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Extended endoscopic endonasal approach to the midline skull base: the evolving role of transsphenoidal surgery

  • P. Cappabianca
  • L. M. Cavallo
  • F. Esposito
  • O. de Divitiis
  • A. Messina
  • E. de Divitiis
Part of the Advances and Technical Standards in Neurosurgery book series (NEUROSURGERY, volume 33)

Abstract

The evolution of the endoscopic endonasal transsphenoidal technique, which was initially reserved only for sellar lesions through the sphenoid sinus cavity, has lead in the last decades to a progressive possibility to access the skull base from the nose. This route allows midline access and visibility to the suprasellar, retrosellar and parasellar space while obviating brain retraction, and makes possible to treat transsphenoidally a variety of relatively small midline skull base and parasellar lesions traditionally approached transcranially.

We report our current knowledge of the endoscopic anatomy of the midline skull base as seen from the endonasal perspective, in order to describe the surgical path and structures whose knowledge is useful during the operation. Besides, we describe the step-by-step surgical technique to access the different compartments, the “dangerous landmarks” to avoid in order to minimize the risks of complications and how to manage them, and our paradigm and techniques for dural and bony reconstruction. Furthermore, we report a brief description of the useful instruments and tools for the extended endoscopic approaches.

Between January 2004 and April 2006 we performed 33 extended endonasal approaches for lesions arising from or involving the sellar region and the surrounding areas. The most representative pathologies of this series were the ten cranioparyngiomas, the six giant adenomas and the five meningiomas; we also used this procedure in three cases of chordomas, three of Rathke’s cleft cysts and three of meningo-encephaloceles, one case of optic nerve glioma, one olfactory groove neuroendocrine tumor and one case of fibro-osseous dysplasia.

Tumor removal, as assessed by post-operative MRI, revealed complete removal of the lesion in 2/6 pituitary adenomas, 7/10 craniopharyngiomas, 4/5 meningiomas, 3/3 Rathke’s cleft cyst, 3/3 meningo-encephalocele.

Surgical complications have been observed in 3 patients, two with a craniopharyngioma, one with a clival meningioma and one with a recurrent giant pituitary macroadenoma involving the entire left cavernous sinus, who developed a CSF leak and a second operation was necessary in order to review the cranial base reconstruction and seal the leak. One of them developed a bacterial meningitis, which resolved after a cycle of intravenous antibiotic therapy with no permanent neurological deficits. One patient with an intra-suprasellar non-functioning adenoma presented with a generalized epileptic seizure a few hours after the surgical procedure, due to the intraoperative massive CSF loss and consequent presence of intracranial air. We registered one surgical mortality.

In three cases of craniopharyngioma and in one case of meningioma a new permanent diabetes insipidus was observed. One patient developed a sphenoid sinus mycosis, cured with antimycotic therapy. Epistaxis and airway difficulties were never observed.

It is difficult today to define the boundaries and the future limits of the extended approaches because the work is still in progress. Such extended endoscopic approaches, although at a first glance might be considered something that everyone can do, require an advanced and specialized training.

Keywords

Endoscope transsphenoidal surgery extended approach anatomy surgical technique skull base 

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References

  1. 1.
    Al-Mefty O, Ayoubi S, Smith RR (1991) The petrosal approach: indications, technique, and results. Acta Neurochir Suppl 53: 166–170Google Scholar
  2. 2.
    Alfieri A, Jho HD (2001) Endoscopic endonasal approaches to the cavernous sinus: surgical approaches. Neurosurgery 49: 354–362PubMedGoogle Scholar
  3. 3.
    Alfieri A, Jho HD (2001) Endoscopic endonasal cavernous sinus surgery: an anatomic study. Neurosurgery 48: 827–837PubMedGoogle Scholar
  4. 4.
    Arita K, Kurisu K, Tominaga A, Kawamoto H, Iida K, Mizoue T, Pant B, Uozumi T (1998) Trans-sellar color Doppler ultrasonography during transsphenoidal surgery. Neurosurgery 42: 81–85; discussion 86PubMedGoogle Scholar
  5. 5.
    Baskin DS, Wilson CB (1986) Surgical management of craniopharyngiomas. A review of 74 cases. J Neurosurg 65: 22–27PubMedGoogle Scholar
  6. 6.
    Bertalanffy H, Seeger W (1991) The dorsolateral, suboccipital, transcondylar approach to the lower clivus and anterior portion of the craniocervical junction. Neurosurgery 29: 815–821PubMedGoogle Scholar
  7. 7.
    Candrina R, Galli G, Rossi M, Bollati A (1989) Tension pneumocephalus after transsphenoidal surgery for acromegaly. J Neurosurg Sci 33: 311–315PubMedGoogle Scholar
  8. 8.
    Cappabianca P, Alfieri A, de Divitiis E (1998) Endoscopic endonasal transsphenoidal approach to the sella: towards functional endoscopic pituitary surgery (FEPS). Minim Invasive Neurosurg 41: 66–73PubMedGoogle Scholar
  9. 9.
    Cappabianca P, Alfieri A, Thermes S, Buonamassa S, de Divitiis E (1999) Instruments for endoscopic endonasal transsphenoidal surgery. Neurosurgery 45: 392–395; discussion 395–396PubMedGoogle Scholar
  10. 10.
    Cappabianca P, Cavallo LM, Colao A, de Divitiis E (2002) Surgical complications associated with the endoscopic endonasal transsphenoidal approach for pituitary adenomas. J Neurosurg 97: 293–298PubMedGoogle Scholar
  11. 11.
    Cappabianca P, Cavallo LM, de Divitiis E (2004) Endoscopic endonasal transsphenoidal surgery. Neurosurgery 55: 933–940; discussion 940–931PubMedGoogle Scholar
  12. 12.
    Cappabianca P, Cavallo LM, Esposito F, de Divitiis E (2004) Endoscopic endonasal transsphenoidal surgery: procedure, endoscopic equipment and instrumentation. Childs Nerv Syst 20: 796–801PubMedGoogle Scholar
  13. 13.
    Cappabianca P, Cavallo LM, Esposito F, Valente V, De Divitiis E (2002) Sellar repair in endoscopic endonasal transsphenoidal surgery: results of 170 cases. Neurosurgery 51: 1365–1371; discussion 1371–1362PubMedGoogle Scholar
  14. 14.
    Cappabianca P, de Divitiis E (2007) Back to the Egyptians: neurosurgery via the nose. A five-thousand year history and the recent contribution of the endoscope. Neurosurg Rev 30: 1–7; discussion 7PubMedGoogle Scholar
  15. 15.
    Cappabianca P, de Divitiis E (2004) Endoscopy and transsphenoidal surgery. Neurosurgery 54: 1043–1048; discussions 1048–1050PubMedGoogle Scholar
  16. 16.
    Cappabianca P, de Divitiis O, Maiuri F (2003) Evolution of transsphenoidal surgery. In: de Divitiis E, Cappabianca P (eds) Endoscopic endonasal transsphenoidal surgery. Springer, Wien New York, pp 1–7Google Scholar
  17. 17.
    Cappabianca P, Frank G, Pasquini E, de Divitiis O, Calbucci F (2003) Extended endoscopic endonasal transsphenoidal approaches to the suprasellar region, planum sphenoidale & clivus. In: de Divitiis E, Cappabianca P (eds) Endoscopic endonasal transsphenoidal surgery. Springer, Wien New York, pp 176–187Google Scholar
  18. 18.
    Carmel P (1993) Craniopharyngioma: transcranial approaches. In: Apuzzo ML (ed) Brain surgery: complication avoidance and management. Churchill Livingstone, New York, pp 339–356Google Scholar
  19. 19.
    Carrau RL, Jho HD, Ko Y (1996) Transnasal-transsphenoidal endoscopic surgery of the pituitary gland. Laryngoscope 106: 914–918PubMedGoogle Scholar
  20. 20.
    Carrau RL, Snyderman CH, Kassam AB, Jungreis CA (2001) Endoscopic and endoscopic-assisted surgery for juvenile angiofibroma. Laryngoscope 111: 483–487PubMedGoogle Scholar
  21. 21.
    Castelnuovo P, Locatelli D, Mauri S (2003) Extended endoscopic approaches to the skull base. Anterior cranial base CSF leaks. In: de Divitiis E, Cappabianca P (eds) Endoscopic endonasal transsphenoidal surgery. Springer, Wien New York, pp 137–158Google Scholar
  22. 22.
    Castelnuovo P, Pistochini A, Locatelli D (2006) Different surgical approaches to the sellar region: focusing on the “two nostrils four hands technique”. Rhinology 44: 2–7PubMedGoogle Scholar
  23. 23.
    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: 379–389PubMedGoogle Scholar
  24. 24.
    Cavallo LM, de Divitiis O, Aydin S, Messina A, Esposito F, Iaconetta G, Talat K, Cappabianca P, Tschabitscher M (2007) Extended endoscopic endonasal transsphenoidal approach to the suprasellar area. Anatomic considerations: Part 1. Neurosurgery (in press)Google Scholar
  25. 25.
    Cavallo LM, Messina A, Cappabianca P, Esposito F, de Divitiis E, Gardner P, Tschabitscher M (2005) Endoscopic endonasal surgery of the midline skull base: anatomical study and clinical considerations. Neurosurg Focus 19: E2PubMedGoogle Scholar
  26. 26.
    Cavallo LM, Messina A, Esposito F, de Divitiis O, Dal Fabbro M, de Divitiis E, Cappabianca P (2007) Skull base reconstruction in extended endoscopic transsphenoidal approach for supra-sellar lesions. J Neurosurg (in press)Google Scholar
  27. 27.
    Chanda A, Nanda A (2002) Partial labyrinthectomy petrous apicectomy approach to the petroclival region: an anatomic and technical study. Neurosurgery 51: 147–159; discussion 159–160PubMedGoogle Scholar
  28. 28.
    Cho CW, Al-Mefty O (2002) Combined petrosal approach to petroclival meningiomas. Neurosurgery 51: 708–716; discussion 716–708PubMedGoogle Scholar
  29. 29.
    Cinalli G, Cappabianca P, de Falco R, Spennato P, Cianciulli E, Cavallo LM, Esposito F, Ruggiero C, Maggi G, de Divitiis E (2005) Current state and future development of intracranial neuroendoscopic surgery. Expert Rev Med Devices 2: 351–373PubMedGoogle Scholar
  30. 30.
    Ciric I, Ragin A, Baumgartner C, Pierce D (1997) Complications of transsphenoidal surgery: results of a national survey, review of the literature, and personal experience. Neurosurgery 40: 225–236; discussion 236–227PubMedGoogle Scholar
  31. 31.
    Cook SW, Smith Z, Kelly DF (2004) Endonasal transsphenoidal removal of tuberculum sellae meningiomas: technical note. Neurosurgery 55: 239–244; discussion 244–236PubMedGoogle Scholar
  32. 32.
    Couldwell WT, Sabit I, Weiss MH, Giannotta SL, Rice D (1997) Transmaxillary approach to the anterior cavernous sinus: a microanatomic study. Neurosurgery 40: 1307–1311PubMedGoogle Scholar
  33. 33.
    Couldwell WT, Weiss MH, Rabb C, Liu JK, Apfelbaum RI, Fukushima T (2004) Variations on the standard transsphenoidal approach to the sellar region, with emphasis on the extended approaches and parasellar approaches: surgical experience in 105 cases. Neurosurgery 55: 539–547; discussion 547–550PubMedGoogle Scholar
  34. 34.
    Crockard HA, Pozo JL, Ransford AO, Stevens JM, Kendall BE, Essigman WK (1986) Transoral decompression and posterior fusion for rheumatoid atlanto-axial subluxation. J Bone Joint Surg Br 68: 350–356PubMedGoogle Scholar
  35. 35.
    Crockard HA, Sen CN (1991) The transoral approach for the management of intradural lesions at the craniovertebral junction: review of 7 cases. Neurosurgery 28: 88–97; discussion 97–88PubMedGoogle Scholar
  36. 36.
    Crumley RL, Gutin PH (1989) Surgical access for clivus chordoma. The University of California, San Francisco, experience. Arch Otolaryngol Head Neck Surg 115: 295–300PubMedGoogle Scholar
  37. 37.
    Das K, Spencer W, Nwagwu CI, Schaeffer S, Wenk E, Weiss MH, Couldwell WT (2001) Approaches to the sellar and parasellar region: anatomic comparison of endonasal-transsphenoidal, sublabial-transsphenoidal, and transethmoidal approaches. Neurol Res 23: 51–54PubMedGoogle Scholar
  38. 38.
    de Divitiis E (2006) Endoscopic transsphenoidal surgery: stone-in-the-pond effect. Neurosurgery 59: 512–520PubMedGoogle Scholar
  39. 39.
    de Divitiis E, Cappabianca P (2002) Endoscopic endonasal transsphenoidal surgery. In: Pickard JD (ed) Advances and technical standards in neurosurgery. Springer, Wien New York, pp 137–177Google Scholar
  40. 40.
    de Divitiis E, Cappabianca P, Cavallo LM (2002) Endoscopic transsphenoidal approach: adaptability of the procedure to different sellar lesions. Neurosurgery 51: 699–705; discussion 705–697PubMedGoogle Scholar
  41. 41.
    de Divitiis E, Cavallo LM, Cappabianca P, Esposito F (2007) Extended endoscopic endonasal transsphenoidal approach for the removal of suprasellar tumors: part 2. Neurosurgery 60: 46–58; discussion 58–49PubMedGoogle Scholar
  42. 42.
    Delashaw JB Jr, Tedeschi H, Rhoton AL (1992) Modified supraorbital craniotomy: technical note. Neurosurgery 30: 954–956PubMedGoogle Scholar
  43. 43.
    Doglietto F, Prevedello DM, Jane JA Jr, Han J, Laws ER Jr (2005) Brief history of endoscopic transsphenoidal surgery — from Philipp Bozzini to the First World Congress of Endoscopic Skull Base Surgery. Neurosurg Focus 19: E3PubMedGoogle Scholar
  44. 44.
    Dolenc VV, Lipovsek M, Slokan S (1999) Traumatic aneurysm and carotid-cavernous fistula following transsphenoidal approach to a pituitary adenoma: treatment by transcranial operation. Br J Neurosurg 13: 185–188PubMedGoogle Scholar
  45. 45.
    Dusick JR, Esposito F, Kelly DF, Cohan P, DeSalles A, Becker DP, Martin NA (2005) The extended direct endonasal transsphenoidal approach for nonadenomatous suprasellar tumors. J Neurosurg 102: 832–841PubMedGoogle Scholar
  46. 46.
    Elias WJ, Chadduck JB, Alden TD, Laws ER Jr (1999) Frameless stereotaxy for transsphenoidal surgery. Neurosurgery 45: 271–275; discussion 275–277PubMedGoogle Scholar
  47. 47.
    Erdogmus S, Govsa F (2006) The anatomic landmarks of ethmoidal arteries for the surgical approaches. J Craniofac Surg 17: 280–285PubMedGoogle Scholar
  48. 48.
    Esposito F, Becker DP, Villablanca JP, Kelly DF (2005) Endonasal transsphenoidal transclival removal of prepontine epidermoid tumors: technical note. Neurosurgery 56: E443PubMedGoogle Scholar
  49. 49.
    Esposito F, Dusick JR, Fatemi N, Kelly DF (2007) Graded repair of cranial base defects and cerebrospinal fluid leaks in transsphenoidal surgery. Neurosurgery 60: ONS1–ONS9Google Scholar
  50. 50.
    Fahlbusch R, Buchfelder M (1988) Transsphenoidal surgery of parasellar pituitary adenomas. Acta Neurochir (Wien) 92: 93–99Google Scholar
  51. 51.
    Fahlbusch R, Honegger J, Buchfelder M (1996) Clinical features and management of craniopharyngiomas in adults. In: Tindall GT, Cooper PR, Barrow DL (eds) The practice of neurosurgery. Williams & Wilkins, Baltimore, pp 1159–1173Google Scholar
  52. 52.
    Fahlbusch R, Honegger J, Paulus W, Huk W, Buchfelder M (1999) Surgical treatment of craniopharyngiomas: experience with 168 patients. J Neurosurg 90: 237–250PubMedGoogle Scholar
  53. 53.
    Fahlbusch R, Schott W (2002) Pterional surgery of meningiomas of the tuberculum sellae and planum sphenoidale: surgical results with special consideration of ophthalmological and endocrinological outcomes. J Neurosurg 96: 235–243PubMedGoogle Scholar
  54. 54.
    Fraioli B, Esposito V, Santoro A, Iannetti G, Giuffre R, Cantore G (1995) Transmaxillosphenoidal approach to tumors invading the medial compartment of the cavernous sinus. J Neurosurg 82: 63–69PubMedGoogle Scholar
  55. 55.
    Frank G, Pasquini E (2003) Approach to the cavernous sinus. In: de Divitiis E, Cappabianca P (eds) Endoscopic endonasal transsphenoidal surgery. Springer, Wien New York, pp 159–175Google Scholar
  56. 56.
    Frank G, Pasquini E (2002) Endoscopic endonasal approaches to the cavernous sinus: surgical approaches. Neurosurgery 50: 675PubMedGoogle Scholar
  57. 57.
    Frank G, Pasquini E, Doglietto F, Mazzatenta D, Sciarretta V, Farneti G, Calbucci F (2006) The endoscopic extended transsphenoidal approach for craniopharyngiomas. Neurosurgery 59: ONS75–ONS83PubMedGoogle Scholar
  58. 58.
    Frank G, Pasquini E, Mazzatenta D (2001) Extended transsphenoidal approach. J Neurosurg 95: 917–918PubMedGoogle Scholar
  59. 59.
    Frank G, Sciarretta V, Calbucci F, Farneti G, Mazzatenta D, Pasquini E (2006) The endoscopic transnasal transsphenoidal approach for the treatment of cranial base chordomas and chondrosarcomas. Neurosurgery 59: ONS50–ONS57; discussion ONS50–ONS57PubMedGoogle Scholar
  60. 60.
    Gardner PA, Kassam AB, Snyderman CH, Carrau RL, Minz A (2006) Outcomes following purely endoscopic endonasal resection of anterior skull base meningiomas. 17th Annual Meeting North American Skull Base Society, p S12Google Scholar
  61. 61.
    Gardner PA, Kassam AB, Snyderman CH, Carrau RL, Minz A (2006) Outcomes following purely endoscopic endonasal resection of suprasellar craniopharingiomas. 17th Annual Meeting North American Skull Base Society, pp S19–S20Google Scholar
  62. 62.
    Goel A, Desai K, Muzumdar D (2001) Surgery on anterior foramen magnum meningiomas using a conventional posterior suboccipital approach: a report on an experience with 17 cases. Neurosurgery 49: 102–106; discussion 106–107PubMedGoogle Scholar
  63. 63.
    Goel A, Muzumdar D, Desai KI (2002) Tuberculum sellae meningioma: a report on management on the basis of a surgical experience with 70 patients. Neurosurgery 51: 1358–1364PubMedGoogle Scholar
  64. 64.
    Grisoli F, Diaz-Vasquez P, Riss M, Vincentelli F, Leclercq TA, Hassoun J, Salamon G (1986) Microsurgical management of tuberculum sellae meningiomas. Results in 28 consecutive cases. Surg Neurol 26: 37–44PubMedGoogle Scholar
  65. 65.
    Guiot G (1973) Transsphenoidal approach in surgical treatment of pituitary adenomas: general principles and indications in non-functioning adenomas. In: Kohler PO, Ross GT (eds) Diagnosis and treatment of pituitary adenomas. Excerpta Medica, Amsterdam, pp 159–178Google Scholar
  66. 66.
    Hadad G, Bassagasteguy L, Carrau RL, Mataza JC, Kassam A, Snyderman CH, Mintz A (2006) A novel reconstructive technique after endoscopic expanded endonasal approaches: vascular pedicle nasoseptal flap. Laryngoscope 116: 1882–1886PubMedGoogle Scholar
  67. 67.
    Hadley MN, Spetzler RF, Sonntag VK (1989) The transoral approach to the superior cervical spine. A review of 53 cases of extradural cervicomedullary compression. J Neurosurg 71: 16–23PubMedGoogle Scholar
  68. 68.
    Hakuba A, Liu S, Nishimura S (1986) The orbitozygomatic infratemporal approach: a new surgical technique. Surg Neurol 26: 271–276PubMedGoogle Scholar
  69. 69.
    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: 699–704PubMedGoogle Scholar
  70. 70.
    Hao SP, Wang HS, Lui TN (1995) Transnasal endoscopic management of basal encephalocele — craniotomy is no longer mandatory. Am J Otolaryngol 16: 196–199PubMedGoogle Scholar
  71. 71.
    Hashimoto N, Kikuchi H (1990) Transsphenoidal approach to infrasellar tumors involving the cavernous sinus. J Neurosurg 73: 513–517PubMedGoogle Scholar
  72. 72.
    Hayakawa T, Kamikawa K, Ohnishi T, Yoshimine T (1981) Prevention of postoperative complications after a transoral transclival approach to basilar aneurysms: technical note. J Neurosurg 54: 699–703PubMedGoogle Scholar
  73. 73.
    Honegger J, Buchfelder M, Fahlbusch R, Daubler B, Dorr HG (1992) Transsphenoidal microsurgery for craniopharyngioma. Surg Neurol 37: 189–196PubMedGoogle Scholar
  74. 74.
    Hosemann W, Nitsche N, Rettinger G, Wigand ME (1991) [Endonasal, endoscopically controlled repair of dura defects of the anterior skull base]. Laryngorhinootologie 70: 115–119PubMedGoogle Scholar
  75. 75.
    Inoue T, Rhoton AL Jr, Theele D, Barry ME (1990) Surgical approaches to the cavernous sinus: a microsurgical study. Neurosurgery 26: 903–932PubMedGoogle Scholar
  76. 76.
    Jallo GI, Benjamin V (2002) Tuberculum sellae meningiomas: microsurgical anatomy and surgical technique. Neurosurgery 51: 1432–1440PubMedGoogle Scholar
  77. 77.
    James D, Crockard HA (1991) Surgical access to the base of skull and upper cervical spine by extended maxillotomy. Neurosurgery 29: 411–416PubMedGoogle Scholar
  78. 78.
    Jane JA Jr, Han J, Prevedello DM, Jagannathan J, Dumont AS, Laws ER Jr (2005) Perspectives on endoscopic transsphenoidal surgery. Neurosurg Focus 19: E2PubMedGoogle Scholar
  79. 79.
    Javed T, Sekhar LN (1991) Surgical management of clival meningiomas. Acta Neurochir Suppl 53: 171–182Google Scholar
  80. 80.
    Jho HD (1999) Endoscopic pituitary surgery. Pituitary 2: 139–154PubMedGoogle Scholar
  81. 81.
    Jho HD, Carrau RL, Ko Y (1996) Endoscopic pituitary surgery. In: Wilkins H, Rengachary S (eds) Neurosurgical operative atlas. American Association of Neurological Surgeons, Park Ridge, pp 1–12Google Scholar
  82. 82.
    Jho HD, Ha HG (2004) Endoscopic endonasal skull base surgery: part 1. The midline anterior fossa skull base. Minim Invasive Neurosurg 47: 1–8PubMedGoogle Scholar
  83. 83.
    Jho HD, Ha HG (2004) Endoscopic endonasal skull base surgery: part 2. The cavernous sinus. Minim Invasive Neurosurg 47: 9–15PubMedGoogle Scholar
  84. 84.
    Jho HD, Ha HG (2004) Endoscopic endonasal skull base surgery: part 3. The clivus and posterior fossa. Minim Invasive Neurosurg 47: 16–23PubMedGoogle Scholar
  85. 85.
    Kaptain GJ, Vincent DA, Sheehan JP, Laws ER Jr (2001) Transsphenoidal approaches for the extracapsular resection of midline suprasellar and anterior cranial base lesions. Neurosurgery 49: 94–100; discussion 100–101PubMedGoogle Scholar
  86. 86.
    Kassam A, Snyderman CH, Mintz A, Gardner P, Carrau RL (2005) Expanded endonasal approach: the rostrocaudal axis: part I. Crista galli to the sella turcica. Neurosurg Focus 19: E3PubMedGoogle Scholar
  87. 87.
    Kassam A, Snyderman CH, Mintz A, Gardner P, Carrau RL (2005) Expanded endonasal approach: the rostrocaudal axis: part II. Posterior clinoids to the foramen magnum. Neurosurg Focus 19: E4PubMedGoogle Scholar
  88. 88.
    Kassam AB, Gardner P, Snyderman C, Mintz A, Carrau R (2005) Expanded endonasal approach: fully endoscopic, completely transnasal approach to the middle third of the clivus, petrous bone, middle cranial fossa, and infratemporal fossa. Neurosurg Focus 19: E6PubMedGoogle Scholar
  89. 89.
    Kassam AB, Mintz AH, Gardner PA, Horowitz MB, Carrau RL, Snyderman CH (2006) The expanded endonasal approach for an endoscopic transnasal clipping and aneurysmorrhaphy of a large vertebral artery aneurysm: technical case report. Neurosurgery 59: ONSE162–ONSE165PubMedGoogle Scholar
  90. 90.
    Kassam AB, Snyderman C, Gardner P, Carrau R, Spiro R (2005) The expanded endonasal approach: a fully endoscopic transnasal approach and resection of the odontoid process: technical case report. Neurosurgery 57: E213PubMedGoogle Scholar
  91. 91.
    Kato T, Sawamura Y, Abe H, Nagashima M (1998) Transsphenoidal-transtuberculum sellae approach for supradiaphragmatic tumours: technical note. Acta Neurochir (Wien) 140: 715–718; discussion 719Google Scholar
  92. 92.
    Kawase T, Shiobara R, Toya S (1991) Anterior transpetrosal-transtentorial approach for sphenopetroclival meningiomas: surgical method and results in 10 patients. Neurosurgery 28: 869–875; discussion 875–866PubMedGoogle Scholar
  93. 93.
    Kawashima M, Tanriover N, Rhoton AL Jr, Ulm AJ, Matsushima T (2003) Comparison of the far lateral and extreme lateral variants of the atlanto-occipital transarticular approach to anterior extradural lesions of the craniovertebral junction. Neurosurgery 53: 662–674; discussion 674–665PubMedGoogle Scholar
  94. 94.
    Kennedy DW (1985) Functional endoscopic sinus surgery. Technique. Arch Otolaryngol 111: 643–649Google Scholar
  95. 95.
    Kim J, Choe I, Bak K, Kim C, Kim N, Jang Y (2000) Transsphenoidal supradiaphragmatic intradural approach: technical note. Minim Invasive Neurosurg 43: 33–37PubMedGoogle Scholar
  96. 96.
    Kitano M, Taneda M (2001) Extended transsphenoidal approach with submucosal posterior ethmoidectomy for parasellar tumors. Technical note. J Neurosurg 94: 999–1004PubMedGoogle Scholar
  97. 97.
    Kouri JG, Chen MY, Watson JC, Oldfield EH (2000) Resection of suprasellar tumors by using a modified transsphenoidal approach. Report of four cases. J Neurosurg 92: 1028–1035PubMedGoogle Scholar
  98. 98.
    Lakhdar A, Sami A, Naja A, Achouri M, Ouboukhlik A, El Kamar A, El Azhari A (2003) Epidermoid cyst of the cerebellopontine angle. A surgical series of 10 cases and review of the literature. Neurochirurgie 49: 13–24PubMedGoogle Scholar
  99. 99.
    Lalwani AK, Kaplan MJ, Gutin PH (1992) The transsphenoethmoid approach to the sphenoid sinus and clivus. Neurosurgery 31: 1008–1014PubMedGoogle Scholar
  100. 100.
    Lang DA, Neil-Dwyer G, Iannotti F (1993) The suboccipital transcondylar approach to the clivus and cranio-cervical junction for ventrally placed pathology at and above the foramen magnum. Acta Neurochir (Wien) 125: 132–137Google Scholar
  101. 101.
    Lasio G, Ferroli P, Felisati G, Broggi G (2002) Image-guided endoscopic transnasal removal of recurrent pituitary adenomas. Neurosurgery 51: 132–136; discussion 136–137PubMedGoogle Scholar
  102. 102.
    Laufer I, Anand VK, Schwartz TH (2007) Endoscopic, endonasal extended transsphenoidal, transplanum transtuberculum approach for resection of suprasellar lesions. J Neurosurg 106: 400–406PubMedGoogle Scholar
  103. 103.
    Laws ER (1980) Transsphenoidal microsurgery in the management of craniopharyngioma. J Neurosurg 52: 661–666PubMedGoogle Scholar
  104. 104.
    Laws ER Jr (1984) Transsphenoidal surgery for tumors of the clivus. Otolaryngol Head Neck Surg 92: 100–101PubMedGoogle Scholar
  105. 105.
    Laws ER, Kanter AS, Jane JA Jr, Dumont AS (2005) Extended transsphenoidal approach. J Neurosurg 102: 825–827; discussion 827–828PubMedGoogle Scholar
  106. 106.
    Liu JK, Decker D, Schaefer SD, Moscatello AL, Orlandi RR, Weiss MH, Couldwell WT (2003) Zones of approach for craniofacial resection: minimizing facial incisions for resection of anterior cranial base and paranasal sinus tumors. Neurosurgery 53: 1126–1135; discussion 1135–1127PubMedGoogle Scholar
  107. 107.
    Liu JK, Weiss MH, Couldwell WT (2003) Surgical approaches to pituitary tumors. Neurosurg Clin N Am 14: 93–107PubMedGoogle Scholar
  108. 108.
    Locatelli D, Rampa F, Acchiardi I, Bignami M, De Bernardi F, Castelnuovo P (2006) Endoscopic endonasal approaches for repair of cerebrospinal fluid leaks: nine-year experience. Neurosurgery 58: ONS246–ONS256; discussion ONS256–ONS247Google Scholar
  109. 109.
    MacDonald JD, Antonelli P, Day AL (1998) The anterior subtemporal, medial transpetrosal approach to the upper basilar artery and ponto-mesencephalic junction. Neurosurgery 43: 84–89PubMedGoogle Scholar
  110. 110.
    Mason RB, Nieman LK, Doppman JL, Oldfield EH (1997) Selective excision of adenomas originating in or extending into the pituitary stalk with preservation of pituitary function. J Neurosurg 87: 343–351PubMedGoogle Scholar
  111. 111.
    Menezes AH, VanGilder JC (1988) Transoral-transpharyngeal approach to the anterior craniocervical junction. Ten-year experience with 72 patients. J Neurosurg 69: 895–903PubMedGoogle Scholar
  112. 112.
    Messerklinger W (1987) Role of the lateral nasal wall in the pathogenesis, diagnosis and therapy of recurrent and chronic rhinosinusitis. Laryngol Rhinol Otol (Stuttg) 66: 293–299Google Scholar
  113. 113.
    Miller E, Crockard HA (1987) Transoral transclival removal of anteriorly placed meningiomas at the foramen magnum. Neurosurgery 20: 966–968PubMedGoogle Scholar
  114. 114.
    Moon HJ, Kim HU, Lee JG, Chung IH, Yoon JH (2001) Surgical anatomy of the anterior ethmoidal canal in ethmoid roof. Laryngoscope 111: 900–904PubMedGoogle Scholar
  115. 115.
    Nakamura M, Samii M (2003) Surgical management of a meningioma in the retrosellar region. Acta Neurochir (Wien) 145: 215–219; discussion 219–220Google Scholar
  116. 116.
    Nanda A, Vincent DA, Vannemreddy PS, Baskaya MK, Chanda A (2002) Far-lateral approach to intradural lesions of the foramen magnum without resection of the occipital condyle. J Neurosurg 96: 302–309PubMedGoogle Scholar
  117. 117.
    Ohhashi G, Kamio M, Abe T, Otori N, Haruna S (2002) Endoscopic transnasal approach to the pituitary lesions using a navigation system (InstaTrak system): technical note. Minim Invasive Neurosurg 45: 120–123PubMedGoogle Scholar
  118. 118.
    Pasztor E, Vajda J, Piffko P, Horvath M, Gador I (1984) Transoral surgery for craniocervical space-occupying processes. J Neurosurg 60: 276–281PubMedGoogle Scholar
  119. 119.
    Perneczky A, Knosp E, Matula C (1988) Cavernous sinus surgery. Approach through the lateral wall. Acta Neurochir (Wien) 92: 76–82Google Scholar
  120. 120.
    Perneczky A, Muller-Forell W, van Lindert E, Fries G (1999) Keyhole concept in neurosurgery. Thieme, Stuttgart New YorkGoogle Scholar
  121. 121.
    Puxeddu R, Lui MW, Chandrasekar K, Nicolai P, Sekhar LN (2002) Endoscopic-assisted transcolumellar approach to the clivus: an anatomical study. Laryngoscope 112: 1072–1078PubMedGoogle Scholar
  122. 122.
    Rabadan A, Conesa H (1992) Transmaxillary-transnasal approach to the anterior clivus: a microsurgical anatomical model. Neurosurgery 30: 473–481; discussion 482PubMedGoogle Scholar
  123. 123.
    Raftopoulos C, Baleriaux D, Hancq S, Closset J, David P, Brotchi J (1995) Evaluation of endoscopy in the treatment of rare meningoceles: preliminary results. Surg Neurol 44: 308–317; discussion 317–308PubMedGoogle Scholar
  124. 124.
    Reisch R, Bettag M, Perneczky A (2001) Transoral transclival removal of anteriorly placed cavernous malformations of the brainstem. Surg Neurol 56: 106–115; discussion 115–106PubMedGoogle Scholar
  125. 125.
    Reisch R, Perneczky A (2005) Ten-year experience with the supraorbital subfrontal approach through an eyebrow skin incision. Neurosurgery 57: 242–255; discussion 242–255PubMedGoogle Scholar
  126. 126.
    Sabit I, Schaefer SD, Couldwell WT (2000) Extradural extranasal combined transmaxillary transsphenoidal approach to the cavernous sinus: a minimally invasive microsurgical model. Laryngoscope 110: 286–291PubMedGoogle Scholar
  127. 127.
    Samii M, Ammirati M (1988) The combined supra-infratentorial pre-sigmoid sinus avenue to the petro-clival region. Surgical technique and clinical applications. Acta Neurochir (Wien) 95: 6–12Google Scholar
  128. 128.
    Samii M, Klekamp J, Carvalho G (1996) Surgical results for meningiomas of the craniocervical junction. Neurosurgery 39: 1086–1094; discussion 1094–1085PubMedGoogle Scholar
  129. 129.
    Sandeman D, Moufid A (1998) Interactive image-guided pituitary surgery. An experience of 101 procedures. Neurochirurgie 44: 331–338PubMedGoogle Scholar
  130. 130.
    Sano K (1980) Temporo-polar approach to aneurysms of the basilar artery at and around the distal bifurcation: technical note. Neurol Res 2: 361–367PubMedGoogle Scholar
  131. 131.
    Satyarthee GD, Mahapatra AK (2003) Tension pneumocephalus following transsphenoid surgery for pituitary adenoma — report of two cases. J Clin Neurosci 10: 495–497PubMedGoogle Scholar
  132. 132.
    Sawka AM, Aniszewski JP, Young WF Jr, Nippoldt TB, Yanez P, Ebersold MJ (1999) Tension pneumocranium, a rare complication of transsphenoidal pituitary surgery: Mayo Clinic experience 1976–1998. J Clin Endocrinol Metab 84: 4731–4734PubMedGoogle Scholar
  133. 133.
    Schwartz TH, Stieg PE, Anand VK (2006) Endoscopic transsphenoidal pituitary surgery with intraoperative magnetic resonance imaging. Neurosurgery 58: ONS44–ONS51; discussion ONS44–ONS51PubMedGoogle Scholar
  134. 134.
    Seifert V, Raabe A, Zimmermann M (2003) Conservative (labyrinth-preserving) transpetrosal approach to the clivus and petroclival region — indications, complications, results and lessons learned. Acta Neurochir (Wien) 145: 631–642; discussion 642Google Scholar
  135. 135.
    Sekhar LN, Ross DA, Sen CN (1993) Cavernous sinus and sphenocavernous neoplasms. Anatomy and surgery. In: Sekhar LN, Janecka IP (eds) Surgery of cranial base tumors. Raven Press, New York, pp 521–604Google Scholar
  136. 136.
    Sepehrnia A, Knopp U (2002) The combined subtemporal-suboccipital approach: a modified surgical access to the clivus and petrous apex. Minim Invasive Neurosurg 45: 102–104PubMedGoogle Scholar
  137. 137.
    Spaziante R, E. d D, Cappabianca P, Zona G (2006) Repair of the sella following transsphenoidal surgery. In: Schmidek HH, Roberts DW (eds) Chmidek and sweet operative neurosurgical techniques indications, methods and results. W. B. Saunders, Philadelphia, pp 390–408Google Scholar
  138. 138.
    Spencer WR, Levine JM, Couldwell WT, Brown-Wagner M, Moscatello A (2000) Approaches to the sellar and parasellar region: a retrospective comparison of the endonasal-transsphenoidal and sublabial-transsphenoidal approaches. Otolaryngol Head Neck Surg 122: 367–369PubMedGoogle Scholar
  139. 139.
    Stamm AC, Pignatari SS, Vellutini E (2006) Transnasal endoscopic surgical approaches to the clivus. Otolaryngol Clin North Am 39: 639–656, xiPubMedGoogle Scholar
  140. 140.
    Stamm AM (2006) Transnasal endoscopy-assisted skull base surgery. Ann Otol Rhinol Laryngol (Suppl) 196: 45–53Google Scholar
  141. 141.
    Stammberger H (1986) Endoscopic endonasal surgery — concepts in treatment of recurring rhinosinusitis: Part I. Anatomic and pathophysiologic considerations. Otolaryngol Head Neck Surg 94: 143–147PubMedGoogle Scholar
  142. 142.
    Stammberger H (1986) Endoscopic endonasal surgery — concepts in treatment of recurring rhinosinusitis: part II. Surgical technique. Otolaryngol Head Neck Surg 94: 147–156PubMedGoogle Scholar
  143. 143.
    Stammberger H, Hosemann W, Draf W (1997) Anatomic terminology and nomenclature for paranasal sinus surgery. Laryngorhinootologie 76: 435–449PubMedGoogle Scholar
  144. 144.
    Stammberger H, Posawetz W (1990) Functional endoscopic sinus surgery. Concept, indications and results of the Messerklinger technique. Eur Arch Otorhinolaryngol 247: 63–76PubMedGoogle Scholar
  145. 145.
    Stankiewicz JA (1989) The endoscopic approach to the sphenoid sinus. Laryngoscope 99: 218–221PubMedGoogle Scholar
  146. 146.
    Talacchi A, Sala F, Alessandrini F, Turazzi S, Bricolo A (1998) Assessment and surgical management of posterior fossa epidermoid tumors: report of 28 cases. Neurosurgery 42: 242–251; discussion 251–242PubMedGoogle Scholar
  147. 147.
    Tosun F, Carrau RL, Snyderman CH, Kassam A, Celin S, Schaitkin B (2003) Endonasal endoscopic repair of cerebrospinal fluid leaks of the sphenoid sinus. Arch Otolaryngol Head Neck Surg 129: 576–580PubMedGoogle Scholar
  148. 148.
    Tschabitscher M, Galzio RJ (2003) Endoscopic anatomy along the transnasal approach to the pituitary gland and the surrounding structures. In: Divitiis ED, Cappabianca P (eds) Endoscopic endonasal transsphenoidal surgery. Springer, Wien New York, pp 21–39Google Scholar
  149. 149.
    Weiss M (1987) The transnasal transsphenoidal approach. In: Apuzzo MLJ (ed) Surgery of the third ventricle. Williams & Wilkins, Baltimore, pp 476–494Google Scholar
  150. 150.
    White DV, Sincoff EH, Abdulrauf SI (2005) Anterior ethmoidal artery: microsurgical anatomy and technical considerations. Neurosurgery 56: 406–410; discussion 406–410PubMedGoogle Scholar
  151. 151.
    Yamasaki T, Moritake K, Hatta J, Nagai H (1996) Intraoperative monitoring with pulse Doppler ultrasonography in transsphenoidal surgery: technique application. Neurosurgery 38: 95–97; discussion 97–98PubMedGoogle Scholar

Copyright information

© Springer-Verlag/Wien 2008

Authors and Affiliations

  • P. Cappabianca
    • 1
  • L. M. Cavallo
    • 1
  • F. Esposito
    • 1
  • O. de Divitiis
    • 1
  • A. Messina
    • 1
  • E. de Divitiis
    • 1
  1. 1.Division of Neurosurgery, Department of Neurological SciencesUniversità degli Studi di Napoli Federico IINaplesItaly

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