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

Contributor Notes

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.
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