Skip to main content

Advertisement

SpringerLink
Log in

Pituitary adenoma with posterior area invasion of cavernous sinus: surgical anatomy, approach, and outcomes

  • Original Article
  • Published:
Neurosurgical Review Aims and scope Submit manuscript

Abstract

We found a series of Knosp grade 3A–4 pituitary adenomas in the posterior areas of the cavernous sinus (CS), a triangular-like structure on axial MRI. In this study, we dissected the surrounding neurovascular structure, discussed the surgical approach, and analyzed outcomes for patients with this invasion into this area. Eight embalmed adult cadaveric specimens were prepared for this study to demonstrate in detail the surgical anatomy related to this triangular-like structure. We used the “two points and one line” method to determine the surgical approach, and 35 cases with this area invasion were retrospectively reviewed. According to the endoscopic and microsurgical anatomy, the triangular-like structure appearing on the axial MRI is correlated with a square-based pyramid structure in the CS, and the upper surface is the posterior portion of the oculomotor triangle. A total of 37 posterior areas of the CS were involved in 35 patients. The accuracy of the “two points and one line” method in predicting the surgical approach is 86.5% (32/37). All three patients with Knosp 3A underwent gross total resection (GTR). Twenty (62.5%) patients with Knosp 4 underwent GTR, 9 (28.1%) patients underwent subtotal resection, and 3 (9.4%) patients underwent partial resection. Preoperative symptoms were alleviated to varying degrees, and no worsening occurred. Postoperative complications included two (5.7%) cases of cerebrospinal fluid leakage, one (2.9%) case of meningitis, two (5.7%) cases of permanent diabetes insipidus, and three (8.6%) cases of transient cranial nerve palsy. The “two points and one line” method is of great value in predicting the surgical approach of pituitary adenomas with CS invasion. The anatomic description of this particular square-based pyramid structure in the CS refines the understanding of pituitary adenomas with CS invasion.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5

Similar content being viewed by others

References

  1. Bao X, Deng K, Liu X, Feng M, Chen CC, Lian W, Xing B, Yao Y, Wang R (2016) Extended transsphenoidal approach for pituitary adenomas invading the cavernous sinus using multiple complementary techniques. Pituitary 19(1):1–10

    Article  Google Scholar 

  2. Cavallo LM, Cappabianca P, Galzio R, Iaconetta G, de Divitiis E, Tschabitscher M (2005) Endoscopic transnasal approach to the cavernous sinus versus transcranial route: anatomic study. Neurosurgery 56(2 Suppl):379–389 379-389

    PubMed  Google Scholar 

  3. Ceylan S, Anik I, Cabuk B, Caklili M, Anik Y (2019) Extension pathways of pituitary adenomas with cavernous sinus involvement and its surgical approaches. World Neurosurg 127:e986–e995

  4. Ceylan S, Koc K, Anik I (2010) Endoscopic endonasal transsphenoidal approach for pituitary adenomas invading the cavernous sinus. J Neurosurg 112(1):99–107

    Article  Google Scholar 

  5. Cottier JP, Destrieux C, Brunereau L, Bertrand P, Moreau L, Jan M, Herbreteau D (2000) Cavernous sinus invasion by pituitary adenoma: MR imaging. Radiology 215(2):463–469

    Article  CAS  Google Scholar 

  6. Di Maio S, Cavallo LM, Esposito F, Stagno V, Corriero OV, Cappabianca P (2011) Extended endoscopic endonasal approach for selected pituitary adenomas: early experience. J Neurosurg 114(2):345–353

    Article  Google Scholar 

  7. Dolenc V (1983) Direct microsurgical repair of intracavernous vascular lesions. J Neurosurg 58(6):824–831

    Article  CAS  Google Scholar 

  8. Fernandez-Miranda JC, Zwagerman NT, Abhinav K, Lieber S, Wang EW, Snyderman CH, Gardner PA (2018) Cavernous sinus compartments from the endoscopic endonasal approach: anatomical considerations and surgical relevance to adenoma surgery. J Neurosurg 129(2):430–441

    Article  Google Scholar 

  9. Hakuba A, Tanaka K, Suzuki T, Nishimura S (1989) A combined orbitozygomatic infratemporal epidural and subdural approach for lesions involving the entire cavernous sinus. J Neurosurg 71(5 Pt 1):699–704

    Article  CAS  Google Scholar 

  10. Kitano M, Taneda M, Shimono T, Nakao Y (2008) Extended transsphenoidal approach for surgical management of pituitary adenomas invading the cavernous sinus. J Neurosurg 108(1):26–36

    Article  Google Scholar 

  11. Knosp E, Steiner E, Kitz K, Matula C (1993) Pituitary adenomas with invasion of the cavernous sinus space: a magnetic resonance imaging classification compared with surgical findings. Neurosurgery 33(4):610–617 617-618

    CAS  PubMed  Google Scholar 

  12. Komatsu F, Komatsu M, Inoue T, Tschabitscher M (2011) Endoscopic supraorbital extradural approach to the cavernous sinus: a cadaver study. J Neurosurg 114(5):1331–1337

    Article  Google Scholar 

  13. Komatsu F, Shimoda M, Oda S, Imai M, Shigematsu H, Komatsu M, Tschabitscher M, Matsumae M (2014) Identification of the internal carotid artery at the superior part of the cavernous sinus during endoscopic endonasal cavernous sinus tumor surgery. Acta Neurochir 156(3):475–479

    Article  Google Scholar 

  14. Micko A, Oberndorfer J, Weninger WJ, Vila G, Höftberger R, Wolfsberger S, Knosp E (2019) Challenging Knosp high-grade pituitary adenomas. J Neurosurg 132(6):1739–1746

  15. Micko AS, Wohrer A, Wolfsberger S, Knosp E (2015) Invasion of the cavernous sinus space in pituitary adenomas: endoscopic verification and its correlation with an MRI-based classification. J Neurosurg 122(4):803–811

    Article  Google Scholar 

  16. Pal A, Leaver L, Wass J (2019) Pituitary adenomas. BMJ 365:l2091

    Article  Google Scholar 

  17. Parkinson D (1965) A surgical approach to the cavernous portion of the carotid artery. Anatomical studies and case report. J Neurosurg 23(5):474–483

    Article  CAS  Google Scholar 

  18. Parkinson D (1967) Transcavernous repair of carotid cavernous fistula. Case report. J Neurosurg 26(4):420–424

    Article  CAS  Google Scholar 

  19. Raithatha R, McCoul ED, Woodworth GF, Schwartz TH, Anand VK (2012) Endoscopic endonasal approaches to the cavernous sinus. Int Forum Allergy Rhinol 2(1):9–15

    Article  Google Scholar 

  20. Saeger W, Ludecke DK, Buchfelder M, Fahlbusch R, Quabbe HJ, Petersenn S (2007) Pathohistological classification of pituitary tumors: 10 years of experience with the German Pituitary Tumor Registry. Eur J Endocrinol 156(2):203–216

    Article  CAS  Google Scholar 

  21. Serioli S, Doglietto F, Fiorindi A, Biroli A, Mattavelli D, Buffoli B, Ferrari M, Cornali C, Rodella L, Maroldi R, Gasparotti R, Nicolai P, Fontanella MM, Poliani PL (2019) Pituitary adenomas and invasiveness from anatomo-surgical, radiological, and histological perspectives: a systematic literature review. Cancers 11(12):1936

  22. Taniguchi M, Hosoda K, Akutsu N, Takahashi Y, Kohmura E (2015) Endoscopic endonasal transsellar approach for laterally extended pituitary adenomas: volumetric analysis of cavernous sinus invasion. Pituitary 18(4):518–524

    Article  Google Scholar 

  23. Theodosopoulos PV, Cebula H, Kurbanov A, Cabero AB, Osorio JA, Zimmer LA, Froelich SC, Keller JT (2016) The medial extra-sellar corridor to the cavernous sinus: anatomic description and clinical correlation. World Neurosurg 96:417–422

    Article  Google Scholar 

  24. Truong HQ, Lieber S, Najera E, Alves-Belo JT, Gardner PA, Fernandez-Miranda JC (2018) The medial wall of the cavernous sinus. Part 1: surgical anatomy, ligaments, and surgical technique for its mobilization and/or resection. J Neurosurg 131(1):122–130

  25. Zhang Q, Wang Z, Guo H, Yan B, Wang Z, Zhao H, Sahyouni R, Kuan EC (2019) Direct transcavernous sinus approach for endoscopic endonasal resection of intracavernous sinus tumors. World Neurosurg 128:e478–e487

    Article  Google Scholar 

Download references

Acknowledgments

We express our sincere appreciation to Miss Jing Liu for the illustrations.

Funding

This study was funded by the National Natural Science Foundation of China (grant nos. 81560207 and 81460381), the Ganpo555 Engineering Excellence of Jiangxi Science and Technology Department (2013), and the Key Research and Invention Plan of Jiangxi Science and Technology Department (20192BBG70026).

Author information

Authors and Affiliations

  1. Department of Neurosurgery, The First Affiliated Hospital of Nanchang University, 17 Yong Wai Zheng Street, Nanchang, China

    Xiao Wu, Shen Hao Xie, Bin Tang, You Qing Yang, Le Yang, Han Ding, You Yuan Bao, Shi Hai Lan, Lin Zhou & Tao Hong

Authors
  1. Xiao Wu
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Shen Hao Xie
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Bin Tang
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. You Qing Yang
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Le Yang
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Han Ding
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. You Yuan Bao
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Shi Hai Lan
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. Lin Zhou
    View author publications

    You can also search for this author in PubMed Google Scholar

  10. Tao Hong
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Tao Hong.

Ethics declarations

Conflict of interest

All authors declare that they have no conflict of interest.

Ethical approval

Anatomical study with cadaver heads and human subject approval was obtained from the Institutional Ethics Committee of the First Affiliated Hospital of Nanchang University prior to the commencement of the study.

Informed consent

Informed consent was obtained from each patient prior to the study.

Additional information

Publisher’s note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Wu, X., Xie, S.H., Tang, B. et al. Pituitary adenoma with posterior area invasion of cavernous sinus: surgical anatomy, approach, and outcomes. Neurosurg Rev 44, 2229–2237 (2021). https://doi.org/10.1007/s10143-020-01404-1

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s10143-020-01404-1

Keywords

Search

Navigation