Introduction: Trans-Sphenoidal surgery (TSS) is a well-known approach for pituitary tumor treatment. However, neurovascular damage may occur in inexperienced hands. This prospective study was conducted to validate the accuracy of pre-operative image-based segmentation (PIBS) in neurovascular structure localization during TSS.
Methods: Eight patients with pituitary tumor underwent preoperative 3TMRI, which included thin sectioned 3D space T2, 3D TOF and MPRAGE sequences. Images were reviewed by an expert independent neuroradiologist. Imaging sequences were loaded in BrainLab iPlanNet (6/8) and Stryker (2/8) for segmentation and pre-op planning. After patient registration to the intra-op neuronavigation system and surgical exposure, manual navigation probe placement validated each segmented neurovascular element. Micro-Doppler confirmed ICA pulses bilaterally.
Results: PIBS of the ICA and cavernous sinus matched with the intra-operative endoscopic and micro-Doppler findings in all cases (Dice-coefficient =1), reassuring the surgeons regarding the lateral extent of sellar floor bone removal and exploration. Perfect PIBS and endoscopic view correspondence was also found at the tumor surface and tumor-normal gland interfaces, helping prevent normal pituitary gland removal. Image-guidance helped localize the optic nerve and chiasm in 63% of cases and Diaphragma sella in 50% of cases. This helped determine the upward exploration limits and decrease CSF leakage. The measurement accuracy was 0.45+/-0.21 mm (mean +/-SD).
Conclusions: pre-operative image-based segmentation with 3D reconstruction is highly informative and could help prevent neurovascular injury during Trans-sphenoidal surgeries. Additionally, the accuracy found in this study is superior to previously reported neuronavigation measurements. This preliminary study is encouraging for future prospective intraoperative validation with larger patient numbers.
Patient Care: By preventing micro-neurovascular injuries
and improving outcome and decreasing complications.
Learning Objectives: To learn how to prevent neurovascular complications after Trans sphenoidal surgeries.