Intraoperative Doppler ultrasound of the cavernous part of the internal carotid artery in endoscopic transsphenoidal removal of the laterosellar tumors

The study objective is to describe the technique of intraoperative Doppler ultrasound (DU) of brain arteries and to determine the indications for its use during endoscopic transsphenoidal operations. Materials and methods. The study included 100 patients with skull base tumors (pituitary adenomas, trigeminal schwannomas, chordomas), operated via standard or extended transsphenoid endoscopic approaches. For DU, the location of the internal carotid artery (ICA) relative to the surface of the tumor or dura mater was determined as a red and/or blue color of the monitor screen in the M-mode window, accompanied by a characteristic sound signal. Results. DU was used to remove pituitary adenomas in 95 cases, trigeminal schwannomas in 3 cases, chordomas in 2 cases. Intraoperative DU helped to locate the ICA during removal of the laterosellar part of the tumor in all observations. In none of the cases presented were no injuries to the ICA. Сonclusion. DU is an effective and non-invasive method for detecting ICA during endoscopic operations which contributes to the safe disposal of laterosellar tumors. Adequate use of the method does not carry well-known and potential risks. DU should be performed when the tumor is removed from the cavernous sinus or its projection via the lateral extended transsphenoidal endoscopic access (to determine the safe boundaries of the dura mater section in the cavernous sinus projection).

1. Kassam A.B., Gardner P., Snyderman C. et al. Expanded endonasal approach: fully endoscopic, completely transnasal approach to the middle third of the clivus, petrous bone, middle cranial fossa, and infratemporal fossa. Neurosurg Focus 2005;19(1):E6. PMID: 16078820.

2. Dusick J.R., Esposito F., Malkasian D., Kelly D.F. Avoidance of carotid artery injuries in transsphenoidal surgery with the Doppler probe and micro-hook blades. Neurosurgery 2007;60(4 Suppl 2):322–8. DOI: 10.1227/01.NEU.0000255408. 84269.A8. PMID: 17415170.

3. Cappabianca P, Cavallo LM, Colao A, de Divitiis E. Surgical complications associated with the endoscopic endonasal transsphenoidal approach for pituitary adenomas. J Neurosurg 2002;97(2):293–8. DOI: 10.3171/jns.2002.97.2.0293. PMID: 12186456.

4. Tabaee A., Anand V.K., Barrón Y. et al. Endoscopic pituitary surgery: a systematic review and meta-analysis. J Neurosurg 2009;111(3):545–54. DOI: 10.3171/2007.12.17635. PMID: 19199461.

5. Kalinin P.L., Sharipov O.I., Shkarubo A.N. et al. Damage to the cavernous segment of internal carotid artery in transsphenoidal endoscopic removal of pituitary adenomas(report of 4 cases). Voprosy neyrokhirurgii im. N.N. Burdenko = Problems of Neurosurgery n. a. N.N. Burdenko 2013;77(6):28–38. (In Russ.)

6. Usachev D.Yu., Lukshin V.A., Yakovlev S.B. et al. Combined surgical treatment of cavernous internal carotid artery pseudoaneurysm. Voprosy neyrokhirurgii im. N.N. Burdenko = Problems of Neurosurgery n. a. N.N. Burdenko 2016;80(5):116–23. (In Russ.)

7. Eliava Sh.Sh., Shekhman O.D., Zolotukhin S.P. et al. Intraoperative contact Doppler study in the surgery of cerebral aneurysm. Voprosy neyrokhirurgii im. N.N. Burdenko = Problems of Neurosurgery n. a. N.N. Burdenko 2006;(2):42–7. (In Russ.)

8. Brain aneurysm surgery. Ed. by V.V. Krylov. Vol. 1. Moscow, 2011. Pp. 126–165. (In Russ.)

9. Yamasaki T., Moritake K., Nagai H., Kimura Y. Integration of ultrasonography and endoscopy into transsphenoidal surgery with a “picture-in-picture” viewing system – technical note. Neurol Med Chir (Tokyo) 2002;42(6):275–7. PMID: 12116536.

10. Solheim O., Selbekk T., Løvstakken L. et al. Intrasellar ultrasound in transsphenoidal surgery: a novel technique. Neurosurgery 2010;66(1):173–85. DOI: 10.1227/01.NEU. 0000360571.11582.4F. PMID: 20023548.

11. Knosp E., Steiner E., Kitz K., Matula C. Pituitary adenomas with invasion of the cavernous sinus space: a magnetic resonance imaging classification compared with surgical findings. Neurosurgery 1993;33(4):610–7. DOI: 10.1097/00006123-199310000-00008. PMID: 8232800.

12. Kalinin P.L., Sharipov O.I., Pronin I.N. et al. Endoscopic transsphenoidal resection of pituitary adenomas invading the cavernous sinus. Voprosy neyrokhirurgii im. N.N. Burdenko = Problems of Neurosurgery n. a. N.N. Burdenko 2016;80(4):63–74. (In Russ.)

13. Koutourousiou M., Vaz Guimaraes Filho F., Fernandez-Miranda J.C. et al. Endoscopic endonasal surgery for tumors of the cavernous sinus: a series of 234 paients. World Neurosurg 2017;103:713–2. DOI: 10.1016/j.wneu.2017.04.096. PMID: 28450229.