellar transtubercular approach was performed to resect a type IV craniopharyngioma. At 2-month follow-up, the patient’s neurological exam was unremarkable, with improvement in bitemporal hemianopsia. Postoperative MRI confirmed gross-total tumor resection.

LESSONS

The infundibulochiasmatic angle is a radiological tool for evaluating the feasibility of EEA when resecting tumors in the anterior half of the third ventricle. Advantages include reduced brain retraction and excellent rates of resection, with minimal postoperative risks of cerebrospinal fluid leakage and permanent pituitary dysfunction.

Open access

Introducing next-generation transcranial surgery with the head-mounted 3D View Vision display in extracorporeal microsurgery: illustrative cases

Young Ju Kim, Hidehito Kimura, Hiroto Kajimoto, Tatsuya Mori, Masahiro Maeyama, Kazuhiro Tanaka, and Takashi Sasayama

BACKGROUND

Exoscopy in neurosurgery offers various advantages, including increased freedom of the viewing axis while the surgeon maintains a comfortable upright position. However, the optimal monitor positioning to avoid interference with surgical manipulation remains unresolved. Herein, the authors describe two cases in which a three-dimensional head-mounted display (3D-HMD) was introduced into a transcranial neurosurgical procedure using an exoscope.

OBSERVATIONS

Case 1 was a 50-year-old man who presented with recurrent epistaxis and was diagnosed with an olfactory neuroblastoma that extended from the nasal cavity to the anterior cranial base and infiltrated the right anterior cranial fossa. Case 2 was a 65-year-old man who presented with epistaxis and was diagnosed with a left-sided olfactory neuroblastoma. In both cases, en bloc tumor resection was successfully performed via a simultaneous exoscopic transcranial approach using a 3D-HMD and an endoscopic endonasal approach, eliminating the need to watch a large monitor beside the patient.

LESSONS

This is the first report of using a 3D-HMD in transcranial surgery. The 3D-HMD effectively addressed issues with the field of vision and concentration while preserving the effectiveness of traditional microscopic and exoscopic procedures when observed on a 3D monitor. Combining the 3D-HMD with an exoscope holds the potential to become a next-generation surgical approach.

Open access

A silent corticotroph adenoma: making the case for a pars intermedia origin. Illustrative case

Mohammad Bilal Alsavaf, Kyle C. Wu, Guilherme Finger, Eman H. Salem, Maria Jose Castello Ruiz, Saniya S. Godil, Luma Ghalib, Ricardo L. Carrau, and Daniel M. Prevedello

BACKGROUND

Silent corticotroph adenomas (SCAs) are the only pituitary adenomas thought to originate from the pars intermedia. This case report presents the rare finding of a multimicrocystic corticotroph macroadenoma displacing the anterior and posterior lobes of the pituitary gland on magnetic resonance imaging (MRI). This finding supports the hypothesis that silent corticotroph adenomas may originate from the pars intermedia and should be considered in the differential for tumors arising from this location.

OBSERVATIONS

A 55-year-old man presented with an episode of confusion and blurred vision. MRI demonstrated separation of the anterior and posterior glands by a solid-cystic lesion located within the pars intermedia that superiorly displaced the optic chiasm. Endocrinologic evaluation was unremarkable. The differential diagnosis included pituitary adenoma, Rathke cleft cyst, and craniopharyngioma. The tumor was confirmed to be an SCA on pathology and was completely removed through the endoscopic endonasal transsphenoidal approach.

LESSONS

The case highlights the importance of preoperative screening for subclinical hypercortisolism for tumors arising from this location. Knowledge of a patient’s preoperative functional status is critical and dictates their postoperative biochemical assessment to determine remission. The case also illustrates surgical strategies for resecting pars intermedia lesions without injuring the gland.

Open access

Chronic expanding pituitary hematoma with calcification resulting from pituitary adenoma: illustrative case

Fugen Takagi, Ryokichi Yagi, Takuya Kanemitsu, Yuichiro Tsuji, Naokado Ikeda, Naosuke Nonoguchi, Motomasa Furuse, Shinji Kawabata, Toshihiro Takami, and Masahiko Wanibuchi

BACKGROUND

Pituitary apoplexy (PA) is characterized by sudden headache, vomiting, visual dysfunction, anterior lobe dysfunction, and endocrine disorder due to bleeding or infarction from a pituitary adenoma. PA occurs in approximately 0.6–10% of pituitary adenomas, more commonly in men aged 50–60 years, and more frequently in nonfunctioning and prolactin-producing pituitary adenomas. Further, asymptomatic hemorrhagic infarction is found in approximately 25% of PA.

OBSERVATIONS

A pituitary tumor with asymptomatic hemorrhage was detected on head magnetic resonance imaging (MRI). Thereafter, the patient underwent head MRI every 6 months. After 2 years, the tumor was enlarged and visual dysfunction was noticed. The patient underwent endoscopic transnasal pituitary tumor resection and was diagnosed with a chronic expanding pituitary hematoma with calcification. The histopathological findings were very similar to those of chronic encapsulated expanding hematoma (CEEH).

LESSONS

CEEH associated with pituitary adenomas gradually increases in size, causing visual dysfunction and pituitary dysfunction. In case of calcification, total removal is difficult due to adhesions. In this case, calcification developed within 2 years. A pituitary CEEH, even when showing calcification, should be operated on, as visual function can be fully recovered.

Open access

Cerebral vasospasm as a consequence of pituitary apoplexy: illustrative case

Somayah Alsayadi, Rafael Ochoa-Sanchez, Ioana D. Moldovan, and Fahad Alkherayf

BACKGROUND

Cerebral vasospasm is a rare but devastating complication following pituitary apoplexy. Cerebral vasospasm is often associated with subarachnoid hemorrhage (SAH), and early detection is crucial for proper management.

OBSERVATIONS

The authors present a case of cerebral vasospasm after endoscopic endonasal transsphenoid surgery (EETS) in a patient with pituitary apoplexy secondary to pituitary adenoma. They also present a literature review of all similar cases published to date. The patient is a 62-year-old male who presented with headache, nausea, vomiting, weakness, and fatigue. He was diagnosed with pituitary adenoma with hemorrhage, for which he underwent EETS. Pre- and postoperative scans showed SAH. On postoperative day 11, he presented with confusion, aphasia, arm weakness, and unsteady gait. Magnetic resonance imaging and computed tomography scans were consistent with cerebral vasospasm. The patient underwent endovascular treatment of acute intracranial vasospasm and was responsive to intra-arterial milrinone and verapamil infusion of the bilateral internal carotid arteries. There were no further complications.

LESSONS

Cerebral vasospasm is a severe complication that can occur after pituitary apoplexy. It is essential to assess the risk factors linked to the cerebral vasospasm. In addition, a high index of suspicion will allow neurosurgeons to diagnose cerebral vasospasm after EETS early and take the necessary measures to manage it accordingly.