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Chapter 11
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11.1 Indications 106
Suprasellar Approach
to the Third Ventricle
11.2 Surgical Steps 106
11.3 Case Example 111
11.4 Tips and Tricks 111
1
Suprasellar Approach to the Third Ventricle
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11 Suprasellar Approach to the Third Ventricle
Luigi Maria Cavallo, Domenico Solari, Teresa Somma, Alberto Di Somma, Paolo Cappabianca
Introduction
Due to its deep location and strict relationships with
vital neurovascular structures, the third ventricle is
one of the most complex areas to access. Several surgical transcranial routes to the different portions of
the third ventricle, including translamina terminalis,
the frontal transcortical transforaminal, the anterior transcallosal, and the infratentorial supracerebellar approaches, have been described.
approaches enable the entrance to the third ventricle
cavity via its natural communication foramina and/or
passing through relatively avascular areas of the third
ventricle walls, such as the suprapineal recess, the
lamina terminalis, and the tuber cinereum— the tuber
cinereum represents a gray matter layer of the third
ventricle floor that is commonly opened during endoscopic third ventriculostomy.
The endoscopic transsphenoidal approach, initially
adopted for sellar and, later on, for suprasellar lesions,
has recently expanded its boundaries, providing the
possibility to access the third ventricle cavity. Indeed,
in 1987 Weiss
tended endonasal transsphenoidal approach. He performed a transsphenoidal approach removing additional
bone along the tuberculum sellae and the posterior planum sphenoidale, between the optic canals, with subsequent opening of the dura mater above the diaphragma
sellae. Initially, such procedures were performed with
the microscope
contributed to broaden the surgical anatomy knowledge
of these areas, thus widening the possibilities of the
transsphenoidal route
exploration of the third ventricle cavity.
8
termed and originally described the ex-
8–10
; more recently, the endoscope has
11–16
and allowing a safe surgical
1–7
Most of these
17,18
11.1 Indications
• Meningiomas of the planum sphenoidale or tubercu-
lum sellae.
• Suprasellar craniopharyngiomas.
• Giant pituitary macroadenomas.
• Suprasellar Rathke’s cleft cysts.
• Suprasellar and third ventricle arachnoid cysts.
• Intraventricular tumors (colloid cysts, choroid plexus
papillomas, and ependymomas).
11.2 Surgical Steps
The endoscopic endonasal approach allows the visualization of the third ventricle chamber from a different perspective as compared with the conventional transcranial
one, that is, from below.
With the patient supine, the head is positioned in
a slightly extended position to optimize access to the
anterior cranial base. The face is turned 5 to 10 degrees
toward the surgeon. The endoscope is inserted into the
chosen nostril, usually the right, parallel to the nasal
floor, and the nasal septum is visualized medially. The
inferior turbinate is identified laterally and its tail
is followed until the choana, which is limited by the
vomer medially and the floor of the sphenoid sinus superiorly. Once the choana is identified, the endoscope
is angled upward, along the sphenoethmoid recess for
approximately 1 to 1.5 cm above the roof of the choana,
and the sphenoid sinus can be opened either through
its natural ostium or through the sphenoid prow.
Unilateral middle turbinectomy along with bilateral
removal of the posterior ethmoidal cells allows an adequate corridor.
The nasoseptal flap can be designed at this point, as
described by Hadad et al.
the nasopharynx until tumor resection is completed,
taking care to prevent twisting the pedicle to prevent
ischemic damage of the flap. On the other hand, the flap
can be drawn on the nasal septum at the beginning of
the procedure, while it can be raised and rotated on the
osteo-dural defect at the end of the surgery; in this way,
the ischemia of the flap due to twisting of its pedicle can
be prevented.
At this point, the nasal septum is detached from the
anterior wall of the sphenoid sinus with a dissector or
a high-speed microdrill. Then 1 to 2 cm of the posterior
edge of the nasal septum (vomer) is resected with backbiting forceps. It is crucial to widely open the anterior
wall of the sphenoid sinus to gain a proper working angle
for the instruments. Subsequently, the contralateral
middle turbinate is outfractured. All sphenoid intrasinus
septae are trimmed. The main anatomic landmarks
of the posterior wall of the sphenoid sinus must be
recognized (Fig. 11.1). These include the optic nerves
and intracavernous carotid artery canals as well the
lateral and medial opticocarotid recesses (MOCR, medial
optic-carotid recess; LOCR, lateral optic-carotid recess,
respectively) and the clival recess.
A complete removal of the tuberculum sellae, that
is, the suprasellar notch20 as seen from the endonasal
perspective up to both medial opticocarotid recesses, is
mandatory to enter the suprasellar area and reach the
third ventricle: the bone is thinned with the drill and
then removed with a Kerrison rongeur. At this stage,
the dura is opened and the entire suprasellar region
comes into view (Fig. 11.2). This region can be divided
into four areas by two ideal planes, one passing along
the inferior surface of the optic chiasm and the mammillary bodies and another passing via the posterior
margin of chiasm and the dorsum sellae, thus resulting
in the suprachiasmatic region, the subchiasmatic
region, the retrosellar area, and the ventricular region
(Figs. 11.3 and 11.8).
In the suprachiasmatic region, the chiasmatic and
the lamina terminalis cisterns with relative contents
are accessible. The anterior margin of the chiasm,
the medial portion of the optic nerves, the anterior
19
The flap is then stored in
17
106
ocr
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OP
Suprasellar Approach to the Third Ventricle
Fig. 11.1 Endoscopic endonasal
view of the posterior wall of the
sphenoid sinus. C, clivus; CP, carotid
protuberance; ocr, opticocarotid
PS
+
*
*
OP
ocr
recess (lateral opticocarotid recess);
OP, optic protuberance; PS, planum
sphenoidale; SF, sellar fl oor. *Medial
opticocarotid recess; +suprasellar
notch.
ICA
CP
CP
CP
SF
C
Ch
sis
CP
Fig. 11.2 Endoscopic endonasal
access point to the suprasellar
area. Ch, chiasm; dm, dura mater
covering the pituitary gland; ICA,
internal carotid artery; sis, superior
intercavernous sinus.
ICA
cerebral arteries, the anterior communicating artery,
and the recurrent Heubner’s arteries, with the most
posterior portion of the straight gyrus, can be visualized (Figs. 11.4 and 11.5).
In the subchiasmatic space, the pituitary stalk is
encountered below the chiasm, with the superior
hypophyseal arteries and its perforating branches supplying the inferior surface of the chiasm and the optic
nerves. The superior aspect of the pituitary gland and
the dorsum sellae, posteriorly, are also visible. The
dm
superior hypophyseal arteries supply the optic chiasm, the floor of the hypothalamus, and the median
eminence. Each of the superior and inferior hypophyseal arteries anastomoses with the corresponding
vessels of the opposite side, forming an arterial ring
around the hypophysis; this is an important anatomic
note (Fig. 11.3).
The retrosellar area, explored passing with the endoscope between the pituitary stalk and the internal carotid
artery above the dorsum sellae, encloses the upper third
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*
ONONON
Fig. 11.3 Visualization of
the suprasellar area after an
extended endoscopic endonasal
transtuberculum-transplanum
approach showing two possible
surgical corridors to access the third
ventricle cavity. 1, suprachiasmatic
corridor; 2, subchiasmatic corridor;
Ch, optic chiasm; ICA, internal carotid
artery; ON, optic nerve; Pg, pituitary
1
gland; Ps, pituitary stalk; sha, superior
hypophyseal artery. *Ophthalmic
*
artery.
ON
sha
Ch
2
GR GR
Ps
Pg
*
ch
sha
2
ICA
Fig. 11.4 Exposure of the lamina
terminalis cistern. Ch, optic chiasm;
GR, gyrus rectus; ON, optic nerve;
Ps, pituitary stalk; sha, superior
hypophyseal artery. *Lamina
terminalis cistern.
ON
sha
of the basilar artery, the pons, the superior cerebellar
arteries, the oculomotor nerves, the posterior cerebral
arteries, and lastly the mammillary bodies and the floor
of the third ventricle at the level of the tuber cinereum
(Fig. 11.6 and 11.7).
As seen from the endonasal perspective, the third
ventricle cavity can be divided into four areas by means
of two ideal planes, one passing through the optic
chiasm and the interthalamic commissure, and one
passing through the posterior edge of the foramen of
Monro and the interthalamic commissure. Accordingly, two anterior (infundibular and foraminal) and
108
sha
Ps
two posterior (mesencephalic and tectal) areas can be
defined (Fig. 11.8).
Through the endoscopic endonasal approach,
two different corridors can identified, namely the
suprachiasmatic and the subchiasmatic.
• Through the suprachiasmatic pathway, the lamina
terminalis cistern is entered passing above the optic
chiasm. Once the lamina terminalis is opened, the
infundibular area of the third ventricle can be accessed
(Fig. 11.9). As soon as the third ventricle chamber
is entered, endoscopic inspection with 0-degree
endoscope permits the visualization of the thalami
Suprasellar Approach to the Third Ventricle
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Fig. 11.5 Endoscopic endonasal,
close-up view of the neurovascular
structures inside the lamina terminalis
cistern. If the suprachiasmatic route
A
2
AcoA
AcoA
A
1
Ch
A
2
*
A
1
Lt
to the third ventricle is adopted,
the anterior communicating artery
complex has to be lifted up to
expose the lamina terminalis, which
represents the entry point to the third
ventricle. A1, precommunicating
tract of the anterior cerebral artery;
A2, postcommunicating tract of
the anterior cerebral artery; AcoA,
anterior communicating artery; Ch,
optic chiasm; Lt, lamina terminalis.
*Heubner’s artery.
Pg
*
PCA
sca
laterally and the interthalamic commissure. The use
of angled endoscopes allows a better view, especially
of the foraminal area.
• The subchiasmatic route allows the entry into the third
ventricle cavity through its floor, that is, the tuber cinereum, which is localized on the floor of the third
ventricle between the pituitary stalk and the mammillary bodies. Removal of the dorsum sellae, preferably
coupled with the anterior transposition of the pituitary
gland, is a preliminary step during the endoscopic endonasal approach to the tuber cinereum. As a matter
of fact, after complete removal of the sellar floor, the
BA
sca
Fig. 11.6 Endoscopic endonasal
view of the retrosellar area after the
pituitary gland has been elevated
(pituitary transposition). BA, basilar
artery; MB, mammillary body; PCA,
posterior cerebral artery; Pg, pituitary
gland; sca, superior cerebellar
artery; III, oculomotor nerve. *Tuber
cinereum.
IIIIII MB
dorsum sellae, together with the posterior clinoids, has
to be exposed extradurally and carefully removed. To
obtain a wider visualization of the tuber cinereum, an
anterior transposition of the pituitary gland should be
performed as described by Kassam et al.
21
To simplify
the anterior pituitary gland transposition procedure,
two cuts can be made on each lateral aspect of the
gland to leave in place only a thin glandular cuff on both
cavernous sinuses, thus avoiding any dissection on its
medial wall. After that, the gland can be displaced superiorly. Once the transposition has been completed, a
wide view of the retrosellar space and of the floor of
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PCA
Fig. 11.7 Endoscopic endonasal
close-up view of the neurovascular
structures in the retrosellar area.
+
MBMB
PCA
*
When the subchiasmatic corridor
is chosen, the tuber cinereum
represents the entry point to the
third ventricle. BA, basilar artery; MB,
mammillary body; PCA, posterior
cerebral artery; sca, superior
cerebellar artery; III, oculomotor
nerve. *Posterior communicating
artery; +tuber cinereum.
*
III
BA
4
2
sca
3
III
Fig. 11.8 Artistic drawing showing
a sagittal view of the third ventricle.
The third ventricle chamber has been
divided into four areas by means of
two ideal lines: the fi rst one passing
between the optic chiasm and the
interthalamic commissure, and the
second one between the posterior
edge of the foramen of Monro and
the interthalamic commissure. 1,
anteroinferior (infundibular) area; 2,
anterosuperior (foraminal) area; 3,
posteroinferior (mesencephalic) area;
4, posterosuperior (tectal) area.
the third ventricle can be obtained (see Fig. 11.6). The
endoscope can be advanced in an inferosuperior trajectory inside the ventricular cavity, passing through
the tuber cinereum. Once inside the third ventricle, the
thalami and the interthalamic commissure, the foramen of Monro, and the bulging of mammillary bodies
can be seen.
110
1
The endoscopic endonasal exploration of the foraminal
area permits to show the inner surface of the foramen of
Monro, that is, the portion that faces the third ventricle
(Fig. 11.10). As seen from this perspective, the body of the
fornix is located on the middle of the field and it continues upwards and laterally with its columns; on the other
hand, the inferolateral surface of each foramen of Monro,
Suprasellar Approach to the Third Ventricle
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AC
T
ITC
T
*
fThv
Fig. 11.9 Endoscopic endonasal view of the infundibular
region of the third ventricle. fThV, fl oor of the third ventricle;
ITC, interthalamic commissure; T, thalamus. *Mesencephalic
area.
as seen from below, is formed by the ipsilateral thalamus.
The choroid plexus extends within each foramen of Monro and surrounds the body of the fornix like a collar before entering the lateral ventricle through the choroidal
fissure. The anterior commissure is visualized anteriorly
to the foramen of Monro.
Finally, passing under the interthalamic commissure, the posterior portion of the third ventricle can
be reached, that is, the mesencephalic area (Fig. 11.11).
Accordingly, it is possible to show the pineal and suprapineal recesses, the posterior commissure, the habenular
commissure, the stria medullaris, the tela choroidea, and
the beginning of the cerebral aqueduct. The pineal gland
and the internal cerebral veins lateral to the pineal gland
can be seen as well.
f
FM
FM
*
ITC
Fig. 11.10 Endoscopic endonasal view of the third ventricle
foraminal area. The endoscope is angled upward up to visualize
the anterior commissure. AC, anterior commissure; f, body of
fornix; FM, foramen of Monro; ITC, interthalamic commissure.
*Choroid plexus.
A binostril approach was used. A left middle turbinectomy with the resection of the posterior nasal septum
and a wide sphenoidotomy were performed. Tuberculum
sellae and posterior portion of the planum sphenoidale
and sellar floor were removed.
Upon dural opening, a large reddish mass came into
view, arising from the pituitary stalk, appearing as an
infundibular craniopharyngioma. Initial intracapsular
debulking of the tumor was performed followed by fine
extracapsular dissection. The last step consisted of the
fragmentation and peeling of the tumor capsule, which
was found to compress and obstruct the infundibular recess of the third ventricle. At the end of the procedure, the
infundibular area of the third ventricle as well as mammillary bodies along its floor and the basilar artery were
visualized (Fig. 11.13).
11.3 Case Example
A 52-year-old woman was admitted to our hospital with
a 1.5-year history of headache and progressive visual loss.
Magnetic resonance imaging (MRI) of the brain showed
a large mass arising from the sella with a significant
suprasellar component, compressing the optic chiasm
and extending into the third ventricle (Fig. 11.12).
Hormonal tests evaluation revealed hypopituitarism.
According to these features, the diagnosis of an infun-
dibular craniopharyngioma was ruled out and removal
via an extended endoscopic endonasal approach to the
suprasellar area was chosen.
11.4 Tips and Tricks
11.4.1 During the Surgical Approach
• Examine the MRI to evaluate the relationship between
the lesion, the suprasellar area, and the floor of the
third ventricle.
• To prevent harming the mammillary bodies or the mid-
brain, avoid traction over the posterior part of the floor
of the third ventricle.
• The double curved suction tubes are useful to explore
the third ventricle cavity.
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sm sm
TC
HC
PC
✱
Fig. 11.11 Endoscopic endonasal
exposure of posterior portions of
the third ventricle. The endoscope
is advanced below the interthalamic
commissure, to show the third
ventricle mesencephalic area. HC,
habenular commissure; PC, posterior
commissure; sm, stria medullaris; TC,
tela choroidea. *Aqueduct of Sylvius.
• When approaching the third ventricle, there is
significant risk of a high-flow cerebrospinal fluid
leak; therefore, we recommend an accurate multilayer
reconstruction technique.
Fig. 11.12 Sagittal MRI scan
showing a large infundibular
craniopharyngioma extending inside
the third ventricular cavity with the
fl oor displaced inferiorly (see white
arrow).
• When opening the third ventricle chamber, there
is significant risk of the pneumocephalus; therefore, we recommend postoperative rehydration
therapy.
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ON
Pg
✱
ITC
T
MB
BA
T
MB
ON
Fig. 11.13 Intraoperative view of the
third ventricle cavity after the removal
of the infundibular craniopharyngioma
shown in Fig. 11.12. BA, basilar
artery; ITC, interthalamic commissure;
MB, mammillary body; T, thalamus.
*Choroid plexus.
Fig. 11.14 Endoscopic endonasal
transposition of the pituitary gland
allowing the drilling of the dorsum
sellae. ON, optic nerve; Pg, pituitary
gland; Ps, pituitary stalk. *Dorsum
sellae.
Ps
*
11.4.2 During the Anatomic
Dissection
• As already highlighted, the access to the third ventricle
can be obtained passing both through the lamina terminalis and/or via the tuber cinereum:
– Via the lamina terminalis, it is mandatory to raise
superiorly the anterior cerebral artery complex
while displacing the chiasm inferiorly (Fig. 11.5);
however, the exposition of the lamina terminalis
through this route is highly dependent on the position and orientation of the chiasm.
– Removal the dorsum sellae and anterior transposi-
tion of the pituitary gland permit to expose properly the tuber cinereum and enter the third ventricle
cavity (Figs. 11.14 and 11.15).
• The lateralization of the superior hypophyseal arteries to
enlarge the space above the sella is an important maneuver during the surgical access through the tuber cinereum.
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Pg
Fig. 11.15 Endoscopic endonasal
extradural removal of the left
posterior clinoid process. ICA,
internal carotid artery; PC, posterior
clinoid; Pg, pituitary gland. *Inferior
hypophyseal artery.
*
PC
PC
Acknowledgment
The authors wish to thank Prof. Manfred Tschabitscher,
Head of the Study Group, ‘Microsurgical and Endoscopic Anatomy’ at the University of Wien, and Prof. Alberto
Prats-Galino, Chief of the Laboratory of Surgical Neuroanatomy at the University of Barcelona. Anatomic dissections were made in their wonderful labs.
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