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30. Okada T, Mikuni N, Miki Y, Kikuta K, Urayama S, Hanakawa T, Fushimi Y, Yamamoto A, Kanagaki M,FukuyamaH,HashimotoN,TogashiK:Corticospinal tract localization: integration of diffusiontensor tractography at 3-T MR imaging with intraoperative white matter stimulation mapping— preliminary results. Radiology 240:849-857, 2006. 31. Schneider JP, Trantakis C, Rubach M, Schulz T, Dietrich J, Winkler D, Renner C, Schober R, Geiger K, Brosteanu O, Zimmer C, Kahn T: Intraoperative MRI to guide the resection of primary supratentorial glioblastoma multiforme—a quantitative radiological analysis. Neuroradiology 47:489-500, 2005. 32. Steinmeier R, Fahlbusch R, Ganslandt O, Nimsky C, Buchfelder M, Kaus M, Kaus M, Heigl T, Lenz G, Kuth R, Huk W: Intraoperative magnetic resonance

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imaging with the magneton open scanner: concepts, neurosurgical indications, and procedures: a preliminary report. Neurosurgery 43:739-747, 1998. 33. Sutherland GR, Kaibara T, Louw D, Hoult DI, Tomanek B, Sanders J: A mobile high-field magnetic resonance system for neurosurgery. J Neurosurg 91:804-813, 1999. 34. Taniguchi M, Cedzich C, Schramm J: Modification of cortical stimulation for motor evoked potentials under general anesthesia: technical description. Neurosurgery 32:219-226, 1993. 35. Truwit CL, Hall WA: Intraoperative magnetic resonance imaging-guided neurosurgery at 3-T. Neurosurgery 58(4 Suppl 2):ONS-338-346, 2006. 36. Yingling CD, Ojemann S, Dodson B, Harrington MJ, Berger MS: Identification of motor pathways during

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Conflict of interest statement: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. received 24 May 2009; accepted 13 March 2010 Citation: World Neurosurg. (2010) 74, 1:153-161. DOI: 10.1016/j.wneu.2010.03.022 Journal homepage: www.WORLDNEUROSURGERY.org Available online: www.sciencedirect.com 1878-8750/$ - see front matter © 2010 Elsevier Inc. All rights reserved.

Combined Endoscopic Transsphenoidal–Transventricular Approach for Resection of a Giant Pituitary Macroadenoma Antonio Romano1, Salvatore Chibbaro2, Marco Marsella3, Gabriele Oretti1, Toma Spiriev 2, Corrado Iaccarino1, Franco Servadei1

Key words 䡲 Endoscopy 䡲 Endoventricular lesion 䡲 Giant pituitary macroadenoma 䡲 Transsphenoidal approach 䡲 Transventricular approach Abbreviations and Acronyms MRI: Magnetic resonance imaging From the 1Department of Neurosurgery, Parma University Hospital, Parma, Italy; 2Department of Neurosurgery, Lariboisere University Hospital, Paris, France; 3 Center for Neurosciences, Tucson, Arizona, USA To whom correspondence should be addressed: Salvatore Chibbaro, M.D. [E-mail: [email protected]] Citation: World Neurosurg. (2010) 74, 1:161-164. DOI: 10.1016/j.wneu.2010.02.024 Journal homepage: www.WORLDNEUROSURGERY.org Available online: www.sciencedirect.com 1878-8750/$ - see front matter © 2010 Elsevier Inc. All rights reserved.

䡲 OBJECTIVES: Sellar lesions, such as pituitary adenomas, even when extended to the suprasellar space may be usually removed through a trans-sphenoidal approach. Larger lesions extending well beyond the edges of the sellar diaphragm such as giant adenomas are best controlled with craniotomy and/or a combined approach that implies both, transphenoidal and transcranial route. Currently, the availability of more sophisticated endoscopes in this type of surgery has provided optimal angles of view and rendered the trans-sphenoidal route less invasive yet, more effective. 䡲 CASE DESCRIPTION: The authors report a case of a giant pituitary adenoma successfully managed by a simultaneous, combined endoscopic trans-sphenoidal-transventricular approach. 䡲 CONCLUSION: In selected case of giant pituitary adenoma with ventricular extension, this technique may help to achieve a gross total removal avoiding the need of staged procedures allowing also a direct visualization of the extent of removal. Finally this approach can potentially improve gross total resection rate of different types of tumor involving this region such as cranipharyngiomas while reducing morbidity and mortality.

INTRODUCTION The transsphenoidal approach currently is the criterion standard for treatment of lesions located within the sellar space; this approach allows optimal visualization of the sellar content as well as the inferior suprasellar cistern. One of its advantages remains its minimal invasiveness. On the other hand, the regions above the suprasel-

lar cistern and the planum sphenoidalis usually are not very well exposed, which poses obvious limitations for larger and laterally extended lesions. The pterional approach, although allowing better exposure of larger suprasellar masses, requires some amount of brain retraction. When compared to the transsphenoidal route, it is as-

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sociated with higher perioperative morbidity and longer recovery time. Sellar lesions with significant suprasellar extension generally remain a neurosurgical challenge because of their complexity and the lack of a well-standardized approach. Recently, extended endoscopic approaches have been attempted and described; the goal is to en-

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Figure 3. Perioperative endoscopic view from above (at the end of procedure) through the Monroe foramen showing the basilar artery (BA) with its upper branches, the optic chiasm (OCh), choroid plexus (ChP), and gross total removal of the tumor.

Figure 1. Sagittal (A) and coronal (B) contrastenhanced T1 magnetic resonance image, showing a large enhancing lesion extending from the sella through the suprasellar cistern into the third and left lateral ventricle causing obstructive hydrocephalus.

large the transsphenoidal route superiorly and laterally. Accordingly, these extended approaches have made possible removal of the tuberculum sellae and planum sphenoidale (2, 4-6, 8, 9, 11, 17, 23-25). Despite this significant improvement, endoscopy-assisted transsphenoidal approach remains insufficient yet to manage larger lesions extending up to the third and lateral ventricles and beyond. Because of these limitations, we felt challenged to attempt the resection of a large sellar lesion by using only an endoscopic approach and we describe the successful management of a giant pituitary adenoma removed through a simultaneous endoscopic transsphenoidal–transventricular approach. CASE REPORT The patient is a 71-year-old woman who presented with an 8-week history of progressive headache, drowsiness, spatial disorientation, and generalized weakness.

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Figure 2. Six-month follow-up sagittal (A) and coronal (B) enhanced T1 magnetic resonance image showing tumor gross total removal.

On admission, her neurologic examination was consistent with a Glasgow Coma Scale score of E2, V3, M5 (10/15). Although she had no focal deficits, her visual fields were hard to determine as she had cooperated poorly with the examiner. A contrast-enhanced magnetic resonance image (MRI) was obtained, and it showed an enhancing lesion extending from the sella through the suprasellar cistern into the third and left lateral ventricle; obviously there was evidence of obstructive left ventricular hydrocephalus (Figure 1). The radiologic features were consistent with a giant pituitary macroadenoma. Endocrinologic evaluation revealed panhypopituitarism; therefore, hormone replacement therapy was immediately instituted. At the same time, surgical resection through a simultaneous minimally invasive combined endoscopic transsphenoidal and transventricular approach was planned. Although the procedure was carried out without complications (details are discussed

below), the patient developed diabetes insipidus in the immediate postoperative period. Desmopressin (DDAVP) was initiated and diabetes insipidus was controlled within 5 days. Neurologic examination revealed no focal deficits, and her consciousness returned to her baseline. Ultimately she was discharged home on the 7th postoperative day. The pathology report confirmed a nonsecreting pituitary adenoma. Six- and 24-week follow-ups confirmed stable recovery of the patient, who remained neurologically intact. Repeat MRIs showed gross total resection of tumor (Figure 2).

SURGICAL TECHNIQUE Under general anesthesia, the patient was placed supine on the operating table with the head fixed on a 3-point fixation system; the head was kept in neutral position and a left frontal burr hole (similar to that for an endoscopic third ventriculostomy) as well as endoscopic transsphenoidal approach were planned. Two surgical teams were available and worked simultaneously. Two rigid endoscopes of 0 and 30 degrees, 30 cm long and 2.9 mm in diameter (Hopkins II optical system; EndoscopyAmerica, Charlton, Massachusetts, USA; operative channel by Karl Storz, Tuttlingen, Germany) were used. The surgeons completing the transsphenoidal approach positioned themselves on the patient’s right side (neurosurgeon and ear, nose, and throat surgeon using a four-hands endoscopic technique) and the surgeon completing the transventricular approach was

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PEER-REVIEW REPORTS ANTONIO ROMANO ET AL.

standing at the head of the operating table; all surgeons were able to watch simultaneously the two monitors. The tumor was first removed from the sella and suprasellar cisterns; the tumor capsule was easily penetrated and the soft tumor content was suctioned out. The capsule, however, turned out to be of harder and fibrotic consistency; in addition, a thick arachnoid membrane was encountered extruding into the sella and sphenoid sinus. This was hindering tumor descent even after repeated Valsalva maneuver. To avoid excessive and dangerous traction from below, attention was turned to the ventricular component, from where more of the tumor could be mobilized by using only blunt dissection and a Fogarty catheter with the balloon inflated. Still under direct endoscopic visualization, the lesion could be pushed down through the foramen of Monroe into the third ventricle and ultimately into the sella, and from here down to the sphenoid sinus, simply by applying gentle pressure. After the tumor was fully delivered into the sphenoid sinus, it could be completely removed. Following tumor removal, thorough endoscopic observation lead to the identification of the normal anatomical structures seen from the third ventricle, such as the basilar artery with its upper branches and the optic chiasm (Figure 3). In addition, we were able to identify in transparence the light source of the transsphenoidal endoscope. This was not directly visible because of the presence of an abundant and thick arachnoid membrane. Finally, the sellar floor was reconstructed using a nasoseptal flap (15) and sealed by fibrin glue. We must mention that in the postoperative period, the patient did not develop cerebrospinal fluid leakage.

DISCUSSION Giant sellar lesions with wide extension into the suprasellar compartment often represent a surgical challenge. Although the best management of these lesions is still controversial, the transsphenoidal and transcranial approaches remain the most commonly used. Various surgical approaches have been proposed to manage these lesions. A rather complex one was proposed by Konovalov (16) that allows to reach the tumor through a simultaneous transcallosal and pterional route. Although this remains very fascinating, we

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strongly believe that whenever possible, any brain retraction and/or neurovascular manipulation should be avoided. Because of its minimal invasiveness, low perioperative morbidity, and conceptually straighter and shorter path to the tumor (3, 6, 10, 12, 13, 18-20, 22, 26), the transsphenoidal approach remains a preferred choice. A major problem associated with the standard transsphenoidal approach for giant adenomas remains the limited visualization of the suprasellar region. This often results in unacceptable incomplete resection of larger lesions. To circumvent this problem various solutions have been proposed, such as intrathecal injection of saline to facilitate the descent of the suprasellar portion of the tumor, Valsalva maneuver, and a combined transsphenoidal and transcranial approach (1, 7, 21). A combined and exclusively endoscopic approach, to our knowledge, has been rarely used (14); our report describes this technique to manage a giant pituitary adenoma extended into the third and left lateral ventricle, through a simultaneous minimally invasive endoscopic transsphenoidal and transventricular approach. The goal was that to mobilize the tumor from the intraventricular location and deliver it into the sphenoid sinus. In addition, by using two endoscopes, we were able to verify directly the gross total resection of both the intraventricular and sellar component. Because of the extension of the tumor into the third and left lateral ventricle with resulting obstructive hydrocephalus, we felt that this elegant combined approach could ensure minimal morbidity and optimal results. Nonetheless, we were prepared to convert this approach to an open craniotomy should any complication or difficulty arise. Through the transventricular route, we were able to mobilize approximately 60%–70% of the lesion; this was accomplished by dissecting it from the ventricular wall with the usual endoscopic instruments as well as by applying gentle pressure using a Fogarty catheter with the balloon inflated. With regard to the reconstruction of the sellar floor, we completed a nasoseptal flap as usual; we prefer this reconstructive method because of our substantial experience with endoscopic techniques carried out in direct cooperation with ear, nose, and throat surgeons (four-hands endoscopic technique). Although we are aware that this technique is not necessarily the standard of care, we feel very comfortable with it. Ultimately, because we have been routinely using this technique, the cerebrospinal

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fluid leak rate in our case has been dramatically low. Altogether, the endoscopes allowed maximal visualization and mobilization of the tumor while minimizing the invasiveness of the surgery. We opine that this approach can potentially allow gross total resection of other types of tumor arising in this area, such as craniopharyngiomas. Because brain retraction is not needed and vascular manipulation is reduced to a minimum, it is of no surprise that the morbidity and mortality rates both are significantly minimized. This, however, is clearly an undeniable negligible advantage. We are fully aware that in cases of large tumors invading or encasing crucial structures, especially if away from the midline (i.e., cavernous sinus), and when of very hard consistency, this technique may not be used unless combined with open approaches. We were very intrigued by the recent introduction of ultrasonic aspirator and/or microdebrider applied to endoscopy. We feel that in the near future, more complex and harder lesions may be attempted to be resected by using this technology. When tumor consistency becomes a less significant hurdle, then exclusive endoscopic approach of large, firm lesions (via transseptal and transcortical routes) may become simpler. Finally, the use of an extended endoscopic endonasal approach is a valuable option for the resection of larger and more anteriorly extended skull base masses: although it currently should represent part of the routine armamentarium of any modern skull base neurosurgeon, it still remains, in our opinion, of limited use in case of lesions extended superiorly toward or within the third and lateral ventricle, especially if they are of firm consistency and/or very adherent to surrounding structures.

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received 15 November 2009; accepted 10 February 2010

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Citation: World Neurosurg. (2010) 74, 1:161-164. DOI: 10.1016/j.wneu.2010.02.024

21. Ojha BK, Husain M, Rastogi M, Chandra A, Chugh A, Husain N: Combined trans-sphenoidal and si-

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