Quantification of Tumor Blush of Highly Vascularized Tumors with Slow Feeding System: Representative Use for Giant Pituitary Adenomas
Background Modern imaging techniques can identify adverse factors for tumor removal such as cavernous sinus invasion before surgery, but surgeries for giant pituitary adenomas often reveal discrepancies between preoperative imaging and intraoperative findings because pituitary adenomas have feeding arteries with narrow diameters. Current imaging methods are not suitable for tumors with not only large vascular beds but also slow arterial filling.
Patients and Methods This prospective study recruited 13 male subjects and 9 female subjects with giant pituitary adenomas between November 2011 and 2018. All the patients were investigated with three-dimensional magnetic resonance (MR) imaging, bone image computerized tomography (CT), and digital subtraction angiography (DSA) using a C-arm cone-beam CT scanner with a flat-panel detector and 50% diluted contrast medium. Fine angioarchitecture was evaluated and the tumor blush was quantified using newly developed region of interest (ROI) analysis to establish surgical strategies.
Results Seven patients demonstrated no or very faint tumor blushes. In these patients, feeding arteries run centripetally from the surface of the tumor. Fifteen patients showed significant tumor blushes, and the feeding arteries penetrated centrifugally from the inferoposterior pole to the upper pole of the tumor. All the patients were treated according to the angiographic information with successful hemostasis. The patients showed improvement and/or disappearance of the neurologic deficits. The faint and significant blush groups showed significant differences in intraoperative bleeding (p < 0.01) and operation time (p < 0.05).
Conclusion Specialized evaluation focused on vascularization is required for successful therapy of giant pituitary adenomas.
Ethics and Consent to Participate
The surgical policy was explained preoperatively to the patients and written informed consent was obtained. The overall study design was approved by the Ethics Committee of Kohnan Hospital in 2018.
Consent to Publish
Written informed consent was obtained from the patients for publication of these case reports and accompanying images. A copy of the written consent is available for review by the editor of this journal.
Y.O. was a major contributor in writing the manuscript, performed tumor removal, and analyzed the patient data regarding in the context of endocrinologic outcomes. K.S. was also a major contributor, and performed and analyzed the fine angioarchitecture and tumor blush. T.E. gave technical advice in writing this manuscript. T.T. thoroughly supervised this manuscript. All the authors read and approved the final manuscript.
Eingereicht: 28. Juni 2019
Angenommen: 19. März 2020
Artikel online veröffentlicht:
12. Dezember 2021
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- 1 Ciric I, Ragin A, Baumgartner C, Pierce D. Complications of transsphenoidal surgery: results of a national survey, review of the literature, and personal experience. Neurosurgery 1997; 40 (02) 225-236 , discussion 236–237
- 2 Kurwale NS, Ahmad F, Suri A. et al. Post operative pituitary apoplexy: preoperative considerations toward preventing nightmare. Br J Neurosurg 2012; 26 (01) 59-63
- 3 Laws Jr ER. Vascular complications of transsphenoidal surgery. Pituitary 1999; 2 (02) 163-170
- 4 Aburakawa D, Ogawa Y, Sato K, Niizuma K, Tominaga T. Surgical planning for a giant pituitary adenoma based on evaluation of the fine feeding system and angioarchitecture: a case report [in Japanese]. No Shinkei Geka 2018; 46 (08) 691-697
- 5 Ogawa Y, Sato K, Matsumoto Y, Tominaga T. Evaluation of fine feeding system and angioarchitecture of giant pituitary adenoma: implication for establishment of surgical strategy. World Neurosurg 2016; 85: 244-251
- 6 Ogawa Y, Sato K, Tominaga T. Surgical strategy for giant pituitary adenoma based on evaluation of fine feeding system and angioarchitecture. Interdiscip Neurosurg 2017; 8: 1-3
- 7 Camp PE, Paxton HD, Buchan GC, Gahbauer H. Vasospasm after trans-sphenoidal hypophysectomy. Neurosurgery 1980; 7 (04) 382-386
- 8 Friedman JA, Meyer FB, Wetjen NM, Nichols DA. Balloon angioplasty to treat vasospasm after transsphenoidal surgery. Case illustration. J Neurosurg 2001; 95 (02) 353
- 9 Hyde-Rowan MD, Roessmann U, Brodkey JS. Vasospasm following transsphenoidal tumor removal associated with the arterial changes of oral contraception. Surg Neurol 1983; 20 (02) 120-124
- 10 Kasliwal MK, Srivastava R, Sinha S, Kale SS, Sharma BS. Vasospasm after transsphenoidal pituitary surgery: a case report and review of the literature. Neurol India 2008; 56 (01) 81-83
- 11 Krayenbuehl H. A contribution to the problem of cerebral angiospastic insult [in German]. Schweiz Med Wochenschr 1960; 90: 961-965
- 12 Mawk JR, Ausman JI, Erickson DL, Maxwell RE. Vasospasm following transcranial removal of large pituitary adenomas. Report of three cases. J Neurosurg 1979; 50 (02) 229-232
- 13 Ono N, Misumi S, Nukui H, Kawafuchi JI. Vasospasm following removal of a large pituitary adenoma by the subfrontal approach: report of a case and review of the literature (author's transl) [in Japanese]. Neurol Med Chir (Tokyo) 1981; 21 (06) 609-614
- 14 Popugaev KA, Savin IA, Lubnin AU. et al. Unusual cause of cerebral vasospasm after pituitary surgery. Neurol Sci 2011; 32 (04) 673-680
- 15 Tsunoda M, Ohwada T, Kuramae H, Takagi H, Nakamura N, Miyasaka Y. Two cases of cerebral angiospasm after removal of pituitary tumor. Discussion of clinical course and pathogenesis. Proceedings of the 5th Symposium of Special Problems in Neurosurgery. Tokyo: Neuron Co; 1972: 7-17
- 16 Chong MY, Quak SM, Chong CT. Cerebral ischaemia in pituitary disorders--more common than previously thought: two case reports and literature review. Pituitary 2014; 17 (02) 171-179
- 17 Goel A, Deogaonkar M, Desai K. Fatal postoperative “pituitary apoplexy”: its cause and management. Br J Neurosurg 1995; 9 (01) 37-40
- 18 Kurschel S, Leber KA, Scarpatetti M, Roll P. Rare fatal vascular complication of transsphenoidal surgery. Acta Neurochir (Wien) 2005; 147 (03) 321-325 , discussion 325
- 19 Puri AS, Zada G, Zarzour H, Laws E, Frerichs K. Cerebral vasospasm after transsphenoidal resection of pituitary macroadenomas: report of 3 cases and review of the literature. Neurosurgery 2012; 71 (01) 173-180 , discussion 180–181
- 20 Dawson BH. The blood vessels of the human optic chiasma and their relation to those of the hypophysis and hypothalamus. Brain 1958; 81 (02) 207-217
- 21 Gibo H, Kobayashi S, Kyoshima K, Hokama M. Microsurgical anatomy of the arteries of the pituitary stalk and gland as viewed from above. Acta Neurochir (Wien) 1988; 90 (1–2): 60-66
- 22 Lang J. Clinical Anatomy of the Head. Neurocranium, Orbit, Craniocervical Regions. Berlin: Springer; 1983
- 23 McConnell EM. The arterial blood supply of the human hypophysis cerebri. Anat Rec 1953; 115 (02) 175-203
- 24 Parkinson D. A surgical approach to the cavernous portion of the carotid artery. Anatomical studies and case report. J Neurosurg 1965; 23 (05) 474-483
- 25 Ohkawa M, Fujiwara N, Hino I. et al. Transvenous embolization of high flow carotid cavernous fistula: a case report. Radiat Med 1996; 14 (03) 163-166
- 26 Remonda L, Frigerio SB, Bühler R, Schroth G. Transvenous coil treatment of a type a carotid cavernous fistula in association with transarterial trispan coil protection. AJNR Am J Neuroradiol 2004; 25 (04) 611-613
- 27 Sato K, Shimizu H, Inoue T. et al. Angiographic circulation time and cerebral blood flow during balloon test occlusion of the internal carotid artery. J Cereb Blood Flow Metab 2014; 34 (01) 136-143
- 28 Gondim JA, Almeida JP, Albuquerque LA, Gomes EF, Schops M. Giant pituitary adenomas: surgical outcomes of 50 cases operated on by the endonasal endoscopic approach. World Neurosurg 2014; 82 (1–2): e281-e290
- 29 Mortini P, Barzaghi R, Losa M, Boari N, Giovanelli M. Surgical treatment of giant pituitary adenomas: strategies and results in a series of 95 consecutive patients. Neurosurgery 2007; 60 (06) 993-1002 , discussion 1003–1004
- 30 Müslüman AM, Cansever T, Yılmaz A. et al. Surgical results of large and giant pituitary adenomas with special consideration of ophthalmologic outcomes. World Neurosurg 2011; 76 (1-2): discussion 63–66 141-148
- 31 Bi WL, Brown PA, Abolfotoh M, Al-Mefty O, Mukundan Jr S, Dunn IF. Utility of dynamic computed tomography angiography in the preoperative evaluation of skull base tumors. J Neurosurg 2015; 123 (01) 1-8
- 32 Romano A, Rossi Espagnet MC, Calabria LF. et al. Clinical applications of dynamic susceptibility contrast perfusion-weighted MR imaging in brain tumours. Radiol Med (Torino) 2012; 117 (03) 445-460
- 33 Shi R, Jiang T. Evaluation of tumor vessel of cerebral meningiomas with MR perfusion weighted imaging [in Chinese]. Zhonghua Yi Xue Za Zhi 2015; 95 (17) 1335-1337
- 34 Wetzel SG, Cha S, Law M. et al. Preoperative assessment of intracranial tumors with perfusion MR and a volumetric interpolated examination: a comparative study with DSA. AJNR Am J Neuroradiol 2002; 23 (10) 1767-1774
- 35 Zeng Q, Jiang B, Shi F, Ling C, Dong F, Zhang J. 3D pseudocontinuous arterial spin-labeling MR imaging in the preoperative evaluation of gliomas. AJNR Am J Neuroradiol 2017; 38 (10) 1876-1883
- 36 Ogawa Y, Nakagawa A, Takayama K, Tominaga T. Pulsed laser-induced liquid jet for skull base tumor removal with vascular preservation through the transsphenoidal approach: a clinical investigation. Acta Neurochir (Wien) 2011; 153 (04) 823-830