- Department of Neurological Surgery, Wexner Medical Center at The Ohio State University, Columbus, OH, USA
- Department of Otolaryngology – Head and Neck Surgery, Wexner Medical Center at The Ohio State University, Columbus, OH, USA
Correspondence Address:
Daniel M. Prevedello
Department of Otolaryngology – Head and Neck Surgery, Wexner Medical Center at The Ohio State University, Columbus, OH, USA
DOI:10.4103/2152-7806.95418
Copyright: © 2012 de Lara D. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.How to cite this article: Lara Dd, Ditzel Filho LF S, Prevedello DM, Otto BA, Carrau RL. Application of image guidance in pituitary surgery. Surg Neurol Int 26-Apr-2012;3:
How to cite this URL: Lara Dd, Ditzel Filho LF S, Prevedello DM, Otto BA, Carrau RL. Application of image guidance in pituitary surgery. Surg Neurol Int 26-Apr-2012;3:. Available from: http://sni.wpengine.com/surgicalint_articles/application-of-image-guidance-in-pituitary-surgery/
Abstract
Background:Surgical treatment of pituitary pathologies has evolved along the years, adding safety and decreasing morbidity related to the procedure. Advances in the field of radiology, coupled with stereotactic technology and computer modeling, have culminated in the contemporary and widespread use of image guidance systems, as we know them today. Image guidance navigation has become a frequently used technology that provides continuous three-dimensional information for the accurate performance of neurosurgical procedures. We present a discussion about the application of image guidance in pituitary surgeries.
Methods:Major indications for image guidance neuronavigation application in pituitary surgery are presented and demonstrated with illustrative cases. Limitations of this technology are also presented.
Results:Patients presenting a history of previous transsphenoidal surgeries, anatomical variances of the sphenoid sinus, tumors with a close relation to the internal carotid arteries, and extrasellar tumors are the most important indications for image guidance in pituitary surgeries. The high cost of the equipment, increased time of surgery due to setup time, and registration and the need of specific training for the operating room personnel could be pointed as limitations of this technology.
Conclusion:Intraoperative image guidance systems provide real-time images, increasing surgical accuracy and enabling safe, minimally invasive interventions. However, the use of intraoperative navigation is not a replacement for surgical experience and a systematic knowledge of regional anatomy. It must be recognized as a tool by which the neurosurgeon can reduce the risk associated with surgical approach and treatment of pituitary pathologies.
Keywords: Image guidance, neuronavigation, pituitary, transsphenoidal
INTRODUCTION
The surgical management of pituitary lesions, as in many other fields of medicine, has evolved over time, with significant advances credited to the persistence and innovation of pioneer surgeons. Harvey Cushing advanced the field of pituitary surgery in the early 20th century with the transsphenoidal approach. However, he ended up abandoning the approach for unclear reasons most likely related to lack of technology.[
Radiological improvements have added accuracy and safety to all neurosurgical procedures. The first reports of preoperative imaging for sellar diseases date from 1899, when Hermann Oppenheim demonstrated that the sella turcica was enlarged in a patient with acromegaly.[
Continued advances occurred in the field of radiology, leading to better imaging, and consequently, better understanding of the pituitary gland and sellar pathologies. Information regarding the working distance between the carotid arteries, location of the optic chiasm and nerves, and exact characteristics of the disease could be well documented with these diagnostic imaging modalities; however, this did not necessarily translate to improved morbidity related to transsphenoidal surgery.[
Incessant efforts to reduce the surgical risks through the improvement in surgical techniques led to the innovative use of existing imaging techniques to guide the surgeon intraoperatively.[
Image-guided neurosurgery may be broadly defined as any neurosurgical procedure assisted by imaging, regardless of whether the images are acquired before or during the surgery.[
IMAGE GUIDANCE NAVIGATION SYSTEM
Three-dimensional image-guided navigation systems (IGNSs) have been increasingly utilized in many neurosurgical procedures.[
Initial intraoperative image guidance systems utilized a stereotactic frame, which required fixation of the patient's head with cranial screws during surgery. These systems evolved to frameless and wandless systems based on one of the two main tracking technologies: electromagnetic or optical. Electromagnetic tracking systems use a radiofrequency transmitter attached to a patient headset and an electromagnetic sensor integrated to a handpiece. Optical-based systems utilize an infrared camera array that localizes the instrument and head position through the detection of light-emitting diodes (LEDs) that are fixed to the surgical instrument and to a headset worn by the patient.[
Regardless of the tracking technology, most systems include a monitor, workstation, referential system (or receiver), and a localizer [
PITUITARY LESIONS AND INTRAOPERATIVE IMAGING NAVIGATION
Because of the close relationship to important orbital and intracranial structures, transsphenoidal approaches to the sella demand a high degree of surgical precision and an accurate understanding of the pertinent anatomical relationships. This task can be challenging in patients with poor anatomical landmarks, especially in those who have had previous surgery or who have disease invading or engulfing the surrounding structures.[
Both osseous and neurovascular structures may serve as important landmarks during transsphenoidal approaches to the sella. Hence, both computed tomography (CT) and magnetic resonance imaging (MRI) have their advantages and disadvantages – CT scans are generally optimal for identifying bone integrity and bony landmarks, while MRI is more suited for soft tissue differentiation. Accordingly, CT or MRI may be used independently or fused depending on the specific needs for a given case.[
Registration is the process by which digitized imaging data in the computer workstation are correlated with the patient anatomy. This is performed in the operating suite following induction of anesthesia and optimal patient positioning. Although the specific process varies depending on the manufacturer of the IGNS, registration is performed using surface landmarks. These landmarks are matched to corresponding anatomical landmarks on the MRI and / or CT. This process necessitates the use of a soft tissue window for registration to a CT scan. Following registration, the scan can be adjusted to a bony window. After completing registration and confirming accuracy, the IGNS can be properly used.[
In order for the system to remain accurate, the anatomical landmarks used for registration must remain stable in reference to the localizer / tracker. Although pin-less systems offer convenience, this may come at the cost of accuracy if shifting of the patient / system occurs during the procedure. The use of a head pin holder not only allows the surgeon to minimize head movement during the case, but also helps to stabilize the relationship to the localizer / tracker for those systems that connect to the head pin device rather than the patient's head.
INDICATIONS
In our department, we currently use intraoperative navigation for all endoscopic endonasal procedures, including the transsphenoidal approaches. Although transsphenoidal surgery can be performed easily and without significant risk of complications in most patients, resection of even limited tumors may be challenging when adjacent anatomical landmarks are absent or obscured.[
IGNS is especially useful during revision surgery, where normal anatomical structures may be distorted.[
Figure 2
Axial (a) and coronal (b) T1-weighted MR images of a patient with a non-functioning macroadenoma and poorly pneumatized sphenoid sinus. Intraoperative neuronavigation image (c) shows sphenoid sinus presenting a left lateral pneumatization, which may make midline orientation difficult. The pneumatization leads directly to the left ICA
Figure 3
Intraoperative neuronavigation images and each respective endoscopic endonasal intraoperative view. (a) Pituitary adenoma extending laterally and posteriorly to the left cavernous sinus and Meckel's cave – detail: T1-weighted contrast-enhanced axial MR image showing tumor invasion of the left cavernous sinus (arrow). (b) Large macroadenoma with a suprasellar extension and superior displacement of the optic chiasm. (c) Upper clivus invasion by a macroadenoma
Due to the deleterious effects of carotid artery damage, any surgeon performing transsphenoidal procedures should remain acutely aware and respectful of the ICA throughout the entire procedure.[
Figure 4
Illustrative case: A 30-year-old male presented with headaches and progressive visual loss. Endocrine evaluation showed increased Thyrotropin (TSH) levels. MR imaging was performed and a macroadenoma, partially embracing the right carotid artery, was diagnosed. The neuronavigation system was used to assist the approach and to evaluate tumor proximity to the right carotid artery. Coronal (a), Sagittal (b) and Axial (c) intraoperative neuronavigation images of a transsphenoidal approach for a macroadenoma. (d) Endoscopic endonasal surgical view of left ICA localization during tumor (*) removal
IGNS is also very helpful when addressing suprasellar tumors expanding along the anterior cranial base, when an expanded endonasal transellar transplanum approach needs to be formed. In this approach, the tuberculum sellae and planum sphenoidale are removed to provide increased access and ensure proper visualization. IGNS can assist the bone removal to the lateral limits of the carotid arteries and the anterior limit of the tumor, avoiding entering into the cribriform plate and facilitating the identification of the anatomical landmarks and identifying the extrasellar components of the tumor[
Figure 5
Sagittal (a), axial (b), and coronal (c and d) T1-weighted, contrast-enhanced MR images of a macroadenoma extending to the anterior fossa. (e) Endoscopic view of tumor resection during an endoscopic endonasal transellar transplanum approach. ACA: anterior cerebral artery, OCh: optic chiasm, T: tumor
Computer-based neuronavigation system may also contribute to increase surgeon proficiency. Surgeons with a not so broad experience in transsphenoidal approaches can be more confident about planning and executing the procedure, when assisted by this sort of technology. Computer-based image guidance technology is also helpful for training purposes, since visualization in different sectional planes augments the understanding of normal and pathological anatomy. Some studies report that it enhances surgical efficiency and improves the learning curve of residents.[
DISCUSSION
Advances in medical imaging technology along with the implementation of minimally invasive procedures have contributed greatly to contemporary neurosurgical practice. Today, the use of IGNS is commonplace in neurosurgery, as it is extremely useful as both a pre-surgical and intraoperative device that improves accuracy in defining anatomical structures.[
During pituitary surgery, IGNS may help the surgeon deal with anatomical variances and discrimination of tumor from normal tissue when the lesion extends into the extrasellar space. Without question, a thorough knowledge of the anatomy of the nose, sinuses, and anterior skull base remains the most important foundation to perform safe transsphenoidal surgeries.[
In contrast to traditional craniotomy approaches, where shifting of brain and intracranial structures may reduce intraoperative accuracy of intraoperative navigation, transsphenoidal surgery is particularly suited to the use of IGNSs, as the landmarks are generally bony and not prone to shifting [
Disadvantages related to the use of IGNSs exist and should be considered. One limitation to the widespread of this technology is the cost added to the surgical procedure.[
CONCLUSION
Major innovations in medical imaging have played a key role in decreasing morbidity and mortality once associated with pituitary surgery. Intraoperative IGNS provides real-time stereotactic feedback, increasing surgical accuracy and enabling safe and effective minimally invasive interventions.[
Publication of this manuscript has been made possible by an educational grant from
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