Imaging and the expanded endonasal approach to the skull

base: What the neurosurgeons need to know

Poster No.: C-721

Congress: ECR 2009
Type: Educational Exhibit
Topic: Neuro
Authors: N. J. Klitsch, V. Agarwal, W. T. Rothfus, M. M. Rahman, A. B.
Kassam, P. A. Gardner, D. M. S. Prevedello; Pittsburgh, PA/US
Keywords: expanded endonasal approach, skull base surgery, nasoseptal
flap, anatomical study
DOI: 10.1594/ecr2009/C-721

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Learning objectives

1. Provide an overview of the endoscopic expanded endonasal approach

(EEA) to the skull base and its applications, with a focus on sella/parasellar
lesions
2. Examine the role of imaging in patients who are being considered for EEA
3. Highlight radiographic features critical for surgical planning and intraopertive
guidance
4. Present unique findings on post-operative imaging studies after EEA

Background

Rationale

• Expanded endonasal approach (EEA) is a minimally invasive, endoscopic technique

increasingly utilized to allow access to the ventral skull base from crista galli to the odontoid
(Fig. 1) and laterally as far as the middle/infratemporal fossae, without disturbing the face or
skull.
• This technique has the advantage of avoiding the retraction or transgression of important
neurovascular structures that traditional posterior or lateral approaches cross.

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Fig.: Fig. 1. Sagittal CT reconstruction in a patient with a large calcified meningioma
demonstrates the extent of rostral and caudal reach of EEA. The Kassam line (K-line),
is drawn from the nasal bridge through the back of the hard palate and defines the
most caudal reach of EEA.

Sella and Parasellar Lesions

• Sella and parasellar lesions are among the most commonly accessed lesions using EEA.
• Traditional pterional and subfrontal approaches to the sella are limited by the optic chiasm
from above.

Surgical Technique

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• Two surgeons (neurosurgeon and otolaryngologist) employ a binarial approach (Fig. 2).

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Page 5 of 23
Fig.: Fig. 2. Photograph showing binarial approach.

• All EEAs begin with an intial exposure, which creates a single large rectangular space
within the sphenoid sinus. This cavity is accomplished by performing wide bilateral
sphenoidotomies, resecting a small portion of the posterior nasal septum, and resecting the
right middle turbinate.
• For sella/parasellar lesions, the sphenoidotomy is extended to include the lateral sphenoid
recess beyond the level of the carotid canal and rostrally to the posterior ethmoid air cells,
and the floor of the sphenoid is resected back to the level of the clivus.
• Key to EEA is careful preoperative planning and intraoperative guidance with special
attention to sinus anatomy and its relationship to the skull base.
• Ultimate goal is complete resection, but often this is not possible. In these cases, tumor
debulking and cytoreduction are performed in order to decrease mass effect and patient
symptoms.

Anatomy

• Following surgical exposure, the next step is identification of key anatomical landmarks
(Figs. 3 and 4), which help guide the surgeons to stuctures that lie deep to the osseous
skull base.

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Fig.: Fig. 3. Endoscopic view following surgical exposure for sella/parasellar approach
with key anatomical landmarks. ON = optic nerve; LOCR = lateral opticocarotid recess;
MOCR = medial opticocarotid recess; ICA = internal carotid artery.

Fig.: Fig. 4. Illustration of key neurovascular structures as viewed endoscopically

during surgery. mOCR=medial opticocarotid recess; ICA=internal carotid artery.
Also note the vidian nerve (VN) within the vidian canal, a key anatomic landmark for
resection of lesions beyond the sella/parasellar region.

• Medial opticocarotid recess (mOCR): Osseous indentation between the carotid canal,
traveling vertically adjacent to the sella, and the optic canal, traveling in an AP-oblique
orientation (Figs. 5A-C)
• • Drilling posteriorly through this recess, one encounters the middle
clinoid process, representing the lateral border of the anterior sella
• Careful and complete removal of bone to the level of the mOCR
exposes the paraclinoid ICA as well as the optic nerves within the
optic canal.
• As a result, less medial retraction of tumors is necessary and the risk
of neurovascular injury is reduced

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Fig.: Fig. 5A. Axial CT image shows the carotid canal containing the paraclinoid
internal carotid artery (curved arrows) caudal and slightly lateral to the mOCR.
SS=sphenoid sinus.

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Fig.: Fig. 5B. More cranially, axial CT image illustrates the middle clinoid processes
(arrowheads) immediately deep to the medial opticocarotid recesses (arrows). This
relationship is key for a safe surgical approach to the sella/parasellar region.

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Fig.: Fig 5C. Further cranially, axial CT image shows the optic canals (curved arrows)
superior to the mOCR. Anterior clinoid processes (arrowheads) are also seen.

• The anatomic relationship of pathology to ossesous structures of the sella and posterior
sinuses (Figs. 6 and 7) is essential to preoperative planning.

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Fig.: Fig. 6. 3D volume-rendered image of the osseous skull base as viewed from
above. Note the relationship of the middle clinoid process, which lies deep to the
mOCR.

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Fig.: Fig. 7. Sagittal CT reconstruction image illustrates the anatomic relationship of
the planum sphenoidale (arrowhead), tuberculum sellae (curved arrow) and dorsum
sellae (straight arrow). SS=sphenoid sinus, C=clivus

• Soft tissue structures are generally better assessed with MRI, as illustrated in this patient
with a pitutary microadenoma (Fig. 8).

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Fig.: Fig. 8. Coronal and sagittal post-contrast T1-weighted MR images illustrate
neurovascular anatomy of the skull base in a patient with a left inferior pituitary
microadenoma (asterisk). The pituitary gland (white arrow) and infundibulum (thin
arrow) are minimally displaced, and the anterior cerebral arteries (arrowhead) and optic
chiasm (curved arrow) are nondisplaced.

Imaging findings OR Procedure details

Typical Imaging Protocols for EEA

• Preoperative
• • MRI
• • Axial T1, T2, T2 FLAIR
• Sagittal T1
• Coronal T1, T2
• T2 3D FIESTA
• Post Contrast
• • Axial, Sagittal, Coronal T1 with Fat supression
• Axial 3D Volume SPGR
• CT
• • CT Angiogram 1.25mm with sagittal and coronal reconstructions
• Postoperative
• • MRI
• • Axial T1, T2 FLAIR, GRE
• Sagittal T1
• Post Contrast
• • Axial, Sagittal, Coronal T1 with Fat supression
• Axial 3D Volume SPGR
• CT
• • Noncontrast 5mm

Intraoperative Imaging

• An intraoperative navigational system is utilized to register preoperative images with the

patient's head position in the operating room.
• #
The patient is placed in a fixation system with the head rotated 5-10 to the right. Ten
fiducial markers are placed on the patient's face and scalp, and accurate registration is
accomplished by touching the fiducial markers with a probe.
• During the procedure, the navigation system displays the real-time position of a viewing
wand in three planes for accurate intraoperative guidance.

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Fig.: Fig. 1. Axial, sagittal and coronal CT images of intraoperative image guidance.
The position of the viewing wand is displayed in all three planes to allow the surgeons
to see underlying anatomic structures during the procedure.

Critical Imaging Findings

• While it is essential to attempt to identify all important neurovascular structures on

preoperative imaging, special attention should be paid to certain key structures which may
alter the operative approach for sella/parasellar lesions.
• Critical anatomic structures include:
• • ACA and its branches
• Cavernous/supraclinoid ICA
• Basilar artery
• Infundibulum
• Optic nerves, chiasm, and tracts

Illustrative Cases

(see figure captions for more detail)

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 • Craniopharyngioma: Recently a new classification system has been proposed based on the
relationship of the tumor to the indundibulum, which has implications for safe approach of
these lesions endonasally.
• •
• • preinfundibular
•
• • transinfundibular (extending into the stalk)
•
• • retroinfundibular
•
•

Postoperative Imaging

• The primary goal of reconstruction following resection is to isolate the cranial cavity to
prevent pneumocephalus, cerebrospinal fluid (CSF) leak, and infection. The technique
currently utilized by surgeons at our institution is based on the use of a vascularized
nasoseptal mucosal flap (Hadad-Bassagasteguy flap).
• The flap is harvested during initial exposure, before posterior septecomy, and is stored in
the nasopharynx until the reconstructive phase of the procedure.
• Following resection of the lesion, a subdural inlay graft composed of collagen matrix is
positioned between brain and dura mater. Occasionally fat packing may be placed between
the inlay graft and the nasoseptal flap. The flap is then placed in contact with the denuded
walls of the sinonasal tract which surround the osseous defect. Finally the nasoseptal flap
is fixed in place with biological glue and nasal sponge packing, and a 12-French Foley
catheter secures the flap against the defect (Fig. 8).

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Fig.: Fig. 8. Drawing illustrates the vascularized nasoseptal musocal flap secured in
place against the osseous skull base defect with a Foley cathter balloon and packing
material. From Kassam A, Thomas A, Carrau R, et al. Endoscopic reconstruction of
the cranial base using a pedicled nasoseptal flap. Neurosurgery (2008) Jul;63(1 Suppl
1):ONS44-52.

Normal Postoperative Imaging

(see figure captions for more detail)

•
• • Typical postoperative MR imaging shows "C"- shaped soft tissue, isointense on T1
and T2 sequences, with at least some degree of postoperative enhancement.
•
• • In this case, initial postoperative image showed no significant enhancement of the
nasoseptal flap. Fourteen months later, there is brisk enhancment of the flap.

Imaging of Postoperative Complications

Page 16 of 23
(see figure captions for more detail)

• Cerebrospinal fluid (CSF) leak (Fig. 11) on page 19

• Encephalocele (Fig. 12) on page 20

Video of Resection of Pituitary Macroadenoma on page

• This short video shows portions of an endonasal resection of a pituitary macroadenoma.

Images linked within the text of this section:

Page 17 of 23
Fig.: Fig. 11. Axial CT cisternogram shows an osseous defect in posterior sphenoid bone
following transsphenoidal resection of a pituitary macroadenoma.

Fig.: Fig. 12. Coronal post contrast T1-weighted MR images show a large planum
sphenoidale meningioma (left), which was resected in a staged procedure. Two-month
postoperative image (right) shows a right frontal encephalocele (arrow) extending into the
nasoethmoidal region through a defect in the onlay graft (arrowheads). Reconstruction for
this case utilized abdominal fat graft and pericardial onlay graft rather than the nasoseptal
flap technique.

Page 18 of 23
Fig.

Additional images for this section:

Page 19 of 23
Fig. 1: Fig. 11. Axial CT cisternogram shows an osseous defect in posterior sphenoid
bone following transsphenoidal resection of a pituitary macroadenoma.

Page 20 of 23
Fig. 2: Fig. 12. Coronal post contrast T1-weighted MR images show a large planum
sphenoidale meningioma (left), which was resected in a staged procedure. Two-month
postoperative image (right) shows a right frontal encephalocele (arrow) extending into the
nasoethmoidal region through a defect in the onlay graft (arrowheads). Reconstruction for
this case utilized abdominal fat graft and pericardial onlay graft rather than the nasoseptal
flap technique.

Page 21 of 23
Conclusion

• Expanded endonasal approach (EEA) is a new and rapidly evolving

minimally invasive technique for treating skull base pathology.
• Preoperative planning and intraoperative guidance using a combination
of CT and MRI helps to identify the relationship of skull base lesions to
important neurovascular structures and to the posterior paranasal sinuses.
• A key anatomic landmark is the medial opticocarotid recess (mOCR), an
osseous indentation between the carotid canal and optic canal as viewed
from the sphenoid sinus. The mOCR marks the middle clinoid process, the
lateral border of the anterior sella.
• Normal postoperative MRI after EEA shows the osseous skull base
defect covered by enhancing "C"-shaped soft tissue, which represents a
vascularized nasoseptal mucosal flap.

Personal Information

I would like to sincerely thank Dr. William Rothfus for his guidance in the conception and creation of this
presentation, Dr. Vikas Agarwal for his assistance and advice throughout the project, and Dr. Moshin
Rahman for his help in the initiation of this project. I would also like to thank the Department of Neurosurgery
at UPMC, most notably Dr. Amin Kassam, Dr. Paul Gardner and Dr. Daniel Prevedello for their time and
assistance in this project.

Notice: Information contained within this presentation is the sole intellectual property of
UPMC. The information is for the use of the intended recipient(s) only and may contain
confidential and privileged information. Any unauthorized review, replication, duplication,
use, disclosure, or distribution is prohibited.

© Copyright 2009 UPMC

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