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
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5. Pituitary is yellow in color like Jack fruit pulp ; spikes on fruit are
pituitary ligaments
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. Endosteal layer & Meningeal layer are
fused to each other at all places
except where the cranial venous
sinuses are enclosed between them .
8. Endosteal layer
& Meningeal
layer are fused
to each other
at all places
except where
the cranial
venous sinuses
are enclosed
between them
11. 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.
12.
13. 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 .
15. 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.
18. 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).
23. 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.
24. 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.
28. 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
29. 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
30. 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
31. 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 ) .
33. 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.)
35. 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.)
36. 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
37. 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.)
38. 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.)
39. 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
40. 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
41. 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
42. 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.)
43. 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.)
44. 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
45. 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.
46. 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).
47. 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).
48. 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).
49. Ds= Dorsum Sellae after removing the pituitary mass in
craniopharyngioma case
50. “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 .
51. 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.
52. 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.
53. 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.
54. 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.
55. 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.
56. 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.
57. 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.
58. 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
59. 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.
60. 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
61. 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.
62. 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
63. 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.
64. 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.
65. 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.
73. 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
74. Click this facebook link for discussion
https://www.facebook.com/groups/enttoday/permalink/893847500698013/
75. • 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...
82. 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....
83. • 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..
84. • 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.
85. 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);
86. a thin, fibrous envelope (C);
yellowish, discolored, normal glandlike, thin membrane (D–F);
87.
88. thick, fibrous tissue (G); and calcification (H) after removal of the
main tumor mass. N, normal pituitary gland.
89. 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.
90. 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
91. • 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..
93. 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
96. 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
97. 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
98. 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.
99. 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
100. Parasagittal cadaveric specimen with a postfixed chiasm. Note the more
inclined pituitary stalk (stalk). For reference, note the left and right optic
nerves
102. 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)
110. 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
111. 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.
