Bilateral coagulation of inferior hypophyseal artery and pituitary transposition during endoscopic endonasal interdural posterior clinoidectomy: do they affect pituitary function?

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OBJECTIVE

The endoscopic endonasal transcavernous approach with interdural pituitary transposition provides surgical access to the posterior clinoids and interpeduncular cistern. Prior to posterior clinoidectomy, selective coagulation and transection of the inferior hypophyseal artery (IHA) is recommended to prevent uncontrolled tearing of the artery and its avulsion from the wall of the cavernous carotid artery. The authors’ preliminary experience has shown that unilateral sacrifice of the IHA caused no permanent endocrine dysfunction. In this study, they investigated the pituitary function in the setting of bilateral sacrifice of IHAs and pituitary transposition.

METHODS

All patients with normal preoperative pituitary function who underwent endoscopic endonasal bilateral posterior clinoidectomy with bilateral IHA sacrifice between March 2010 and December 2016 were included and retrospectively evaluated. All data regarding pituitary function were collected. The degree of pituitary gland manipulation was estimated based on tumor size on preoperative MRI. An angle between a line from the point where the gland meets the floor of the sella to the highest point of the tumor and the horizontal plane of the sellar floor, or access angle, was also measured. Posterior pituitary bright spots on pre- and postoperative T1-weighted MRI were also reported.

RESULTS

Twenty patients had bilateral transcavernous posterior clinoidectomies with coagulation of both IHAs. There were 13 chordomas, 3 epidermoid cysts, 2 chondrosarcomas, 1 meningioma, and 1 hemangiopericytoma. The mean follow-up was 19 months (range 13–84 months). Two patients experienced transient diabetes insipidus (DI) requiring desmopressin, which resolved before hospital discharge. One patient (with chordoma) developed delayed permanent DI, and a second patient (with hemangiopericytoma) developed permanent DI and panhypopituitarism. The access angle was higher in the group with pituitary dysfunction (47.25° compared to 33.81°; p = 0.07). Posterior pituitary bright spots were preserved in 75% of cases with normal postoperative endocrine function.

CONCLUSIONS

The endoscopic endonasal transcavernous approach to the interpeduncular cistern with pituitary transposition and bilateral sacrifice of the IHAs does not cause pituitary dysfunction in a majority of patients. When endocrine deficit occurs, it appears to be more likely to have been caused by surgical manipulation than loss of blood supply. This finding confirms clinically the crucial concept of interarterial anastomosis of pituitary vasculature proposed by anatomists.

ABBREVIATIONS DI = diabetes insipidus; ICA = internal carotid artery; IHA = inferior hypophyseal artery; SHA = superior hypophyseal artery.

Article Information

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

INCLUDE WHEN CITING Published online August 3, 2018; DOI: 10.3171/2018.2.JNS173126.

H.Q.T. and H.B.R. contributed equally to this study.

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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    Case 11. A: MR image of sagittal plane shows upper clival tumor, with high cranial extension of the lesion and compression on floor of the third ventricle (arrow). B: Measurement of access angle of the tumor, which is the angle between line a from the point where the gland meets the floor of the sella to the highest point of the tumor and the horizontal plane (line h) of the floor of the sella. C: Measurement of the height of pituitary gland (line b) compared to the cranial extension of tumor (line c) above the sellar floor (line h). D: Postoperative MR image of the case shows tumor removal and morphologically intact pituitary gland and thinned-out floor of the third ventricle.

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    Case 9. Left: Sagittal postcontrast T1-weighted MR image shows an upper clival tumor invading and filling up the sella. Right: Coronal postcontrast T1-weighted MR image showing the gland being compressed by the tumor against the diaphragma sellae.

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    Posterior pituitary bright spot (insets). A and B: Preoperative and postoperative sagittal T1-weighted MR images, respectively, of a clival chordoma case showing the preservation of the bright spot in the posterior lobe of the pituitary gland. C: Preoperative sagittal T1-weighted MR image of a case of chondrosarcoma that invaded the sellar floor, in which no bright spot can be identified. D: Postoperative imaging of the same plane and sequence reveals the bright spot.

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    Schematic illustration of interarterial connection between blood supplies of pituitary gland, by Stanfield JP in “The blood supply of the human pituitary gland.” Journal of Anatomy. 1960; 94(Pt 2):257–273. (Courtesy of Wiley Publishing.) In this diagram, the IHAs from contralateral sides anastomose to form a vascular circle that sends out blood supply to the posterior lobe. The SHA from intracranial space provides blood supply to stalk and adenohypophysis through loral and long stalk arteries. Those arteries then connect to the vascular circle formed by IHAs. Original author’s annotation: A.S.H. = anterior superior hypophyseal artery; C. = communicating arteries; F.C. = artery of fibrous core; G. = genual artery; I.H. = inferior hypophyseal artery; I.H.C. = inferior hypophyseal circle; I.L. = interlobar arteries; L. = loral artery; L.S. = long stalk arteries; L.S.H. = lateral superior hypophyseal artery; P. = parallel vessels; S.C. = subcapsular artery; S.S. = short stalk arteries. © Anatomical Society, 1960, with permission of John Wiley & Sons, Inc.

References

1

Colombo NBerry IKucharczyk JKucharczyk Wde Groot JLarson T: Posterior pituitary gland: appearance on MR images in normal and pathologic states. Radiology 165:4814851987

2

Côté MSalzman KLSorour MCouldwell WT: Normal dimensions of the posterior pituitary bright spot on magnetic resonance imaging. J Neurosurg 120:3573622014

3

Essayed WISingh HLapadula GAlmodovar-Mercado GJAnand VKSchwartz TH: Endoscopic endonasal approach to the ventral brainstem: anatomical feasibility and surgical limitations. J Neurosurg 127:113911462017

4

Fernandez-Miranda JCGardner PARastelli MM JrPeris-Celda MKoutourousiou MPeace D: Endoscopic endonasal transcavernous posterior clinoidectomy with interdural pituitary transposition. J Neurosurg 121:91992014

5

Greenberg MS: Handbook of Neurosurgeryed 8. New York: Thieme2016p 79

6

Keleştimur F: Sheehan’s syndrome. Pituitary 6:1811882003

7

McConnell EM: The arterial blood supply of the human hypophysis cerebri. Anat Rec 115:1752031953

8

Phatouros CCHigashida RTMalek AMSmith WSDowd CFHalbach VV: Embolization of the meningohypophyseal trunk as a cause of diabetes insipidus. AJNR Am J Neuroradiol 20:111511181999

9

Reisch RVutskits LPatonay LFries G: The meningohypophyseal trunk and its blood supply to different intracranial structures. An anatomical study. Minim Invasive Neurosurg 39:78811996

10

Stanfield JP: The blood supply of the human pituitary gland. J Anat 94:2572731960

11

Tran-Dinh H: Cavernous branches of the internal carotid artery: anatomy and nomenclature. Neurosurgery 20:2052101987

12

Xuereb GPPrichard MMLDaniel PM: The arterial supply and venous drainage of the human hypophysis cerebri. Q J Exp Physiol Cogn Med Sci 39:1992171954

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