Cadaveric Anatomic Study of Pituitary Stalk Mobilization: Implications for Neurosurgery

Abstract

Objetive

Surgical intervention in the subchiasmal region is complex due to the presence of critical neurovascular structures. This study aimed to elucidate the detailed anatomy of this region and identify safe surgical mobilization techniques.

Methods

Eight cadaveric specimens underwent anatomical dissection to examine the subchiasmal region, its neurovascular components, and skull base structures. The supportive structures of the pituitary stalk were meticulously exposed to assess its mobility.

Results

During dissection of the arachnoid membranes surrounding the pituitary stalk, two distinct, thick arachnoid bands were identified enveloping the stalk and superior hypophyseal arteries. These bands were situated within the inner layer of the arachnoid membranes, forming a funnel-like structure that enclosed and protected the pituitary stalk. These bands originated from the inferior aspects of the bilateral optic nerves and extended medially from both internal carotid arteries.

Conclusion

The internal arachnoid bands identified in our study encase and protected the superior hypophyseal arteries. By stabilizing the pituitary stalk and preserving pituitary gland perfusion, these bands may act as a protective mechanism against neuroendocrine complications, such as diabetes insipidus, particularly in mild to moderate head trauma.

 

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Resumo

Objetivo

A intervenção cirúrgica na região subquiasmática é complexa devido à presença de estruturas neurovasculares críticas. Este estudo teve como objetivo elucidar a anatomia detalhada desta região e identificar técnicas seguras para a mobilização cirúrgica.

Métodos

Foram dissecados oito espécimes cadavéricos para examinar detalhadamente a região subquiasmática, seus componentes neurovasculares e as estruturas da base do crânio. As estruturas de suporte do pedúnculo hipofisário foram cuidadosamente expostas para avaliar sua mobilidade.

Resultados

Durante a dissecação das membranas aracnoides que envolvem o pedúnculo hipofisário, foram identificadas duas bandas aracnoideas distintas e espessas, envolvendo o pedúnculo e as artérias hipofisárias superiores. Essas bandas estavam situadas na camada interna das membranas aracnoideas, formando uma estrutura semelhante a um funil, que envolvia e protegia o pedúnculo hipofisário. As bandas tiveram origem nas faces inferiores dos nervos ópticos bilaterais e se estendiam medialmente a partir de ambas as artérias carótidas internas.

Conclusão

As bandas aracnoideas internas identificadas em nosso estudo envolvem e protegem as artérias hipofisárias superiores. Ao estabilizar o pedúnculo hipofisário e preservar a perfusão da glândula pituitária, essas bandas podem atuar como um mecanismo protetor contra complicações neuroendócrinas, como diabetes insipidus, particularmente em traumas cranianos leves a moderados.

 

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Keywords

skull base - subchiasmal region - arachnoid bands - surgical mobilization - pituitary

Palavras-chave

base do crânio - região subquiasmática - bandas aracnoideas - mobilização cirúrgica - hipófise

Introduction

The subchiasmal region, a complex interplay of neural and vascular structures, poses a formidable challenge for neurosurgeons.[1] [2] [3] Despite advances in technology such as neuronavigation and intraoperative imaging, the intricacies of this region continue to demand meticulous surgical planning and execution.[4] [5] While previous studies have shed light on certain aspects of subchiasmal anatomy, a comprehensive understanding of the dynamic relationships between structures remains elusive.[6] [7] [8]

Surgical interventions in this region, targeting pathologies like meningiomas, craniopharyngiomas, and pituitary adenomas, are fraught with risk due to the proximity of vital neural and vascular elements. The limitations imposed by both endoscopic and transcranial approaches underscore the critical need for detailed anatomical knowledge to maximize surgical maneuverability and minimize complications. Management of pituitary stalk lesions requires a multidisciplinary approach, considering both surgical resection and preservation of endocrine function.[9] Mobilization of the pituitary stalk is crucial for enhancing surgical access to parasellar and suprasellar regions, facilitating tumor resection while minimizing neural and vascular injury.[10]

Although previous studies have explored the anatomical structure of the pituitary stalk, the presence of internal arachnoid bands has not been systematically described. This study aims to delve deeper into the pituitary stalk anatomy, focusing on the neurohypophysis and its associated structures. By meticulously dissecting cadaveric specimens, we seek to elucidate the complex spatial relationships between neural, vascular, and bony landmarks. This enhanced anatomical comprehension will provide invaluable insights into safe surgical corridors and potential mobilization techniques, ultimately contributing to improved patient outcomes.

 

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Methods

This study employed a cadaveric dissection approach to investigate the anatomy of the subchiasmal region. Eight formalin-fixed autopsy specimens, obtained between 2009 and 2019, were utilized. Cadaveric specimens were obtained and dissected following standard anatomical preservation protocols under institutional ethical approval (approval number 2019–11/15, date 01.07.2019). The authors hereby confirm that every effort was made to comply with all local and international ethical guidelines and laws concerning the use of human cadaveric donors in anatomical research.

The dissection technique was adapted from Dr. Yilmazlar's[11] with modifications to focus on the subchiasmal region. Block dissections were performed to preserve the anatomical integrity of the sellar, parasellar, and superior clivus regions, including the internal carotid and anterior cerebral arteries, optic and oculomotor nerves, and cavernous sinus structures.

Microsurgical techniques were employed to meticulously dissect the subchiasmal region, preserving neuronal tissue, vascular structures, and bony landmarks. The anatomical relationships and spatial configurations within the region were thoroughly examined, following predefined surgical corridors. A surgical microscope (Carl Zeiss OPMI Pentero), a professional camera (Canon EOS 600D), and a surgical endoscope (Karl Storz 26003 AA, BA) were utilized to document the dissection process.

Pre- and post-dissection assessments of anatomical relationships were conducted, and metric measurements were obtained using digital calipers and image analysis software (tpsDig version 2.17). Photographic records were systematically categorized for subsequent analysis. Although color silicone injection was not performed, the anatomical structures were documented using high-resolution photography and digital image analysis to ensure precision.

Qualitative Examination

Cadaveric specimens were initially examined in a quadrangular plane encompassing the bilateral optic nerves, optic chiasm, hypothalamus, internal carotid arteries (ICAs), and pituitary stalks. The integrity of the pituitary stalk, dura mater, and associated vascular structures (superior hypophyseal arteries and perforating arteries) was verified. The lateral boundaries of the study area included the interclinoid ligaments and medial walls of the cavernous sinuses. Particular attention was given to the arachnoid collar surrounding the pituitary stalk.

Following removal of the brainstem and Circle of Willis, the pituitary stalk was transected at the level of the third ventricle floor and detached from the cerebrum. The optic chiasm was divided along the midline, and the ICAs were transected at the supraclinoid level. The oculomotor, trochlear, and abducens nerves were dissected from their origins. The outer arachnoid bands surrounding the pituitary stalk were dissected, allowing for the visualization of the course of the superior hypophyseal artery within the arachnoid.

 

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Quantitative Examinations

The distance between the pituitary stalk and the supraclinoid segments of both ICAs at the level of the pituitary gland exit was measured in the horizontal plane. Descriptive statistics (mean and standard deviation) were calculated for these measurements.

After opening the outer arachnoid collar, the inner arachnoid bands surrounding the pituitary stalk were measured in the axial plane to determine their anterior and posterior lengths.

 

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Results

Qualitative Examinations

Dissection of the arachnoid membranes surrounding the pituitary stalk revealed a funnel-shaped structure composed of medial carotid and Lilequist's membranes ([Fig. 1]). Within this collar, spider-web-like arachnoid structures originating from the optic nerves and ICAs formed thickened anterior and posterior bands with a reticular intermediate region ([Fig. 2]). The superior hypophyseal artery was embedded within the posterior thickened arachnoid band. These arachnoid structures stabilized the pituitary stalk and superior hypophyseal artery ([Fig. 3], [4]). The identified arachnoid bands consistently enclosed the superior hypophyseal arteries in all specimens, suggesting a potential protective role in neurovascular integrity.

Fig. 1 Figure 1 illustrates the anatomical positioning of the arachnoid bands enveloping the pituitary stalk, providing mechanical stabilization and protection. The funnel-shaped arachnoid collar surrounding the pituitary stalk (a) and (b) (posterior view of the posterior hypophyseal fossa). Abbreviations: DS, Dorsum sellae. black arrow: The arachnoid sheath formed by the arachnoid structures; ICA, Internal Carotid Artery; ON, Optic nerve; PG, Pituitary gland; S, Stalk; SHA, Superior hypophyseal artery.

Fig. 2 Figure 2 shows the close relationship between the superior hypophyseal arteries and the newly identified internal arachnoid bands. The arachnoid bands seen in the inner part after dissection of the arachnoid sheath form a thick band structure in the anterior and posterior regions originating from both the ICA and the optic nerves. Weaker reticular arachnoid structures are seen between the two band structures (posterior view of the posterior hypophyseal fossa from the posterior). Abbreviations: AAA: Anterior arachnoid arc; DS: Dorsum sellae; ICA: Internal Carotid Artery; ON: Optic nerve; PAA: Posterior arachnoid arc; PG: Pituitary gland; S: Pituitary stalk; SHA: Superior hypophyseal artery.

Fig. 3 The arachnoid bands seen in the inner part after dissection of the arachnoid collar form a thick band structure anteriorly and posteriorly, originating from both the ICA and the optic nerves, while the posterior arachnoid band surrounds the superior hypophyseal artery (posterior hypophyseal fossa, top view). Abbreviations: AAA, Anterior arachnoid arc; DS, Dorsum sellae. The blue dashed line represents the distance between both ICAs; ICA, Internal Carotid Artery; L, Distance between the midline of the pituitary stalk and the left ICA; ON, Optic nerve; PAA, Posterior arachnoid arc; PG, Pituitary gland; R, Distance between the midline of the pituitary stalk and the right ICA; S, Stalk of pituitary; SHA, Superior hypophyseal artery.

Fig. 4 Illustration of the internal arachnoid bands fixing the pituitary stalk (Illustration by O.A.) (a) Posterior view of the posterior hypophyseal fossa. (b) Plan view of the posterior hypophyseal fossa. Abbreviations: AAA, Anterior arachnoid arc; AT, Arachnoid trabeculae; DS, Dorsum sellae; ICA, Internal Carotid Artery; ON, Optic nerve; PAA, Posterior arachnoid arc; PG, Pituitary gland; S, Stalk; SHA, Superior Hypophyseal Artery.

 

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Quantitative Considerations

The horizontal distance between the supraclinoid segments of ICAs at the level of the pituitary stalk exit was measured ([Fig. 3]). The mean distance was 8.25 ± 1.76 mm on the right side and 8.38 ± 2.28 mm on the left side ([Table 1]).

Table 1 Distance between stalk and bilateral ICA

Sample No	Right (mm)	Left (mm)
1	7.90	8.11
2	7.02	4.59
3	7.48	8.62
4	7.16	7.12
5	6.70	7.04
6	12.00	9.69
7	9.60	9.55
8	8.12	12.32
*Mean ± SD	8.25 ± 1.76	8.38 ± 2.28

(*Mean ± SD: Mean + Standard Deviation).

After dissecting the outer arachnoid collar, the axial lengths of the anterior and posterior arachnoid bands were measured. The mean lengths were 19.16 ± 3.35 mm anteriorly and 20.04 ± 3.22 mm posteriorly ([Table 2]).

Table 2 Length measurements of the arachnoid bands fixing the stalk

Sample No	Anterior arachnoid band (mm)	Posterior arachnoid band (mm)
1	26.69	26.75
2	16.60	15.66
3	18.10	19.64
4	17.35	20.34
5	20.42	19.88
6	19.75	21.34
7	16.40	17.71
8	17.99	18.96
*Mean ± SD	19.16 ± 3.35	20.04 ± 3.22

(*Mean ± SD: Mean + Standard Deviation).

 

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Discussion

Lesions within the subchiasmal region necessitate either endoscopic or transcranial surgical approaches, with the specific choice influenced by the nature of the pathology and its proximity to critical neurovascular structures.[4] [12] The absence of a standardized treatment protocol is evident from the variety of surgical techniques and the availability of alternative modalities like radiosurgery.[12] Endoscopic endonasal approaches have revolutionized pituitary surgeries, offering direct visualization of the pituitary stalk and surrounding structures, thereby enhancing surgical precision and outcomes.[13] Despite advancements in endoscopic and microscopic technologies, a comprehensive understanding of regional anatomy remains crucial due to the constraints imposed by neural and vascular structures on surgical maneuvers.[3] Strategic mobilization of the pituitary stalk can facilitate a safer and more comprehensive surgical approach to retrochiasmatic and retrosellar regions, optimizing tumor resection while minimizing the risk of vascular injury. Careful preservation of the pituitary stalk during surgery is paramount to reducing the risk of postoperative complications, such as hypopituitarism and diabetes insipidus, which can significantly impact patient outcomes.[14]

The arachnoid membrane, situated anterior to the bilateral internal carotid arteries, anterior cerebral artery segments, and optic nerves, is termed the medial carotid membrane. While derived arachnoid layers envelop the pituitary stalk's anterolateral surface, additional trabecular arachnoid layers from the Lilequist membrane surround the posterior and posterolateral aspects, collectively forming a funnel-shaped arachnoid collar. Ciapetta et al.[15] explored the relationship between these arachnoid membranes and craniopharyngiomas, proposing a novel classification system for these tumors. Conversely, Song-Tao et al.[16] identified suprasellar meningiomas as tumor entities that exert significant compression on the pituitary stalk, creating a dissection plane within this relatively pliable and resilient arachnoid membrane. Our cadaveric study involving eight specimens suggests that this arachnoid collar safeguards the pituitary stalk by anchoring it to the third ventricle floor.

The chiasm type, the medial cavernous sinus wall, the interclinoid ligaments, the pituitary stalk position, and its anatomical relationship to the sella base significantly influence postoperative complications and surgical approaches to regional lesions.[17] [18] [19] [20] Gulsen et al.[21] through a cadaveric study involving 60 specimens, emphasized the crucial role of understanding pituitary stalk variations in preventing unintended injuries during transcranial sellar surgery. It is essential to consider that the pituitary stalk's position can be altered, particularly in cases of extensive tumor invasion. Truong et al.[22] in their endoscopic anatomical study of the superior hypophyseal artery, described the descent and variations of bilateral superior hypophyseal arteries from the stalk to the pituitary gland, forming anastomoses at the stalk apex. They concluded that the risk of endocrinological deficits due to unilateral superior hypophyseal artery injuries resulting from preinfundibular anastomoses is relatively low.

Recent anatomical studies have identified distinct arachnoid bands enveloping the pituitary stalk, which play a significant role in maintaining its positional stability and protecting adjacent neurovascular structures.[23] A novel finding of our study was the identification of two anatomical arachnoid bands that internally stabilize the pituitary stalk. These structures have not been previously described in the literature. Our dissection revealed internal arachnoid structures within the funnel-shaped outer arachnoid membrane surrounding the pituitary stalk. These structures originated from the inferior aspects of the bilateral optic nerves and internal carotid arteries (ICAs), forming thickened anterior and posterior bands with a reticular intermediate region. The superior hypophyseal arteries coursed within the posterior thickened arachnoid band, creating bilateral anastomoses in the proximal pituitary stalk ([Fig. 3]). Measurements of these inner arachnoid structures in eight cases indicated a mean anterior length of 19.16 ± 3.35 mm and a posterior length of 20.04 ± 3.22 mm. The mean distance from the pituitary stalk to the bilateral ICAs was 8.25 ± 1.76 mm on the right and 8.38 ± 2.28 mm on the left. The arcuate configuration of these internal arachnoid structures, combined with their length exceeding the distance between the ICA and pituitary stalk, suggests a protective role through stretching in response to trauma or tumor-related stress. Beyond stabilizing the pituitary stalk, these bands also protect the superior hypophyseal arteries, thereby potentially mitigating the risk of neuroendocrine complications, including diabetes insipidus. Our findings expand upon existing anatomical knowledge by providing a detailed description of previously unrecognized arachnoid bands surrounding the pituitary stalk, which may have significant neurosurgical implications. Despite the modest sample size, the consistency of anatomical findings across all specimens suggests these structures are reproducible and not incidental variations.

The identification of these internal arachnoid bands is not only of anatomical significance but also has critical implications for surgical interventions involving the pituitary stalk. By reinforcing stalk stability and protecting superior hypophyseal arteries, these structures could play a pivotal role in mitigating surgical trauma-related endocrine dysfunctions such as diabetes insipidus and hypopituitarism. Their role extends beyond safeguarding the pituitary stalk, as they also protect the superior hypophyseal arteries, thereby contributing to the prevention of endocrinological complications such as diabetes insipidus. The mechanisms underlying the prevention of diabetes insipidus, particularly in cases of mild to moderate head trauma, can be attributed to the funnel-shaped outer arachnoid collar, the arched inner arachnoid bands with their stretching capacity, and the protective envelopment of the superior hypophyseal arteries by the posterior arachnoid band.

The intricate anatomy of the pituitary stalk, with its close association with critical vascular and neural structures, necessitates meticulous surgical planning and technique.[24] The inner arachnoid membrane enveloping the pituitary stalk represents an essential anatomical structure that neurosurgeons must consider during surgical interventions to prevent inadvertent disruption of its vascular and neural components. While these arachnoid structures offer protection, they can also hinder pituitary mobilization during surgery, especially in transphenoidal approaches. Advanced techniques for mobilizing the pituitary stalk, such as selective arachnoid dissection, have been developed to improve surgical access while preserving stalk integrity.[25] To enhance maneuverability, bilateral release of the anterior inner arachnoid band and dissection of the intervening trabecular arachnoid membranes can be considered. Selective dissection of these structures may optimize surgical exposure while minimizing the risk of vascular and neural injury, ultimately improving functional outcomes. The superior hypophyseal artery provides critical vascular support to the pituitary stalk, ensuring adequate perfusion to maintain its structural integrity and neuroendocrine function. Intraoperative injury to the pituitary stalk can result in significant postoperative complications, including permanent diabetes insipidus and panhypopituitarism.[26] To preserve the superior hypophyseal arteries and their anastomoses, a distal-to-proximal dissection approach of the pituitary stalk is recommended, avoiding dissection of the posterior inner arachnoid band.

To the best of our knowledge, our study is the first in the literature to describe the arachnoid bands that stabilize and protect the superior hypophyseal artery and the pituitary stalk. Understanding the presence and mechanical properties of these inner arachnoid bands is vital for neurosurgeons performing pituitary and skull base surgeries. These bands could serve as key surgical landmarks, and their selective dissection may improve tumor resection efficacy while minimizing iatrogenic neurovascular injury. While the sample size in this study is limited, the consistency of findings across all specimens suggests a structural feature rather than an anatomical variation. Future studies integrating high-resolution in vivo imaging and larger cadaveric series will further validate these findings and assess their clinical implications.

 

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Conclusion

This study provides novel insights into the arachnoid bands encircling the pituitary stalk, with potential implications for neurosurgical approaches and the preservation of neurovascular integrity. We propose that recognizing and preserving this delicate anatomical structure during dissection and mobilization procedures for regional lesions is essential for optimal surgical outcomes.

 

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Conflict of Interest

The authors declare that they have no conflict of interest.

Authors' Contributions

S Yilmazlar and R Fedakar designed the study. O Altunyuva and R Kasab performed the dissections. O Altunyuva contributed to data analysis and manuscript drafting. S Yilmazlar provided critical revision and supervision. All authors read and approved the final version of the manuscript.

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Publikationsverlauf

Eingereicht: 30. April 2025

Angenommen: 09. Juni 2025

Artikel online veröffentlicht:
07. Juli 2025