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Transnasal removal of pituitary tumors: Revised approach and new instrumentation
SI22
Tumours of the eNS /I
(without the aid of the described tools), shows that the post-operative Kamofsky rating of the first group was significantly better.
IV-3-35!
Contemporary surgical treatment of eloquent area lesions using MEG and intraoperative monitorings
Takamasa Kayama 1 , Kaori Sakurada t , Tadashi Ando' , Akira Kuroki 1 , Nobukazu Nakasatc". Takashi Yosblmoto". ' Departmentof Neurosurgery.
Yamagata University School of Medicine, Yamagata, Japan, 2 Departmentof Neurosurgery. Tohoku UniversitySchool of Medicine. Sendai. Japan
Tuesday, 8 July /997 cations associated with the use of the MSIS in 303 cases of acromegaly from 1985-94 were seen. ThUS, we can recommend the use of this system which will be demonstrated in a video.
IV-3-3SI Superimposing radiofluoroscopy for transsphenoidal surgery
Y. Tanaka, S. Kobayash i, K. Kyoshima. Dept. of Neurosurgery, School of Medicine, ShinshuUniversity, 3-1-1 Asahi, Matsumoto390. Japan
For the purpose of safe and sure surgical removal of lesions around cerebral eloquent areas, we have made use of MEG (magnetoencephaloraphy) for identifying the sensorimotor and auditory cortex and for intraoperative monitoring of motor evoked potential (MEP) to prevent motor function deficit. During the recent 2 ~ years, 20 patients with lesions around the cerebral motor cortex underwent surgery with intraoperative MEP monitoring. Fourteen of 20 patients underwent MEG. MEP was recorded from the electrodes inserted percutaneously into the cervical epidural space in response to electrical stimulation of the motor cortex. The amplitude of MEP was monitored during removal of the lesions. We have evaluated pre- & postoperative motor function and the change of the MEP amplitude in each patient. MEG revealed that the lesions were adjacent to the motor cortex in t1 patients. The MEP amplitude increased compared to recordings before tumor resection in 3 patients whose preoperative paresis subsequently improved. Motor function deficit did not occur or the morbidity was mild and transient when the MEP amplitude was unchanged or 50010 and larger than the baseline amplitude . The amplitude decreased less than 50% in 2 patients who suffered moderate paresis that required rehabilitation. MEP disappeared in 1 patient who showed severe paresis and did not improve well. MEG provided important information on the cerebral eloquent areas for planning surgery. MEP was useful for monitoring motor function and predicting postoperative motor deficit and its recovery.
Introduction: A new method "superimposing radiofJuoroscopy" was devised to improve intraoperative anatomical orientation during transsphenoidal resection of tumors. Methods: A composite image consisted of outlines of a tumor, a cavemous portion of the internal carotid artery and osseous structures is preoperatively prepared using a magnetic resonance image and a skull x-ray film. At the time of operation, the composite image is superimposed over a fluoroscop ic image using a videomixer and the surgeon recognizes the tumor contour and the course of the carotid artery during surgical maneuvers. Tumor removal cavity is visualized by introducing a balloon which contains contrast medium. This method was applied to following cases; 1. parasellar skull base tumors which lost the bony landmarks. 2. pituitary adenomas invading the cavemous sinus, 3. pituitary adenomas with marked suprasellar extension. Results: The superimposing method was applied to five parasellar skull base tumors and ten pituitary adenomas . This method was effective to visualize the tumor margin in the skull base tumor destruct ing the surround ing bone. The tumor around the cavemous carotid artery was adequately removed . The suprasellar part of the tumor was removed by deep curettage and the residual tumor was estimated by the balloon opacification. The tumors were extensively removed without major operative morbidity. Conclusion: Superimposing radiofluoroscopy added more accuracy and accessibility to the transsphenoidal surgery with the convent ional radiofluoroscopy.
IV-3-36I
IV-3-39I
Transnasal removal of pituitary tumors: Revised approach and new instrumentation
Albert L. Rhoton. Jr.. Universityof Florida College of Medicine, Departmentof NeurologicalSurgery, Gainesville, Florida, USA Recently, after operating more than 400 pituitary tumors by the sublabial route. we switched to a transnasal procedure done from start to finish under the operating microscope. The change in approach in 71 consecutive patients was associated with a significant reduction in operative time and with earlier discharge resulting in a significant reduction in cost. Video tape will review the technique as well as the use of several unique instruments including blunt ring curettes and angled transspheno idal suctions for the removal of these tumors. The reduced intranasal exposure has not been associated with any reduction in exposure at the anterior sellar wall or at the target site within the sella. No patient experienced a postoperat ive cerebrospinal fluid leak. This alteration in the procedure played a major role in making our costs for transsphenoidal surgery among the lowest in our region and also in the University Hospital Consortium in the United States .
IV-3-37I
Usefulness of a microsurgical pressure irrigation-suction system in direct transnasal surgery
Dieter K. LUedecke, Takumi Abe. Departmentof Neurosurgery. Pituitary
Surgery Unit, UniversityHospital Eppendorf. Hamburg, Gennany Since the first video presentation at the WFNS meeting in t985. our microsurgical pressure irrigation-suction-system (MSIS) has been used in more than 1000 direct transnasal operations . The advantages of the system in small rnicroadenomas (e.g. Cushing's disease) as well as in large invasive lesions (e.g. acromegaly) have been thus extensively evaluated. We will focus here on large GH secreting adenomas. Essential is the ability of a quick adaptation of suction and irrigation to the different surgical needs at the handpiece . In combination with slim real mirrors of different size and cannulas and bipolars of different length of the angled tips even in case of a narrow access very eccentric tumor parts may be safely removed. Lateral bleeding from vessels arising from the carotid artery can be coagulated under vision with fixed mirrors. Adenomas within the medial part of the cavernous sinus may be radically removed with reduced venous pressure in semi-sitting position under constant irrigation. No case of air embo lism has been encountered . Thus, the extent of resection of large invasive adenomas could be increased with a low morbidity. This could be clearly demonstrated in acromegaly where pretreatment with octreotide led to a liquidification of the adenomas in two third of the patients and made suction easier. Intraoperative growth hormone measurement with further tumor removal in case of inadequate decline led to an improvement of surgical results in large adenomas. There were less than 0.6% infections directly related to surgery. No compli-
Transsphenoidal surgery gUided by transsellar color Doppler Ultrasonography
Kazunori Arita, Kaoru Kurisu, Atsushi Tominaga. Hitoshi Kawamoto . Koji lida, Tatsuya Mizoue. Department of Neurosurgery. HiroshimaUniversitySchool of
Medicine, Hiroshima, Japan Aim: In order to improve the safety and radicality of transsphenoidal surgery, we introduced intraoperative color Doppler ultrasonography using transesophageal echo probe which is easily available in almost all well equipped institutions . Material and Method: The SUbjects were 22 cases (20 cases with pituitary adenoma including 5 microadenomas and 15 macroadenomas, one case with Rathke's cleft cyst, and one case with craniopharyngioma) who underwent transsphenoidal surgery. The Hitachi EUB555 color Doppler ultrasound system was used with pediatric biplane transesophageal echo probe (EUP-ES533 , 7.5 MHz, bi-plane phased array sector probe. 9.8 mm tip). The probe was inserted into the saline filled sphenoid sinus after the sellar floor was opened. Intra and supra-sellar images were obtained just before dural incision and after the tumor removal was thought to have been accomplished . The detectability of the tumor, cavernous sinus invasion, normal pituitary gland, chiasm. pituitary stalk, major cerebral arteries. and residual tumor was evaluated. Result: In almost all cases, the tumor was depicted as a slightly hyperechoic mass. Major cerebral arteries were depicted clearly by color Doppler image. Pituitary glands. pituitary stalks, and optic chiasms were observed in cases with microadenomas and small expansive adenomas . Cavernous sinus invasion of the adenoma, concomitant aneurysm. and residual tumors were also clearly shown. Conclusion: Trans-sellar color Doppler ultrasonography using transesophageal echo probe is a very useful and a convenient intraoperative guiding system which should improve the safety and radicality of transsphenoidal surgery.
IV-3-40 I pituitary Transcolummellar incision in transsphenoidal surgery for small nostril patients Sun Ho Kim 1• Ju Hun Yoon 2. Jung Uhn Choi' . Sang Sup Chung t . Kyu Chang Lee 1 . t Department of Neurosurgery. Yonsei University, College of Medicine, Seoul, Korea, 2 Department of Otorhinolaryngology, Yonsei
University. College of Medicine, SeOUl, Korea The sublabial approach has been widely used as the standard technique for transephenoidal pituitary surgery. But ~ has several possible drawbacks , such as: 1) flat nose deformity that can occur as a result of resection of the anterior nasal spine; 2) frequent hypesthesia of the upper gum; 3) changing color of the upper teeth; 4) feeding difficulty until 2-3 weeks after surgery. As an alternative, endonasal incision was adopted by several surgeons for patients who had large nostrils, such as caucasians or acromegalic patients. In patients with small
Tumours of the eNS /I
(without the aid of the described tools), shows that the post-operative Kamofsky rating of the first group was significantly better.
IV-3-35!
Contemporary surgical treatment of eloquent area lesions using MEG and intraoperative monitorings
Takamasa Kayama 1 , Kaori Sakurada t , Tadashi Ando' , Akira Kuroki 1 , Nobukazu Nakasatc". Takashi Yosblmoto". ' Departmentof Neurosurgery.
Yamagata University School of Medicine, Yamagata, Japan, 2 Departmentof Neurosurgery. Tohoku UniversitySchool of Medicine. Sendai. Japan
Tuesday, 8 July /997 cations associated with the use of the MSIS in 303 cases of acromegaly from 1985-94 were seen. ThUS, we can recommend the use of this system which will be demonstrated in a video.
IV-3-3SI Superimposing radiofluoroscopy for transsphenoidal surgery
Y. Tanaka, S. Kobayash i, K. Kyoshima. Dept. of Neurosurgery, School of Medicine, ShinshuUniversity, 3-1-1 Asahi, Matsumoto390. Japan
For the purpose of safe and sure surgical removal of lesions around cerebral eloquent areas, we have made use of MEG (magnetoencephaloraphy) for identifying the sensorimotor and auditory cortex and for intraoperative monitoring of motor evoked potential (MEP) to prevent motor function deficit. During the recent 2 ~ years, 20 patients with lesions around the cerebral motor cortex underwent surgery with intraoperative MEP monitoring. Fourteen of 20 patients underwent MEG. MEP was recorded from the electrodes inserted percutaneously into the cervical epidural space in response to electrical stimulation of the motor cortex. The amplitude of MEP was monitored during removal of the lesions. We have evaluated pre- & postoperative motor function and the change of the MEP amplitude in each patient. MEG revealed that the lesions were adjacent to the motor cortex in t1 patients. The MEP amplitude increased compared to recordings before tumor resection in 3 patients whose preoperative paresis subsequently improved. Motor function deficit did not occur or the morbidity was mild and transient when the MEP amplitude was unchanged or 50010 and larger than the baseline amplitude . The amplitude decreased less than 50% in 2 patients who suffered moderate paresis that required rehabilitation. MEP disappeared in 1 patient who showed severe paresis and did not improve well. MEG provided important information on the cerebral eloquent areas for planning surgery. MEP was useful for monitoring motor function and predicting postoperative motor deficit and its recovery.
Introduction: A new method "superimposing radiofJuoroscopy" was devised to improve intraoperative anatomical orientation during transsphenoidal resection of tumors. Methods: A composite image consisted of outlines of a tumor, a cavemous portion of the internal carotid artery and osseous structures is preoperatively prepared using a magnetic resonance image and a skull x-ray film. At the time of operation, the composite image is superimposed over a fluoroscop ic image using a videomixer and the surgeon recognizes the tumor contour and the course of the carotid artery during surgical maneuvers. Tumor removal cavity is visualized by introducing a balloon which contains contrast medium. This method was applied to following cases; 1. parasellar skull base tumors which lost the bony landmarks. 2. pituitary adenomas invading the cavemous sinus, 3. pituitary adenomas with marked suprasellar extension. Results: The superimposing method was applied to five parasellar skull base tumors and ten pituitary adenomas . This method was effective to visualize the tumor margin in the skull base tumor destruct ing the surround ing bone. The tumor around the cavemous carotid artery was adequately removed . The suprasellar part of the tumor was removed by deep curettage and the residual tumor was estimated by the balloon opacification. The tumors were extensively removed without major operative morbidity. Conclusion: Superimposing radiofluoroscopy added more accuracy and accessibility to the transsphenoidal surgery with the convent ional radiofluoroscopy.
IV-3-36I
IV-3-39I
Transnasal removal of pituitary tumors: Revised approach and new instrumentation
Albert L. Rhoton. Jr.. Universityof Florida College of Medicine, Departmentof NeurologicalSurgery, Gainesville, Florida, USA Recently, after operating more than 400 pituitary tumors by the sublabial route. we switched to a transnasal procedure done from start to finish under the operating microscope. The change in approach in 71 consecutive patients was associated with a significant reduction in operative time and with earlier discharge resulting in a significant reduction in cost. Video tape will review the technique as well as the use of several unique instruments including blunt ring curettes and angled transspheno idal suctions for the removal of these tumors. The reduced intranasal exposure has not been associated with any reduction in exposure at the anterior sellar wall or at the target site within the sella. No patient experienced a postoperat ive cerebrospinal fluid leak. This alteration in the procedure played a major role in making our costs for transsphenoidal surgery among the lowest in our region and also in the University Hospital Consortium in the United States .
IV-3-37I
Usefulness of a microsurgical pressure irrigation-suction system in direct transnasal surgery
Dieter K. LUedecke, Takumi Abe. Departmentof Neurosurgery. Pituitary
Surgery Unit, UniversityHospital Eppendorf. Hamburg, Gennany Since the first video presentation at the WFNS meeting in t985. our microsurgical pressure irrigation-suction-system (MSIS) has been used in more than 1000 direct transnasal operations . The advantages of the system in small rnicroadenomas (e.g. Cushing's disease) as well as in large invasive lesions (e.g. acromegaly) have been thus extensively evaluated. We will focus here on large GH secreting adenomas. Essential is the ability of a quick adaptation of suction and irrigation to the different surgical needs at the handpiece . In combination with slim real mirrors of different size and cannulas and bipolars of different length of the angled tips even in case of a narrow access very eccentric tumor parts may be safely removed. Lateral bleeding from vessels arising from the carotid artery can be coagulated under vision with fixed mirrors. Adenomas within the medial part of the cavernous sinus may be radically removed with reduced venous pressure in semi-sitting position under constant irrigation. No case of air embo lism has been encountered . Thus, the extent of resection of large invasive adenomas could be increased with a low morbidity. This could be clearly demonstrated in acromegaly where pretreatment with octreotide led to a liquidification of the adenomas in two third of the patients and made suction easier. Intraoperative growth hormone measurement with further tumor removal in case of inadequate decline led to an improvement of surgical results in large adenomas. There were less than 0.6% infections directly related to surgery. No compli-
Transsphenoidal surgery gUided by transsellar color Doppler Ultrasonography
Kazunori Arita, Kaoru Kurisu, Atsushi Tominaga. Hitoshi Kawamoto . Koji lida, Tatsuya Mizoue. Department of Neurosurgery. HiroshimaUniversitySchool of
Medicine, Hiroshima, Japan Aim: In order to improve the safety and radicality of transsphenoidal surgery, we introduced intraoperative color Doppler ultrasonography using transesophageal echo probe which is easily available in almost all well equipped institutions . Material and Method: The SUbjects were 22 cases (20 cases with pituitary adenoma including 5 microadenomas and 15 macroadenomas, one case with Rathke's cleft cyst, and one case with craniopharyngioma) who underwent transsphenoidal surgery. The Hitachi EUB555 color Doppler ultrasound system was used with pediatric biplane transesophageal echo probe (EUP-ES533 , 7.5 MHz, bi-plane phased array sector probe. 9.8 mm tip). The probe was inserted into the saline filled sphenoid sinus after the sellar floor was opened. Intra and supra-sellar images were obtained just before dural incision and after the tumor removal was thought to have been accomplished . The detectability of the tumor, cavernous sinus invasion, normal pituitary gland, chiasm. pituitary stalk, major cerebral arteries. and residual tumor was evaluated. Result: In almost all cases, the tumor was depicted as a slightly hyperechoic mass. Major cerebral arteries were depicted clearly by color Doppler image. Pituitary glands. pituitary stalks, and optic chiasms were observed in cases with microadenomas and small expansive adenomas . Cavernous sinus invasion of the adenoma, concomitant aneurysm. and residual tumors were also clearly shown. Conclusion: Trans-sellar color Doppler ultrasonography using transesophageal echo probe is a very useful and a convenient intraoperative guiding system which should improve the safety and radicality of transsphenoidal surgery.
IV-3-40 I pituitary Transcolummellar incision in transsphenoidal surgery for small nostril patients Sun Ho Kim 1• Ju Hun Yoon 2. Jung Uhn Choi' . Sang Sup Chung t . Kyu Chang Lee 1 . t Department of Neurosurgery. Yonsei University, College of Medicine, Seoul, Korea, 2 Department of Otorhinolaryngology, Yonsei
University. College of Medicine, SeOUl, Korea The sublabial approach has been widely used as the standard technique for transephenoidal pituitary surgery. But ~ has several possible drawbacks , such as: 1) flat nose deformity that can occur as a result of resection of the anterior nasal spine; 2) frequent hypesthesia of the upper gum; 3) changing color of the upper teeth; 4) feeding difficulty until 2-3 weeks after surgery. As an alternative, endonasal incision was adopted by several surgeons for patients who had large nostrils, such as caucasians or acromegalic patients. In patients with small