Surgical strategy for giant pituitary adenoma based on evaluation of fine feeding system and angioarchitecture Interdisciplinary Neurosurgery Advanced Techniques and Case Management 8 (2017) 1–3 Conte[.]
Interdisciplinary Neurosurgery: Advanced Techniques and Case Management (2017) 1–3 Contents lists available at ScienceDirect Interdisciplinary Neurosurgery: Advanced Techniques and Case Management journal homepage: www.inat-journal.com Case report Surgical strategy for giant pituitary adenoma based on evaluation of fine feeding system and angioarchitecture Yoshikazu Ogawa, M.D., Ph.D a,⁎, Kenichi Sato, M.D., Ph.D b, Teiji Tominaga, M.D., Ph.D c a b c Department of Neurosurgery, Kohnan Hospital, 4-20-1 Nagamachiminami, Taihaku-ku, Sendai, Miyagi 982-8523, Japan Department of Neuroendovascular Treatment, Kohnan Hospital, 4-20-1 Nagamachiminami, Taihaku-ku, Sendai, Miyagi 982-8523, Japan Department of Neurosurgery, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi 980-8574, Japan a r t i c l e i n f o Article history: Received December 2016 Accepted January 2017 Available online xxxx Keywords: Angioarchitecture Feeding artery Giant pituitary adenoma Surgical strategy a b s t r a c t Background: Giant pituitary adenomas continue to carry higher surgical risks, and postoperative acute catastrophic hemodynamic changes are associated with very poor outcome but remain difficult to predict Method: Surgical planning based on information about the fine angioarchitecture was achieved using C-arm cone-beam computed tomography Particular feeding systems and semi-quantitative evaluations for tumor staining were also investigated Conclusion: Major blood supply was different from the normal supply to the anterior pituitary gland and did not necessarily correspond to tumor shape and extension Surgical strategy should be established based on the tumor feeding systems and hemodynamics in giant pituitary adenomas © 2017 The Authors Published by Elsevier B.V This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/) Introduction Case report Modern imaging studies can identify adverse surgical factors such as cavernous sinus invasion, encasement of major intracranial vessels, and extensive destruction of the skull base, which are all known to occur with giant pituitary adenomas However, postoperative acute catastrophic changes without major vessel disturbance are associated with very poor outcome but remain difficult to predict Retrospective analysis of a single center experience found acute hemodynamic changes after surgery in 13 of 177 cases of giant pituitary adenoma, resulting in 12 deaths [1] The probable mechanisms of these changes include intratumoral primary hemorrhage, acute ischemia and resultant necrosis in the secondary hemorrhagic tissues, and increased intratumoral pressure resulting in continuous hemorrhage [2,3] These mechanisms are associated with injuries to the minute intratumoral feeders and/or drainers, which frequently have diameters of b300 μm, and the resultant drastic changes in the hemodynamics We describe a case of surgical planning based on information about the fine angioarchitecture and feeding systems, and semi-quantitative evaluations for tumor staining using angiography specially modified for giant pituitary adenomas A 65-year-old man was referred to our hospital MR imaging disclosed a huge skull base tumor, consisting of two major compartments with a narrow connecting portion at the planum sphenoidale The anterior part of the tumor extended into the interhemispheric fissure and the left frontal lobe was significantly compressed upwards The postero-inferior part of the tumor had occupied the enlarged sella turcica with destruction from the sellar floor to the upper part of the clivus, and protruded to the sphenoidal sinus (Fig 1a, b) After the introduction of general anesthesia, the angioarchitecture of the tumors was evaluated with digital subtraction angiography (DSA) using a C-arm cone-beam CT scanner with a flat-panel detector (GE Healthcare, Buc, France) and 50%-diluted contrast medium The three-dimensional volume rendered images and CT-like reconstructions in the sagittal, coronal, and axial planes were developed with an Advantage Workstation 4.6 (GE Healthcare) Cone-beam CT angiography identified two independent feeding systems, from the branches of the left anterior cerebral artery to the anterior part, and arteriovenous shunt-like fast flow from the left meningohypophyseal trunk to the posterior part of the tumor (Fig 1c, d) 2.1 Tumor stain measurement ⁎ Corresponding author E-mail address: yogawa@kohnan-sendai.or.jp (Y Ogawa) Angiographical image sequence data were processed with Image J (NIH, Bethesda, MD) to measure optical density as the contrast medium passed through the tumor Because tumor staining is regarded as http://dx.doi.org/10.1016/j.inat.2017.01.002 2214-7519/© 2017 The Authors Published by Elsevier B.V This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/) 2 Y Ogawa et al / Interdisciplinary Neurosurgery: Advanced Techniques and Case Management (2017) 1–3 Fig MR imaging disclosed a huge skull base tumor (a, b), and angiography identified two independent feeding systems (c, d) contrast retention in the late phase of angiography, so we measured differences in the optical density between the beginning of a run and a plateau of the late phase in the time-density curve [4] 2.2 Tumor removal Multi-stepped removals were thought to be possible, consisting of initial surgery using the interhemispheric approach to the anterior part, followed by removal using the extended transsphenoidal approach of the infero-posterior part of the tumor Basic strategy was planned as initial removal and coagulation of the tumor from the side of the main feeding systems with greater optical density difference, and extending gradually to the other side The tumor was subtotally (99.4%) removed except for small remnants in the right cavernous portion (Fig 2) He was discharged without neurological or endocrinological deficits Discussion Giant pituitary adenomas are extremely difficult to remove totally, with the risk of postoperative pituitary apoplexy from the residual tumors [1–3] The hemodynamics and feeding system of pituitary adenomas are little understood, partly because these feeding arteries generally have diameters of b 300 μm and are arranged in mesh-like patterns as shown in our case, so are extremely difficult to identify intraoperatively even with careful exploration DSA cannot easily visualize such fine angioarchitecture Moreover, the present trend to reduction of invasiveness of medical procedures may restrain preoperative examination, so only verification of major vessels with MR angiography or CT angiography is performed The main feeding artery to the anterior lobe is the superior hypophyseal artery based on accurate anatomical research [5] However, blood supply from the superior hypophyseal artery was barely present in our case originating from the pituitary anterior lobe Our preliminary investigation for giant pituitary adenomas revealed the blood supply was much more extensive from the lower plane of the tumor, suggesting that giant pituitary adenomas may acquire different blood supply patterns from the normal anatomy during the process of enlargement [4] The surgical approach is usually decided based on the shape, volume, and extension of the tumor, usually the transsphenoidal or transcranial approach But this tumor is basically removed without intraoperative differentiation of the tumor from its feeding arteries, and these arteries passing through the tumor are cut and torn together with the tumor If total removal could not be achieved a cross section of the tumor with untreated feeding arteries inevitably remains just after the operation, Fig Subtotal removal was achieved Y Ogawa et al / Interdisciplinary Neurosurgery: Advanced Techniques and Case Management (2017) 1–3 which may cause postoperative acute changes in the tumor hemodynamics and consequent serious complications Detailed preoperative examination of the feeding system and hemodynamics of this tumor is not a priority at present, but we emphasize the need for case-by-case operative strategy to prevent devastating outcomes after surgery for this so-called benign but formidable tumor Conclusion Surgical planning was described based on information about the fine angioarchitecture and feeding systems Case-by-case operative strategy is essential for giant pituitary adenomas Conflict of interest The authors report no conflict of interest concerning the materials and methods used in this study or the findings in this paper References [1] N.S Kurwale, F Ahmad, A Suri, S.S Kale, B.S Sharma, A.K Mahapatra, V Suri, M.C Sharma, Post operative pituitary apoplexy: preoperative considerations toward preventing nightmare, Br J Neurosurg 26 (2012) 59–63 [2] M.Y Chong, S.M Quak, C.T Chong, Cerebral ischemia in pituitary disorders – more common than previously though: two case reports and literature review, Pituitary 17 (2014) 171–179 [3] S.K Kurschel, K.A Leber, M Scarpatetti, P Roll, Rare fatal vascular complication of transsphenoidal surgery, Acta Neurochir 147 (2005) 321–325 [4] Y Ogawa, K Sato, Y Matsumoto, T Tominaga, Evaluation of fine feeding system and angioarchitecture of giant pituitary adenoma – implications for establishment of surgical strategy, World Neurosurg 85 (2016) 244–251 [5] J Lang, Clinical Anatomy of the Head Neurocranium, Orbit, Craniocervical Regions, Springer, Berlin, Heidelberg, New York, 1983 200–201 ... but formidable tumor Conclusion Surgical planning was described based on information about the fine angioarchitecture and feeding systems Case-by-case operative strategy is essential for giant pituitary. .. K Sato, Y Matsumoto, T Tominaga, Evaluation of fine feeding system and angioarchitecture of giant pituitary adenoma – implications for establishment of surgical strategy, World Neurosurg 85 (2016)... Discussion Giant pituitary adenomas are extremely difficult to remove totally, with the risk of postoperative pituitary apoplexy from the residual tumors [1–3] The hemodynamics and feeding system of pituitary