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Pituitary 360°

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Pituitary 360°

  1. 1. Pituitary 360° 26-5-2017 12.31 pm
  2. 2. Great teachers – All this is their work . I am just the reader of their books . Prof. Paolo castelnuovo Prof. Aldo Stamm Prof. Mario Sanna Prof. Magnan
  3. 3. For Other powerpoint presentatioins of “ Skull base 360° ” I will update continuosly with date tag at the end as I am getting more & more information click www.skullbase360.in - you have to login to slideshare.net with Facebook account for downloading.
  4. 4. So much material has to be added to this PPT – stay tuned
  5. 5. Pituitary is yellow in color like Jack fruit pulp ; spikes on fruit are pituitary ligaments
  6. 6. Pituitary 1. Jackfruit analogous to pituitary 2. Normal pituitary is yellow in color . Preserve it in surgery . Unless DI / panhypo comes . 3. Jackfruit surface has spikes . Analogous to Pituitary Ligaments which is plane for extracapsular pituitary - between pituitary capsule & meningeal layer . 4. Jackfruit peel is pituitary capsule after periosteal layer & meningeal layer of dura . So total 3 layers to enter into pituitary yellow mass from sphenoid sellar bone. Endosteal layer & Meningeal layer are fused to each other at all places except where the cranial venous sinuses are enclosed between them . 5 . Superior & inferior intercavernous sinus present between periosteal & meningeal layer of dura
  7. 7. Endosteal layer & Meningeal layer are fused to each other at all places except where the cranial venous sinuses are enclosed between them .
  8. 8. Endosteal layer & Meningeal layer are fused to each other at all places except where the cranial venous sinuses are enclosed between them
  9. 9. Saggital section
  10. 10. Therefore, in regions of the cranial base where the dura is not covered by overlying bone, the periosteal layer is absent. This is best exemplified along the superior and lateral portions of the sella, where the lack of bone creates a very unique morphological arrangement of the dura mater. Over the lateral portion of the cavernous sinus, on each side, there is a meningeal layer along the sphenoid ridge. As this then spans medially traveling along the roof of the cavernous sinus and toward the sellar roof, the meningeal layer invaginates into the sella, forming a pouch. As the meningeal layer from both sides progresses centrally and begins to invaginate, a central oval aperture is formed through which the stalk eventually runs (46). Now given that the sella, is completely covered by bone anteriorly, posteriorly, and inferiorly along the sellar floor, the invaginating meningeal layer encounters the periosteal layer in these regions forming the dense double-layered dura mater of the sellar face, which often is interpreted as a single layer (46). Laterally, by virtue of the fact that there is no bone separating the pituitary fossa from the cavernous sinus, the periosteal layer is absent and therefore the meningeal layer alone separates the pituitary gland from the cavernous sinus.
  11. 11. Lateral wall of cavernous sinus has 2 layers – there is clear cut plain between dura propria & inner membranous layer . 1. outer meningeal layer is also called Dura propria which we elevate in dolenc approach . 2. inner membranous layer formed by sheats of nerves of 3 , 4 , V1 .
  12. 12. G & H are present observations
  13. 13. Artist's drawings of different types of cavernous sinus. Left. Normal cavernous sinus. The whole cavernous sinus is enveloped by a thin membranous layer that separates the contents of the lateral wall (third (III), fourth (IV), and ophthalmic division (V~) of the fifth cranial nerves) from the venous channels of the cavernous sinus proper. The abducens nerve (VI) is the only intracavemous cranial nerve. The internal carotid artery (ICA) and second division of the trigeminal nerve (V2) are also depicted. Center: Intracavemous (Type I) tumors (for example, meningiomas) arise within the cavernous sinus, encircle and displace the cranial nerves laterally, and tend to encase and narrow the ICA. Right; Interdural (Type II) tumors (tumors of the lateral wall of the cavernous sinus) arise and remain between the two layers of the lateral wall. The deep membranous layer separates these tumors from the venous channels of the cavernous sinus. The ICA is displaced medially, but not encased or narrowed.
  14. 14. Trigeminal nerves present between
  15. 15. 3 layers anteriorly, posteriorly, and inferiorly along the sellar floor 1. periosteal dura [ PD ] 2. meningeal dura [ MD ] 3. pituitary capsule [ PC ] Intraoperative view with a zero- degree endoscope showing the two components of the dura mater located along the face and floor of the sella. The dura here is formed by an inner meningeal dura (MD) and an outer periosteal dura (PD). The intercavernous sinuses run in between both layers as the IIS shown in the picture. Once these layers reach the cavernous sinus, they bifurcate and only the meningeal layer forms the medial wall of the cavernous sinus (CS) along the lateral border of the sella. The pituitary gland is shown with a preserved pituitary capsule (PC).
  16. 16. rt cavernous sinus.. look at the McConnell's capsular artery – Dr. Janakiram
  17. 17. The intercavernous sinuses run in between both layers as the IIS shown in the picture. P = PD = Periosteal dura
  18. 18. P = periosteal dura ; SHA = superior hypophyseal artery
  19. 19. A, schematic drawing showing the sellar region in a frontal view. The pituitary gland (P) is demonstrated in the center attached to the medial wall of the cavernous sinus (CS) by the pituitary ligaments (PLs). The anterior dura covering the pituitary gland was removed, and the pituitary stalk was freed under the chiasm (Ch). The internal carotid arteries are shown on both sides. The inferior hypophyseal arteries (IHa) originate from the meningohypophyseal trunk of the ICA within the CS, and they travel medially and posteriorly to vascularize the inferior posterior third of the gland. The inferior hypophyseal arteries are ligated and cut along with the IIS and the PLs to allow the gland to be mobilized superiorly. The superior hypophyseal arteries (SHa) are preserved, and care should be taken when opening the dural fold of the aperture to avoid injuring them.
  20. 20. yellow arrow inferior part ( Sphenoidal part ) of the medial wall of the cavernous sinus ( yellow line ), blue-sky arrow superior ( Sellar part ) of the medial wall of the cavernous sinus ( blue-sky line ) In the upper part, the medial wall is given by the meningeal layer, that is a continuation of the diaphragma sellae, which surrounds the pituitary capsule inferiorly (Yasuda et al. 2005 ; Martins et al. 2011 ) . In the inferior part, the medial wall is given by the endosteal layer that covers the body of the sphenoid bone.
  21. 21. Adenohypophysis = anterior lobe [ pink color ] Neurohypophysis = posterior lobe [ yellow color ]
  22. 22. Although the main goal of the pituitary transposition is an adequate visualization of the interpeduncular cistern, we are buoyed by the fact that seven of the eight patients with normal preoperative pituitary function (87.5%) maintained their normal pituitary function. This reinforces the fact that the pituitary gland is principally vascularized by the superior hypophyseal artery, and the ligation of the inferior hypophyseal artery, which we performed in every case, does not interfere with the global pituitary function. – from kassam paper http://www.ncbi.nlm.nih.gov/pu bmed/18424968 - get this paper from www.sci-hub.io
  23. 23. Inferiorly, the largest vessel contributing to this network is the superior hypophyseal artery, which gives off a recurrent branch along the inferomedial border of the proximal intracranial part of the optic nerve (Blunt and Steele, 1956; Abuzayed et al., 2010). – craniopharyngioma book
  24. 24. CP circuminfundibular plexus - The SHAs usually arise from the fi rst part of the cisternal segment of the ICA and terminate on the pituitary stalk and gland, but that can also send branches to the optic nerves and chiasm and the fl oor of the third ventricle. The infundibular arteries originate from the PcomA and are mainly directed to the infundibulum. Both the infundibular and the SHAs pass medially, below the chiasm, to reach the tuber cinereum. They form several anastomoses around the pituitary stalk, creating the circuminfundibular plexus (Rhoton 2003 ) . Secondary braches from this plexus are directed to the anterior lobe of the pituitary gland, the tuber cinereum, the optic chiasm, and nerves. CP circuminfundibular plexus, ICAi intracranial portion of the internal carotid artery, OT optic tract, PCP posterior clinoid process, PG pituitary gland, PS pituitary stalk, SHA superior hypophyseal artery, white asterisks coaxial branches
  25. 25. Within the medial part of the carotid cistern a tremendous arterial network given by the superior hypophyseal arteries, the infundibular arteries and perforating branches from the internal carotid artery is visible. The superior hypophyseal arteries and infundibular arteries (from the posterior communicating artery) form a complex network around the pituitary stalk, named circuminfundibular plexus (Rhoton 2003 ) . This plexus gives rise to descending (for the anterior lobe of PG) and ascending (for tuber cinereum, median eminence and inferior surface of optic chiasm) branches (Rhoton 2003 ) .
  26. 26. ICA various positions & ICA relation to pituitary
  27. 27. Endoscopic view of the internal carotid artery showing 3 types of angles (black lines) between the posterior ascending and horizontal portions of the C4 segment. (A) angle <80; (B) angle >100; and (C) angle between 80 and 100. PG, pituitary gland; ON, optic nerve. *C4 bend. (Printed with permission from Mayfield Clinic.)
  28. 28. See video lecture at https://www.youtube.com/watch?v=4tiRfPLYkBo
  29. 29. Transnasal transsphenoidal endoscopic view of the parasellar region illustrate that types I- III are symmetric and type IV is asymmetric. (A) Type I angle between the posterior ascending and horizontal portions of C4 segment is <80, resulting in direct contact between the pituitary gland and the internal carotid artery (ICA) and a tortuous ICA configuration. (B) Type II angle between the posterior ascending and the horizontal portions of the C4 segment is between 80 and 100. (C) Type III angle between the posterior ascending and the horizontal portions of the C4 segment is >100. ICA appears slightly curvilinear and less tortuous than the type I or the type II. (D) Type IV angles of the left and right ICAs are asymmetric. PG, pituitary gland; ON, optic nerve. *C4 bend. (Printed with permission from Mayfield Clinic.)
  30. 30. Authors speculate that type I presents the highest risk for vascular injury based on its contact between the ICA and pituitary gland. In 50% of our specimens, the C4 bend was behind the pituitary gland (Figure 4A). Risk of potential vascular injury decreases in types II and III. – Get paper at http://dx.doi.org.sci-hub.cc/10.1016/j.wneu.2014.09.021
  31. 31. Transnasal transsphenoidal endoscopic view of a type II angle (between 80 and 100) that has no contact with the pituitary gland. Angle allows a corridor to the posterior aspect of the cavernous sinus and the oculomotor nerve without retraction of the internal carotid artery or the pituitary gland. CN III, oculomotor nerve; CS, cavernous sinus; PG, pituitary gland. (Printed with permission from Mayfield Clinic.)
  32. 32. Transnasal transsphenoidal endoscopic view between the C3 and the C4 segments of the internal carotid artery at the lacerum and clivus levels. Two distinct shapes (green) were identified as trapezoid (A) in 80%or hourglass (B) in20%of specimens. (Printed with permission from Mayfield Clinic.)
  33. 33. core diagram of anterior skull base If we don't know these diagrams posterior genu carotid blowout happens in pituitary & anterior skull base surgery especially when the angle between paraclival carotid & horizontal part of the parasellar carotid is < 80 degrees where pituitary is very adhere to posterior genu
  34. 34. core diagram of anterior skull base If we don't know these diagrams posterior genu carotid blowout happens in pituitary & anterior skull base surgery especially when the angle between paraclival carotid & horizontal part of the parasellar carotid is < 80 degrees where pituitary is very adhere to posterior genu
  35. 35. core diagram of anterior skull base If we don't know these diagrams posterior genu carotid blowout happens in pituitary & anterior skull base surgery especially when the angle between paraclival carotid & horizontal part of the parasellar carotid is < 80 degrees where pituitary is very adhere to posterior genu
  36. 36. Conceptual illustration of the endoscopic perspective depicts the various internal carotid artery (ICA) classifications. (Left) Bouthillier et al. (2) used 7 segments: C1 ¼ cervical, C2 ¼ petrous, C3 ¼ lacerum, C4 ¼ cavernous, C5 ¼ clinoid, C6 ¼ ophthalmic, and C7 ¼ communicating. (Right) De Powell et al. (5) modification includes C3-C4 bend, C4 bend, and C4-C5 bend. Depending on the angle of the C4 bend (green plane), a potential corridor between the ICA and the pituitary allows access to the posterior cavernous sinus (yellow arrow). SOF, superior orbital fissure; OS, optic strut; OCR, opticocarotid recess; TS, tuberculum sellae. (Printed with permission Mayfield Clinic.)
  37. 37. Anatomic measurements between the internal carotid arteries and the pituitary gland in 20 specimens. (A) (aee) Intercarotid distances between the left and right ICAs. (B) Measurements (a’, b’, c’) of the space between the ICA and the pituitary gland at 3 levels (cephalic, middle, caudal). (Printed with permission from Mayfield Clinic.)
  38. 38. Pituitary transpostion ENDOSCOPIC ENDONASAL PITUITARY TRANSPOSITION FOR A TRANSDORSUM SELLAE APPROACH TO THE INTERPEDUNCULAR CISTERN – get the paper at www.sci-hub.cc or www.sci-hub.bz
  39. 39. Intraoperative view with a zero-degree endoscope showing the face of the sella and the planum sphenoidale after removal of the overlying bone. Note the critical landmarks: lateral optic–carotid recesses (LOCR), ICA, the left and right optic nerves (LON, RON), and the middle optic recesses (mOCR). The dura (D) of the suprasellar compartment was opened above the SIS, and the arachnoid (A) was preserved. The opening of the sellar dura is initiated under the SIS, and the pituitary gland (P) is shown.
  40. 40. Intraoperative view with a zero- degree endoscope illustrating the transaction of the previously coagulated SIS with endoscissors. The dura (D) of the suprasellar region was opened, and the arachnoid (A) preserved. At this point, the dura of the face of the sella is also incised with the pituitary gland (P) exposed. The bony resection extends laterally to expose the cavernous sinus (CS).
  41. 41. Intraoperative view using a zero-degree endoscope demonstrating coagulation of the SIS with an endobipolar. The bipolars can be seen straddling the SIS located between the sella (S) below and the suprasellar cistern (A) above. Note the dura (D) overlying the cistern was opened without transgressing the arachnoid (A).
  42. 42. 3 layers anteriorly, posteriorly, and inferiorly along the sellar floor 1. periosteal dura [ PD ] 2. meningeal dura [ MD ] 3. pituitary capsule [ PC ] Intraoperative view with a zero- degree endoscope showing the two components of the dura mater located along the face and floor of the sella. The dura here is formed by an inner meningeal dura (MD) and an outer periosteal dura (PD). The intercavernous sinuses run in between both layers as the IIS shown in the picture. Once these layers reach the cavernous sinus, they bifurcate and only the meningeal layer forms the medial wall of the cavernous sinus (CS) along the lateral border of the sella. The pituitary gland is shown with a preserved pituitary capsule (PC).
  43. 43. Ds= Dorsum Sellae after removing the pituitary mass in craniopharyngioma case
  44. 44. “pituitary ligaments”are analogous to the dentate ligaments that attach the lateral portion of the spinal cord to the dura. Pituitary ligaments starts from pituitary capsule to meningeal layer of dura over cavernous sinus .
  45. 45. A, schematic drawing showing the sellar region in a frontal view. The pituitary gland (P) is demonstrated in the center attached to the medial wall of the cavernous sinus (CS) by the pituitary ligaments (PLs). The anterior dura covering the pituitary gland was removed, and the pituitary stalk was freed under the chiasm (Ch). The internal carotid arteries are shown on both sides. The inferior hypophyseal arteries (IHa) originate from the meningohypophyseal trunk of the ICA within the CS, and they travel medially and posteriorly to vascularize the inferior posterior third of the gland. The inferior hypophyseal arteries are ligated and cut along with the IIS and the PLs to allow the gland to be mobilized superiorly. The superior hypophyseal arteries (SHa) are preserved, and care should be taken when opening the dural fold of the aperture to avoid injuring them.
  46. 46. B, endonasal cadaveric dissection using a zero-degree endoscope after releasing the pituitary gland from the dural fold (DF) that forms the aperture is shown. The SHa runs above the DF, and care should be taken at the last cut when opening the sellar aperture to avoid damaging the SHa. The CS, the IHa, the dorsum sellae (DS), and the clivus (C) are shown. The pituitary stalk (S) can be seen moved to the right side with the pituitary gland (PG) still being tethered by several PLs, preventing complete mobilization.
  47. 47. A, endonasal cadaveric dissection through a zero-degree endoscope demonstrating a pituitary transposition. The left inferior hypophyseal artery (IHa) was transected. The pituitary gland (PG) is being rotated medially away from the cavernous sinus (CS). The pituitary capsule can be seen covering the underlying pituitary gland (PG). Soft tissue attachments “pituitary ligaments” (PL) can be seen connecting the PC to the CS. Endoscissors are shown transecting the PL along the left side of the sella. The clivus (C) is labeled along the midline for orientation proposes. B, correlative intraoperative endonasal view demonstrating mobilizing the right side of the PG. Note the PL tethering the gland to the CS are identified and released.
  48. 48. intraoperative suprasellar view with a zero-degree endoscope showing the pituitary gland (PG) and the pituitary stalk (S) after the opening of the suprasellar and sellar dura, ligation of the SIS, and complete excision of the anterior dural fold (DF) that forms the pituitary aperture. The chiasm (Ch) is visualized superiorly and anteriorly. A small subchiasmatic perforator (SP) branch of the superior hypophyseal artery is shown.
  49. 49. endonasal cadaveric dissection view using a zero-degree endoscope during a pituitary transposition is shown. At this point, the left lateral aspect of the pituitary gland covered by its capsule (PC) is totally disconnected from the cavernous sinus (CS) and the superior soft tissue adherence (AI) between the gland and the DF that forms the pituitary aperture is demonstrated.
  50. 50. endonasal cadaveric dissection using a zero-degree endoscope is shown after releasing the pituitary gland from the DF that forms the aperture. It allows for a suprasellar view. The PG and the S after the opening of the suprasellar and sellar dura are shown. The Ch is visualized superiorly. The location of the left CS and the dorsum sellae (DS) are shown.
  51. 51. schematic drawing showing the sellar region after the pituitary gland (PG) is transposed superiorly. Before detaching the posterior clinoid process (PC), the dorsum sellae (DS) is drilled. The ICA is retracted laterally within the cavernous sinus (CS), allowing the surgeon to drill the carotid canal with a high-speed drill using a 1-mm diamond drill bit. The ligated IIS is shown.
  52. 52. intraoperative view using a zero-degree endoscope showing the PC being thinned with a high-speed drill in between the DS and the medial wall of the cavernous sinus (RCS) at the level of the carotid canal. The pituitary gland (P) is transposed superiorly
  53. 53. Intraoperative view with a zero-degree endoscope showing the pituitary gland (P) transposed superiorly to expose the dorsum sellae (DS). The right posterior clinoid process (PC) is resected after detachment from the posterior carotid canal. The laterally retracted medial wall of the right cavernous sinus (CS) is shown.
  54. 54. Intraoperative view using a 45-degree endoscope showing the contents of the interpeduncular cistern after the opening of the retrosellar dura. The basilar artery (B) can be seen at its upper level bifurcating into both posterior cerebral arteries (P1). The superior cerebellar arteries (SCA) originating immediately before the bifurcation. The right third cranial nerve (III) is seen at its origin in between the right P1 and SCA. The tumor (Tu) was invading the floor of the third ventricle. Some small perforators (SP) are seen originating from the left P1
  55. 55. Schematic drawing showing the direct view of the tumor (Tu) in the interpeduncular cistern that is obtained after the pituitary transposition. Note that the pituitary gland (PG) is elevated and fixed in place with fibrin glue. The dotted lines represent the bone that was removed during the approach (transplanum, transsellar, transclival approaches). The optic nerves (ONs), left optic tract (OT), third ventricle (III-v), brainstem (BS), basilar artery (B), clivus (C), and sphenoid sinus (SS) are shown.
  56. 56. Intraoperative view using a 45-degree endoscope showing the contents of the interpeduncular cistern after the opening of the retrosellar dura. The basilar artery (B) can be seen at its upper level bifurcating into both posterior cerebral arteries (P1). The superior cerebellar arteries (SCA) originating immediately before the bifurcation. The right third cranial nerve (III) is seen at its origin in between the right P1 and SCA. The tumor (Tu) was invading thefloor of the third ventricle. Some small perforators (SP)are seen originating from the left P1
  57. 57. Intraoperative view using a 45-degree endoscope showing the lateral border of the interpeduncular cistern on the left side. ICA subchiasmatic perforators that vascularize the left optic nerve (LON) and optic chiasm (Ch) are seen. The left posterior communicating artery (Pcomm) is seen joining the posterior cerebral artery (P1/P2 junction). A small perforator (SP) from Pcomm that supplies the left optic tract (LOT) is shown. After the origin of the anterior choroidal artery (covered by Pcomm), the ICA bifurcates into the middle and anterior cerebral arteries. The first segment of the anterior cerebral artery (A1) is seen as it travels over the genu of the left optic nerve/tract.Inferiorly, the basilar artery can be seen with the left superior cerebellar artery (SCA). The left third cranial nerve is seen in between the left SCA and P1.
  58. 58. Intraoperative view with a 45-degree endoscope positioned in the lower aspect of the sphenoid sinus where a clivectomy was performed aiming superiorly and showing the pituitary gland (PG) transposed. The tumor (Tu) is being resected using the two-suction technique. The right cavernous sinus (CS) is shown.
  59. 59. A and B, intraoperative views with a 45- degree endoscope positioned in the lower aspect of the sphenoid sinus where a clivectomy was performed aiming superiorly and showing the third ventricle of two different patients at the end of the tumor resection. Various anatomic structures can be seen in both images as such as the foramen of Monro (FM), the column of the fornix (CF), the anterior commissure (AC), the thalamic mass intermedia (MI), the choroid plexus (CP), and the walls of the hypothalamus (H). The patient in Figure 13 had hydrocephalus preoperatively; body of the fornix (F) is also identified at the level of the septum pellucidum. The internal cerebral veins (ICV) are also prominent and can be easily seen.
  60. 60. http://www.ncbi.nlm.nih.gov/pubmed/18424968 - get paper at www.sci-hub.io
  61. 61. Perneckys space
  62. 62. Hemitransposition of pituitary
  63. 63. For better understanding of hemitransposition of pituitary see this video by Dr. Janakiram https://www.youtube.com/watch?v =CqM6qJE12Fw
  64. 64. Extracapsular dissection
  65. 65. Strong opponents of extracapsular dissection of pituitary surgery likeSatish Jain sir argument is IHA is damaged sothat posterior pituitary compromised & diabetes insipidus develops . Still I need to refer literature for pros & cons of intra & extracapsular dissection of pituitary . Discussion welcome . Check others at www.skullbase360.in
  66. 66. Click this facebook link for discussion https://www.facebook.com/groups/enttoday/permalink/893847500698013/
  67. 67. • Vinod Felix The advantage of extracapsular dissection, is that you can be 100% sure that you got the entire tumor out, provided the tumor is delivered in toto with an intact capsule....and this is at times, the only way to remove a large fibrous tumor....But , a boon comes with a curse...the curse is that , if you are not meticulous with your microdissection , you can damage the IHA or at times peel the gland along with the tumor.....So be judicial in using extracapaular, respect your learning curve, use it for fibrous tumors, which may be more difficult to remove intracapsular.......And at times, you can have the capsule identified initially, debulk the tumor internally and then go extracapaular...
  68. 68. Both extracapsular ABOVE & intracapsular BELOW – Vinod Felix
  69. 69. Roof - two triangles: 1. clinoid (anterior) 2. oculomotor (posterior) ACP anterior clinoid process, APCF anterior petroclinoid fold, DS dorsum sellae, ICF interclinoid fold, PF pituitary fossa, PLL petrolingual ligament (inferior sphenopetrosal ligament), PPCF posterior petroclinoid fold, PS planum sphenoidale, SSPL superior sphenopetrosal ligament (Gruber’s ligament), TS tuberculum sellae, black asterisk middle clinoid process , CSR cavernous sinus roof , white asterisk oculomotor nerve If the Gruber’s ligament is ossificated it is called Wegener’s bridge.
  70. 70. Interclinoidal ligament/fold [ ICF ] after pituitary extracapsular extraction
  71. 71. Note normal gland
  72. 72. Note normal gland
  73. 73. Unilateral extracapsular dissection for craniopharyngioma to prevent panhypopituitarism – vinod felix – this point has to be referred literature
  74. 74. Vinod Felix Murali ji, pure extracapsular should be avoided , unless tumor is fibrous..... Pituitary tumors originate inside normal gland. So there is always a layer of normal gland over the pseudocapsule ( this has been proved by various hpe studies by Prof Ari Chacko)...we are hence at risk of peeling off the normal gland and of course more risk to injure inferior hypophyseal art in pure extracapsular....
  75. 75. • Radhamadhab Sahu The transsphenoidal pseudocapsule-based extracapsular resection provides a more effective and safe alternative compared to the traditional intracapsular one because of its higher tumor removal and remission rates and lower recurrence rate ....but fully agree with Dr. Vinod Felix .....the meticulous description he had provided with his vast experience....few things to add ...just a situation...if there is an aneurysm which was silent and a nonfunctional pituitary macro adenoma you are operating, then situation can be worst with pseudo extra capsular approach...literature says there is 4 to 7percent association of ICA aneurysms with pit macro adenoma....journey of a skull base surgeon..usually starts with intra capsular and then gradually moved to intra capsular decompression and extra capsular resection then to extra capsular....any how nice post by Dr.Murali Chand Nallamothu....keep posting..
  76. 76. • Shahin Bastaninejad Extra capsular tumor dissection is a newer concept in endoscopic trans sphenoid pituitary tumor surgery, you should seek for inclusion criteria for extra capsular dissection: it is mainly suitable for smaller tumors, so that you can diminish the recurrence rate while try to save vital structures. The normal adenohypophysis was more often found at histopathology in the extracapsular excisions, rather than in the intracapsular excisions. The trans- sphenoidal pseudocapsule-based extracapsular resection approach provides a more effective and safe alternative compared to the traditional intracapsular technique. Better tumor removal, good remission and lower recurrence rate could be achieved compared to intracapsular approach. Gross total extracapsular dissection may be accomplished either by using a standard approach to the pituitary fossa or by extending the exposure. This technique could need removal of a portion of the planum sphenoidale and division of the superior inter cavernous sinus especially in tumors with suprasellar extension. Separation of the tumor from the normal gland, stalk, and cavernous sinus contents could be possible. It should be noted that the improved visualization provided by the endoscope does allow extracapsular dissection in many cases but it is not always possible especially in giant tumor. Intracapsular resection has also been found to be a safe and effective treatment.
  77. 77. From paper “ TUMOR TISSUE IDENTIFICATION IN THE PSEUDOCAPSULE OF PITUITARY ADENOMA: SHOULD THE PSEUDOCAPSULE BE REMOVED FOR TOTAL RESECTION OF PITUITARY ADENOMA? “ – Eun Jig Lee, M.D., Ph.D. - DOI: 10.1227/01.NEU.0000330406.73157.49 - – get paper from www.sci-hub.cc or www.sci- hub.bz Intraoperative photographs showing the pseudocapsule (arrow) in varying fashion as follows: a well- developed capsule entirely covering the whole tumor mass (A and B);
  78. 78. a thin, fibrous envelope (C); yellowish, discolored, normal glandlike, thin membrane (D–F);
  79. 79. thick, fibrous tissue (G); and calcification (H) after removal of the main tumor mass. N, normal pituitary gland.
  80. 80. A summary of 10 key points: - Extracapsular dissection technique with the Cotton Swab for pituitary adenomas through an endoscopic endonasal approach – How I do it - Daniel M. Prevedello - DOI 10.1007/s00701-013-1766-1 – get paper from www.sci-hub.cc or www.sci- hub.bz 1. The term "extracapsular dissection" refers to the pseudocapsule formed by the compressed acini-reticulin structure surrounding almost 50 % of cases a pituitary adenoma. 2. The patient is positioned supine, tilted discretely to the left, with the head slightly turned to the right. 3. Neuronavigation and intraoperativemonitoring (SEP/EMG) enhance the safety of the procedure. 4. Two surgeons (otolaryngologist and neurosurgeon), three- to four-hands technique. 5. Adequate bone removal and dura exposure are essential; expose the “four blues”. 6. Use the interface between the compressed tissue and the normal gland as surgical plane for dissection. 7. Perform twisting movements with the cotton swab to enucleate pseudocapsule and adenoma. 8. Asecond cotton swab may be used as a retractorwhen the diaphragm descends prematurely, obscuring visualization of the sellar content, especially the superolateral angle. 9. If two cotton swabs are introduced through the left nostril position, one is placed at the 12 o’clock position acting as a retractor and another is at the 6 o’clock position for microsurgical dissection. 10. Not all pituitary adenomas are suitable for extracapsular dissection.
  81. 81. From paper DOI 10.1007/s00701-011-0961-1 – “Transsphenoidal pseudocapsule- based extracapsular resection for pituitary adenomas ” - Xin Qu - – get paper from www.sci-hub.cc or www.sci-hub.bz Diagrams illustrating the pseudocapsule-based intracapsular (a) and extracapsular (b) resection approaches for large pituitary adenomas. A, adenoma; B, pseudocapsule; C, normal pituitary gland; D, pituitary capsule; E, dural envelope
  82. 82. • Anand Veluswamy why dont you ask an experienced neuro surgeon on the merrits of total removal of a pitutary beningn slow growing lesion with high morbidity or intracapsular method with less morbidity and late possible recurrence .i know atleast 2 cases of overzealous removal of pituitary benign adenomas by ent and death of the pts. both cases happened in live surgery workshops.I have done revisions in endoscopic,open,post RT pituitaries and will not advise risky techniques as a primary modality just to avoid a redo after many years..
  83. 83. Microadenoma
  84. 84. To get any paper of any journal free click www.sci-hub.bz or www.sci-hub.cc How to get FREE journal papers in www.sci-hub.bz or www.sci-hub.cc 1. When same paper published in different journals , the same paper has different DOIs -- so we have to try with different DOIs in www.sci- hub.bz orwww.sci-hub.cc if one of the DOI is not working. 2. If the paper has no DOI , copy & paste URL of that paper from the main journal website . If you can't get from one journal URL try with different journal URL when the author publishes in different journals . 3. Usually all new papers have DOIs . Old papers don't have DOIs . Then search in www.Google.com . Old papers are usually kept them free in Google by somebody . Sometimes the Old papers which are re-published will have DOIs. Then keep this DOI in www.sci-hub.bz or www.sci-hub.cc 4. Add " .pdf " to title of the paper & search in www.Google.com if not found in www.sci-hub.bz or www.sci-hub.cc
  85. 85. pituitary transposition / extracapsular papers http://www.ncbi.nlm.nih.gov/pubmed/23793961 http://www.ncbi.nlm.nih.gov/pubmed/20526794 http://www.ncbi.nlm.nih.gov/pubmed/24360179 https://www.thieme- connect.com/products/ejournals/abstract/10.1055/ s-0032-1312181 https://www.youtube.com/watch?v=VS2CzVt_XAg
  86. 86. Craniopharyngioma
  87. 87. Prof. Amin kassam says SHA decided into 1. Recurrent optic nerve branch 2. Middle anastamotic branch with opposite SHA 3. Descending infundibular/diaphragmatic branch & best seen in endoscopic approach than transcranial approach
  88. 88. Prof. Amin kassam says SHA decided into 1. Recurrent optic nerve branch 2. Middle anastamotic branch with opposite SHA 3. Descending infundibular/diaphragmatic branch & best seen in endoscopic approach than transcranial approach
  89. 89. Prof. Amin kassam says SHA devided into 1. Recurrent optic nerve branch 2. Middle anastamotic branch with opposite SHA 3. Descending infundibular/diaphragmatic branch & best seen in endoscopic approach. This is one of the reason for choosing endoscopic approach for craniopharyngioma.
  90. 90. The optic chiasm is referred to as prefixed when it is located above the tuberculum sellae and as a postfixed chiasm when it is situated superior to the dorsum sellae
  91. 91. Parasagittal cadaveric specimen with a postfixed chiasm. Note the more inclined pituitary stalk (stalk). For reference, note the left and right optic nerves
  92. 92. Parasagittal cadaveric specimen with a normally positioned optic chiasm. For reference, note the right optic nerve (II)
  93. 93. Subfrontal cadaveric dissection in a specimen found to have a prefixed chiasm. Note the anterior location of the pituitary stalk (arrow). For reference, note the optic nerves (II) and left internal carotid artery (ICA)
  94. 94. Case 1
  95. 95. Case 2
  96. 96. Petrosal Approach for Retrochiasmatic Craniopharyngiomas – separate chapter present in this book – I am thinking this approach because there are higher chance of injurying the SHA in trans nasal endoscopic approch to approch this tumor through the narrow corridor of subchiasmatic cistern
  97. 97. For Other powerpoint presentatioins of “ Skull base 360° ” I will update continuosly with date tag at the end as I am getting more & more information click www.skullbase360.in - you have to login to slideshare.net with Facebook account for downloading.
  98. 98. • dfd

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