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Endoscopic Sellar Approach
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14. de Notaris M, Prats-Galino A, Enseñat J, et al. Quantitative analysis
of progressive removal of nasal structures during endoscopic
suprasellar approach. Laryngoscope 2014;124(10): 2231–2237
15. de Notaris M, Prats-Galino A. Surgical freedom: a challenging
topic in endoscopic endonasal approaches. World Neurosurg
2014;82(1–2):e387–e388
16. Castelnuovo P, Pistochini A, Locatelli D. Different surgical
approaches to the sellar region: focusing on the “two nostrils four
hands technique”. Rhinology 2006;44(1):2–7
17. Fernandez-Miranda JC, Prevedello DM, Gardner P, Carrau R,
Snyderman CH, Kassam AB. Endonasal endoscopic pituitary
surgery: is it a matter of fashion? Acta Neurochir (Wien)
2010;152(8):1281–1282
18. Carrau RL, Kassam AB, Snyderman CH. Pituitary surgery.
Otolaryngol Clin North Am 2001;34(6):1143–1155, ix
19. Stamm AC, Pignatari S, Vellutini E, Harvey RJ, Nogueira JF Jr. A
novel approach allowing binostril work to the sphenoid sinus.
Otolaryngol Head Neck Surg 2008;138(4):531–532
20. de Notaris M, Solari D, Cavallo LM, et al. The “suprasellar notch,” or
the tuberculum sellae as seen from below: definition, features, and
clinical implications from an endoscopic endonasal perspective. J
Neurosurg 2012;116(3):622–629
21. Chin GY, Rice DH. Transnasal endoscopic closure of cerebrospinal
fluid leaks. Laryngoscope 2003;113(1):136–138
22. Cappabianca P, Cavallo LM, Valente V, et al. Sellar repair with fibrin
sealant and collagen fleece after endoscopic endonasal transsphenoidal surgery. Surg Neurol 2004;62(3):227–233, discussion 233
23. Leng LZ, Brown S, Anand VK, Schwartz TH. “Gasket-seal” watertight
closure in minimal-access endoscopic cranial base surgery. Neurosurgery 2008;62(5, Suppl 2):E342–E343, discussion E343
24. Kassam AB, Thomas A, Carrau RL, et al. Endoscopic reconstruction
of the cranial base using a pedicled nasoseptal flap. Neurosurgery
2008;63(1, Suppl 1):ONS44–ONS52, discussion ONS52–ONS53
25. Esposito F, Dusick JR, Fatemi N, Kelly DF. Graded repair of cranial base
defects and cerebrospinal fluid leaks in transsphenoidal surgery.
Neurosurgery 2007;60(4, Suppl 2):295–303, discussion 303–304
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Chapter 13
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13.1 Indications 128
Cavernous Sinus
Approach
13.2 Surgical Steps 128
13.3 Case Example 139
13.4 Complications 140
13.5 Tips and Tricks 141
Cavernous Sinus Approach
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13 Cavernous Sinus Approach
Ernesto Pasquini, Diego Mazzatenta, Matteo Zoli, Michael Ghirelli, Giorgio Frank
Introduction
The endoscopic endonasal approach (EEA) to cavernous
sinus (CS) tumors is a safe and effective route for the
treatment of tumors located in the medial and lateral
compartments of the CS. This approach allows the
surgeon to follow the extension of the tumor into
the CS through a straightforward and completely
extracranial route, and permits to tailor the approach
for each specific case. At the beginning of the last
decade, the main issues related to CS surgery were
the high invasiveness and elevated morbidity rate of
standard transcranial approaches.
to a progressive abandoning of CS surgery in favor
of radiosurgery.
1–5
The renewing interest of the CS
1–3
These factors led
surgery started thanks to the works of Alfieri and Jho,
who reconsidered the anatomy of the CS under the
endoscopic endonasal perspective.
6,7
The contribution
of these and many other authors has permitted this
approach to become widely adopted with satisfactory
results in terms of tumor removal and complications
8–10
rate.
In recent years, the endonasal CS approach has
proved to be a replicable technique with similar results
in different surgical series.
8–10
Thus, it represents
a technique that can be learn, transmitted, and
adopted with satisfaction by incoming generations of
neurosurgeons after a proper endoscopic endonasal
training. In this chapter, we will analyze the anatomic
and surgical premises and the results of this approach.
13.1 Indications
The case selection is one of the most important features
to maximize the potentiality of the EEA to CS and
minimize the morbidity. There are two main parameters
that must be kept in consideration: (1) the biologic
features, in terms of tumor infiltration of vessels and
nerves; and (2) the pattern of growth, in particular in
relationship with the dural layers. Some tumors, for
example, meningiomas, metastasis, or carcinomas,
tend to infiltrate the walls of internal carotid artery
(ICA) and the cranial nerves (CNs). Thus, for these cases
the EEA can cause catastrophic consequences, such as
ICA rupture or permanent CN palsies, as dissection
between the tumor and the surrounding structures
is not possible.
and especially for meningiomas, the risk of massive
intra- or postoperative bleeding is represented by the
occurrence of ICA rupture and/or by the injury of the
hypertrophic tumor feeders from the intracavernous
ICA, such as the meningohypophyseal trunk or the
inferolateral artery.
particularly hazardous, as it is quite complex to identify
9
It is noteworthy that for these cases,
11
The latter makes this surgery
the course of these vessels even with neuronavigation
or intraoperative Doppler. For meningiomas or
malignancies of the CS, some authors only recommend
an endoscopic endonasal osteodural decompression as
a palliative measure in cases of ophthalmoplegia. This
technique consists in drilling the posterior wall of the
sphenoid in the sella and parasellar area, followed by
the opening of the dura layer to decompress the neural
structures.
12–14
A further parameter to be considered is the growth of
the tumor. Some substantially extradural tumors, for instance, chondrosarcoma or chordomas, could, in their
growth, compress and displace the CS without any in-
15,16
vasion.
In these cases, the EEA allows to approach
the tumor through an extradural route, following the
same extension of the tumor to the CS. Also in case of
infiltration of the CS, for example, by a pituitary macroadenoma, this approach permits as well to follow the direction of growth of the tumor.17 When persistent trigeminal
arteries (PTAs) involve only the medial or posterosuperior compartments of CS, displacing laterally the ICA, a
midline transsphenoidal approach is enough to manage
the entire extension of the tumor. Conversely, when the
tumor involves the anteroinferior or lateral compartments,
displacing medially the ICA, we consider an ethmoido-pterygoido-sphenoidal (EPS) corridor more appropriate. A third
selection criterion that should be taken into account for the
case selection is the tumor consistency. When the tumor
is soft, its resection is clearly favored; conversely, a hard,
fibrous consistency with a hemorrhagic aspect greatly increases the surgical complexity, hampering the tumor resection with a greater risk of vessel or nerve damage during
the surgical maneuvers. Unfortunately, this crucial feature
of the tumor, which is associated with better outcome, is
still scarcely predictable before surgery. Until now, this selection criterion is purely theoretic;
16,18–27
but in the future,
neuroimaging exams, such as magnetic resonance elastography, would maybe ensure the consistency of the tumor
preoperatively.
27
13.2 Surgical Steps
Depending on the different types of tumor invasion, two
different surgical approaches to CS can be adopted: the
mid to line transsphenoidal and the EPS.
For the former, the first target of the surgeon should
be the identification of the sphenoid ostium. The tail of
the superior turbinate points to the sphenoidal ostium as
an arrow, and it is the more useful landmark in the nasal
stage (Figs. 13.1 and 13.2). For such approach, in case of
normal pneumatization of the sinus, a complete sphenoidotomy is enough to identify the landmarks on the
posterior wall of the sphenoid sinus and to identify the
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Cavernous Sinus Approach
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sellar bulge, the ICA protuberances, and the optic nerves
(Figs. 13.1–13.3). In case of conchal or presallar variant
of the sphenoidal sinus, the adoption of neuronavigation
and intraoperative Doppler is mandatory to identify the
course of the carotid artery, while drilling off the bone to
expose the sella and parasellar region.
The CS region is represented by the quadrangular
space limited by the optic nerve superiorly, a horizontal
line passing at the level of the vidian nerve inferiorly, the
Middle
turbinate
Nasal septum
sellar bulge medially, and the junction between petrosal
and cavernous ICA laterally (Fig. 13.2). This anatomic
exposure allows dissecting the entire extension of the
CS both medially and laterally to the ICA. However, it is
disadvantageous to work laterally to vessel, because it
imposes an angled trajectory to the surgeon. To expand this
approach laterally, it is necessary to expose and partially
remove the upper part of pterygoid plates. This maneuver
requires the resection of the middle turbinate and the
Superior
turbinate
Supreme
turbinate
Nasal septum
Sphenopalatine
branch
Middle
turbinate
Choana
a
Supreme
turbinate
Sellar
wall
Nasal
septum
Sphenopalatine
artery branch
c
Fig. 13.1 Midline transnasal approach. The lateral dislocation of the middle and the upper turbinate permits identifi cation of the
natural ostium of the sphenoid sinus (a,b). The opening of the sphenoidal sinus starts with the enlargement of the natural ostium,
with a Kerrison or with a Stammberger punch (c). All the intersinusal septa that reduce the vision and limit the maneuverability in
front of the sella should be removed (d).
Choana
Middle
turbinate
b
ICA
Sellar
wall
Clivus
d
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Cavernous Sinus Approach
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Left optic canal
Superior intercavernous sinus
C3
a
ICA
Superior intercavernous sinus
Sella
Pituitary gland
C6
Clivus
Planum
C3
ICA
OCR
C5
C5
ICA
ICA
b
C3
Sup hyp
Tuberculum sellae
Superior intercavernous sinus
Pituitary gland
Clivus
A
Superior intercavernous sinus
Pituitary gland
C5
ICA
C3
ICA
c
Fig. 13.2 Frontal view of the posterior wall of the sphenoidal sinus: the optic protuberance, the optic recess, the parasellar carotid
protuberance, the tuberculum sellae, the planum, the sella, the paraclival carotid protuberance, and the clival indentation are visible
(a). The opening of the sellar fl oor should be as wide as possible from one cavernous sinus to the other and from the superior to the
inferior intercavernous sinuses (four blue lines) (b–d). Landmarks: parasellar (C5) and paraclival (C3) protuberance of internal carotid
artery (ICA), superior intercavernous sinus, lateral opticocarotid recess (OCR).
Clivus
d
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A. 2
A. 1
Sup hyp. art
Sup hyp. art
Ant. com.
A ancurycm
A. 1
Chiasm
Pituitary
stalk
Chiasm
Pituitary
stalk
Pituitary gland
Left CNII
Dursum sellae
C6
Sup hyp. art
Fig. 13.3 The intercavernous sinus
is resected, and dura resection is
extended to the diaphragma sellae.
The surgical route gives a straight
access to the region of the chiasm, the
suprasellar cistern, and the pituitary
stalk. The zoomed image shows
the incidental fi nding of an anterior
communicating artery aneurysm at
the dissection. A1–A2, fi rst and second
segment of anterior cerebral artery;
C6, intradural portion of internal
carotid artery; CNII, optic nerve; Sup
hyp. art, superior hypophyseal artery.
exposure of the uncinate process and the bulla ethmoidalis
(Fig. 13.4). By removing these structures, the natural
ostium of maxillary sinus is usually visible. The tail of
the middle turbinate permits locating the sphenopalatine
foramen. When this landmark is identified, it is possible
to enlarge the sphenopalatine foramen on the vertical
process of the palatine bone, which is the posteromedial
border of maxillary sinus. After its removal, the upper part
of pterygoid plates is exposed (Fig. 13.5). The EPS ends
when the medial and superior aspects of these processes
are removed and the ethmoid is completely resected. This
permits to clearly identify from a more lateral perspective
all anatomic landmarks from the pterygoid canal with the
vidian nerve to the opticocarotid recess, exposing frontally
the entire region of CS (Fig. 13.6). Opening the dura
medially or laterally toward the ICA, the medial or lateral
compartment of CS can be accessed (Figs. 13.7–13.12).
The course of the ICA can be verified by the auxilium of
neuronavigation and intraoperative Doppler to avoid the
damage this vessel (Fig. 13.13).
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MT
UP
B.eth.
B.eth
Max.o.
a
LP
Ground
lamella
c
Fig. 13.4 (a) Uncinectomy. (b) Opening of the ethmoidal bulla. The opening of the bulla should be performed inferomedially to
stay away from the risky areas; lamina papyracea, ethmoidal roof, and ethmoidal artery. The medial portion of the posterior wall
of the maxillary sinus could be resected to expose the posterior wall of maxillary antrum and the vertical process of palatine bone.
(c) Exposure of second portion of ground lamella of middle turbinate. (d) Final vision after sphenoethmoidectomy. Aeth a., anterior
ethmoidal artery; B. eth, bulla ethmoidalis; Fs.o., frontal sinus ostium; LP, lamina papyracea; Max. o., maxillary ostium; MT, middle
turbinate; Peth a., posterior ethmoidal artery; UP, uncinate process.
Max o.
b
d
Fs.o.
Aeth a.
LP
MT
Peth a.
Sph.s
132
MT
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Cavernous Sinus Approach
ST
Oa
LP
MT
Prth c
OC
ICA
a
LP
ST
OC
ICA
SphS
c
Fig. 13.5 Combination of transnasal and transethmoidal approaches. The resection of middle (a, b) and superior turbinate (c, d)
gives a full peripheral view of the sellar and parasellar region and improves the maneuverability of surgical instruments in the region.
The vertical portion of the insertion of the middle and superior turbinate is usually kept in place to avoid frontal recess stenosis and
damage of olfactory fi bers. Aeth. a, anterior ethmoidal artery; ICA, internal carotid artery; LP, lamina papyracea; MT, middle turbinate;
Oa, opthalmic artery; OC, optic canal; SphS, sphenoid sinus; ST, superior turbinate.
b
Aeth. a
LP
ST
Oa
d
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Peth. a
OC
OCr
ICA
Sphs
Sphenopal. a
ab
OC
opth A.
ICA
Area
Chiasm
Pituitary
gland
On
LP
OCr
V2
OC
Pituitary
gland
ICA
Chiasm
Pituitary
gland
OCr
Sphenopal. a
Opth. a
Upper ring
ICA
C5
OCR
clivus
Clivus
Pterygoid can.
c d
Fig. 13.6 Transpterygoid access. The drill-out of upper portion of pterygoid process (PTproc) gives a lateral enlarging of the surgical
fi eld with the exposure of the lateral recess of sphenoid sinus and the region of CS from the lacerous portion of ICA to the OCr (a, b).
The CS region has a quadrilateral shape, located between the opticocarotid recess and the paraclival carotid protuberance medially,
and the orbital apex and the trigeminal nerve protuberance laterally (c, d). The pterygoid canal on the fl oor of the sphenoid sinus
is a useful landmark because it indicates the junction between the horizontal petrosal part of the carotid artery and the ascending
paraclival segment of the vessel and, therefore, it is a guide to the inferior portion of the cavernous sinus. C5, parasellar internal
carotid artery; ICA, internal carotid artery; OC, optic canal; OCr, optic carotid recess; Opht. a., ophthalmic artery; P.eth a., posterior
ethmoidal artery; SphS, sphenoid sinus.
Pterygoid canal
ptherygcanal
Pthering process
134
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