The medial wall of the cavernous sinus. Part 2: Selective medial wall resection in 50 pituitary adenoma patients

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OBJECTIVE

Pituitary adenomas often invade the medial wall of the cavernous sinus (CS), but this structure is generally not surgically removed because of the risk of vascular and cranial nerve injury. The purpose of this study was to report the surgical outcomes in a large series of cases of invasive pituitary adenoma in which the medial wall of the CS was selectively removed following an anatomically based, stepwise surgical technique.

METHODS

The authors’ institutional database was reviewed to identify cases of pituitary adenoma with isolated invasion of the medial wall, based on an intraoperative evaluation, in which patients underwent an endoscopic endonasal approach with selective resection of the medial wall of the CS. Cases with CS invasion beyond the medial wall were excluded. Patient complications, resection, and remission rates were assessed.

RESULTS

Fifty patients were eligible for this study, 15 (30%) with nonfunctional adenomas and 35 (70%) with functional adenomas, including 16 growth hormone–, 10 prolactin-, and 9 adrenocorticotropic hormone (ACTH)–secreting tumors. The average tumor size was 2.3 cm for nonfunctional and 1.3 cm for functional adenomas. Radiographically, 11 cases (22%) were Knosp grade 1, 23 (46%) Knosp grade 2, and 16 (32%) Knosp grade 3. Complete tumor resection, based on intraoperative impression and postoperative MRI, was achieved in all cases. The mean follow-up was 30 months (range 4–64 months) for patients with functional adenomas and 16 months (range 4–30 months) for those with nonfunctional adenomas. At last follow-up, complete biochemical remission (using current criteria) without adjuvant treatment was seen in 34 cases (97%) of functional adenoma. No imaging recurrences were seen in patients who had nonfunctional adenomas. A total of 57 medial walls were removed in 50 patients. Medial wall invasion was histologically confirmed in 93% of nonfunctional adenomas and 83% of functional adenomas. There were no deaths or internal carotid artery injuries, and the average blood loss was 378 ml. Four patients (8%) developed a new, transient cranial nerve palsy, and 2 of these patients required reoperation for blood clot evacuation and fat graft removal. There were no permanent cranial nerve palsies.

CONCLUSIONS

The medial wall of the CS can be removed safely and effectively, with minimal morbidity and excellent resection and remission rates. Further follow-up is needed to determine the long-term results of this anatomically based technique, which should only be performed by very experienced endonasal skull base teams.

ABBREVIATIONS ACTH = adrenocorticotropic hormone; CN = cranial nerve; CS = cavernous sinus; EEA = endoscopic endonasal approach; GH = growth hormone; ICA = internal carotid artery; IGF-I = insulin-like growth factor–1; IHA = inferior hypophyseal artery; UFC = urinary free cortisol.

Article Information

Correspondence Juan C. Fernandez-Miranda: Department of Neurological Surgery, Stanford University, Stanford, CA. drjfm@stanford.edu.

INCLUDE WHEN CITING Published online September 7, 2018; DOI: 10.3171/2018.5.JNS18595.

Disclosures The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    Case involving a 69-year-old patient with abnormal IGF levels (1004 µg/L) and acromegalic features. A: Preoperative coronal postcontrast T1-weighted MR image showing a pituitary microadenoma (5 mm, arrow) adjacent to the right medial CS wall. B: Intraoperative view of the tumor after extracapsular dissection. C: Identification of the area suspicious for tumor invasion at the inferior aspect of the medial wall of the CS. D: Separation between the medial and anterior walls of the CS and mobilization of the medial wall away from the ICA. E: The medial wall has been completely removed, with exposure of the cavernous ICA laterally and the posterior clinoid posteriorly. F: Postoperative coronal postcontrast T1-weighted MR image showing complete tumor and right medial wall resection. The patient had normal IGF levels and resolution of acromegalic symptoms at 3 months’ follow-up. Ant. = anterior; Clin. = clinoid; Med. = medial; Pit. = pituitary; Post. = Posterior. Figure is available in color online only.

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    Case involving a 44-year-old patient presenting with elevated UFC levels (734 µg/24 hr) and symptoms of Cushing’s disease. A: Preoperative coronal postcontrast T1-weighted MR image showing a hypoenhancing pituitary adenoma (10 mm, arrow) with potential right medial wall invasion and displacing the gland to the left (arrowhead). B: Intraoperative view of the tumor during extracapsular dissection. C: Opening of the anterior wall of the CS after tumor invasion of the medial wall was suspected. D: Transection of the inferior parasellar ligament, which is attached to the vertical portion of the cavernous ICA. E: Mobilization of the medial wall away from the ICA and progressing in a posterior direction. F: Intraoperative image with a 45° scope showing the interclinoid ligament after complete right medial wall resection. Ant. = anterior; ICL = interclinoid ligament; IPL = inferior parasellar ligament; Med. = medial; Pit. = pituitary. Figure is available in color online only.

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    MR images and histological findings obtained in a 41-year-old patient with a GH-secreting adenoma and evidence of right medial wall invasion during surgery and upon histological analysis. A and B: Preoperative coronal (A) and axial (B) postcontrast T1-weighted MR images showing a hypoenhancing pituitary adenoma (12 mm, arrow) displacing the gland to the left (arrowhead). C and D: Photomicrographs of H & E–stained sections of the right medial wall of the CS obtained during surgery demonstrating tumor invasion. E and F: Postoperative coronal (E) and axial (F) postcontrast T1-weighted MR images showing complete tumor resection. Figure is available in color online only.

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    Case involving a 33-year-old patient with Cushing’s symptoms and abnormal UFC levels (317 µg/24 hrs). A: Preoperative coronal postcontrast T1-weighted MR image showing a pituitary macroadenoma (28 mm) with potential bilateral medial wall invasion. B: Early postoperative coronal T1-weighted MR image obtained after the patient underwent removal of the medial wall of CS bilaterally and developed a progressive CN VI palsy. The MRI study showed complete tumor resection but presence of a large-size clot occupying the tumor bed, for which the patient subsequently underwent surgical evacuation. C: Postoperative coronal T1-weighted MR image obtained after surgical re-exploration and clot evacuation. Complete improvement of the CN VI palsy was achieved at 3 months’ follow-up, and the patient remained in clinical and biochemical remission at 5 years’ follow-up.

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    Case involving a 64-year-old patient with secondary hypogonadism and a nonsecreting pituitary adenoma. A: Preoperative coronal postcontrast T1-weighted MR image showing an adenoma (arrow) with potential right medial wall invasion and displacing the gland to the left (arrowhead). B: Intraoperative image of the anterior wall of the CS and paraclinoid segment of the ICA after adequate sellar and parasellar exposure. C: Opening of the anterior wall of the CS was performed after evidence of invasion of the medial wall was observed intraoperatively. D: Selective coagulation and transection of the IHA to mobilize the medial wall of the CS away from the ICA; there is obvious tumor attached to the medial wall of the CS. E: Postoperative coronal postcontrast T1-weighted MR image showing complete tumor and right medial wall resection with the presence of a small Surgicel-related blood clot in the CS. F: Three-month follow-up coronal postcontrast T1-weighted MR image obtained after conservative treatment with steroids showing complete resolution of the blood clot; the patient had complete recovery of the partial CN VI palsy just 2 weeks after surgery. Ant. = anterior; Car.-Clin. Lig. = caroticoclinoid ligament; Clin = clinoid; Inf. Hyp. A. = inferior hypophyseal artery; Paraclin. = paraclinoid; Pit. = pituitary; Med. = medial; Mid. = middle. Figure is available in color online only.

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