Name:
10.3171/2023.4.FOCVID22150
Description:
10.3171/2023.4.FOCVID22150
Thumbnail URL:
https://cadmoremediastorage.blob.core.windows.net/e6de52ff-7a26-45df-a407-f55e6f70fdb6/videoscrubberimages/Scrubber_346.jpg
Duration:
T00H06M40S
Embed URL:
https://stream.cadmore.media/player/e6de52ff-7a26-45df-a407-f55e6f70fdb6
Content URL:
https://cadmoreoriginalmedia.blob.core.windows.net/e6de52ff-7a26-45df-a407-f55e6f70fdb6/22-150.mp4?sv=2019-02-02&sr=c&sig=mgFeKi1f9ywjcfurVBNDor6NUVstYQthsPNLXCCQKIY%3D&st=2026-01-20T01%3A27%3A00Z&se=2026-01-20T03%3A32%3A00Z&sp=r
Upload Date:
2023-05-22T00:00:00.0000000
Transcript:
Language: EN.
Segment:0 .
SPEAKER 1: This video demonstrates an endoscopic intranasal transsellar and transcavernous approach for resection of a pituitary adenoma that was invading the medial wall of the cavernous sinus. Patient had a confirmation of Cushing's disease. And an MRI demonstrated a hypointensity on the left side of the sella that was questionable for invasion of the medial wall of the cavernous sinus and the medial compartment of the cavernous sinus.
SPEAKER 1: Patient was brought to the operating room. And an endoscopic intranasal approach was performed. Binostril approach was accomplished. And the sella was drilled in a standard fashion. Our initial plan was to explore the sella and evaluate the medial wall of the cavernous sinus to then make a decision if a cavernous sinus approach would be needed. We drilled the sella initially, exposing the dura of the sella.
SPEAKER 1: The dura of the sella was opened sharply with a blade. The subdural compartment was dissected, separating the dura from the tunica of the pituitary gland. With endoscopic scissors, we were able to expand the opening particularly on the left side where the disease was located. And initially, dissection demonstrated just the pituitary gland in the area. We explored the medial aspect of the medial wall of the cavernous sinus.
SPEAKER 1: We prepared for potential dissection in the direction of the cavernous sinus by dividing the space between the periosteal and meningeal layers of the dura of the face of the sella. At this point, we didn't see any obvious invasion in that compartment. And we felt that potentially, it would be just a pituitary adenoma located in the sella. We dissect the pituitary adenoma in an extracapsular fashion, identified the structures, and confirmed with an ultrasound.
SPEAKER 1: With the ultrasound, we were able to see the pituitary adenoma located superficially and laterally on the left side. Also, a clear-cut separation between the pituitary gland anterior portion and the posterior portion of the pituitary gland. We could also see the carotid artery more laterally. We continued our dissection.
SPEAKER 1: And we were able to obtain an extracapsular resection of the pituitary adenoma that was located on the left side of the pituitary gland. We were very careful not to damage the posterior gland to avoid diabetes insipidus. And we dissected posteriorly. And the ultrasound during the surgery was also important to define that we were not reaching the posterior gland.
SPEAKER 1: We dissected away from the posterior gland, and we were able to rotate the pituitary adenoma from the sella. There was some attachments to the lateral wall that made us worried that this was infiltrating the medial wall of the cavernous sinus. At this point, we removed the pituitary adenoma, carefully watching the behavior in relation to the medial wall of the cavernous sinus.
SPEAKER 1: We were able to remove, and we felt that there was some thickness located laterally in the medial wall of the cavernous sinus. So we went back to that space and analyzed. And when we elevate the medial wall of the cavernous sinus, it looked extremely thick. And we then confirmed the need for expansion. And we then opened the space by drilling the anterior wall of the covenant sinus, exposing the periosteum of the carotid artery on the left side.
SPEAKER 1: With more space, we're able to cut the ligaments located inside the cavernous sinus and rotate the medial all of the cavernous sinus away. And initially, we cut the inferior portion of the medial wall of the cavernous sinus that was extremely thick and protecting the carotid artery that was located more laterally. We removed the first piece of the medial wall of the cavernous sinus, sent that to pathology.
SPEAKER 1: And we were still seeing some thickening superiorly. What you see immediately lateral, that's the carotid artery. So there was no obvious tumor located inside the cavernous sinus, but the wall definitely looked thicker than usual. So we expanded the opening superiorly to allow us to do the final cut in the abnormal medial wall of the cavernous sinus without causing any CSF leak or causing any problems with the cavernous sinus structures.
SPEAKER 1: We were able to remove the last piece that was abnormal of the medial wall of the cavernous sinus. With then irrigated with hydrogen peroxide and performed reconstruction with collagen matrix, followed by the mucosa of the sphenoid sinus that was rotated back in place, covering the sella and the entire skull base defect. Patient did very well after surgery. We noticed a peak of ACTH that happened intraoperatively, followed by the descent of ACTH to undetectable levels.
SPEAKER 1: The cortisol was measured every 6 hours and proved to go down below normality. In conclusion, we proved that the ultrasound was a very useful tool to identify the microadenoma, particularly immediately medial to the internal carotid artery. And the interdural peeling was a great method to enter the cavernous sinus.
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