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

Guilherme Finger Department of Neurosurgery, The Ohio State University College of Medicine, Columbus, Ohio

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Maria Jose C Ruiz Department of Otolaryngology and Skull Base Surgery, Hospital Torrecardenas, Almeria, Spain

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Eman H Salem Department of Otolaryngology, Mansoura University, Mansoura, Egypt

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Matthew D Marquardt The Ohio State University College of Medicine, Columbus, Ohio

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Kyle C Wu Department of Neurosurgery, The Ohio State University College of Medicine, Columbus, Ohio

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Lucas P Carlstrom Department of Neurosurgery, The Ohio State University College of Medicine, Columbus, Ohio

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Ricardo L Carrau Department of Otolaryngology and Skull Base Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio; and

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Luciano M Prevedello Department of Radiology, The Ohio State University College of Medicine, Columbus, Ohio

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Daniel M Prevedello Department of Neurosurgery, The Ohio State University College of Medicine, Columbus, Ohio

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Open access

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.

ABBREVIATIONS

DI = diabetes insipidus; EEA = endoscopic endonasal approach; MRI = magnetic resonance imaging; SIS = superior intercavernous sinus; WHO = World Health Organization

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.

ABBREVIATIONS

DI = diabetes insipidus; EEA = endoscopic endonasal approach; MRI = magnetic resonance imaging; SIS = superior intercavernous sinus; WHO = World Health Organization

Craniopharyngioma is a World Health Organization (WHO) grade I tumor of the central nervous system centered on the parasellar region and derived from the ectodermal remnants of the craniopharyngeal duct.1 Because of its growth, infiltration, and propensity for regrowth, it is considered locally aggressive, threatening the function of surrounding structures, including the optic apparatus, pituitary infundibulum, and hypothalamus.2

For this reason, several classification systems have been developed to guide approach selection for each patient. Traditionally, transcranial approaches such as the frontolateral (e.g., pterional, orbitozygomatic) and midline supraorbital approaches (e.g., subfrontal, transcallosal, and anterior interhemispheric) have been used for resection. With the evolution of the endoscopic endonasal approach (EEA), this technique has been added to the treatment armamentarium.3

Traditionally, in accordance with Kassam and colleagues’ classification,4 type IV craniopharyngiomas originate within the infundibulum and at the top of the pars tuberalis, making them difficult to access through the endonasal route. Furthermore, adamantinomatous craniopharyngiomas often have an intimate relation with the floor and walls of the third ventricle, making gross-total resection of the tumor difficult with an increased risk of iatrogenic injury.4 However, individual tumor characteristics can make the EEA a reasonable consideration in specific cases.

We describe the translamina terminalis corridor via an EEA for selected type IV craniopharyngiomas, taking into consideration the anatomical constraints and tumor morphology in relation to the infundibulochiasmatic angle.

Illustrative Case

A 66-year-old male developed progressive peripheral vision loss, manifesting as bumping into objects over a period of 3 months. He was initially evaluated by a neurologist, who detected bitemporal hemianopsia. Further investigation with brain computed tomography revealed a solid cystic lesion in the suprasellar region protruding into the third ventricle, without calcification (Fig. 1).

FIG. 1
FIG. 1

Preoperative axial (A), coronal (B), and sagittal (C) computed tomography scans showing an isodense sellar region tumor with no calcification.

During his initial evaluation, the patient was found to have bitemporal hemianopsia. He also reported a 1-year history of erectile dysfunction associated with nocturia (two or three times per night) and feeling lightheaded with coughing and fast movements. A complete pituitary hormone work-up demonstrated central hypothyroidism (thyroid-stimulating hormone inappropriately normal with low free thyroxine levels) and low testosterone with normal follicle-stimulating hormone and luteinizing hormone.

Magnetic resonance imaging (MRI) demonstrated a 2.9-cm partially cystic mass expanding into the third ventricle, with an enhancing nodular component extending inferiorly, causing mass effect on the optic tract (Fig. 2). It was radiologically classified as a type II/type IV intraventricular craniopharyngioma.

FIG. 2
FIG. 2

Preoperative axial (A), coronal (B), and sagittal (C) MRI showing a solid cystic sellar region tumor with gadolinium enhancement in its solid portion and in its capsule.

In the sagittal MRI view, a line was drawn overlying the optic nerves. A second line was drawn overlying the pituitary stalk, creating an angle between the two lines (Fig. 3). This angle, named the “infundibulochiasmatic angle,” appeared favorable for an EEA approach for two reasons: 1) It is possible to notice a corridor between the two highlighted structures, allowing direct access to the tumor; and 2) the point of intersection between the lines was at the inferior portion of the tumor (on the floor of the third ventricle) and in the half/posterior third of the tumor on its anteroposterior length. These two characteristics indicated the feasibility of tumor resection.

FIG. 3
FIG. 3

The infundibulochiasmatic corridor is the working space between the optic chiasm and the anterior border of the pituitary stalk. A: Sagittal T1-weighted MRI of the tumor and the neural structures of the sellar and chiasmatic regions. B: Sagittal T1-weighted MRI delineating the tumor (white line), the pituitary stalk (red line), and the optic nerve/optic chiasm (yellow line).

A standard endoscopic approach to the sphenoid sinus was performed. The floor of the sphenoid sinus and the planum were drilled. A nasal septal flap was elevated on the right side. The tuberculum and posterior planum were thinned using a high-speed drill, and bone was removed to expose the underlying dura. After ligation of the superior intercavernous sinus using bipolar cautery, the sellar and anterior fossa dura were opened with a feather blade, and a plane between the dura and the gland was dissected. The intercavernous ligaments were sharply transected on the right side to release the pituitary gland and allow gentle inferomedial manipulation of the gland. This created a clear path toward the sellar diaphragm. The pituitary stalk was identified, and care was taken to protect and preserve the superior hypophyseal arteries. The diaphragm was cut, allowing access to the subarachnoid space and further dissection above the gland on the right side.

Once the arachnoid was cut, the lesion was identified toward the right of the pituitary stalk. The hypothalamus and the third ventricle’s floor were identified. A corridor between the right side of the pituitary stalk and underside of the optic chiasm was further dissected, with preservation of the hypophyseal arteries. The anterior face of the lesion was opened using microscissors. Pieces of specimen were obtained and sent to pathology. Tumor was removed from the suprasellar nodule, and debulking was performed within the third ventricle using a combination of suction and microforceps. After significant debulking, it was possible to define a plane around the tumor, allowing complete resection of its solid component, followed by opening of the cystic cavity. Due to adherence of the cystic wall of the tumor to the hypothalamus, with no plane to dissect those structures, the tumor cyst wall could not be resected. Reconstruction was performed with DuraGen (Integra LifeSciences Corp.) placed as a soft gasket seal. The skull base defect was covered with a nasal septal flap followed by pieces of nonbiological material to bolster the vascularized flap reconstruction in place.

Histopathological analysis was consistent with WHO grade I craniopharyngioma. On immunohistochemical staining, no beta-catenin was noted. Additional testing was notable for the presence of the BRAF V600E mutation.

On postoperative day 1, the patient developed polyuria and dilute urine, consistent with central diabetes insipidus (DI). This condition was treated with desmopressin, resulting in clinical and laboratory improvement.

At 2-month follow-up, the patient’s neurological exam was unremarkable, with improvement in his bitemporal hemianopsia. Postoperative MRI revealed a (near-total) tumor resection with no signs of complication (Fig. 4). Unfortunately, the patient did not feel comfortable during the postoperative MRI exam and did not tolerate the phase with contrast infusion. Even though T1-weighted imaging with contrast is ideal for evaluation of the extent of tumor resection, we were able to analyze only the T1-weighted sequences without contrast (Fig. 4).

FIG. 4
FIG. 4

Postoperative coronal (AC) and sagittal (D) T1-weighted MRI without contrast showing complete resection of the solid portion of the tumor, the optic apparatus decompressed (A), the cavity after tumor resection (B), the third ventricle without tumor, and patency of both foramen of Monro (C).

At his last endocrinological follow-up, the patient continued to experience DI and central hypothyroidism, requiring desmopressin 0.05 mg three times daily and levothyroxine 50 µg daily.

The case review and report followed the CARE (Case Report) guidelines.5

Patient Informed Consent

The necessary patient informed consent was obtained in this study.

Discussion

Type IV craniopharyngiomas originate within the infundibulum and top of the pars tuberalis and grow dorsally to invade the third ventricle. Traditionally, many cases with substantial third ventricular involvement have been managed using open approaches. Here, we show that for selected patients, the extended EEA can be a reasonable alternative. It is important to have significant experience with the EEA and work within a multidisciplinary team familiar with the anatomy of the suprasellar region and third ventricle to safely perform this approach (Fig. 5). The floor of the third ventricle extends from the optic chiasm anteriorly to the sylvian aqueduct posteriorly. The anterior wall of the third ventricle is formed by the anterior column of the fornix, anterior commissure, and lamina terminalis.6 This approach is adjacent to many important structures, including the optic chiasm, infundibulum, tuber cinereum, mammillary bodies, posterior perforated substance, and superior and medial part of the mesencephalic tegmentum, which must be carefully preserved throughout the operation.

FIG. 5
FIG. 5

Intraoperative photographs of the infundibulochiasmatic corridor. This corridor is delimited by the optic nerves and chiasm (superiorly) and the pituitary stalk (inferiorly and posteriorly) (A). Endoscopic translamina terminalis view of the third ventricle (B).

The feasibility of and surgical planning for the approach proposed herein is based on high-quality MRI. The surgical corridor to access the third ventricle is analyzed using thin-cut T1-weighted imaging and high-resolution T2 sequences in the sagittal view. Two trajectory lines are drawn to determine feasibility: The first trajectory line is drawn tangential to the inferior border of the optic chiasm, and the second line is drawn along the anterior border of the infundibulum (Fig. 3). If the point of intersection reaches the middle or posterior third of the craniopharyngioma at its most caudal portion (at the floor of the third ventricle), this suggests that complete tumor excision may be possible via the EEA (Video 1).

VIDEO 1. Clip showing the infundibulochiasmatic angle: a radiological tool for detecting the favorability of the EEA in type IV craniopharyngioma. Click here to view.

The surgical approach used in these cases begins with a traditional binostril EEA to expose the sphenoid sinus as well as elevation of a nasoseptal flap for reconstruction.7,8 Once the sphenoid sinus is opened, the intrasphenoidal septations are removed, and bone drilling is extended laterally to the medial wall of the cavernous sinuses. Once completed, key landmarks of the transsellar approach are identified, including the internal carotid arteries bilaterally, optic prominences, lateral and medial opticocarotid recesses, sella turcica, tuberculum sella, and planum sphenoidale.9

The posterior planum, tuberculum, and face of the sella are drilled until “eggshell” thin. The bone is removed using a Kerrison punch to expose the underlying sellar dura, superior intercavernous sinus (SIS), and dura of the anterior fossa.10

A sharp horizontal durotomy is performed horizontally inferior to the SIS, allowing access to the sellar region. A second sharp horizontal durotomy is then made parallelly over the anterior fossa. The SIS, which is between the two horizontal durotomies, is then coagulated with bipolar cautery and cut sharply. The durotomy is then extended rostrocaudally from the craniotomy limit superiorly to the diaphragm sella inferiorly. For these cases, the pituitary gland does not need to be completely exposed, but the surgical team does need to be able to identify the pituitary stalk and the pituitary gland extradurally. Its identification allows manipulation of the gland, consequently increasing the working corridor above the gland. The arachnoid membrane is dissected, exposing the pituitary stalk inferoposteriorly in the working corridor, and the optic nerves and optic chiasm are located superiorly in the working corridor. The lamina terminalis is identified and opened, providing access to the third ventricle, where the tumor is located.

The solid portion of the tumor is debulked carefully, dissecting it from surrounding vascular and neural structures, avoiding significant manipulation of the stalk and chiasm. It is well described that craniopharyngiomas are usually infiltrating tumors, very attached to the floor or lateral walls of the third ventricle (hypothalamus and thalamus, respectively) without a cleavage plane to dissect the tumor from those structures. In this scenario, it is advised not to dissect the tumor from the thalamic structures because of the high risk of hypothalamic and/or thalamic dysfunction in postoperative care. This surgical principle should be followed for the resection of any tumor located in the supradiaphragmatic region invading the third ventricle, regardless of the surgical approach chosen by the neurosurgeon (transcranial transsylvian, transcranial subfrontal, transcranial transventricular, transcranial transcalosum, or expanded endoscopic endonasal). Therefore, we do not classify the inability to resect the cystic wall in the presented case as a limitation of the described approach, because it is unexpected that it would be possible to be resected through a transcranial approach.

Once resection of the solid portion of the tumor and meticulous hemostasis are completed, an inlay DuraGen graft is placed to cover the exposed brain parenchyma. Pieces of Gelfoam are placed within and around the graft to bolster the DuraGen and hold it in place. Then the nasal septal flap is rotated to cover and reconstruct the exposed anterior fossa and sellar floor, making sure the graft has sufficient anterior extension and circumferential bony contact. This is held in place using soft packing and nasal trumpets, if required.

Observations

Although transcranial approaches have traditionally been used for type IV craniopharyngiomas, the extended EEA mentioned herein can be considered for lesions located in the anterior third of the third ventricle and included between the borders of the infundibulochiasmatic angle. Both surgical options carry distinct risks and benefits; however, this approach affords the advantages of enhanced visualization of the surrounding neurovascular structures and, consequently, the potential for safe resection and reduced brain retraction. Modern endoscopic approaches and reconstruction techniques have substantially reduced the risks of postoperative cerebrospinal fluid leakage and neuroendocrine dysfunction.11

It is important to intensively review preoperative imaging because the EEA is a poor option for lesions located in the posterior third of the third ventricle or with an acute infundibulochiasmatic angle.

Lessons

Although type IV craniopharyngiomas are traditionally removed via open surgical approaches, distinct patient and tumor characteristics make the extended EEA a viable option. The infundibulochiasmatic angle is a helpful radiological tool to evaluate the feasibility of an EEA for the resection of tumors located in the anterior portion of the third ventricle. This approach has the benefit of reduced brain retraction and potentially increased rates of gross-total resection. Adequate patient selection and approach considerations can greatly reduce the risks of postoperative CSF leakage and permanent pituitary dysfunction.

Author Contributions

Conception and design: DM Prevedello, Ruiz, Salem, Wu, Carrau, LM Prevedello. Acquisition of data: DM Prevedello, Ruiz, Salem. Analysis and interpretation of data: Finger, Ruiz, Marquardt, Carrau. Drafting the article: Finger, Ruiz, Salem, Marquardt, Carlstrom, Carrau. Critically revising the article: DM Prevedello, Finger, Marquardt, Wu, Carlstrom, Carrau, LM Prevedello. Reviewed submitted version of manuscript: DM Prevedello, Finger, Marquardt, Wu, Carlstrom, LM Prevedello. Approved the final version of the manuscript on behalf of all authors: DM Prevedello. Administrative/technical/material support: Finger, Carlstrom, LM Prevedello. Study supervision: DM Prevedello, Wu.

Supplemental Information

Videos

Video 1. https://vimeo.com/885677763.

References

  • 1

    Lubuulwa J, Lei T Pathological and topographical classification of craniopharyngiomas: a literature review. J Neurol Surg Rep. 2016;77(3):e121e127.

  • 2

    Lei C, Chuzhong L, Chunhui L, et al. Approach selection and outcomes of craniopharyngioma resection: a single-institute study. Neurosurg Rev. 2021;44(3):17371746.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 3

    Hardesty DA, Montaser AS, Beer-Furlan A, Carrau RL, Prevedello DM Limits of endoscopic endonasal surgery for III ventricle craniopharyngiomas. J Neurosurg Sci. 2018;62(3):310321.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 4

    Kassam AB, Gardner PA, Snyderman CH, Carrau RL, Mintz AH, Prevedello 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. 2008;108(4):715728.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 5

    Riley DS, Barber MS, Kienle GS, et al. CARE guidelines for case reports: explanation and elaboration document. J Clin Epidemiol. 2017;89:218235.

  • 6

    Pascual JM, Prieto R Craniopharyngioma and the third ventricle: this inescapable topographical relationship. Front Oncol. 2022;12(March):872689.

  • 7

    Kassam AB, Prevedello DM, Thomas A, et al. Endoscopic endonasal pituitary transposition for a transdorsum sellae approach to the interpeduncular cistern. Neurosurgery. 2008;62(3 suppl 1):5774.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 8

    Hadad G, Bassagasteguy L, Carrau RL, et al. A novel reconstructive technique after endoscopic expanded endonasal approaches: vascular pedicle nasoseptal flap. Laryngoscope. 2006;116(10):18821886.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 9

    Solari D, Morace R, Cavallo LM, et al. The endoscopic endonasal approach for the management of craniopharyngiomas. J Neurosurg Sci. 2016;60(4):454462.

  • 10

    Kassam A, Snyderman CH, Mintz A, Gardner P, Carrau RL Expanded endonasal approach: the rostrocaudal axis. Part I. Crista galli to the sella turcica. Neurosurg Focus. 2005;19(1):E3.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 11

    Hardesty DA, Montaser A, Kreatsoulas D, et al. Complications after 1002 endoscopic endonasal approach procedures at a single center: lessons learned, 2010-2018. J Neurosurg. 2021;136(2):393404.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • Collapse
  • Expand
  • FIG. 1

    Preoperative axial (A), coronal (B), and sagittal (C) computed tomography scans showing an isodense sellar region tumor with no calcification.

  • FIG. 2

    Preoperative axial (A), coronal (B), and sagittal (C) MRI showing a solid cystic sellar region tumor with gadolinium enhancement in its solid portion and in its capsule.

  • FIG. 3

    The infundibulochiasmatic corridor is the working space between the optic chiasm and the anterior border of the pituitary stalk. A: Sagittal T1-weighted MRI of the tumor and the neural structures of the sellar and chiasmatic regions. B: Sagittal T1-weighted MRI delineating the tumor (white line), the pituitary stalk (red line), and the optic nerve/optic chiasm (yellow line).

  • FIG. 4

    Postoperative coronal (AC) and sagittal (D) T1-weighted MRI without contrast showing complete resection of the solid portion of the tumor, the optic apparatus decompressed (A), the cavity after tumor resection (B), the third ventricle without tumor, and patency of both foramen of Monro (C).

  • FIG. 5

    Intraoperative photographs of the infundibulochiasmatic corridor. This corridor is delimited by the optic nerves and chiasm (superiorly) and the pituitary stalk (inferiorly and posteriorly) (A). Endoscopic translamina terminalis view of the third ventricle (B).

  • 1

    Lubuulwa J, Lei T Pathological and topographical classification of craniopharyngiomas: a literature review. J Neurol Surg Rep. 2016;77(3):e121e127.

  • 2

    Lei C, Chuzhong L, Chunhui L, et al. Approach selection and outcomes of craniopharyngioma resection: a single-institute study. Neurosurg Rev. 2021;44(3):17371746.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 3

    Hardesty DA, Montaser AS, Beer-Furlan A, Carrau RL, Prevedello DM Limits of endoscopic endonasal surgery for III ventricle craniopharyngiomas. J Neurosurg Sci. 2018;62(3):310321.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 4

    Kassam AB, Gardner PA, Snyderman CH, Carrau RL, Mintz AH, Prevedello 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. 2008;108(4):715728.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 5

    Riley DS, Barber MS, Kienle GS, et al. CARE guidelines for case reports: explanation and elaboration document. J Clin Epidemiol. 2017;89:218235.

  • 6

    Pascual JM, Prieto R Craniopharyngioma and the third ventricle: this inescapable topographical relationship. Front Oncol. 2022;12(March):872689.

  • 7

    Kassam AB, Prevedello DM, Thomas A, et al. Endoscopic endonasal pituitary transposition for a transdorsum sellae approach to the interpeduncular cistern. Neurosurgery. 2008;62(3 suppl 1):5774.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 8

    Hadad G, Bassagasteguy L, Carrau RL, et al. A novel reconstructive technique after endoscopic expanded endonasal approaches: vascular pedicle nasoseptal flap. Laryngoscope. 2006;116(10):18821886.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 9

    Solari D, Morace R, Cavallo LM, et al. The endoscopic endonasal approach for the management of craniopharyngiomas. J Neurosurg Sci. 2016;60(4):454462.

  • 10

    Kassam A, Snyderman CH, Mintz A, Gardner P, Carrau RL Expanded endonasal approach: the rostrocaudal axis. Part I. Crista galli to the sella turcica. Neurosurg Focus. 2005;19(1):E3.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 11

    Hardesty DA, Montaser A, Kreatsoulas D, et al. Complications after 1002 endoscopic endonasal approach procedures at a single center: lessons learned, 2010-2018. J Neurosurg. 2021;136(2):393404.

    • PubMed
    • Search Google Scholar
    • Export Citation

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