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Laws Jr Edward R. - Atlas of Sellar and Parasellar Lesions Clinical, Radiologic, and Pathologic Correlations

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Book:
Atlas of Sellar and Parasellar Lesions Clinical, Radiologic, and Pathologic Correlations
Author:
Laws Jr Edward R / Lopes M Beatriz S / Mukundan Jr Srinivasan / Zada Gabriel
Publisher:
Springer International Publishing
Genre:
Books / Romance novel
Year:
2016
City:
Cham
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3 / 5
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Atlas of Sellar and Parasellar Lesions Clinical, Radiologic, and Pathologic Correlations: summary, description and annotation

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This book presents, in a stepwise and interactive fashion, approximately 75 clinical-pathological entities that reflect the wide spectrum of pathology encountered in the sellar and parasellar region and have been gathered over a period of decades by the authors. Multiple examples of high-quality radiologic and histopathologic images depicting the differentiating features of the varying lesions are presented, and key operative and clinical management pearls are briefly reviewed in a concise, bullet point format. The interdisciplinary nature of this easy-to-use color atlas and textbook reflects the fact that the management of patients with sellar and parasellar lesions is itself often interdisciplinary,making this atlas a useful resource for any practitioner or trainee who cares for patients with pituitary disease and anterior skull base pathology. The format is unique in that no similar interdisciplinary book is dedicated specifically to the comprehensive catalogue of lesions in this intricate region of the brain and skull base. Atlas of Sellar and Parasellar Lesions: Clinical, Imaging, and Pathologic Correlations is of great value for practitioners and trainees in a range of medical specialties, including radiology, neurology, endocriniology, pathology, oncology, radiation oncology, and neurosurgery.

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Part I
Basic Principles

Springer International Publishing Switzerland 2016

Gabriel Zada , M. Beatriz S. Lopes , Srinivasan Mukundan Jr. and Edward R. Laws Jr. (eds.) Atlas of Sellar and Parasellar Lesions 10.1007/978-3-319-22855-6_1

1. Anatomy of the Sellar and Parasellar Region

Luigi Maria Cavallo 1

(1)

Division of Neurosurgery, Department of Neurosciences, Reproductive and Odontostomatological Sciences, Universita degli Studi di Napoli Federico II, Naples, Italy

Luigi Maria Cavallo (Corresponding author)

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Domenico Solari

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Alessandro Villa

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Teresa Somma

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Paolo Cappabianca

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Keywords

Endoscopic endonasal surgery Skull base surgery Sella Endoscopic anatomy

1.1 Introduction

The skull base is one of the most complex anatomical regions, incorporating many different anatomical structures. The pathology of the skull base may involve a variety of lesions, neoplastic and otherwise, whose management can be difficult. In the past, this area has been accessed by many extensive and often aesthetically disfiguring transcranial and/or transfacial approaches, including the anterior, anterolateral, and posterolateral routes.

The transsphenoidal route facilitates access to the skull base via the nose. Because of its versatility, it can be considered the least traumatic route to the sella. The transsphenoidal route provides excellent visualization of the pituitary gland and related pathology, and it offers lower morbidity and mortality than open approaches to this region []. Direct exposure of the suprasellar, retrosellar, and retroclival spaces can now be gained using these approaches. With the evolution of technical procedures in such critical areas reached through narrow corridors, perfect understanding and knowledge of the surgical anatomy is fundamental.

1.2 Endoscopic Anatomy of the Sphenoid Sinus

The anatomy of the sphenoid sinus cavity and skull base as seen from the endoscopic endonasal point of view can be divided into four areas, according to the different surgical approaches:

The sellar area
The suprasellar area, explored through the transtuberculum-transplanum approach
The parasellar area (for lesions of the cavernous sinus and Meckels cave)
The clival area

1.2.1 Basic Concepts

The endoscopic endonasal procedure is usually performed using a rigid 0 endoscope, 18 cm in length and 4 mm in diameter (Karl Storz Endoscopy, Tuttlingen, Germany), as the sole visualizing tool; angled scopes can be used to further explore the suprasellar area. A high-definition (HD) camera, connected to a widescreen HD monitor, guarantees excellent image quality. Dedicated surgical instruments with different angled tips are needed to permit movements in all the visible corners of the surgical field [].

1.2.2 Head Positioning

The head is not placed in a neutral position. According to the target area of interest, it can be extended approximately 1015 for anterior approaches, or it may be slightly flexed for approaches to the clivus, to facilitate the mobility of the endoscope and prevent surgical instruments from being restricted by the thorax. The surgeon works from the patients right side.

1.3 Standard Endoscopic Endonasal Approach to the Sellar Region

The endoscope is usually introduced through one nostril, sliding along the floor of the nasal cavity following the inferior turbinate; the choana is identified, limited medially by the vomer (which is often a reliable midline marker) and superiorly by the floor of the sphenoid sinus [].

Thereafter, the middle turbinate is compressed laterally to enlarge the space between the middle turbinate and the nasal septum, and the endoscope is angled upward along the roof of the choana approximately 1.5 cm, until the sphenoid ostium is identified.

It is not always mandatory to visualize the sphenoid ostium once the choana is identified; access to the sphenoid cavity can also be achieved by ascending along the sphenoethmoidal recess for approximately 11.5 cm.

Thereafter, the nasal septum is detached from the sphenoid rostrum, and the anterior wall of the sphenoid sinus is enlarged circumferentially, taking care to not extend too aggressively in an inferolateral direction, where the sphenopalatine artery or its major branches lie [].

Septa inside the sphenoid sinus should be identified and resected or carefully drilled down so that the posterior and lateral walls of the sphenoid sinus are visible, with the sellar floor at the center, the planum sphenoidale above, and the clival indentation below (Fig. ].

Fig. 1.1

Anatomical picture showing the posterior wall of the sphenoid sinus; all the anatomical landmarks are visible, but they may vary according to the degree of pneumatization of the sphenoid sinus. ^ tuberculum sellae as seen from the endoscopic endonasal view (recently called the suprasellar notch), C clival indentation, CPc paraclival segment of the carotid protuberance, CPs parasellar segment of the carotid protuberance, ocr lateral optocarotid recess, OP optic protuberance, PS planum sphenoidale, SF sellar floor

Once the sellar dura is opened, the anterior lobe of the pituitary gland comes into view. Its inferior surface usually conforms to the shape of the sellar floor, but its lateral and superior margins vary in shape because these walls are composed of soft tissue rather than bone. Posteriorly, the neurohypophysis (posterior pituitary gland) can be observed and is often softer, gelatinous, and more densely adherent to the posterior sellar wall, the dorsum sellae. Above, the diaphragma sellae covers the pituitary gland, except for a small central opening through which the pituitary stalk (infundibulum) passes. Folds of dura mater, which constitute the lateral walls of the hypophyseal fossa, also comprise the medial wall of the cavernous sinuses; the internal carotid artery (ICA) coursing through the cavernous sinus can be appreciated at this level [].

The pituitary gland derives its blood supply from two major groups of arteries. The superior hypophyseal artery primarily supplies the anterior lobe, the pituitary stalk, and the inferior surface of the optic nerve and chiasm, whereas the inferior hypophyseal artery is primarily related to the pars nervosa. The superior hypophyseal artery can arise from the supraclinoid portion of the ICA or from the posterior communicating artery, whereas the inferior hypophyseal artery arises from the meningohypophyseal trunk, a branch of the cavernous segment of the ICA.

1.4 Extended Endoscopic Transsphenoidal Approaches

1.4.1 Suprasellar Area

The sphenoid sinus represents a window of access to the midline skull base via the endonasal corridor; when the sinus is well pneumatized, all main bony landmarks can be identified. The sellar floor occupies a central position, with the planum sphenoidale above and the clival indentation below; on both sides, lateral to the sellar floor, are the two bony prominences of the intracavernous internal carotid arteries, and the optic nerves can be identified slightly superiorly. Between these two protuberances, depending on the degree of pneumatization of the sphenoid sinus, the projection of the optic strut of the anterior clinoid process creates the lateral opticocarotid recess [].

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