Current and Future Advances in Surgical Therapy for Pituitary Adenoma

The vital physiological role of the pituitary gland, alongside its proximal critical neurovascular structures means pituitary adenomas cause significant morbidity or mortality. Whilst enormous advancements have been made in the surgical care of pituitary adenomas, treatment failure and recurrence remain challenges. To meet these clinical challenges, there has been an enormous expansion of novel medical technologies (e.g. endoscopy, advanced imaging, artificial intelligence). These innovations have the potential to benefit each step of the patient journey, and ultimately, drive improved outcomes. Earlier and more accurate diagnosis addresses this in part. Analysis of novel patient data sets, such as automated facial analysis or natural language processing of medical records holds potential in achieving an earlier diagnosis. After diagnosis, treatment decision-making and planning will benefit from radiomics and multimodal machine learning models. Surgical safety and effectiveness will be transformed by smart simulation methods for trainees. Next-generation imaging techniques and augmented reality will enhance surgical planning and intraoperative navigation. Similarly, the future armamentarium of pituitary surgeons, including advanced optical devices, smart instruments and surgical robotics, will augment the surgeon's abilities. Intraoperative support to team members will benefit from a surgical data science approach, utilising machine learning analysis of operative videos to improve patient safety and orientate team members to a common workflow. Postoperatively, early detection of individuals at risk of complications and prediction of treatment failure through neural networks of multimodal datasets will support earlier intervention, safer hospital discharge, guide follow-up and adjuvant treatment decisions. Whilst advancements in pituitary surgery hold promise to enhance the quality of care, clinicians must be the gatekeepers of technological translation, ensuring systematic assessment of risk and benefit. In doing so, the synergy between these innovations can be leveraged to drive improved outcomes for patients of the future

Comparison of the lateral supraorbital approach and endoscopic endonasal transclival approach to basilar apex aneurysms among other possible applications of the endoscopic endonasal technique to vascular neurosurgery: anatomic and clinical study.

Abstract Introduction. The expansion of the endoscopic endonasal approach in neurosurgery during the last three decades recently led the neurosurgical clinical interest to the investigation of further application of this technique, namely to neurovascular pathologies. Cadaver dissections studies have represented the milestone in the progressive application of this technique. Integrating anatomical studies with advanced visualization tools and quantification methods increases their impact toward clinical application. Material and methods. The main endoscopic endonasal approaches were performed and exposure of the vascular intracranial structures was analyzed: the anterior communicating artery complex was investigated through the transplanum transtuberculum approach; the transsphenoidal approach to the sellar area was performed for the exposure of the intracavernous internal carotid artery; the basilar artery was exposed by means of the endoscopic endonasal transclival approach, and the vertebral arteries through the extended endonasal approach to the craniovertebral junction. Possible clinical application of each approach was investigated during anatomical dissections upgraded with imaging and quantification methods. Results. The transtuberculum transplanum approach allows for the exposure and control of the anterior communicating artery complex; the relationship between the proximal anterior cerebral artery, gyrus rectus, and optic chiasm is the main determinant for the exposure and control of the vessel. Temporary occlusion of the internal carotid artery with a Fogarty balloon catheter through the endoscopic transsphenoidal route might be another maneuver that is useful for obtaining intraoperative control of the vessel. The endoscopic transclival approach may be considered a minimally invasive route to the basilar apex in the presence of specific anatomical and pathological features. Comparative analysis of the anatomical exposure of the vertebro-basilar junction as obtained through transcranial and endoscopic endonasal approaches may be helpful in unlocking this complex skull base area. Conclusions. The introduction of the endoscopic endonasal approaches for the treatment of cerebrovascular pathologies represents the most advanced and innovative step forward of the skull base endoscopic endonasal surgical technique. The present PhD research activity may add relevant anatomical and clinical information to the rather sparse literature directly focused on surgical indication of the endoscopic endonasal approaches to vascular neurosurgery

ICAR: endoscopic skull‐base surgery

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Minimally invasive tubular retraction and transtubular approaches in neurosurgery

Minimally invasive surgical approaches have revolutionized surgical care and are becoming increasingly common and sought after in neurosurgery. Despite significant advancements in these techniques and associated technologies, the use of spatulas, that remain essentially unchanged since the late 1800s, for brain retraction endures as a mainstay of neurosurgical practice. In the last decade, tubular retractors have been successfully used in the management of deep-seated intraparenchymal and intraventricular lesions but have yet to be used to minimize brain retraction in skull base surgery. In order to determine the full applicability of transtubular techniques in neurosurgery, we compare brain retraction pressures between tubular retractors and brain spatulas in common neurosurgical approaches, assess the feasibility of performing minimally invasive transtubular skull base and general neurosurgical approaches, and introduce a novel technique for closure of transtubular minicraniectomies with maintenance of anatomic integrity. In all approaches assessed, tubular retraction resulted in average brain retraction pressures that were 57% less collectively than those resulting from spatula retraction. Tubular retractors demonstrated more consistent average retraction pressures between approaches and required 50% less mean retraction distance compared to spatula retractors, while cortical tearing was observed microscopically in 39% of cases following spatula retraction. Transtubular supraorbital, anterior transpetrosal, interhemispheric transcallosal, retrosigmoid, and supracerebellar infratentorial approaches are safe and effective surgical corridors to their respective intracranial targets, with ample surgical exposure, freedom, and maneuverability and minimal retraction of brain tissue. The tubular retractor provided sufficient working space for standard bimanual surgical technique without obstruction of the visual field and permitted sufficient surgical freedom while allowing for constant monitoring of retracted tissues. Adequate preoperative planning of the surgical trajectory was critical for facilitating a safe, direct, and practicable surgical corridor. Closure of transtubular minicraniectomies could be accomplished by rapid on-demand 3D printing of patient-specific cranioprostheses which was found to be a novel, feasible, and inexpensive option that was accomplished with minimal technical difficulty. Tubular retraction in neurosurgery provides a safe and effective conduit for the application of percutaneous minimally invasive approaches while inducing substantially reduced brain retraction pressures than conventional spatula retractors. Advances in neuronavigation and surgical robotics will continue to expand the indications for tubular retraction in neurosurgery