Micko, a.Md, phd, hosmann, a.Md, wurzer, a.Md, maschke, s.Md, marik, w.Md, knosp, e.Md and wolfsberger, a.Md.An advanced protocol for intraoperative visualization of sinunasal structures: experiences from pituitary surgery.J neurosurg.2019.133:240¿248, 2020 doi: 10.3171/2019.3.Jns1985 summary: objective the transsphenoidal route to pituitary adenomas challenges surgeons because of the highly variable sinunasal anatomy.Orientation may be improved if the appropriate information is provided intraoperatively by image guidance.The authors developed an advanced image guidance protocol dedicated to sinunasal surgery that extracts information from multiple modalities and forms it into a single image that includes fine sinunasal structures and arteries.The aim of this study was to compare the advantages of this novel image guidance protocol with the authors¿ previous series, with emphasis on anatomical structures visualized and complication rate.Methods this retrospective analysis comprised 200 patients who underwent surgery for pituitary adenoma via a transnasal transsphenoidal endoscopic approach.The authors¿ standard image guidance protocol consisting of ct for solid bone, t1cemri for soft tissues, and mra for the carotid artery was applied in 100 consecutive cases.The advanced image guidance protocol added a first-hit ray casting of the ct scan for visualization of fine sinunasal structures, and adjustments to the mra to visualize the sphenopalatine artery (spa) were applied in a subsequent 100 consecutive cases.Results a patent sphenoid ostium¿i.E., an ostium not covered by a mucosal layer¿was visualized significantly more often by the advanced protocol than the standard protocol (89% vs 40%, p <(><<)> 0.001) in primary surgeries.The spa and its branches were only visualized by the advanced protocol (87% and 91% of cases in primary surgeries and reoperations, respectively) and not once by the standard protocol.The number of visualized complete and incomplete sphenoid septations matched significantly more commonly with the surgical view when using the advanced protocol than the standard protocol at primary operation (mean 1.9 vs 1.6, p <(><<)> 0.001).However, in 25% of all cases a complex and not a simple sinus anatomy was present.In comparison with the intraoperative results, a complex sphenoid sinus anatomy was always detected by the advanced but not by the standard protocol (25% vs 8.5%, p = 0.001).Furthermore, application of the advanced protocol reduced the cumulative rate of complications (25% vs 18% [standard vs advanced group]).Although an overall significant difference could not be determined (p = 0.228), a subgroup analysis of reoperations (35/200) revealed a significantly lower rate of complications in the advanced group (5% vs 30%, p = 0.028).Conclusions the data show that the advanced image guidance protocol could intraoperatively visualize the fine sinunasal sinus structures and small arteries with a high degree of detail.By improving intraoperative orientation, this may help to reduce the rate of complications in endoscopic transsphenoidal surgery, especially in reoperations.Reported events: a total of 7 patients developed epistaxis a total of 15 patients developed a postoperative csf leak.Of the 15 patients only one had a csf leakage occurred in the standard imaging protocol group without visualization of the fine bony structures when the frontal skull base was inadvertently opened by the drill.They needed a revision operation due to a csf leak that arose by involuntary opening of the frontal skull base.A total of 17 patients developed an anterior pituitary insufficiency a total of 2 patients developed transient diabetes insipidus a total of 2 patients developed permanent diabetes insipidus.
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