Transsphenoidal Resection

Used for resecting pituitary tumors (hypophysectomy) and other sellar and para sellar lesion

The surgery consists of accessing sella via nasa cavity and para nasal sinuses involve resecting
posterior bony septum back to shenoid fac e and forming sphenoidotomy

A. Axial CT Image show posterior nasal septostomy and

B. Coronal CT spheinoidotomy on arrow and also surgical defect in
anterior wall of of expanded sella -> thickened walls

The process of drilling bone during transsphenoid approach can leave behind metallic debris that
has detached from surgical instruments, this metal particles can deposited anywhere along the path
of access route, such as in nasal cavity and sphenoid sinus, Metal debris can cause considerable
artifact on MRI, and often appears as focal signal voids surrounded by a rim of high signal in T1-
Weighted Sequennces

B. On Coronal T2 MRI Show Metal

A. On Sagittal T1 MRI show mettalic
susceptibility artifact along floor of
artifact in posterior nasal cavity
sella

Giant adenomas or large lesion of pituitary region are sometimes not amenable to reception via TS
approach Such tumors require craniotomy and/or a combined approach

Combined Transventricular-transsphenoidal reception

On Coronal T2 MRi show a linear defect through the right frontal

lobe on arrow. Which communicates with lateral and third
ventricle ventricles. There is residual tumor on arrowhead
Fat graft is commonly used to pack skull base defect after transsphenoidal reception of pituitary
region tumor. The packing serves to prevent CSF leakage and hemorrhage. Fat graft are
hyperintense on both T! and T2 Wighted sequences and decrease in size overtime, such that in
most cases, the fat graft resorb completely after 1 year following surgery can use all of this or
combined
A.Fat graft base line postoperative in
saggital T1 W MRI show fat graft
packing within the sella on arrow

B.Sagittal T1 W MRI in 6 month show

interval decrease in size of the fat
pacing on arrow

Other material used to plug defect

in skull base and/or buttress of the fat graft include gelatin sponge.

On image merocel packing, on Coronal T2 MRI in sella and sphenoid sinus,

which appears as low signal intesity round balls on arrow
Pedicled mucosal flap C. Coronal T1 MRI and D too

A. Sagittal pre-contrast T1 Show an enhancing predicted mucosal flap in

B. Post contast sagittal arrow transposed into sphenoid sinus

Titanium mesh

a.coronal and b.sagittal

T1 W MRI show sheets
of titanium mesh on
arrow along the floor of
sella

Bone Graft Coronal T1 MRI show hypointense structure

subjacent to fat graft in sella which correspons to nasal
septum bone graft used as buttress on arrow

The early post overative

imaging appearance of
 pituitary after TS resection is variable, ranging from no enchancement, nodular enhancement, to
peripheral riim enhancement. In addition there may be post operative mass caused by residual tumor,
edema, hemorrhage implant material, granulation tissue, or a combinantion of these. In particular,
granulation tissue can be difficult to differentiate from residual tumor on imaging initially. However
on follow up, granulation tissue should involute, while residual tummor is expected to persist or grow

A.show pituitary adenoma. Post operative, C.1 year after surgery show near resolution of the
contrast enhanced T1 W MRI enhancing material in the sella

B.Coronal contrast enhanced T1 W MRI show 3

months after surgery show heterogeneously
enhancing tissue in sella on arrow

Residual tumor from subtotal resection of pituitary macroadenomas is usually distributed lateral to
sella, where it is difficult to attain and
left behind in order to minimize
complication (miss image 6.25 on page
257and 258)

Nasal stents and sinonasal fluid related to bloody mucus drainage can be encountered on early
postoperative imaging

Expected early postoperative sinonasal findings after TS

surgery. Axial CT image shows fluid in bilateral maxillary
sinus and bilateral nasal stents

The early postoperative imaging appearance of pituitary after TS resection is variable, Ranging from
non enhancement, to peripheral rim enhancement. There can also be postoeprative reexpansion of
the normal pituitary gland, thickening of the pituitary stalk, and swelling of the optic apparatus. In
addition, there may be a postoperative mass caused by residual tumor, edema, hemorrhage, implant
material, granulation tissue, or a combination of these. In particular, granulation tissue can be
difficult to differentiate from residual tumor on imaging initially. However, on follow-up, granulation
tissue typically involutes, while residual tumor is expected to persist or grow

Granulation tissue after transsphenoidal surgery. Preoperative coronal contrast-enhanced T1-

weighted MRI (a) shows a pituitary adenoma. Postoperative contrast-enhanced T1-weighted MRI (b)
obtained 3 months after surgery shows heterogeneously enhancing tissue in the sella (arrow).
Postoperative contrast-enhanced T1-weighted MRI (c) obtained 1 year after surgery shows near
resolution of the enhancing material in the sella

Primary goal of the surgery is not to remove the entire tumor but alleviate the mass effect upon
optic chiasm

Bone remodeling is a chronic process that can occure post op, manifest as thickening, ossification
and high T1 Signal intensity, most common in along planum sphenoidale 6.26

Although it can be striking, this finding is likely of no clinical significance, a similar appearance may
be encountered with skull base meningioma and slow growing sinus tumor for example

Complication
 Sellar hematomas are not uncommon after
transsphenoidal resection. When large, these can cause
mass effect upon surrounding structures and produce
symptoms. Subacute hematomas in the sella can
display high signal on T1- and T2-weighted MRI
sequences and should not be mistaken for fat graft or
residual tumor

Gradient echo (GRE) or susceptibility-weighted imaging (SWI) techniques can sometimes be useful
for identifying blood products on MRI, although susceptibility effects from air in the adjacent
sphenoid sinus can limit assessment. Arterial injury during transsphenoidal resection is uncommon,
but can manifest as pseudoaneurysm and/or subarachnoid hemorrhage, which can lead to
vasospasm. Most arterial complications related to transsphenoidal surgery involve the internal
carotid artery, but the ophthalmic, posterior communicating, and anterior cerebral arteries may also
be affected. Arterial injury may occur during dural opening, tumor resection, or reconstruction of the
sinuses and may be predisposed by anatomic variants of the sinuses and internal carotid arteries and
large tumors that involve the cavernous sinus. Therefore, meticulous preoperative planning with
imaging is important for minimizing arterial injury. Once arterial injury is suspected during
transsphenoidal resection, angiography is essential for identifying the presence of
pseudoaneurysms. The speculum and packing material may be kept within the sphenoid sinus in
order to prevent exsanguination, and excess packing may result in arterial stenosis or occlusion.
Endovascular control of bleeding may be achieved by either balloon occlusion or coil embolization of
the affected internal carotid artery, coil embolization of the pseudoaneurysm, or stenting alone of
the affected segment of the internal carotid artery
Peritumoral hemorrhage can lead to delayed cerebral vasospasm and
associated progressive worsening neurological deficits. Malposition or
migration of packing material for transsphenoidal resection is
uncommon. The displaced packing material can exert mass effect
upon the optic chiasm, resulting in visual symptoms that may differ
from the preoperative deficits
 Alternatively, the packing material can extend posteriorly and
compress the brainstem Such complications can be readily
demonstrated on multiplanar CT or MRI. However, in some cases,
displacement of packing material can potentially mimic tumor
invasion.

Lanjut page 260

Discussion

Mucosal inflammation is fairly common after TS resection and commonly involves sphenoid sinus
 The patient presented with
symptomps of congestion
following TS pituitary adenoma
Resection

A.Preoperative sagittal B.coronal

contrast enhanced T1 W MRI show
pituitary macroadenoma but a
clear sphenoid sinus C.Post

operative Coronal e. sagittal f. T1 MRI demonastrate complete opacification of the spheoid sinus in arrow

Mucocele formation after TS resection is a rare or perhaps underreported complication. Scar tissue
can obstruct the egress of mucous secretions, resulting in their accumulation. On MRI, Mucocele are
often homogeneously iso to hyperintense on T1 and T2 and display peripheral enhancement. These
may sometimes be multilocular. The main differential consideration is a post operative hematoma,
although these can be distinguished by their time course. Hematomas tend to absorb overtime,
while mucoceles persist or even expand. Susceptibility weighted imaging can also be helpful
whereby hematomas are hypointense, while mucocele don’t. Postoperative mucocele can cause
symptomps such headache and diplopia, but they can be successfully treated via incision and
drainage
 Although prophylactic antibiotics are routinely given before
transsphenoidal surgery, the incidence of postoperative meningitis
is in the range of 0.4–9%. This complication can manifest as
leptomeningeal enhancement in the basilar cistern region on MRI

CSF leak is known complication of TS resection, serious complication that can predispose to
meningitis and Intracranial hupotension. Beta 2 transferrin assay is an accurate test for confirming
the presence of csf lekas, imaging also play an important role in the work up of CSF leak. Its used to
confirm the diagnosis, localize the site of CSF leka, identift a potential cause and help plan surgical
repair. Several imaging modalities are available to evaluate CSF leak, including high resolution CT, CT
cisternography. MRI and radionuclide cisternography.

However, high resolution of CT is

the first line imaging modality and can correctly predict the site of CSF leak in over 90 % of cases.
When beta-2 transferrin is positive and high resolution CT demonstrates a single bony defect
without any sign of encephalocele, no other imaging is necessary. CT cisternogaph is reserved for
patients with a negative high resolution CT or multiple bony defect and active CSF leakage. The
sensitivity of CT cisternography is only about 50% in patients with intermittent CSF leak, MR
cisternography should be performed in High resolution CT show bony defect with an associated soft
tissue opacity in order to exclude the possibility of meningocele or encephalocele. Contrast
enhanced sequences are useful for detecting dural enchancement at the site of the leak. Nuclear
cisternography using in-111 sometimes performed for complex cases and to help determine whether
ther is indeed a csf leak.
A variety of endocrinological disturbances can occur after TS reception. In acute postoperative
setting, a minority patients experience Diabetes insipidus because absence of posterior pituitary
bright spot on imaging. Hyponatremia related on TS surg to have a delay onset. Panhypopituitarism
can result too. Can evaluated via MRI high resolution. Such CISS and Thin section T1 W images

Pituitary stalk Transection. The pastient status PostTS

decompression of sellar/ suprasellar rathkes cleft cyst
compicated by transection of Putuitart stalk. And secondary
panhypopituitarism the thick slab sagittal MIP T1 MRI show
interruption of infundibulum on arrow

In addition, an ectopic post pituitarty bright spot can be

observed in this condition.

Ptosis of optic chiasm is not an uncommon finding following pituitry tumor resection, occur when a
large prtion of pituitary sella contents have been evacuated reusilting in a nearly or completely
empty sella

Optic chiasm ptosis.

Preoperative T2 W MRI a) show a large macrocystic pituitary adenoma that uptlift the optic chiasm
on arrow b) postoperative coronal T2 and c) sagittal T1 demonstrate ptosis of optic chiasm on arrow
into and empt sella

Ptosis is recognized by a convex down configuration of the optic chiasm on a coronal or sagittal
plane. When severe, this condition has the potention to cause visual deficit. The problematic empty
sella with optic chiasm ptosis can be treated via chiasmpexy. This procedure cosists supporting the
optic chiasm in near-anatomic position via TS silastic struts and coils, among other materials
Chiasmpexy two coronal *a,b) CT show strips on siliastic material on arrow and titanium mesh ona
arrowhead in the sphenoid sinus

Acute visual loss related to transsphenoidal surgery can result from

infarction of the optic apparatus if the blood supply is disrupted
during tumor resection. This can be assessed on coronal T2-
weighted MRI, which may show new signal abnormality in the optic
apparatus

Fibrosis following TS pituitary surgery is not an uncommon finding on postoperative MRI. Fibrosis
may manifest as nonspecific, amorphous areas along the floor of sella. The imaging appearance is
often indistinguishable from implat matereials or residual tumor. Occasionally, adhesion bands form,
which can extend across the sella or diaphragm to brain or residual tumor. Adhesion appear as linear
structures with low to intermediate signal intensity on T1 T2 MRI and enhance less and/or slower
than the pituitary stalk.

Postoperative fibrosis
AxialT2 (a) and post
contrast T1(b) MrI show
an intermediate intensity
band on arrow traversing
the sella anterior to
pituitary stalk on
arrowhead

These adhesuin can hamper subsequent surgical resection of

residual tumor. Fibrosis may also prevent normal pituitary gland re expansion and cause stalk
deviation

Injury to internal carotid arteries during TS resection is a reare but serious complication, arterial
complications related TS surgery of wich 80% involve internal carotid artery are found in about 1 %
of cases and have a mortality rate of 14%. Pseudoaneurysm of internal carotid artery may occur
diring diral opening, tumor resecting, or reconstruction of the sinuses and may be predisposed by
anatomic variants of the sinuses and internal carotid and large tumor that involve the cavernous
sinus. Therefore meticulous preoperative planning with imaging is important for minimizing arterial
injury. Once arterial injury is suscepted during TS resection, angiography is essential. The Speculum
and packing aterial are left in the sphenoid sinus in order to prevent exsanguination and are readily
identified in imaging. Excess packing may result in carotid stenosis or occlusion. Endovascular,
control, of bleeding may be achieved by either balloon occlusion or coil embolization of affected
internal carotid artery, coil embolization of pseudoaneurysm, or stenting alone of the affected
segments of internal carotid artery. Miss page 256 and 257