Endonasal Route for Tuberculum and Planum Meningiomas.

Tuberculum and planum meningiomas are challenging tumors per their critical location and neurovascular relationships. The standard treatment is usually represented by complete tumor removal, being the transcranial approaches the well-established routes. During the last decades, novel surgical routes have been experimented with emphasis on the concept of minimal invasive approaches. The peculiar perspective from below the endoscopic endonasal approach provides a short and direct access avoiding brain and neurovascular structures manipulation, featuring excellent outcomes and a reduced morbidity. Ideal indications are small or medium size midline meningiomas, with wide tuberculum sellae angle and deep sella at the sphenoid sinus, possibly with no optic nerve and/or vessels encasement. Adequate removal of paranasal structures and extended bony opening over the dural attachment provide a wide surgical corridor ensuring safe intradural exposure at the suprasellar area. The main advantage is related to early decompression of the optic apparatus and reduced manipulation of subchiasmatic perforating vessels, with improved visual outcomes. Direct exposure of the inferomedial aspect of the optic canals allows for maximal decompression in cases of tumor extending within. Transcranial approaches tend to be selected for larger tumors with lateral extension beyond optic nerves and supraclinoid carotid arteries, in inaccessible areas from an endonasal corridor.

Solitary isolated disseminations of glioblastoma to sellar and suprasellar regions: two case reports.

Herein, we present two cases of isolated suprasellar dissemination of glioblastoma in patients with well-controlled primary lesions. A 22-year-old woman and a 56-year-old woman developed rapid growth of suprasellar glioblastoma dissemination 26 and 17 months after initial surgery, respectively. Both patients presented with acute visual impairment (decreased acuity and visual field disturbances) but lacked severe pituitary dysfunction. During surgery for the disseminated tumors, gross total tumor resection was difficult due to intraoperative findings suggesting optic pathway invasion. Both patients developed further intracranial dissemination within several months post-surgery. The presence of solitary sellar and suprasellar dissemination may indicate a terminal stage.

"Evaluating surgical approaches for Rathke's cleft cysts and sellar meningiomas: factors influencing treatment of choice".

This study reviews recent progress in the surgical treatment of Rathke's cleft cysts (RCCs) and Sellar region meningiomas, based on findings from three key studies. RCCs are benign, fluid-filled remnants from pituitary gland development that are usually asymptomatic and found by chance. However, surgical intervention is needed when they become symptomatic or increase in size. Research by Stefan Linsler et al. and others examines various surgical methods, including transcranial keyhole and transsphenoidal techniques for RCCs, and endoscopic endonasal and supraorbital keyhole approaches for Sellar meningiomas. The results show that both transcranial keyhole and transsphenoidal surgeries for RCCs have high success rates with no recurrences over 5.7 years, although the keyhole approach has fewer complications. For Sellar meningiomas, the choice between endoscopic endonasal and supraorbital keyhole techniques should be based on tumor characteristics, highlighting the importance of surgeon proficiency in both methods. These studies emphasize the need for personalized treatment strategies tailored to patient and tumor characteristics and highlight the importance of ongoing surgical skill development and further research to refine minimally invasive techniques. This study highlights the crucial role of personalized surgical approaches in improving outcomes for patients with RCCs and Sellar region meningiomas.

Endoscopic Endonasal Approach Is Superior to Transcranial Approach for Small to Medium Tuberculum Sellae Meningiomas in Terms of Visual Outcome and Complications: A Retrospective Study in a Single Center.

OBJECTIVE: This study compared the effectiveness of the endoscopic endonasal approach (EEA) with the conventional transcranial approach (TCA) for treating tuberculum sellae meningiomas (TSMs), aiming to identify the superior surgical method and the risk factors affecting outcomes. METHODS: Patients treated for TSM from 1998 to 2023 at our institution were retrospectively analyzed, evaluating patient characteristics, tumor features, outcomes, and complications. A novel grading system for preoperative evaluation of TSMs was proposed. RESULTS: Among 49 patients, 26 underwent EEA and 23 underwent TCA. The maximum diameters were comparable between the groups (mean 22 mm vs. 23 mm). Gross total resection rates were 62% for EEA and 70% for TCA, showing no significant difference. However, postsurgical visual improvement was significantly higher in the EEA group compared with the TCA group (77% vs. 44%; P = 0.020), with fewer complications in the EEA group (8% vs. 35%; P = 0.032). CONCLUSIONS: EEA is a safe and effective treatment approach for small to medium TSMs, with outcomes comparable to TCA in terms of resection but superior in visual improvement and fewer complications. Selection of surgical approach should consider patient and tumor characteristics as well as surgeon experience.

[The Transcranial Approach for Parasellar Meningiomas].

Patients with parasellar meningiomas often initially present with visual impairment. Understanding the surrounding anatomy is essential when preparing for surgery of parasellar meningiomas, as this region includes various crucial neurovascular structures. Historically, invasive craniotomy, such as the orthozygomatic approach or zygotomy, has often been attempted to access the region; however, the use of these invasive approaches has become less common, because of the accumulation of anatomical knowledge, as well as the development of surgical techniques and devices, including the endonasal endoscopic approach. Herein, we summarize how we perform surgery for parasellar meningiomas, and outline tips and pitfalls that could be useful for young residents and trainees who are new to the skull base field.

How I do it: Endoscopic endonasal resection of the medial wall of the cavernous sinus.

BACKGROUND: Resection of the medial wall of the cavernous sinus (MWCSR) is a growing surgical maneuver for the radical removal of pituitary adenomas. METHOD: We present a simple modification of the technique following the two dural layers of the floor of the sella turcica, allowing for early identification of the medial wall and simplifying dissection. We support this technique with an anatomical analysis on cadaveric specimens and clarifying dissection images. CONCLUSION: Recognition and dissection of the dural unfolding of the floor of the sella turcica are "key points" that lower the risk and facilitate the MWCSR.

Effectiveness of a Sellar Reconstruction Algorithm in Transsphenoidal Pituitary Surgery: Insights from 490 Cases.

BACKGROUND: Rhinorrhea is a common complication after endoscopic endonasal transsphenoidal pituitary surgery (EETPS). This study evaluates the effectiveness of our sellar reconstruction technique in preventing rhinorrhea. METHODS: From June 2020 to March 2024, a surgical team performed 490 EETPS procedures on 458 pituitary adenoma patients. Demographic data, surgery status, and radiological and histopathological classifications were retrospectively analyzed. 4 grades for sellar reconstruction were defined based on intraoperative cerebrospinal fluid (CSF) leakage and diaphragm sella defect size. Grade 0: no CSF leakage; cavity filled with absorbable material. Grade 1: small defect; covered with fat and fascia lata grafts. Grade 2: large defect; added lumbar drainage. Grade 3: extended approach; added nasoseptal flap. RESULTS: Of the 490 operations, 433 were primary and 57 recurrent. Patients were 50.2% male, mean age 49.01 years. Follow-up averaged 20.5 months. Postoperative rhinorrhea occurred in 8 cases (1.6%). In 404 surgeries (82.5%) without intraoperative CSF leakage, 3 cases (0.7%) developed postoperative rhinorrhea. CSF leakage was detected in 86 cases (17.5%), with postoperative rhinorrhea in 5 cases (5.8%). The risk of rhinorrhea was 8.3 times higher with intraoperative CSF leakage (P = 0.005). Rhinorrhea rates: 0.7% in Grade 0, 3% in Grade 1, 8.7% in Grade 2, and 0% in Grade 3 (P = 0.017). Meningitis occurred in 8 patients (1.7%) and pneumocephalus in 4 (0.9%), with one death (0.2%). The average hospital stay was 17.4 days with rhinorrhea and 5.2 without (P = 0.024). CONCLUSIONS: Intraoperative CSF leakage is highly correlated with rhinorrhea. Multilayered and graded closure strategies significantly reduce postoperative rhinorrhea rates in EETPS.

Shaping the curve from the microscopic transsphenoidal to the endoscopic endonasal approach for the sellar region.

OBJECTIVE: This study aimed to investigate the limitations, barriers, and complications in the early transition from the microscopic transsphenoidal approach (MTA) to the endonasal endoscopic approach (EEA) to the skull base in our institution. METHODS: Technical challenges, as well as clinical features and complications, were compared between MTA, EEA, and mixed cases during the early surgical curve. RESULTS: The period from the early learning curve was 1 year until the EEA protocol was used routinely. A total of 34 patients registered a resection using a transsphenoidal approach. Eighteen patients underwent EEA, 11 underwent MTA, and five underwent a mixed endonasal and microscopic approach. Non-significant differences were found in endocrine outcomes between the three groups. Patients with unchanged or improved visual function were higher in the EEA group (p = 0.147). Non-significant differences were found in terms of the extent of resection (EOR) between groups (p = 0.369). Only 1 (2.9%) patient in the whole series developed a post-operative CSF leaking that resolved with medical management, belonging to the EEA group (5.5%). CONCLUSIONS: The early phase of the learning curve did not affect our series significantly in terms of the EOR, endocrine status, and visual outcomes.

OBJETIVO: Investigar las limitaciones, las barreras y las complicaciones en la transición del abordaje transesfenoidal microscópico (ATM) al abordaje endonasal endoscópico (AEE) para la base del cráneo en nuestra institución. MÉTODO: Se compararon las características clínicas y las complicaciones entre ATM, AEE y casos mixtos durante la curva quirúrgica temprana. RESULTADOS: El periodo desde la curva de aprendizaje inicial fue de 1 año hasta que se utilizó el protocolo AEE de forma sistemática. Un total de 34 pacientes tuvieron una resección por vía transesfenoidal. A 18 pacientes se les realizó AEE, a 11 ATM y a 5 abordaje mixto endonasal y microscópico. Se encontraron diferencias no significativas en los resultados endocrinos entre los tres grupos. Los pacientes con función visual sin cambios o mejorada fueron más en el grupo AEE (p = 0.147). No se encontraron diferencias significativas respecto a la extensión de la resección (p = 0.369). Solo 1 (2.9%) paciente desarrolló una fístula de líquido cefalorraquídeo que se resolvió con manejo médico, perteneciente al grupo AEE (5.5%). CONCLUSIONES: La fase inicial de la curva de aprendizaje no afectó significativamente a nuestra serie en términos de extensión de la resección, estado endocrino y resultados visuales.

Application of Dural Suturing in Reconstruction of Sellar Floor for Cerebrospinal Fluid Leakage During Neuroendoscopic Intranasal Approach Surgery: A Meta-Analysis.

AIM: To assess the safety and efficacy of utilizing dural suturing as an adjunctive procedure for saddle floor reconstruction in patients undergoing endoscopic surgery in the sellar region. MATERIAL AND METHODS: According to the PRISMA guidelines, we searched the literature on sellar floor reconstruction in endoscopic sellar surgery. Fixed- or random-effects meta-analysis was used to pool the rate of return to postoperative cerebrospinal fluid (poCSF) leakage, repair operations, postoperative hospitalization, complete resection, infection, lumbar drainage (LD), and operative duration. RESULTS: A total of six studies involving 723 participants were included in the current meta-analysis. The pooled results demonstrated that patients in the dural suturing group had a lower incidence of poCSF leakage [odds ratio (OR), 0.18; 95% confidence interval (CI), 0.07 - 0.44; p=0.0002] and repair operation [OR, 0.24; 95% CI, 0.07 - 0.78; p=0.02], as well as a shorter hospitalization period [standardized mean difference (SMD), -0.45; 95% CI, -0.62 - -0.28; p < 0.00001]. There was no significant difference between the two groups in terms of the complete resection [OR, 1.06; 95% CI, 0.62 - 1.80; p=0.84], postoperative infection [OR, 0.49; 95% CI, 0.21 - 1.15; p=0.10] and lumbar drainage (LD) [OR, 0.28; 95% CI, 0.06 - 1.23; p=0.09]. Additionally, the dural suturing group may require a longer operative duration [SMD, 0.29; 95% CI, 0.02 - 0.56; p=0.03]. CONCLUSION: The results suggest that dural suturing can be advantageous in reducing postoperative complications and shortening postoperative hospitalization following neuroendoscopic surgery in the sellar region without increasing the risk of infection.

Langerhans cell histiocytosis of the sella in a pediatric patient: case report with review of the literature.

PURPOSE: Langerhans cell histiocytosis (LCH) is a rare condition arising from the monoclonal expansion of myeloid precursor cells, which results in granulomatous lesions that characteristically express CD1a/CD207. We report a case of LCH in a 3-year-old male involving the sphenoid bone with extension into the sellar/suprasellar region. CASE REPORT: A 3-year-old male presented with progressively worsening headaches and associated night sweats, neck stiffness, and fatigue over the previous 4 weeks. Magnetic resonance imaging (MRI) revealed a 2.4-cm lytic lesion within the basisphenoid, exerting mass effect upon the pituitary gland. A biopsy was performed to determine the etiology of the lesion. Postoperatively, the patient developed an intralesional hematoma with visual complications requiring emergent surgical resection via endoscopic endonasal approach. Final pathology confirmed LCH. The patient had improvement in his vision long term. CONCLUSIONS: LCH extending into the sella is a rare but important diagnosis to consider in pediatric patients presenting with lesions in this region. We presented a case of a pediatric patient presenting with LCH of the sphenoid bone extending into the sella, with subsequent apoplexy and vision loss. Review of the literature showed varying treatment options for these patients, including purely surgical and non-surgical treatments. Early intervention may be necessary to avoid potentially devastating neurologic sequelae.

Sellar metastasis: A rare intraoperative finding - surgical treatment, strategies and outcome.

OBJECTIVE: The sellar region, though uncommon for metastatic spread, may become more prevalent due to longer survival of patients with metastatic malignancies. Compression of adjacent vital anatomy can cause disabling symptoms and endocrine disturbances, leading to significant morbidity METHODS: This study analyzed sellar pathologies treated via endonasal approach from January 2011 to December 2021 to assess the incidence of sellar metastases. Patient demographics, presenting symptoms, radiological and histological findings, management, and outcomes were evaluated RESULTS: Among 334 patients treated during the study period, eight (2.3 %) had metastases confirmed histopathologically, with one having a known malignant tumor history. Preoperative imaging suspected malignancy or metastasis in two cases. Diagnosis was unexpectedly confirmed in 57 % of cases. Subtotal resection was achieved in three cases, near-total resection in one. Mean follow-up was 2.4 years, with 71 % mortality CONCLUSIONS: The sellar region can manifest metastatic disease, with sellar symptoms potentially indicating neoplastic disease onset. Rapid hormonal dysfunction or ophthalmoplegia suggests metastasis, even without a known primary. Further meta analysis of reported cases is necessary to determine the incidence and optimal treatment of these rare metastases.

Endoscopic endonasal pituitary sacrifice for select tumors with retrochiasmatic and/or retrosellar extension: surgical anatomy, operative technique, and case series.

OBJECTIVE: Tumors located in the retrochiasmatic region with extension to the third ventricle might be difficult to access when the pituitary-chiasmatic corridor is narrow. Similarly, tumor extension into the interpeduncular and retrosellar space poses a major surgical challenge. Pituitary transposition techniques have been developed to gain additional access. However, when preoperative pituitary function is already impaired or the risk of postoperative panhypopituitarism (PH) is considered to be particularly high, removal of the pituitary gland (PG) might be the preferred option to increase the working corridor. The aim of this study was to describe the relevant surgical anatomy, operative steps, and clinical experience with the endoscopic endonasal pituitary sacrifice (EEPS) and transsellar approach. METHODS: This study comprised anatomical dissections to highlight the relevant surgical steps and a retrospective case series reporting clinical characteristics, indications, and outcomes of patients who underwent EEPS. The surgical technique is as follows: both lateral opticocarotid recesses are exposed laterally, the limbus sphenoidale superiorly, and the sellar floor inferiorly. After opening the dura, the PG is detached circumferentially and mobilized off the medial walls of the cavernous sinuses. The descending branches of the superior hypophyseal artery are coagulated, and the stalk is transected. After removal of the PG, drilling of the dorsum sellae and bilateral posterior clinoidectomies are performed to gain access to the hypothalamic region, interpeduncular, and prepontine cisterns. RESULTS: From 2018 to 2023, 11 patients underwent EEPS. The cohort comprised mostly tuberoinfundibular craniopharyngiomas (n = 8, 73%). Seven (64%) patients had partial or complete anterior PG dysfunction preoperatively, while 4 (36%) had preoperative diabetes insipidus. Because of the specific tumor configuration, the chance of preserving endocrine function was estimated to be very low in patients with intact function. The main reasons for pituitary sacrifice were impaired visibility and surgical accessibility to the retrochiasmatic and retrosellar spaces. Gross-total tumor resection was achieved in 10 (91%) patients and near-total resection in 1 (9%) patient. Two (18%) patients experienced a postoperative CSF leak, requiring surgical revision. CONCLUSIONS: When preoperative pituitary function is already impaired or the risk for postoperative PH is considered particularly high, the EEPS and transsellar approach appears to be a feasible surgical option to improve visibility and accessibility to the retrochiasmatic hypothalamic and retrosellar spaces, thus increasing tumor resectability.

Usefulness of Opening the Diaphragma Sellae Before Transecting Interclinoidal Ligament for Endoscopic Endonasal Transoculomotor Triangle Approach: Technical Nuances and Surgical Outcomes.

OBJECTIVE: Opening the oculomotor triangle (OT) and removing the posterior fossa lesion by endoscopic endonasal approach (EEA) is challenging for even an experienced endoscopic neurosurgeon. We summarize the treatment experience and technical nuances with EEA for resection of pituitary neuroendocrine tumors and cavernous sinus (CS) meningiomas invading through the OT. METHODS: Between 2018 and 2022, 8 patients, comprising 5 with pituitary neuroendocrine tumors (3 with nonfunctioning and 2 with somatotroph tumors with increased levels of growth hormone) and 3 CS meningiomas, were treated using an endoscopic endonasal transoculomotor triangle approach. The critical surgical technique is continuously opening the diaphragma sellae from medial to lateral toward the interclinoidal ligament and transecting it to enlarge the OT. We evaluated preoperative tumor size, previous surgical history, preoperative symptoms, extent of tumor resection, histopathology, and postoperative complications for all patients. RESULTS: The gross total resection (defined as complete removal) in 3 patients (38%), near-total resection (defined as >95% removal) in 4 patients (50%), and subtotal resection (defined as ≤90% removal) in 1 patient (12%) and gross total resection of tumor invading through the OT was achieved in all patients through pure EEA. Two of 3 patients with visual deficits in nonfunctioning pituitary neuroendocrine tumors improved, and the other remained stable postoperatively. One patient showed transient oculomotor nerve palsy. The growth hormone level of the 2 patients with somatotroph tumors declined to normal. For 3 patients with CS meningiomas, cranial nerve palsy improved in 2 patients, whereas the other patient developed increased facial numbness after surgery. CONCLUSIONS: The endoscopic endonasal transoculomotor triangle approach is an efficient surgical option for tumors with CS invasion and OT penetration.

Factors influencing postoperative visual improvement in 208 patients with tuberculum sellae meningiomas.

OBJECTIVE: Tuberculum sellae meningiomas (TSMs) usually compress the optic nerve and optic chiasma, thus affecting vision. Surgery is an effective means to remove tumors and improve visual outcomes. On a larger scale, this study attempted to further explore and confirm the factors related to postoperative visual outcomes to guide the treatment of TSMs. METHODS: Data were obtained from 208 patients with TSMs who underwent surgery at our institution between January 2010 and August 2022. Demographics, ophthalmologic examination results, imaging data, extent of resection, radiotherapy status, and surgical approaches were included in the analysis. Univariate and multivariate logistic regressions were used to assess the factors that could lead to favorable visual outcomes. RESULTS: The median follow-up duration was 63 months, and gross total resection (GTR) was achieved in 174 (83.7%) patients. According to our multivariate logistic regression analysis, age < 60 years (odds ratio [OR] = 0.310; P = 0.007), duration of preoperative visual symptoms (DPVS) < 10 months (OR = 0.495; P = 0.039), tumor size ≤ 27 mm (OR = 0.337; P = 0.002), GTR (OR = 3.834; P = 0.006), and a tumor vertical-to-horizontal dimensional ratio < 1 (OR = 2.593; P = 0.006) were found to be significant independent predictors of favorable visual outcomes. CONCLUSION: Age, DPVS, tumor size, GTR, and the tumor vertical-to-horizontal dimensional ratio were found to be powerful predictors of favorable visual outcomes. This study may help guide decisions regarding the treatment of TSMs.

[Preoperative Simulation of Endoscopic Endonasal Approach for Craniopharyngiomas or Tuberculum Sellae Meningiomas].

Preoperative simulation for endoscopic endonasal approach(EEA)using computed tomography and magnetic resonance imaging evaluates tumor extension and the relationship between adjacent structure(the pituitary stalk, major vessels, and cranial nerves); therefore, preoperative planning of nasal procedure, skull base bony removal, and cranial base reconstruction are possible. Additionally, three-dimensional(3D)fusion image aids surgeons to visualize intraoperative 3D findings. These preoperative simulations are critical to avoid complications and predict pitfalls perioperatively. However, tumor consistency or adhesion with adjacent structure cannot be predicted but is judged perioperatively, which affects the extent of tumor resection. This manuscript describes important points of preoperative simulation for EEA, especially the transplanum-transtuberculum approach for craniopharyngiomas or tuberculum sellae meningiomas, showing some examples in patients.

The Sellar Region as Seen from Transcranial and Endonasal Perspectives: Exploring Bony Landmarks Through New Surface Photorealistic Three-Dimensional Model Reconstruction for Neurosurgical Anatomy Training.

BACKGROUND: Virtual reality-based learning of neuroanatomy is a new feasible method to explore, visualize, and dissect interactively complex anatomic regions. We provide a new interactive photorealistic three-dimensional (3D) model of sellar region microsurgical anatomy that allows side-by-side views of exocranial and endocranial surfaces to be explored, with the aim of assisting young neurosurgery residents in learning microsurgical anatomy of this complex region. METHODS: Four head specimens underwent an endoscopic endonasal approach extended to the anterior and posterior skull base to expose the main bony anatomic landmarks of the sellar region. The same bony structures were exposed from a transcranial perspective. By using a photogrammetry method, multiple photographs from both endocranial and exocranial perspectives, different for angulations and depth, were captured, fused, and processed through dedicated software. RESULTS: All relevant bony structures were clearly distinguishable in the 3D model reconstruction, which provides several benefits in neuroanatomy learning: first, it replicates bony structures with high degrees of realism, accuracy, and fidelity; in addition, it provides realistic spatial perception of the depth of the visualized structures and their anatomic relationships; again, the 3D model is interactive and allows a 360° self-guided tour of the reconstructed object, so that the learner can read the bones and their anatomic relationship from all desired points of view. CONCLUSIONS: Detailed knowledge of key surgical landmarks representing keyholes and/or anatomic structures to not violate is mandatory for safer surgery, especially for a complex region such as the skull base. Highly accurate virtual and functional neurosurgical models, such as photogrammetry, can generate a realistic appearance to further improve surgical simulators and learn neuroanatomy.

Intrasellar Arachnoid Diverticulae as a Risk Factor for Intraoperative Cerebrospinal Fluid Leakage in Patients Undergoing Endoscopic Transsphenoidal Surgery.

BACKGROUND AND OBJECTIVES: Intrasellar arachnoid diverticulae can often be identified on preoperative imaging in patients undergoing endoscopic transsphenoidal surgery. The objective of this study was to characterize arachnoid diverticulae both qualitatively and quantitatively in a large institutional cohort of patients with pituitary tumors and to evaluate its association with intraoperative cerebrospinal fluid (CSF) leak. METHODS: Preoperative imaging studies of 530 patients who underwent primary endoscopic transsphenoidal resection of pituitary tumors were examined both quantitatively and qualitatively for the presence of an intrasellar arachnoid diverticulum. A matched cohort analysis was performed to compare patients with a "significant" (>50% sellar depth) diverticulum with those with nonsignificant/no diverticulum. Morphologically, diverticulae were separately classified as Type 1 (ventral CSF cleft with no tumor/gland tissue between sellar face and infundibulum) or Type 2 (central CSF cleft with tumor/gland tissue between sellar face and infundibulum). RESULTS: Arachnoid diverticulae were noted in 40.2% of cases, and diverticulum depth was linearly correlated with tumor size and body mass index. A significant diverticulum was identified in 66 cases (12.5%) and was significantly associated with the functional tumor subtype ( P = .005) and intraoperative CSF leak ( P < .001). Type 1 clefts were associated with nonfunctional pathology ( P = .034) and the presence of suprasellar extension ( P = .035) and tended to be deeper than Type 2 clefts ( P < .001), with a higher incidence of intraoperative CSF leak ( P = .093). On logistic regression analysis, only the presence of a significant diverticulum was independently associated with intraoperative CSF leak (odds ratio 4.545; 95% CI 2.418-8.544; P < .001). CONCLUSION: The presence of an intrasellar arachnoid diverticulum should alert the surgeon to an elevated risk of intraoperative CSF leak during transsphenoidal surgery for pituitary tumors. A relatively limited surgical exposure tailored to the craniocaudal extent of the sellar pathology should be considered in these patients.

Measurement of the intersiphon distance for normal skull base development and estimation of the surgical window for the endoscopic transtuberculum approach in children.

OBJECTIVE: Due to the underdeveloped skull base in children, it is crucial to predict whether a sufficient surgical window for an endoscopic endonasal approach can be achieved. This study aimed to analyze the presumed surgical window through measurement of the intersiphon distance (ISD) and the planum-sella height (PSH) on the basis of age and its correlation with the actual surgical window for the endoscopic transtuberculum approach. METHODS: Twenty patients of each age from 3 to 18 years were included as the normal skull base population. ISD and PSH were measured and compared among consecutive ages. Additionally, 42 children with craniopharyngiomas or Rathke's cleft cysts who underwent treatment via the endoscopic transtuberculum approach were included. ISD and PSH were measured on preoperative images and then correlated with the dimensions of the surgical window on postoperative CT scans. The intraoperative endoscopic view was classified as narrow, intermediate, or wide based on operative photographs or videos, and relevant clinical factors were analyzed. RESULTS: In the normal skull base population, both ISD and the estimated area of the surgical window increased with age, particularly at 8 and 11 years old. On the other hand, PSH did not show an incremental pattern with age. Among the 42 children who underwent surgery, 24 had craniopharyngioma and 18 had Rathke's cleft cysts. ISD showed the strongest correlation with the actual area of the surgical window [r(40) = 0.69, p < 0.001] rather than with age or PSH. The visual grade of the intraoperative endoscopic view was narrow in 17 patients, intermediate in 21, and wide in 4. Preoperative ISD was 14.58 ± 1.29 mm in the narrow group, 16.13 ± 2.30 mm in the intermediate group, and 18.09 ± 3.43 mm in the wide group (p < 0.01). There were no differences in terms of extent of resection (p = 0.41); however, 2 patients in the narrow group had postoperative complications. CONCLUSIONS: Normal skull base development exhibited age-related growth. However, in children with suprasellar lesions, the measurement of the ISD showed a better correlation than age for predicting the surgical window for the endoscopic transtuberculum approach. Children with a small ISD should be approached with caution due to the limited surgical window.

A transmandibular lateral transsphenoidal navigated surgical approach to access a pituitary macroadenoma in a warmblood mare.

A 16-year-old warmblood mare was referred with a progressive history of behavioral changes and left-sided blindness. Following neuroanatomical localization to the forebrain, magnetic resonance imaging of the head revealed a well-delineated, 4.5 cm in diameter, round pituitary mass causing marked compression of the midbrain and optic chiasm. Euthanasia was recommended but declined by the owners. Veterinary specialists and a human neurosurgeon collaboratively prepared for surgical case management. A novel navigated transmandibular lateral transsphenoidal approach was developed to access the region of the sella turcica and practiced on cadaver specimens. The horse was anesthetized and placed in sternal recumbency with the head above the heart line. Using a cone beam computed tomography (CBCT)-coupled navigation system, a navigated pin traversing the vertical ramus of the mandible and the lateral pterygoid muscle was placed in a direct trajectory to the predetermined osteotomy site of the basisphenoid bone. A safe corridor to the osteotomy site was established using sequential tubular dilators bypassing the guttural pouch, internal and external carotid arteries. Despite the use of microsurgical techniques, visualization of critical structures was limited by the long and narrow working channel. Whilst partial resection of the mass was achieved, iatrogenic trauma to the normal brain parenchyma was identified by intraoperative imaging. With consent of the owner the mare was euthanized under the same general anesthesia. Post-mortem magnetic resonance imaging and gross anatomical examination confirmed partial removal of a pituitary adenoma, but also iatrogenic damage to the surrounding brain parenchyma, including the thalamus.

Congenital trans-sellar trans-sphenoidal encephalocele: a systematic review of diagnosis, treatment, and prognosis.

PURPOSE: Clinical presentations encompass respiratory, feeding issues, nasopharyngeal mass, meningitis, CSF leakage, craniofacial anomalies, and endocrine problems. Surgery is the primary treatment, transitioning from frontal craniotomy to endoscopic methods, offering improved outcomes. Yet, more studies are needed. A comprehensive review on trans-sellar trans-sphenoidal encephalocele (TSTSE) is missing. Our study aims to fill this gap, offering a comprehensive perspective for physicians. METHODS: This review adhered to the PRISMA guideline. Eligible studies focused on human subjects, specifically trans-sellar encephaloceles, and provided comprehensive treatment details. English language articles published up to April 11th, 2023, were considered. Two trained researchers conducted article screening using consistent criteria. Data extraction covered various aspects, including clinical presentation, surgical methods, and outcomes, with results presented descriptively in two tables. Due to the rarity of this congenital anomaly, meta-analysis and publication bias assessment were not feasible. Data extraction was independently conducted by two reviewers, with subsequent cross-verification. RESULTS: A total of 36 patients were identified from 14 studies, the most frequently observed clinical presentation was dyspnea (41.67%) and the most frequently observed accompanying anomaly was cleft lip/palate (55.56%). CT and MRI were adopted in nearly all the cases, and trans-nasal approach was the most often used surgical approach (57.14%) with the 'soft material combination' the most commonly used method for cranial base repairment (35.71%). A total of two deaths occurred and diabetes insipidus was the most common perioperative complication which occurred in six surgery patients (21.43%). CONCLUSION: TSTSE predominantly affects males and presents with dyspnea, visual deficits, pituitary insufficiency, and cranial base-related symptoms. Early diagnosis is critical, with advanced imaging playing a key role. Endocrine assessment is vital for hormone management. Surgery offers symptom relief but entails risks, including reported fatalities and complications. The choice between surgery and conservative management requires careful deliberation. The trans-nasal approach is favored for its reduced trauma, yet further research is necessary to validate this preference.