Endoscopic endonasal transoculomotor triangle approach for adenomas invading the parapeduncular space: surgical anatomy, technical nuances, and case series

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OBJECTIVE

Pituitary adenomas may extend into the parapeduncular space by invading through the roof of the cavernous sinus. Currently, a transcranial approach is the preferred choice, with or without the combination of an endonasal approach. In this paper the authors present a novel surgical approach that takes advantage of the natural corridor provided by the tumor to further open the oculomotor triangle and resect tumor extension into the parapeduncular space.

METHODS

Six injected specimens were used to demonstrate in detail the surgical anatomy related to the approach. Four cases in which the proposed approach was used were retrospectively reviewed.

RESULTS

From a technical perspective, the first step involves accessing the superior compartment of the cavernous sinus. The interclinoid ligament should be identified and the dura forming the oculomotor triangle exposed. The oculomotor dural opening may be then extended posteriorly toward the posterior petroclinoidal ligament and inferolaterally toward the anterior petroclinoidal ligament. The oculomotor nerve should then be identified; in this series it was displaced superomedially in all 4 cases. The posterior communicating artery should also be identified to avoid its injury. In all 4 cases, the tumor invading the parapeduncular space was completely removed. There were no vascular injuries and only 1 patient had a partial oculomotor nerve palsy that completely resolved in 2 weeks.

CONCLUSIONS

The endoscopic endonasal transoculomotor approach is an original alternative for removal of tumor extension into the parapeduncular space in a single procedure. The surgical corridor is increased by opening the dura of the oculomotor triangle and by working below and lateral to the cisternal segment of the oculomotor nerve.

ABBREVIATIONS AChA = anterior choroidal artery; ACP = anterior clinoid process; CSI = cavernous sinus invasion; GTR = gross-total resection; ICA = internal carotid artery; PCA = posterior cerebral artery; PComA = posterior communicating artery; PCP = posterior clinoid process; SCA = superior cerebellar artery.

Article Information

Correspondence Juan C. Fernandez-Miranda: UPMC Presbyterian Hospital, University of Pittsburgh School of Medicine, Pittsburgh, PA. fernandezmirandajc@upmc.edu.

INCLUDE WHEN CITING Published online April 13, 2018; DOI: 10.3171/2017.10.JNS17779.

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.

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Figures

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    A: Microscopic view of the roof of the cavernous sinus and oculomotor triangle in a colored silicone-injected human cadaveric specimen showing the cisternal segment of the oculomotor nerve in the lateral portion of the interpeduncular cistern and its entry into the roof of the cavernous sinus; note the intimate relationship between the PComA, the PCP, and the oculomotor nerve. B: Same specimen. After removal of the superficial layer of the dura mater, the anterior petroclinoidal fold or dural ligament, the posterior petroclinoidal dural ligament, and the interclinoidal dural ligament can be identified forming the lateral, posteromedial, and anteromedial boundaries of the oculomotor triangle, respectively. C: Artistic illustration of the sellar and parasellar region showing the typical pattern of extension of adenomas through the oculomotor triangle into the parapeduncular space. Note the superomedial displacement of the cisternal segment of the oculomotor nerve, and the mass effect on the uncus laterally and the cerebral peduncle medially. Ant, Ant. = anterior; CN II = optic nerve; CN III = oculomotor nerve; CN IV = trochlear nerve; CN V = trigeminal nerve; CN VI = abducens nerve; lig. = ligament; Oculo-Motor Tr = oculomotor triangle; Post, Post. = posterior. Copyright Juan C. Fernandez-Miranda. Published with permission.

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    A: Medial-to-lateral view of the cavernous sinus, oculomotor triangle, and parapeduncular space in a colored silicone-injected human specimen. The pituitary gland and the medial wall of the cavernous sinus have been removed to facilitate identification of key anatomical landmarks for the endoscopic endonasal transoculomotor triangle approach. The horizontal segment of the cavernous ICA is being retracted inferiorly to increase access to the superior compartment of the cavernous sinus, where the ventral aspect of the oculomotor triangle can be identified. The prominence of the interdural segment of the oculomotor nerve can be identified through the inner dural layer of the oculomotor triangle. Note the location of the uncus, which forms the lateral aspect of the parapeduncular space. B: The roof of the cavernous sinus is being retracted inferiorly to show the dorsal aspect of the oculomotor triangle and the dural entry point of the oculomotor nerve. Note the large PComA located just above the oculomotor nerve. C: Artistic illustration of the typical pattern of extension of adenomas into the parapeduncular space; ventral view simulating an endoscopic endonasal approach using a straight endoscope. D: Enlargement of inset in panel C. Artistic illustration of the typical pattern of extension of adenomas into the parapeduncular space; ventrolateral view, simulating the view from the endoscopic endonasal approach when using an angled (45°) endoscope. The tumor perforates the oculomotor triangle to extend into the parapeduncular space. The interclinoidal ligament is a key landmark to be identified at the roof of the superior compartment of the cavernous sinus. BA = basilar artery; IHA = inferior hypophyseal artery; MB = mammillary bodies; MHT = meningohypophyseal trunk. Copyright Juan C. Fernandez-Miranda. Published with permission.

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    Endoscopic endonasal transoculomotor triangle approach: step-by-step surgical technique in a colored silicone-injected human specimen. ​A: The first step includes full skeletonization of the ventral paraclinoidal ICA and anterior wall of the cavernous sinus. B: Next, the cavernous sinus is accessed with identification of the cavernous ICA; the superior compartment is located above the horizontal segment of the ICA. In this dissection, the anterior wall of the cavernous sinus was removed to facilitate access. In surgery, the tumor would have created a large opening through the medial wall into the cavernous sinus. C: The interclinoidal ligament was then identified as a key landmark for the approach at the roof of the superior compartment of the cavernous sinus. The dura forming the oculomotor triangle, lateral to the interclinoidal ligament, was then inspected to identify the dural breakage point and potentially the trajectory of the oculomotor nerve and PComA. Intraoperatively, electrostimulation and Doppler ultrasonography were used to investigate their location, respectively. D: Access to the parapeduncular space was implemented by further increasing the oculomotor triangle dural opening laterally toward the anterior petroclinoidal ligament and inferoposteriorly toward the posterior petroclinoidal ligament. Note the indentation in the oculomotor nerve, which marks its dural entry point. E: The interclinoidal ligament can be transected medially to increase the working space and join the parapeduncular and interpeduncular spaces. In this dissection, the oculomotor nerve is being displaced inferiorly to facilitate identification of the vascular structures of the parapeduncular space, including the PCA, PcomA, and AChA. In surgery, the tumor caused superomedial displacement of the cisternal segment of the oculomotor nerve. Therefore, the surgical corridor was developed by working below and lateral to the cisternal segment of the oculomotor nerve. F: Further dural opening provides greater access and identification of neurovascular structures in the parapeduncular and interpeduncular spaces. Note the tentorial edge (which is the continuation of the anterior petroclinoidal ligament) and the uncus above forming the lateral limit of the approach. Cav. = cavernous; Comp. = compartment; CP = cerebral peduncle; Inf. = inferior; Interclin. = interclinoidal; OT = optic tract; Paraped. = parapeduncular; Pit. = pituitary; Tent. = tentorial. Copyright Juan C. Fernandez-Miranda. Published with permission.

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    Case 1. A 65-year-old woman with a giant pituitary adenoma. A: Preoperative coronal T1-weighted contrast-enhanced MRI showing a pituitary adenoma with tumor extension into the left parapeduncular space through the oculomotor triangle. B and C: Early (B) and 6-month (C) postoperative coronal slices showing complete resection of the tumor extension into the parapeduncular space and small residual in the cavernous sinus. D: Preoperative axial T1-weighted contrast-enhanced MRI showing the tumor in the parapeduncular space, displacing the uncus laterally and the cerebral peduncle and the PComA medially; note the intimate relationship between the PComA and the anteromedial aspect of the tumor. E and F: Six-month postoperative axial T1 contrast-enhanced MRI showing complete removal of the tumor from the parapeduncular space with a small residual in the cavernous sinus.

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    Case 2. A 36-year-old man with acromegaly and a giant pituitary tumor. A and B: Preoperative coronal T1-weighted contrast-enhanced MRI showing a pituitary adenoma with bilateral cavernous sinus invasion (Knosp grade IV) and extension into the suprasellar space, and significantly into the left parapeduncular space. C: Postoperative axial T1-weighted contrast-enhanced MRI showing complete tumor removal from the parapeduncular space with significant residual within the cavernous sinus. D: Preoperative axial T1-weighted contrast-enhanced MRI showing tumor in the parapeduncular space, displacing the uncus laterally; the left oculomotor nerve (CN III) is located medial to the tumor. E and F: Postoperative axial T1-weighted contrast-enhanced MRI showing complete tumor removal from the parapeduncular space and residual tumor within the cavernous sinus. The cisternal segment of the oculomotor nerve can be visualized free of compression. Basilar A = basilar artery.

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    Case 3. A 62-year-old woman with a pituitary adenoma. A: Preoperative axial T1-weighted contrast-enhanced MRI showing a pituitary macroadenoma with suprasellar and left parapeduncular extension. B: The left uncus is displaced laterally by the tumor and the PComA is in close proximity to the posteromedial aspect of the tumor. C and D: Postoperative axial T1-weighted contrast-enhanced MRI showing no residual tumor in the parapeduncular space; the oculomotor nerve is now identified in its cisternal segment.

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    Case 4. A 52-year-old man with a recurrent pituitary adenoma following two transsphenoidal surgeries at an outside institution. A–C: Preoperative axial (A and B) and coronal (C) T1-weighted contrast-enhanced MRI showing recurrent tumor in the left cavernous sinus with extension into the parapeduncular space. The PComA is displaced medially and in intimate relationship with the posteromedial aspect of the tumor. The left uncus is displaced dorsolaterally. The tumor extends laterally toward the temporal horn of the left lateral ventricle. D–F: Postoperative axial (D and E) and coronal (F) T1-weighted contrast-enhanced MRI showing complete removal of the tumor.

References

1

Abuzayed BTanriover NGazioglu NKafadar AMAkar Z: Endoscopic anatomy of the oculomotor nerve: defining the blind spot during endoscopic skull base surgery. Childs Nerv Syst 26:6896962010

2

Chen CCCarter BSWang RPatel KSHess CBodach ME: Congress of Neurological Surgeons systematic review and evidence-based guideline on preoperative imaging assessment of patients with suspected nonfunctioning pituitary adenomas. Neurosurgery 79:E524E5262016

3

Dhandapani SSingh HNegm HMCohen SAnand VKSchwartz TH: Cavernous sinus invasion in pituitary adenomas: systematic review and pooled data meta-analysis of radiologic criteria and comparison of endoscopic and microscopic surgery. World Neurosurg 96:36462016

4

Fernández-Miranda JCde Oliveira ERubino PAWen HTRhoton AL Jr: Microvascular anatomy of the medial temporal region: part 1: its application to arteriovenous malformation surgery. Neurosurgery 67 (3 Suppl Operative):ons237–ons2762010

5

Ferreli FTurri-Zanoni MCanevari FRBattaglia PBignami MCastelnuovo P: Endoscopic endonasal management of non-functioning pituitary adenomas with cavernous sinus invasion: a 10- year experience. Rhinology 53:3083162015

6

Goel ANadkarni TMuzumdar DDesai KPhalke USharma P: Giant pituitary tumors: a study based on surgical treatment of 118 cases. Surg Neurol 61:4364462004

7

Goel ANadkarni TD: Giant pituitary tumors: a study based on surgical treatment of 325 cases. Int J Neurol Neurosurg 1:39522009

8

Hoang NTran DKHerde RCouldwell GCOsborn AGCouldwell WT: Pituitary macroadenomas with oculomotor cistern extension and tracking: implications for surgical management. J Neurosurg 125:3153222016

9

Kassam ASnyderman CHMintz AGardner PCarrau RL: Expanded endonasal approach: the rostrocaudal axis. Part I. Crista galli to the sella turcica. Neurosurg Focus 19(1):E32005

10

Kassam ASnyderman CHMintz AGardner PCarrau RL: Expanded endonasal approach: the rostrocaudal axis. Part II. Posterior clinoids to the foramen magnum. Neurosurg Focus 19(1):E42005

11

Komotar RJStarke RMRaper DMSAnand VKSchwartz TH: Endoscopic endonasal compared with microscopic transsphenoidal and open transcranial resection of giant pituitary adenomas. Pituitary 15:1501592012

12

Koutourousiou MGardner PAFernandez-Miranda JCPaluzzi AWang EWSnyderman CH: Endoscopic endonasal surgery for giant pituitary adenomas: advantages and limitations. J Neurosurg 118:6216312013

13

Martins CYasuda ACampero ARhoton AL Jr: Microsurgical anatomy of the oculomotor cistern. Neurosurgery 58 (4 Suppl 2):ONS-220ONS-2282006

14

Paluzzi AFernandez-Miranda JCTonya Stefko SChallinor SSnyderman CHGardner PA: Endoscopic endonasal approach for pituitary adenomas: a series of 555 patients. Pituitary 17:3073192014

15

Pratheesh RRajaratnam SPrabhu KMani SEChacko GChacko AG: The current role of transcranial surgery in the management of pituitary adenomas. Pituitary 16:4194342013

16

Rhoton AL Jr: The posterior fossa cisterns. Neurosurgery 47 (3 Suppl):S287S2972000

17

Yaşargil MG: Microneurosurgery Volume IVA. CNS Tumors: Surgical Anatomy Neuropathology Neuroradiology Neurophysiology Clinical Considerations Operability Treatment Optionsed 1. New York: Thieme1994

18

Youssef ASAgazzi Svan Loveren HR: Transcranial surgery for pituitary adenomas. Neurosurgery 57 (1 Suppl):1681752005

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