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Ossama Al-Mefty and Luis A. B. Borba

was achieved in three patients: tumor was left in the occipital condyle (one patient) and the cerebellopontine angle (two patients). Partial removal was achieved in two patients; in both cases, tumor was left in the prepontine area and the patients experienced recurrent tumors. Extended Transsphenoidal Approach The classic transsphenoidal approach is useful for some cases of clival chordomas that are limited to the upper clivus, with or without invasion of the medial wall of the cavernous sinus. 38 This approach does not allow radical removal of a more

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Masahiko Kitano and Mamoru Taneda

posterior ethmoid sinus and the sphenoid sinus. The presence of the posterior ethmoid sinus indicates that direct visualization of the superolateral portion of the sphenoid sinus would be impossible. Fig. 2. Diagrams illustrating the submucosal posterior ethmoidectomy in the extended transsphenoidal approach. a: Mucosal elevation from the perpendicular plate of the ethmoid bone. b: Detachment of the nasal mucosa in the sphenoid ostium to expose the bony surface of the superior turbinate. c: Removal of the superior turbinate and posterior ethmoidectomy

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“Coded Harmonic Angio” technique Hideo Otsuki Susumu Nakatani Mami Yamasaki Akira Kinoshita Fuminori Iwamoto Naoki Kagawa June 2001 94 6 992 995 10.3171/jns.2001.94.6.0992 External carotid artery reconstruction performed using an autologous internal carotid artery patch Michael B. Pritz June 2001 94 6 996 998 10.3171/jns.2001.94.6.0996 Extended transsphenoidal approach with submucosal posterior ethmoidectomy for parasellar tumors Masahiko Kitano Mamoru Taneda June 2001 94 6 999 1004 10.3171/jns

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Neurosurgical Forum: Letters to the Editor To The Editor Giorgio Frank , M.D. “Bellaria” Hospital Ernesto Pasquini , M.D. University of Bologna—Sant'Orsola-Malpighi Hospital Diego Mazzatenta , M.D. “Bellaria” Hospital Bologna, Italy 917 918 Abstract The authors have developed an extended transsphenoidal approach with submucosal posterior ethmoidectomy for resection of tumors located in the cavernous sinus or the suprasellar region that are difficult to remove via the

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Intracranial Hypotension November 2001 95 5 10.3171/jns.2001.95.5.0914 Supracerebellar Transtentorial Approach November 2001 95 5 10.3171/jns.2001.95.5.0916 Extended Transsphenoidal Approach November 2001 95 5 10.3171/jns.2001.95.5.0917 Receiver—Operating Characteristic Curves November 2001 95 5 10.3171/jns.2001.95.5.0918 Third Ventriculostomy November 2001 95 5 10.3171/jns.2001.95.5.0919 Resection of low-grade gliomas Edward R. Laws Jr. November 2001 95 5 731 732 10.3171/jns.2001.95.5.0731 Intercenter variance

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James K. Liu, Kaushik Das, Martin H. Weiss, Edward R. Laws Jr and William T. Couldwell

these modifications, the extended transsphenoidal approach provides exposure for removal of tumors growing beyond the traditional boundaries of the sella turcica and suprasellar cistern; the approach may be extended anteriorly to resect suprasellar lesions, inferiorly to expose clival lesions, and laterally to access CS lesions ( Figs. 13 – 15 ). Fig. 13. Drawings showing the extended transsphenoidal approach with exposure of the anterior skull base. A purely suprasellar tumor may be approached by extending the bone resection anteriorly over the tuberculum

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Toshiki Yamasaki, Kouzo Moritake, Hidemasa Nagai, Takeshi Uemura, Takashi Shingu and Yoshifumi Matsumoto

possibility of vascular damage can be minimized by a combination of technology and technique. First, appropriate control of suction pressure can be achieved using this compact ultrasonic surgical aspirator with the extra-long bayonet handpiece. Adequate suction pressure is the most important factor in preventing ultrasonic aspirator—related vascular damage. Our apparatus allows such pressure control, and this is one of the main benefits of the device. Second, the transmaxillosphenoidal approach or extended transsphenoidal approach with posterior ethmoidectomy allows access

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Indro Chakrabarti, Arun P. Amar, William Couldwell and Martin H. Weiss

Object. The authors report on a cohort of patients with craniopharyngioma treated principally through transnasal (TN) resection and followed up for a minimum of 5 years. More specifically, they evaluate the role of the TN approach in the management of craniopharyngioma.

Methods. Between 1984 and 1994, 68 patients underwent TN resection of craniopharyngiomas at the University of Southern California. The tumor was at least partially cystic in 88% of cases. Four tumors were purely intrasellar, 53 had intra- and suprasellar components, and 11 were exclusively suprasellar. During the same period, 18 patients underwent transcranial (TC) resection of purely suprasellar craniopharyngiomas. Long-term neurological, visual, and endocrine outcomes were reviewed for all patients.

In 61 (90%) of 68 patients in the TN group, total resection was achieved, according to 3-month postoperative magnetic resonance images, although four patients suffered a recurrence. Three (43%) of the seven tumors that had been partially resected were enlarged on serial imaging. Fifty-four (87%) of 62 patients with preoperative visual loss experienced improvement in one or both eyes, but two patients (3%) with exclusively suprasellar tumors experienced postoperative visual worsening in one or both eyes. New instances of postoperative endocrinopathy (that is, not present preoperatively) occurred as follows: hypogonadism (eight of 22 cases), growth hormone (GH) deficiency (four of 18 cases), hypothyroidism (11 of 49 cases), hypocortisolemia (nine of 52 cases), and diabetes insipidus (DI; four of 61 cases). One case each of hypocortisolemia and hypothyroidism resolved after surgery. Hyperphagia occurred in 27 (40%) of 68 patients. One patient had short-term memory loss. Postoperative complications included one case of cerebrospinal fluid leak.

Among the 18 patients in the TC group, 11 had complete resections. In one case (9%) the tumors recurred. Three (43%) of the seven subtotally resected tumors grew during the follow-up interval. Vision improved in 11 (61%) of 18 cases and worsened in three (17%) as a result of surgery. New instances of postoperative endocrinopathy occurred as follows: hypogonadism (one of six cases), GH deficiency (four of seven cases), hypothyroidism (11 of 14 cases), hypocortisolemia (eight of 15 cases), and DI (nine of 16 cases). No instance of preoperative endocrinopathy was corrected through TC surgery. Four patients (22%) exhibited short-term memory loss and 11 (61%) had hyperphagia after surgery. When compared with those in the TC group, patients in the TN group had shorter hospital stays.

Conclusions. Use of the TN approach can render good outcomes in properly selected patients with craniopharyngioma, particularly when the tumor is cystic. Even in mostly suprasellar cases, an extended TN approach can afford complete resection. Note that endocrine function often worsens after surgery and that postoperative obesity can be a significant problem.

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Joshua R. Dusick, Felice Esposito, Daniel F. Kelly, Pejman Cohan, Antonio DeSalles, Donald P. Becker and Neil A. Martin

, and supraglandular Rathke cleft cysts. 15, 20, 29, 34–36, 38, 39, 43, 51, 61 Termed the extended transsphenoidal approach and originally described by Weiss 61 in 1987, this approach requires removal of additional bone along the tuberculum sellae and the posterior planum sphenoidale with subsequent opening of the dura mater above the diaphragma sellae. This route allows excellent midline access and visibility to the suprasellar space while obviating brain retraction. The technique does require a large opening in the dura mater over the tuberculum sellae and the

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Edward R. Laws, Adam S. Kanter, John A. Jane Jr. and Aaron S. Dumont

since then we have enthusiastically pursued the approach and have investigated its utility and challenges. 11, 13, 14, 22 The challenges of course include the selection of suitable patients. Not every patient with a midline suprasellar lesion is a candidate, and a good deal depends on the surgical anatomy, which is beautifully displayed by high-quality magnetic resonance imaging studies. These serve as a guide and roadmap to determine whether an extended transsphenoidal approach will be safe and adequate for dealing with a given lesion. In the selection process the