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Amin B. Kassam, Paul A. Gardner, Arlan Mintz, Carl H. Snyderman, Ricardo L. Carrau and Michael Horowitz

clip access to the proximal ICA was confirmed ( Fig. 5 ). A transplanum exposure of the paraclinoidal carotid artery in the opticocarotid cistern provided distal control ( Fig. 6 ). F ig . 3. Endoscopic view of the initial exposure after a wide sphenoidotomy was performed. PCP = paraclival carotid protuberance; pl = planum sphenoidale; tub = tuberculum sellae. F ig . 4. Endoscopic view of the left paraclival segment of the ICA exposed to obtain proximal control. CR = clival recess. F ig . 5. Endoscopic view of proximal control. Potential

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Amin B. Kassam, Paul A. Gardner, Carl H. Snyderman, Ricardo L. Carrau, Arlan H. Mintz and Daniel M. Prevedello

identified. A critical anatomical landmark is the osseous indentation or recess that is formed at the medial junction of the parasellar carotid canal (traveling vertically) and the optic canal (traveling obliquely in an anterior to posterior direction, away from the orbit). This mOCR represents the indentation or pneumatization of the middle clinoid and lateral portions of the tuberculum sellae, as viewed from the sinuses. The middle, or medial, clinoids form the lateral border of the anterior sella. 1 , 17 The prominence of the mOCR as seen from the endonasal side will

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Paul A. Gardner, Daniel M. Prevedello, Amin B. Kassam, Carl H. Snyderman, Ricardo L. Carrau and Arlan H. Mintz

. Laryngoscope 106 : 914 – 918 , 1996 6 Chakrabarti I , Amar AP , Couldwell W , Weiss MH : Long-term neurological, visual, and endocrine outcomes following transnasal resection of craniopharyngioma . J Neurosurg 102 : 650 – 657 , 2005 7 Cohen-Gadol AA , Liu JK , Laws ER Jr : Cushing's first case of transsphenoidal surgery: the launch of the pituitary surgery era . J Neurosurg 103 : 570 – 574 , 2005 8 Cook SW , Smith Z , Kelly DF : Endonasal transsphenoidal removal of tuberculum sellae meningiomas: technical note . Neurosurgery

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Luigi M. Cavallo, Daniel M. Prevedello, Domenico Solari, Paul A. Gardner, Felice Esposito, Carl H. Snyderman, Ricardo L. Carrau, Amin B. Kassam and Paolo Cappabianca

the advantage of facing the tumor immediately after the dural opening without brain retraction, and optimizes visualization of the relevant anatomy through a straight surgical route. 42 Indeed, such a corridor seems even more attractive in recurrent tumors in patients with previous craniotomies, in whom it is a virgin route, providing the possibility of bypassing adherences and avoiding further brain manipulation ( Fig. 1 ). F ig . 1. Schematic drawing of the suprasellar area as observed from a transcranial pterional approach. The tuberculum sellae and the

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Amin B. Kassam, Daniel M. Prevedello, Ricardo L. Carrau, Carl H. Snyderman, Ajith Thomas, Paul Gardner, Adam Zanation, Bulent Duz, S. Tonya Stefko, Karin Byers and Michael B. Horowitz

Table 3 ). TABLE 2: Median sagittal plane EEAs * Module Corridor Anatomical Boundary Cistern Neurovascular Structures Key Anatomical Landmark Common Pathology transsellar sphenoid & pst ethmoid SIS to IIS, cavernous to cavernous subdiaphragmatic & suprasellar carotid siphon; medial cavernous sinus; CNs III, IV, & VI; optic chiasm tuberculum sellae, sellar floor, “4 blues” SIS to IIS & cavernous sinuses RCC, pituitary adenoma transplanum sphenoid & pst ethmoid pst ethmoidal artery, sella pst, optic

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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.

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Maria Koutourousiou, Paul A. Gardner, Juan C. Fernandez-Miranda, Alessandro Paluzzi, Eric W. Wang and Carl H. Snyderman

transsphenoidal approach for tuberculum sellae meningiomas . Neurosurgery 62 : 6 Suppl 3 1192 – 1201 , 2008 7 de Paiva Neto MA , Vandergrift A , Fatemi N , Gorgulho AA , Desalles AA , Cohan P , : Endonasal transsphenoidal surgery and multimodality treatment for giant pituitary adenomas . Clin Endocrinol (Oxf) 72 : 512 – 519 , 2010 8 Dehdashti AR , Ganna A , Witterick I , Gentili F : Expanded endoscopic endonasal approach for anterior cranial base and suprasellar lesions: indications and limitations . Neurosurgery 64 : 677 – 689

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Maria Koutourousiou, Juan C. Fernandez-Miranda, S. Tonya Stefko, Eric W. Wang, Carl H. Snyderman and Paul A. Gardner

. Seventy-five patients with suprasellar meningiomas originating from the tuberculum sellae and/or planum sphenoidale were identified. One patient with meningiomatosis presented with 2 distinct suprasellar meningiomas of the planum sphenoidale and tuberculum sellae that were treated at the same time with a single EES. All meningiomas included in this study were benign (WHO Grade I). Patient age ranged from 36 to 88 years (mean 57.3 years) and there was a clear female predominance (81.3% female). Among the 75 patients, 71 had primary tumors (94.7%) and 4 (5.3%) were

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Juan C. Fernandez-Miranda, Paul A. Gardner, Milton M. Rastelli Jr., Maria Peris-Celda, Maria Koutourousiou, David Peace, Carl H. Snyderman and Albert L. Rhoton Jr.

between cavernous and paraclinoid ICA segments. Removal of the middle clinoid is required, except when a caroticoclinoidal bony ring is identified; in this case, reduction of the middle clinoid is sufficient and safer. The surgical steps to accomplish a middle clinoidectomy have been recently described. 4 The exposure of the sellar dura continues superiorly up to the tuberculum sellae and medial optic-carotid recesses, which typically do not have to be removed unless suprasellar access is required. Inferiorly, it is important to drill out the sellar floor all the way

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Maria Koutourousiou, Juan C. Fernandez-Miranda, Eric W. Wang, Carl H. Snyderman, M.B.A. and Paul A. Gardner

enhancing area along the skull base ( arrowheads ) represents the vascularized nasoseptal flap. In 1 year of follow-up there has been no tumor regrowth, and the patient is neurologically intact. Fig. 3 An NTR of olfactory groove meningioma with staged EES. Upper: Preoperative axial, coronal, and sagittal MRI studies obtained with contrast illustrating a rounded meningioma with maximum diameter of 60 mm originating from the cribriform plate and planum sphenoidale and extending toward the tuberculum sellae. Clinical presentation included decreased cognition and