Name:
10.3171/2023.4.FOCVID2324
Description:
10.3171/2023.4.FOCVID2324
Thumbnail URL:
https://cadmoremediastorage.blob.core.windows.net/92fdcfdb-9017-4085-9c4a-16f36c4c8a26/videoscrubberimages/Scrubber_228.jpg
Duration:
T00H06M05S
Embed URL:
https://stream.cadmore.media/player/92fdcfdb-9017-4085-9c4a-16f36c4c8a26
Content URL:
https://cadmoreoriginalmedia.blob.core.windows.net/92fdcfdb-9017-4085-9c4a-16f36c4c8a26/5. 23-24.mp4?sv=2019-02-02&sr=c&sig=nRRMWCx9IFjrtujbBykpfZh%2F67tEknbn0Va%2BVHFXXY4%3D&st=2024-12-27T01%3A53%3A07Z&se=2024-12-27T03%3A58%3A07Z&sp=r
Upload Date:
2023-05-30T00:00:00.0000000
Transcript:
Language: EN.
Segment:0 .
[MUSIC PLAYING]
SPEAKER: This surgical video demonstrates the techniques for a safe endoscopic transsphenoidal resection of a pituitary microadenoma in a patient with MRI-negative Cushing's disease. The surgical approach differs from conventional resection of pituitary adenomas visible on MRI, as emphasis is placed on the exploration of the pituitary gland and the cavernous sinus while preserving as much of the normal gland as possible. The patient is a 54-year-old male with a history of type 2 diabetes for 12 years and hypertension, presenting to the clinic with poorly controlled diabetes.
SPEAKER: Additional cushingoid features, including increased abdominal girth, facial plethora, and severe limb girdle weakness, prompted evaluation for Cushing disease. Plasma, 24-hour urine free, and late night cortisol levels were elevated. And initial 3T MRI and subsequent 7T MRI were negative. CT of the abdomen also showed a small adrenal mass.
SPEAKER: Inferior petrosal sinus sampling, or IPSS, confirmed the presence of a primary ACTH-secreting adenoma on the right side of the pituitary gland. Endoscopic transsphenoidal surgery for pituitary gland exploration and adenoma resection was indicated. Shown here are the 7T MRI images of the patient's brain, which were taken after the standard 3T MRI was negative.
SPEAKER: This was also negative as the only normal pituitary gland, stalk, and the optic chiasm are visible. A crucial piece of our diagnostic workup included an inferior petrosal sinus and cavernous sinus sampling test. IPSS is indicated when initial diagnostic MRI is equivocal or negative. Venous blood is sampled at the right and left cavernous sinus along with the peripheral femoral vein before and after intravenous injection of desmopressin to stimulate ACTH production.
SPEAKER: This is done by introducing a catheter through the common femoral vein and into the jugular vein. A microcatheter is then navigated through the inferior petrosal and into the cavernous sinus on each side. Significant elevation in ACTH levels from the blood sample on one side, as was present in this case on the right compared to the left and peripheral, confirms the pituitary source of hypercortisolism and the laterality.
SPEAKER: The ACTH values further increased following desmopressin injection. With this information, we know that this surgical exploration should focus on the right side of the pituitary gland. The patient was identified by staff and induced and intubated by anesthesia. He was placed in a supine position, with the head and back elevated at 30 degrees, secured by a 3-pin fixation device, and the head tilted toward the surgeon at 15 degrees.
SPEAKER: The nasal cavity was prepped with oxymetolazine and povidone-iodine. And the abdomen was prepped for potential fat graft. Following initial exposure of the nasal cavity, our video begins with the endoscope in this sphenoid sinus directly facing the sellar. The sellar floor has been partially removed with a Kerrison rongeur extending to the cavernous sinuses.
SPEAKER: Notice that a greater portion of the right parasellar floor has been exposed as a prior IPSS evaluation determined that the source of primary ACTH secretion was on the right side. A neuronavigation probe is then introduced to identify the midline of the sella and the relative position of the internal carotid arteries. A micro-Doppler probe is then used to map out the location of the internal carotid arteries bilaterally, especially the right carotid artery.
SPEAKER: An 11 blade was then used to make a cruciate incision in the sellar dura. Intracavernous sinus bleeding was expected and managed with hemostatic agents and light pressure. A nerve hook was used to open the dura further, and an arachnoid knife was used to extend the incision over the right carotid artery and the right cavernous sinus. The attachments of the pituitary gland were separated from the medial cavernous sinus wall.
SPEAKER: We then explored the right inferior aspect of the pituitary gland. With a small ring curette, we were able to identify fragments of white-appearing adenoma, approximately 3 mm in size. We used endoscopic scissors to resect the medial cavernous sinus wall to open the recess through which we used our ring curette to identify the boundaries of the tumor and remove it.
SPEAKER: Prior to closure, we explored this area and determined that we were able to achieve gross-total resection. Had we not found tumor at this side, our plan was to continue our exploration of the left side of the pituitary gland in similar fashion. If we were still unable to find any tumor tissue, we would proceed with hemiresection of the pituitary gland on the right side.
SPEAKER: Much of the normal pituitary gland was left in place. A Valsalva maneuver was performed and there was no evidence of CSF leak. We then proceeded with repair and closure of the surgical cavity with a monolayer of hemostatic cellulose and sponges soaked in thrombin to fill the dead space. The sponges were held in place with another layer of hemostatic cellulose in cargo net fashion.
SPEAKER: Some bioadhesive was used. There was no evidence of bleeding or CSF leakage. Meticulous hemostasis was then achieved in the sphenoid sinus and nasal cavity. The choanae were suctioned out, and the turbinates were medialized. The patient woke up from anesthesia without neurological deficits and had a stable postoperative course.
SPEAKER: He was discharged on the third day after surgery. Postoperative cortisol trended downward from 4.1 micrograms per deciliter on the evening following surgery down to 2.6 the next morning on postop day 1. The nadir level of 2.6 micrograms per deciliter was consistent with early remission. Surgical pathology confirmed ACTH adenoma. Aside from the steroid supplementation, which we plan to taper over months, no other hormone medications were necessary.
SPEAKER: And this was consistent with our surgical approach to preserve the normal pituitary gland. He continued insulin but was able to wean off all his previous antihypertensive medications. The patient reported that his weakness and fatigue had improved on the first clinical visit, and that healing was progressing well without CSF leak. He continues to do well and regain strength at his recent 3- month follow-up visit.
SPEAKER: His 3-month postoperative MRI, displayed on the right, shows an intact pituitary gland and stalk with no evidence of residual. This concludes our video. Thank you.
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