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Wei-Hsin Wang, Stefan Lieber, Ming-Ying Lan, Eric W. Wang, Juan C. Fernandez-Miranda, Carl H. Snyderman, and Paul A. Gardner

I njury to the internal carotid artery (ICA) is the most feared, stressful, and potentially devastating complication of endoscopic endonasal surgery (EES) of the skull base. Common intraoperative management strategies to control bleeding include bipolar electrocautery, application of aneurysm clips, packing with hemostatic material or a muscle patch, and ICA sacrifice. 2 For efficient control of bleeding while maintaining a patent ICA, packing with a crushed muscle graft may be the most effective option. 1 A suitable muscle graft can be harvested from numerous

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Ahmed Mohyeldin, Jayakar V. Nayak, and Juan C. Fernandez-Miranda

(2:20), these approaches have been associated with increased risk of visual decline postoperatively. The endoscopic endonasal approach offers direct access to the tuberculum sella and allows the surgeon to leverage an infrachiasmatic approach to the tumor and its blood supply. 2:41 Careful review of the anatomy from an endonasal perspective helps us deconstruct the approach. Seen here is an endoscopic view of the ventral skull base (2:50) as seen through the sphenoid sinus. As depicted, the sella is surrounded by the paraclinoidal carotid arteries. Separating the

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Juan C. Fernandez-Miranda, Carlos D. Pinheiro-Neto, Paul A. Gardner, and Carl H. Snyderman

The authors present the technical and anatomical nuances needed to perform an endoscopic endonasal removal of a tuberculum sellae meningioma. The patient is a 47-year-old female with headaches and an incidental finding of a small tuberculum sellae meningioma with no vascular encasement, no optic canal invasion, but mild inferior to superior compression of the cisternal segment of the left optic nerve. Neuroophthalmology assessment revealed no visual defects. Treatment options included clinical observation with imaging follow-up studies, radiosurgery, and resection. The patient elected to undergo surgical removal and an endonasal endoscopic approach was the preferred surgical option.

Preoperative radiological studies showed the presence of an osseous ring between the left middle and anterior clinoids, the so-called carotico-clinoidal ring. The surgical implications of this finding and its management are illustrated. The surgical anatomy of the suprasellar region is reviewed, including concepts such as the chiasmatic sulcus and limbus sphenoidale, medial and lateral optico-carotid recesses, and the paraclinoidal and supraclinoidal segments of the internal carotid artery. Emphasis is made in the importance of exposing the distal dural ring of the internal carotid artery and the precanalicular segment of the optic nerve for adequate intradural dissection. The endonasal route allows for early coagulation of the tumor meningeal supply and extensive resection of dural attachments, and importantly, provides an inferior to superior access to the infrachiasmatic region that facilitates complete tumor removal without any manipulation of the optic nerve. The lateral limit of dural removal is formed by the distal dural ring, which is gently coagulated after the tumor is resected. A 45° scope is used to inspect for any residual tumor, in particular at the entrance of the optic nerve into the optic canal and at the most anterior margin of the exposure (limbus sphenoidale). The steps for reconstruction are detailed and include intradural placement of dural substitute and extradural placement of the nasoseptal flap. The nuances for proper harvesting, positioning, and reinforcement of the flap are described. No lumbar drain was used.

The patient had an uneventful recovery with no CSF leak or any other complications. Imaging follow-up at 6 months showed complete removal of the tumor. The patient had no sinonasal or neurological symptoms, and olfaction was fully preserved.

The video can be found here: http://youtu.be/kkuV-yyEHMg.

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Ahmed Mohyeldin, Peter Hwang, Gerald A. Grant, and Juan C. Fernandez-Miranda

anatomy from the front simulating an endonasal endoscopic approach. We can see the sphenoid sinus and the tumor located above and behind the sella between the pituitary gland. We can also identify the relationship of the tumor with the neurovascular structures, the arteries of the circle of Willis. We can see the carotid artery bifurcation. The basilar bifurcation with the posterior communicating arteries and the posterior cerebral arteries intimately involved with the tumor. 1:43 We are now in the operation. 1:45 We started the drilling, identifying the optic nerve

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Chirag R. Patel, Eric W. Wang, Juan C. Fernandez-Miranda, Paul A. Gardner, and Carl H. Snyderman

internal carotid artery (ICA) and jugular bulb can also limit access with the infralabyrinthine or infracochlear approach. 5 , 7 Endoscopic endonasal approaches (EEAs) to the petrous apex have been used with increasing frequency. The safety and efficacy of the EEA have been demonstrated in multiple publications. 1 , 4 , 7 Medial petrous apex lesions extending into the sphenoid sinus can be accessed directly with minimal risk to the ICA via a transsphenoidal approach. Lesions of the superior petrous apex that are positioned more laterally, however, require exposure and

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David T. Fernandes Cabral, Georgios A. Zenonos, Juan C. Fernandez-Miranda, Eric W. Wang, and Paul A. Gardner

( Fig. 3 ). This patient had undergone a biopsy at another institution prior to presentation, which resulted in right-sided blindness. Interestingly, the patient originally received the diagnosis of sarcoma, given the atypical features of the tumor. Because of the patient’s advanced age and the complete encasement of both carotid arteries, a near-total resection was performed (90%–95%), followed by hypofractionated CyberKnife stereotactic radiotherapy (4 fractions). A left nasal-septal flap was used for reconstruction. As in the previous case, the patient’s original

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Kumar Abhinav, David Hong, Carol H. Yan, Peter Hwang, and, and Juan C. Fernandez-Miranda

of the cavernous sinus anatomy so that we can access the cavernous sinus and mobilize the wall away from the carotid artery by cutting the inferior ligament and the inferior hypophyseal artery. In addition, it is key to understand the anatomy of the pons, the basilar artery, the perforating branches, and the different segments of the abducens nerve. 1:16 Surgical approach, posterior clinoidectomy, and tumor resection So we have performed now our endonasal endoscopic approach. We are working transclival exposing the right carotid artery on the paraclival segment

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Alessandro Paluzzi, Paul Gardner, Juan C. Fernandez-Miranda, Carlos D. Pinheiro-Neto, Tiago Fernando Scopel, Maria Koutourousiou, and Carl H. Snyderman

aperture. C: Coronal postcontrast T1-weighted MR image showing the same CG. D: Schematic representing the Type A CG. E: Endoscopic view (0°) of a cadaveric specimen demonstrating the position of the CG in relation to the carotid artery (dotted circle). F: Postoperative CT scan with bone window showing the bone removed during the transclival approach. To determine the influence that the volume of the cyst and the V-angle had on the choice of approach (1-transclival ± ICA lateralization or 2-transclival + infrapetrous), the point biserial correlation

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Huy Q. Truong, Stefan Lieber, Edinson Najera, Joao T. Alves-Belo, Paul A. Gardner, and Juan C. Fernandez-Miranda

sinus . 24 In a previous publication, however, based on the dural architecture of the sellar and parasellar region, we proposed the identification of an anterior wall of the CS in place of the sphenoidal part and its differentiation from the medial wall of the CS, correspondent to Yasuda’s sellar part. 1 The medial wall of the CS forms the lateral boundary of the hypophyseal fossa and separates the pituitary gland from the cavernous segment of the internal carotid artery (ICA) and the venous channels. While there has been significant confusion regarding the anatomy

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Salomon Cohen-Cohen, Paul A. Gardner, Joao T. Alves-Belo, Huy Q. Truong, Carl H. Snyderman, Eric W. Wang, and Juan C. Fernandez-Miranda

generally not performed due to the risk of vascular and cranial nerve injury and significant blood loss. 14 Our recent anatomical investigations, described in part 1 of this study, 25 have shown that the medial wall of the CS is formed by a single layer of meningeal dura that surrounds and attaches to the pituitary gland. It has multiple ligaments that support its adherence to the internal carotid artery (ICA) and the other walls of the CS. 4 , 5 The surgical technique described in part 1 for selective removal of the medial wall of the CS is based on an accurate