垂体柄的显微应用解剖及其在鞍区肿瘤手术中的保护策略
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摘要
第一部分垂体柄的显微应用解剖学研究
目的：探讨尸颅标本的垂体柄及周围结构的显微解剖，为蝶鞍区肿瘤经颅手术提供重要显微外科解剖学资料。
方法：选取17个甲醛固定的成年尸颅标本，浸入50℃热水中浸泡30min后，用清水、10%氨水及双氧水反复冲洗颈总动脉和椎动脉，然后经颈总动脉、椎动脉加压注入10％的红色明胶液。常规解剖方法锯下颅盖，切除大脑镰和颅顶硬脑膜，先切除垂体柄以上脑组织，观察视交叉、垂体柄的形态并测量长度。然后再切断视交叉、颈内动脉床突上段、动眼神经、滑车神经，横断大脑脚，保留小脑幕下完整结构，取下端脑，在肉眼和手术显微镜下进一步观察垂体柄的位置、形态、走向和周围蛛网膜结构，以及与鞍膈孔、视交叉的关系，并测量记录。
结果：标本中垂体柄呈褐色，长度为(9.4±2.6)mm，上粗下细，上端左右径为(3.4±0.6)mm，下端左右径为(2.4±0.5)mm，15例在垂体柄中点同一水平面较基底动脉细，2例与基底动脉等粗。冠状位观察14例垂体柄居中，2例下端轻度向右偏斜，1例向左偏斜。矢状位观察均自下丘脑底向前下倾斜，11例垂体柄较直，6例垂体柄前后迂曲，其中2例与鞍背关系密切，在鞍背处向后折曲成角。视交叉前缘位于鞍结节后上方(二者之间的距离2mm)1例（5.9%），位于鞍背上方2例（11.8%），第1间隙面积为（28.4±6.2mm2）。垂体柄周围有蛛网膜包绕，并有许多纤维小梁起固定作用。血管丰富，主要由垂体上动脉和垂体下动脉参与供血，共有垂体上动脉92条，平均每侧2.7(14)条，每侧垂体下动脉的出现率为100%。鞍膈孔多呈圆形，孔径为（7.1±1.6）mm，大于5mm的占94.1%。
结论：显微解剖学研究提供了垂体柄及周围重要解剖结构、解剖学参数以及它们之间的解剖联系。垂体柄连于下丘脑和垂体之间，上粗下细，多数形态较直，位于鞍膈孔中间，周围有蛛网膜包被，有固定的垂体上动脉和垂体下动脉供血，这些结构的辨认可为手术中寻找和保护垂体柄提供帮助。手术中还要根据肿瘤的生长方式判定垂体柄的位置，通过不同间隙的操作，沿蛛网膜界面锐性分离，减少牵拉，保护垂体动脉及穿支血管，有利于保护垂体柄的功能，以减少手术并发症的发生。
第二部分经颅鞍区肿瘤切除术中垂体柄的辨认与保护策略
目的：总结采用不同手术入路切除鞍区肿瘤的经验，探讨手术中对垂体柄辨认与保护策略。
方法：回顾性分析110例鞍区肿瘤的临床资料，病例来源于苏州大学附属第二医院和潍坊市人民医院神经外科，2008年1月至2011年12月住院，均为经颅手术的患者。入组要求资料齐全，手术记录中对垂体柄描述详细。手术采用翼点入路34例，额底入路21例，眶上锁孔入路20例，纵裂入路35例（其中额底纵裂入路21例，纵裂终板入路9例，纵裂胼胝体入路5例）。术前通过颅脑MRI扫描，能明确判断垂体柄位置53例（其中位于肿瘤后方37例，上方9例，侧方7例），可能为垂体柄信号25例，32例未发现垂体柄信号。
结果：垂体腺瘤47例，全切除42例，近全切除4例，大部切除1例。垂体柄完好保留44例（93.6%），2例受肿瘤侵蚀部分保留，1例未发现。术后发生电解质紊乱7例，均短期纠正。并发尿崩34例，其中21例在术后12周恢复正常，10例在3月左右逐渐恢复。随访924月，持续性尿崩3例，需口服去氨加压素控制。颅咽管瘤38例，全切除32例，近全切除6例。垂体柄完好保留27例（73.7%），被肿瘤侵蚀垂体柄解剖保留2例，部分保留5例，未发现4例。术后发生电解质紊乱13例，出院时完全纠正。并发尿崩27例，其中10例在3周内恢复，7例3月左右恢复。随访348月，持续性尿崩10例，需口服去氨加压素控制。脑膜瘤25例，全切除23例，近全切除2l例。垂体柄保留24例（96%），1例解剖保留。术后未发生电解质紊乱，仅5例出现短暂性尿崩，13周恢复。术前通过MRI判断垂体柄位置较为明确的53例，与手术中发现垂体柄的位置完全吻合。MRI显示可能为垂体柄信号的25例，有14例在手术中得到证实。无手术死亡。随访垂体腺瘤、颅咽管瘤各复发1例，均行伽玛刀治疗。
结论：术前通过颅脑MRI扫描大多可明确或初步判定垂体柄的位置，手术中结合对下丘脑隆起的漏斗、鞍膈孔、表面静脉髓纹以及垂体上动脉等结构特征进一步辨认。垂体柄大多位于鞍区肿瘤后部，在分离肿瘤后壁时，应特别注意，一定要沿蛛网膜界面仔细锐性分离。颅咽管瘤后部有时与垂体柄粘连无法分离，必要时，需留存后部薄壁。垂体柄的保留率与肿瘤的性质直接相关(P=0.003)，但在四种手术入路中无明显差异（P=0.850），超声吸引刀（CUSA）的使用对垂体柄保护有积极作用。垂体柄能否保留以及损伤程度，直接影响到术后尿崩症的发生率和恢复的时间。完好保留者出现尿崩大多在2周左右恢复，占发生尿崩总数的66.7%（34/51）；垂体柄有破坏或解剖保留，尿崩时间长，大约在3月左右恢复；破坏严重或部分保留者，出现持续性尿崩。
应根据肿瘤的部位、大小、生长方向，以及视交叉位置，选择手术入路。额底或额底纵裂入路适合肿瘤向前颅底和鞍上生长者，主要在第1间隙操作；当肿瘤突至视交叉后、第三脑室或视交叉前缘与鞍结节距离小于2mm，选择额底或纵裂终板入路，主要自第4间隙操作；眶上锁孔入路具有微创的特点，是额底入路的改良，随着技术的成熟，可以处理绝大部分鞍区病变，当肿瘤向一侧鞍旁生长突至颞叶内，不宜采用锁孔入路。肿瘤明显偏侧生长选翼点入路，主要在第2、3间隙操作，并可兼顾第1间隙。掌握娴熟的手术技巧，对垂体柄的辨认和保护，以及减少手术并发症的发生，乃至病人预后起重要作用。
Part1Study on Applied Microanatomy of Pituitary Stalk
Purpose: To study the microanatomy of pituitary stalk and surrounding structures incadaver skull specimens, so as to provide important microsurgical anatomy data ofidentifying and protecting pituitary stalk for transcranial surgery on sellar tumor.
Methods: A total of17formalin fixed specimens of adult cadaver skull were selected,immersed in hot water (50℃) and soaked for30min. After that, the common carotidartery and the vertebral artery were rinsed with fresh water,10%ammonia water andhydrogen peroxide repeatedly, and then10%red gelatin solution was injected by pressurethrough the common carotid artery and vertebral artery. By using routine anatomy method,braincap was sawed off, and then the cerebral flax and parietal dura mater were removed.Afterwards, brain tissues above pituitary stalk were removed first to observe themorphology of optic chiasma and pituitary stalk and measure their lengths. Next, the opticchiasma, supraclinoidal portion of internal carotid artery, oculomotor nerve and trochlearnerve were cut off, and cerebral peduncle was transected, retaining the complete structureunder tentoriumcerebelli; telencephalon was taken, and then the position, morphology andtrend of pituitary stalk, as well as its relationship with diaphragma sellae hole and opticchiasma were further observed with naked eyes and surgery microscope, which were alsomeasured and recorded.
Results: The pituitary stalk in specimens was brown, with the length of (9.4±2.6) mm.It was thick in upper part and thin in lower part with left right diameter of (3.4±0.6) mm inupper end and (2.4±0.5) mm in bottom end. The horizontal plane of pituitary stalkmidpoint of15cases was thinner than basilar artery, and that of2cases was as sick as basilar artery. From the coronal view, pituitary stalks of14cases were in the middle,extremitas inferiors of2cases were slightly skewed to the right, and1case was skewed tothe left. From sagittal view, pituitary stalks of all cases tilted towards front lower from theend of hypothalamus,11cases of pituitary stalks were relatively straight,6cases ofpituitary stalks were tortuous in front and back, among which,2cases were closelyassociated with saddle back, curving backward with an angle in the saddle back. Opticchiasma of1case (5.9%) located above the tuberculum sellae,2cases (11.8%) above thesaddle back; the1st space covered an area of (28.4±6.2mm2). Pituitary stalk wassurrounded by arachnoid and fixed by many fibrous trabeculae. Blood vessels were rich:Superior hypophysial artery and inferior hypophysial artery were mainly involved in bloodsupply; the total number of uperior hypophysial artery was92,2.7(14) on each side onaverage; the emergence rate of inferior hypophysial artery on each side was100%.Diaphragma sellae holes were usually circular, with apertures of (7.1±1.6) mm,94.1%ofwhich were greater than5mm.
Results: The microanatomy study provides important information about anatomicalstructures and anatomical parameters of pituitary stalk and its surrounding structures, aswell as the anatomical relationship among them. Pituitary stalk, connecting hypothalamusand pituitary, is thick in upper part and thin in lower part, being straight mostly; it locatesin the center of diaphragma sellae hole, surrounded by arachnoid, with fixed superiorhypophysial artery and inferior hypophysial artery for blood supply. All the structuresabove offer effective theoretical guidance for identifying and protecting pituitary stalk andother structures in the operation. In addition, during operation, the growth pattern of tumorshould also be considered to determine the position of pituitary stalk. Different spaceoperations, applying sharp dissection along the arachnoid interface, reducing stretch andprotecting hypophyseal artery and perforator artery are conducive to protect the function ofpituitary stalk, so as to reduce the occurrence of surgical complications.
Part2. Identification and Protection Strategy of Pituitary Stalks inTranscranial Saddle Tumor Resection
Purpose: Lesions learned from different saddle tumor resections and discussionsabout identification and protection of pituitary stalks in surgery.
Methods: Retrospective analysis of clinical data of110cases with sellar regiontumors. The cases were selected form neurosurgery department of the Second AffiliatedHospital of Soochow University and Weifang People's Hospital. The patients weretranscranial operated and stayed in hospital from January2008to December2011. Thedata were complete and the descriptions of pituitary stalks were very particularly recordedin operative logs. Pterional approach were used in34cases, subfrontal approach in21cases, supraorbital keyhole approach in20cases, interhemispheric approach in35cases(21used fronto basal interhemispheric approach,9used interhemispheric trans laminaterminalis approach,5used trans callosum hemispheres approach). Preoperative bycraniocerebral MRI scanning, the position of pituitary stalk was clear determined in53cases, might be the signal of pituitary stalk in25cases, not found in32cases.
Results:47pituitary adenoma cases,42of them had complete resections,4subtotalresections, and1partial resection.44cases had well remained pituitary stalks (93.6%),2were partially remained because of tumor erosion,1was undiscovered. Serum electrolytedisorder occurred in7cases, all were corrected in short time. Concurrent diabetes insipidusoccurred in34cases,21of them returned to normal in1or2weeks after operations,10were recovered3months later. In the9to24months follow up, persistent diabetesinsipidus occurred in3cases, patients were prescribed with oral desmopressin to controlthe symptom.
38craniopharyngioma cases,32of them had complete resections,6subtotalresections.27cases had well remained pituitary stalks (73.7%),2were anatomicalpreserved because of tumor erosion,5were partially remained and4were undiscovered.Serum electrolyte disorder occurred in13cases, they were totally corrected when they left hospital. Concurrent diabetes insipidus occurred in27cases,10of them returned to normalin3weeks,7were recovered in3months. In the3to48months follow up, persistentdiabetes insipidus occurred in10cases, patients were prescribed with oral desmopressin tocontrol the symptom.
25meningioma cases,23of them had complete resections,21subtotal resections.24cases had well remained pituitary stalks (96%),1was anatomical preserved. No serumelectrolyte disorder occurred. Transient diabetes insipidus occurred in5cases; theyrecovered in13weeks.
No deaths in all cases.1pituitary adenoma and1craniopharyngioma were relapsedduring the follow up, both were performed gamma knife radiosurgery.
Conclusion: The micro anatomical study of pituitary stalk can provide theoreticalbasis on identification and protection of pituitary stalk in sellar tumor resection. For theposition of pituitary stalk, it can be initially determined by brain Magnetic ResonanceImaging (MRI) before operation and further identified based on the structures ofhypothalamic eminent infundibulum, diaphragma sellae hole, surface vein striae medullaris,superior hypophysial artery and so forth during operation. When separating posterior wallof tumor, sharp dissection must be conducted carefully along the arachnoid interface toprevent feeding artery injury due to over stretch and fulguration. The retention of thepituitary stalk is directly associated with the nature of tumor (P=0.003). However, there isno obvious difference in the four kinds of surgical approaches (P=0.850). The usage ofCUSA can positively protect the pituitary stalk. Whether the pituitary stalk can be retainedand the damage extent can directly influence the incidence and recovery time ofpostoperative diabetes insipidus. Those who retain the pituitary stalk well will experiencediabetes insipidus and recover after about2weeks, accounting for66.7%(34/51) of thetotal number of diabetes insipidus. If the pituitary stalk is damaged or dissected, the time ofdiabetes insipidus is long, and the patients recover after about3months. Those whosepituitary stalks are severely damaged or partially retained experience persistent diabetesinsipidus.
The appropriate surgical approach is chosen according to the location, size, growthdirection of the tumor and the optic chiasm location. Approach of basis frontalis orlongitudinal fissure approach of basis frontalis is suitable for people whose tumor grows inanterior skull base and cranial saddle, which is mainly operated in the first space. When thetumor bulges to optic chiasma and the distance between the third ventricle or optic chiasmaand tuberculum sellae is less than2mm, operations should be made in the fourth space,approaching from basis frontalis and the end plate of interhemisphere fissure. Supraorbitalkeyhole approach has a minimally invasive characteristic and it is an improvement of basisfrontalis approach. Along with the development of technology, most lesions in the sellarregion can be handled. Keyhole approach is not favorable when the tumor obviously growsto one side of the sellar region, or even bulges to the temporal lobe or third ventricle.Pterion approach should be adopted when the tumor grows obviously laterally andoperated mainly in the second and third space, the first space can also be considered.Skillful surgical techniques play an important role in the identifying and protecting of thepituitary stalk, reducing the incidence of surgical complications and the recovery of thepatients.
目的：探讨尸颅标本的垂体柄及周围结构的显微解剖，为蝶鞍区肿瘤经颅手术提供重要显微外科解剖学资料。
方法：选取17个甲醛固定的成年尸颅标本，浸入50℃热水中浸泡30min后，用清水、10%氨水及双氧水反复冲洗颈总动脉和椎动脉，然后经颈总动脉、椎动脉加压注入10％的红色明胶液。常规解剖方法锯下颅盖，切除大脑镰和颅顶硬脑膜，先切除垂体柄以上脑组织，观察视交叉、垂体柄的形态并测量长度。然后再切断视交叉、颈内动脉床突上段、动眼神经、滑车神经，横断大脑脚，保留小脑幕下完整结构，取下端脑，在肉眼和手术显微镜下进一步观察垂体柄的位置、形态、走向和周围蛛网膜结构，以及与鞍膈孔、视交叉的关系，并测量记录。
结果：标本中垂体柄呈褐色，长度为(9.4±2.6)mm，上粗下细，上端左右径为(3.4±0.6)mm，下端左右径为(2.4±0.5)mm，15例在垂体柄中点同一水平面较基底动脉细，2例与基底动脉等粗。冠状位观察14例垂体柄居中，2例下端轻度向右偏斜，1例向左偏斜。矢状位观察均自下丘脑底向前下倾斜，11例垂体柄较直，6例垂体柄前后迂曲，其中2例与鞍背关系密切，在鞍背处向后折曲成角。视交叉前缘位于鞍结节后上方(二者之间的距离2mm)1例（5.9%），位于鞍背上方2例（11.8%），第1间隙面积为（28.4±6.2mm2）。垂体柄周围有蛛网膜包绕，并有许多纤维小梁起固定作用。血管丰富，主要由垂体上动脉和垂体下动脉参与供血，共有垂体上动脉92条，平均每侧2.7(14)条，每侧垂体下动脉的出现率为100%。鞍膈孔多呈圆形，孔径为（7.1±1.6）mm，大于5mm的占94.1%。
结论：显微解剖学研究提供了垂体柄及周围重要解剖结构、解剖学参数以及它们之间的解剖联系。垂体柄连于下丘脑和垂体之间，上粗下细，多数形态较直，位于鞍膈孔中间，周围有蛛网膜包被，有固定的垂体上动脉和垂体下动脉供血，这些结构的辨认可为手术中寻找和保护垂体柄提供帮助。手术中还要根据肿瘤的生长方式判定垂体柄的位置，通过不同间隙的操作，沿蛛网膜界面锐性分离，减少牵拉，保护垂体动脉及穿支血管，有利于保护垂体柄的功能，以减少手术并发症的发生。
第二部分经颅鞍区肿瘤切除术中垂体柄的辨认与保护策略
目的：总结采用不同手术入路切除鞍区肿瘤的经验，探讨手术中对垂体柄辨认与保护策略。
方法：回顾性分析110例鞍区肿瘤的临床资料，病例来源于苏州大学附属第二医院和潍坊市人民医院神经外科，2008年1月至2011年12月住院，均为经颅手术的患者。入组要求资料齐全，手术记录中对垂体柄描述详细。手术采用翼点入路34例，额底入路21例，眶上锁孔入路20例，纵裂入路35例（其中额底纵裂入路21例，纵裂终板入路9例，纵裂胼胝体入路5例）。术前通过颅脑MRI扫描，能明确判断垂体柄位置53例（其中位于肿瘤后方37例，上方9例，侧方7例），可能为垂体柄信号25例，32例未发现垂体柄信号。
结果：垂体腺瘤47例，全切除42例，近全切除4例，大部切除1例。垂体柄完好保留44例（93.6%），2例受肿瘤侵蚀部分保留，1例未发现。术后发生电解质紊乱7例，均短期纠正。并发尿崩34例，其中21例在术后12周恢复正常，10例在3月左右逐渐恢复。随访924月，持续性尿崩3例，需口服去氨加压素控制。颅咽管瘤38例，全切除32例，近全切除6例。垂体柄完好保留27例（73.7%），被肿瘤侵蚀垂体柄解剖保留2例，部分保留5例，未发现4例。术后发生电解质紊乱13例，出院时完全纠正。并发尿崩27例，其中10例在3周内恢复，7例3月左右恢复。随访348月，持续性尿崩10例，需口服去氨加压素控制。脑膜瘤25例，全切除23例，近全切除2l例。垂体柄保留24例（96%），1例解剖保留。术后未发生电解质紊乱，仅5例出现短暂性尿崩，13周恢复。术前通过MRI判断垂体柄位置较为明确的53例，与手术中发现垂体柄的位置完全吻合。MRI显示可能为垂体柄信号的25例，有14例在手术中得到证实。无手术死亡。随访垂体腺瘤、颅咽管瘤各复发1例，均行伽玛刀治疗。
结论：术前通过颅脑MRI扫描大多可明确或初步判定垂体柄的位置，手术中结合对下丘脑隆起的漏斗、鞍膈孔、表面静脉髓纹以及垂体上动脉等结构特征进一步辨认。垂体柄大多位于鞍区肿瘤后部，在分离肿瘤后壁时，应特别注意，一定要沿蛛网膜界面仔细锐性分离。颅咽管瘤后部有时与垂体柄粘连无法分离，必要时，需留存后部薄壁。垂体柄的保留率与肿瘤的性质直接相关(P=0.003)，但在四种手术入路中无明显差异（P=0.850），超声吸引刀（CUSA）的使用对垂体柄保护有积极作用。垂体柄能否保留以及损伤程度，直接影响到术后尿崩症的发生率和恢复的时间。完好保留者出现尿崩大多在2周左右恢复，占发生尿崩总数的66.7%（34/51）；垂体柄有破坏或解剖保留，尿崩时间长，大约在3月左右恢复；破坏严重或部分保留者，出现持续性尿崩。
应根据肿瘤的部位、大小、生长方向，以及视交叉位置，选择手术入路。额底或额底纵裂入路适合肿瘤向前颅底和鞍上生长者，主要在第1间隙操作；当肿瘤突至视交叉后、第三脑室或视交叉前缘与鞍结节距离小于2mm，选择额底或纵裂终板入路，主要自第4间隙操作；眶上锁孔入路具有微创的特点，是额底入路的改良，随着技术的成熟，可以处理绝大部分鞍区病变，当肿瘤向一侧鞍旁生长突至颞叶内，不宜采用锁孔入路。肿瘤明显偏侧生长选翼点入路，主要在第2、3间隙操作，并可兼顾第1间隙。掌握娴熟的手术技巧，对垂体柄的辨认和保护，以及减少手术并发症的发生，乃至病人预后起重要作用。
Part1Study on Applied Microanatomy of Pituitary Stalk
Purpose: To study the microanatomy of pituitary stalk and surrounding structures incadaver skull specimens, so as to provide important microsurgical anatomy data ofidentifying and protecting pituitary stalk for transcranial surgery on sellar tumor.
Methods: A total of17formalin fixed specimens of adult cadaver skull were selected,immersed in hot water (50℃) and soaked for30min. After that, the common carotidartery and the vertebral artery were rinsed with fresh water,10%ammonia water andhydrogen peroxide repeatedly, and then10%red gelatin solution was injected by pressurethrough the common carotid artery and vertebral artery. By using routine anatomy method,braincap was sawed off, and then the cerebral flax and parietal dura mater were removed.Afterwards, brain tissues above pituitary stalk were removed first to observe themorphology of optic chiasma and pituitary stalk and measure their lengths. Next, the opticchiasma, supraclinoidal portion of internal carotid artery, oculomotor nerve and trochlearnerve were cut off, and cerebral peduncle was transected, retaining the complete structureunder tentoriumcerebelli; telencephalon was taken, and then the position, morphology andtrend of pituitary stalk, as well as its relationship with diaphragma sellae hole and opticchiasma were further observed with naked eyes and surgery microscope, which were alsomeasured and recorded.
Results: The pituitary stalk in specimens was brown, with the length of (9.4±2.6) mm.It was thick in upper part and thin in lower part with left right diameter of (3.4±0.6) mm inupper end and (2.4±0.5) mm in bottom end. The horizontal plane of pituitary stalkmidpoint of15cases was thinner than basilar artery, and that of2cases was as sick as basilar artery. From the coronal view, pituitary stalks of14cases were in the middle,extremitas inferiors of2cases were slightly skewed to the right, and1case was skewed tothe left. From sagittal view, pituitary stalks of all cases tilted towards front lower from theend of hypothalamus,11cases of pituitary stalks were relatively straight,6cases ofpituitary stalks were tortuous in front and back, among which,2cases were closelyassociated with saddle back, curving backward with an angle in the saddle back. Opticchiasma of1case (5.9%) located above the tuberculum sellae,2cases (11.8%) above thesaddle back; the1st space covered an area of (28.4±6.2mm2). Pituitary stalk wassurrounded by arachnoid and fixed by many fibrous trabeculae. Blood vessels were rich:Superior hypophysial artery and inferior hypophysial artery were mainly involved in bloodsupply; the total number of uperior hypophysial artery was92,2.7(14) on each side onaverage; the emergence rate of inferior hypophysial artery on each side was100%.Diaphragma sellae holes were usually circular, with apertures of (7.1±1.6) mm,94.1%ofwhich were greater than5mm.
Results: The microanatomy study provides important information about anatomicalstructures and anatomical parameters of pituitary stalk and its surrounding structures, aswell as the anatomical relationship among them. Pituitary stalk, connecting hypothalamusand pituitary, is thick in upper part and thin in lower part, being straight mostly; it locatesin the center of diaphragma sellae hole, surrounded by arachnoid, with fixed superiorhypophysial artery and inferior hypophysial artery for blood supply. All the structuresabove offer effective theoretical guidance for identifying and protecting pituitary stalk andother structures in the operation. In addition, during operation, the growth pattern of tumorshould also be considered to determine the position of pituitary stalk. Different spaceoperations, applying sharp dissection along the arachnoid interface, reducing stretch andprotecting hypophyseal artery and perforator artery are conducive to protect the function ofpituitary stalk, so as to reduce the occurrence of surgical complications.
Part2. Identification and Protection Strategy of Pituitary Stalks inTranscranial Saddle Tumor Resection
Purpose: Lesions learned from different saddle tumor resections and discussionsabout identification and protection of pituitary stalks in surgery.
Methods: Retrospective analysis of clinical data of110cases with sellar regiontumors. The cases were selected form neurosurgery department of the Second AffiliatedHospital of Soochow University and Weifang People's Hospital. The patients weretranscranial operated and stayed in hospital from January2008to December2011. Thedata were complete and the descriptions of pituitary stalks were very particularly recordedin operative logs. Pterional approach were used in34cases, subfrontal approach in21cases, supraorbital keyhole approach in20cases, interhemispheric approach in35cases(21used fronto basal interhemispheric approach,9used interhemispheric trans laminaterminalis approach,5used trans callosum hemispheres approach). Preoperative bycraniocerebral MRI scanning, the position of pituitary stalk was clear determined in53cases, might be the signal of pituitary stalk in25cases, not found in32cases.
Results:47pituitary adenoma cases,42of them had complete resections,4subtotalresections, and1partial resection.44cases had well remained pituitary stalks (93.6%),2were partially remained because of tumor erosion,1was undiscovered. Serum electrolytedisorder occurred in7cases, all were corrected in short time. Concurrent diabetes insipidusoccurred in34cases,21of them returned to normal in1or2weeks after operations,10were recovered3months later. In the9to24months follow up, persistent diabetesinsipidus occurred in3cases, patients were prescribed with oral desmopressin to controlthe symptom.
38craniopharyngioma cases,32of them had complete resections,6subtotalresections.27cases had well remained pituitary stalks (73.7%),2were anatomicalpreserved because of tumor erosion,5were partially remained and4were undiscovered.Serum electrolyte disorder occurred in13cases, they were totally corrected when they left hospital. Concurrent diabetes insipidus occurred in27cases,10of them returned to normalin3weeks,7were recovered in3months. In the3to48months follow up, persistentdiabetes insipidus occurred in10cases, patients were prescribed with oral desmopressin tocontrol the symptom.
25meningioma cases,23of them had complete resections,21subtotal resections.24cases had well remained pituitary stalks (96%),1was anatomical preserved. No serumelectrolyte disorder occurred. Transient diabetes insipidus occurred in5cases; theyrecovered in13weeks.
No deaths in all cases.1pituitary adenoma and1craniopharyngioma were relapsedduring the follow up, both were performed gamma knife radiosurgery.
Conclusion: The micro anatomical study of pituitary stalk can provide theoreticalbasis on identification and protection of pituitary stalk in sellar tumor resection. For theposition of pituitary stalk, it can be initially determined by brain Magnetic ResonanceImaging (MRI) before operation and further identified based on the structures ofhypothalamic eminent infundibulum, diaphragma sellae hole, surface vein striae medullaris,superior hypophysial artery and so forth during operation. When separating posterior wallof tumor, sharp dissection must be conducted carefully along the arachnoid interface toprevent feeding artery injury due to over stretch and fulguration. The retention of thepituitary stalk is directly associated with the nature of tumor (P=0.003). However, there isno obvious difference in the four kinds of surgical approaches (P=0.850). The usage ofCUSA can positively protect the pituitary stalk. Whether the pituitary stalk can be retainedand the damage extent can directly influence the incidence and recovery time ofpostoperative diabetes insipidus. Those who retain the pituitary stalk well will experiencediabetes insipidus and recover after about2weeks, accounting for66.7%(34/51) of thetotal number of diabetes insipidus. If the pituitary stalk is damaged or dissected, the time ofdiabetes insipidus is long, and the patients recover after about3months. Those whosepituitary stalks are severely damaged or partially retained experience persistent diabetesinsipidus.
The appropriate surgical approach is chosen according to the location, size, growthdirection of the tumor and the optic chiasm location. Approach of basis frontalis orlongitudinal fissure approach of basis frontalis is suitable for people whose tumor grows inanterior skull base and cranial saddle, which is mainly operated in the first space. When thetumor bulges to optic chiasma and the distance between the third ventricle or optic chiasmaand tuberculum sellae is less than2mm, operations should be made in the fourth space,approaching from basis frontalis and the end plate of interhemisphere fissure. Supraorbitalkeyhole approach has a minimally invasive characteristic and it is an improvement of basisfrontalis approach. Along with the development of technology, most lesions in the sellarregion can be handled. Keyhole approach is not favorable when the tumor obviously growsto one side of the sellar region, or even bulges to the temporal lobe or third ventricle.Pterion approach should be adopted when the tumor grows obviously laterally andoperated mainly in the second and third space, the first space can also be considered.Skillful surgical techniques play an important role in the identifying and protecting of thepituitary stalk, reducing the incidence of surgical complications and the recovery of thepatients.
引文
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