Endoscopic Endonasal Resection of a Suprasellar Pituitary Adenoma Mimicking Tuberculum Sellae Meningioma in a Patient with an Intrasellar Persistent Trigeminal Artery

Alaa S. Montaser; Alexandre B. Todeschini; Juan M. Revuelta  Barbero; Mostafa Shahein; E. Antonio Chiocca; Bradley A. Otto; Ricardo L. Carrau; Daniel M. Prevedello

doi:10.1055/s-0038-1625943

Journal of Neurological Surgery Part B: Skull Base, Table of Contents

CC-BY-NC-ND 4.0 · J Neurol Surg B Skull Base 2018; 79(S 03): S285-S286
DOI: 10.1055/s-0038-1625943

Skull Base: Operative Videos

Georg Thieme Verlag KG Stuttgart · New York

Endoscopic Endonasal Resection of a Suprasellar Pituitary Adenoma Mimicking Tuberculum Sellae Meningioma in a Patient with an Intrasellar Persistent Trigeminal Artery

Authors

Alaa S. Montaser

¹Department of Neurosurgery, Ohio State University Wexner Medical Center, Columbus, Ohio, United States

²Department of Neurosurgery, Ain Shams University Faculty of Medicine, Cairo, Egypt
Alexandre B. Todeschini

¹Department of Neurosurgery, Ohio State University Wexner Medical Center, Columbus, Ohio, United States
Juan M. Revuelta Barbero

¹Department of Neurosurgery, Ohio State University Wexner Medical Center, Columbus, Ohio, United States
Mostafa Shahein

¹Department of Neurosurgery, Ohio State University Wexner Medical Center, Columbus, Ohio, United States
E. Antonio Chiocca

³Department of Neurosurgery, Brigham and Women's Hospital, Boston, Massachusetts, United States
Bradley A. Otto

¹Department of Neurosurgery, Ohio State University Wexner Medical Center, Columbus, Ohio, United States

⁴Department of Otolaryngology-Head and Neck Surgery, Ohio State University Wexner Medical Center, Columbus, Ohio, United States
Ricardo L. Carrau

¹Department of Neurosurgery, Ohio State University Wexner Medical Center, Columbus, Ohio, United States

⁴Department of Otolaryngology-Head and Neck Surgery, Ohio State University Wexner Medical Center, Columbus, Ohio, United States
Daniel M. Prevedello

¹Department of Neurosurgery, Ohio State University Wexner Medical Center, Columbus, Ohio, United States

⁴Department of Otolaryngology-Head and Neck Surgery, Ohio State University Wexner Medical Center, Columbus, Ohio, United States

Abstract

A 50-year-old female with an incidentally diagnosed suprasellar lesion was initially managed conservatively due to the presence of an intrasellar persistent trigeminal artery going through the dorsum sellae and fundamentally forming the blood supply of the entire posterior circulation. Serial follow-up brain magnetic resonance imaging (MRI) revealed progressive enlargement of the suprasellar lesion over 4 years period. Surgery was indicated after the initial tumor growth; however, the patient refused surgery for fear of complications related to the persistent trigeminal artery. Two-and-a-half years later, she presented with deterioration of vision. Formal visual field testing revealed a right temporal field defect. Brain MRI demonstrated significantly enlarged suprasellar lesion, most consistent with tuberculum sellae meningioma, exerting mass effect on the optic apparatus.

The patient underwent endoscopic endonasal resection of the lesion through a transplanum/transtuberculum approach. Intraoperatively, absence of hypertrophic McConnel arteries, hyperostosis, and the fact that the dura was soft and not under tension was against the diagnosis of tuberculum sellae meningioma. Additionally, the tumor consistency was similar to a pituitary adenoma. A complete resection was accomplished and multilayer skull base reconstruction was performed with no complications. On postoperative day 1 (POD 1), she was operated upon for the evacuation of small suprasellar hematoma associated with vision deterioration. Histopathological examination confirmed the diagnosis of atypical pituitary adenoma with K _i-67 labeling index of 4 to 5%. The patient ultimately recovered well with improved vision, and was discharged on POD 4 with no new neurological deficits. At 4 years follow-up, her vision was normalized and brain MRI showed no residual or recurrent lesion.

The link to the video can be found at: https://youtu.be/QZmzctjAEbw.

Keywords

endoscopic endonasal - persistent trigeminal artery - pituitary adenoma - suprasellar

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