Optochiasmatic Region Surgery

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Optochiasmatic Region Surgery

• Vladimír Bene
• Department of Neurosurgery
• First Faculty of Medicine
• Charles University
• Central Military Hospital
• Prague

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Optochiasmatic Region

• The most frequent target in intracranial surgery
• (in general)
• The best known anatomy
• (hopefully)
• The most complex anatomy (undoubtedly)

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Sellar Region Structures

• Orbit, Sphenoid Wing, Clinoid Processes
• Frontal and Temporal Lobe
• CN I., II., III., IV., V., VI.
• Optic Chiasm, Optic Tracts
• Hypothalamus
• IIIrd Ventricle, Lamina Terminalis
• Pituitary Gland, Pituitary Stalk
• ICA, ACA, MCA, AChoA, Heubner Artery
• Perforators, BA, PCom, ACom, SCA
• Cavernous Sinus, Sphenoparietal Sinus, Sylvian
  Veins
• Cisterns, Lillienquist Membrane

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Lesions

• tumors
• aneurysms
• other

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Numerous Approaches

• confusing
• overlapping
• terminology
• authorship

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Approaches (Avenues) in General

• lateral (pterional)
• midline (bifrontal)
• basal (transsfenoidal)
• convexity (transventricular)
• posterior (far lateral)

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Lateral

• all types of lesions
• most frequently used
• pterional and various modifications
• along the frontal aspect of the wing
• the higher the lesion the lower the approach
• first encountered structure - CN II.

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Fronto-Lateral x Pterional
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O-Z Approach
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BA Aneurysm
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P1 sin.
BA
Pcom sin.
SCA dx.
ICA
n. III dx.
n. II
a. rec. Heubneri
P1 dx.
Pcom dx.
A2 dx.
a. chor. ant.
MCA dx.
AcomA
A1 dx.
A1 sin.
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n. III dx.
n. III sin.
BA
SCA dx.
Pcom sin.
SCA sin.
AcomA
P1 dx.
P1 sin.
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pituitary stalk
tentorium
SCA
M1 sin.
n. IV dx.
pedunculus
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Meningiomas
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Ant.Clinoid Meningioma
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Sphenoid Wing Meningioma
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Tentorial Meningiomas
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High Grade Glioma
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Low Grade Glioma
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IIIrd Nerve Schwanoma
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IIIrd Nerve Schwanoma
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Midline

• large midline lesions
• bifrontal and various modifications
• along the midline skull base structures
• the more posteriorly lesion the lower the
  approach
• first encountered structure - tumor

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Bifrontal Midline Approach
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Interorbital Approach
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Interorbital Approach
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Sphenoid Plane Meningioma
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Sphenoid Plane Meningioma
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Cribriform Plate Meningioma
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Sellar Meningioma
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Pterional
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Basal

• intrasellar lesions (adenomas)
• transsfenoidal and various modification
• along the sphenoid septum
• the lower the lesion the lower the approach
• first encountered structure - pituitary gland

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Transsphenoidal Approach
Endoscopic
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Pituitary Adenoma
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Pituitary Adenoma
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Sphenoid Plane Meningioma
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Maxillotomy
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Hajdu-Cheney
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Giant-Cell Bone Tumor
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Giant-Cell Bone Tumor
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Convexity

• lesions predominantly in the III ventricle
• behind A1 segments
• frontal parasagittal craniotomy
• transcortical x transcallosal
• via foramen Monroi
• landmarks thalamostriate vein
• corpus callosum

rd
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Craniopharyngioma
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Craniopharyngioma
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Posterior

• Skull base lesions
• Extension to CC junction and posteriorly
• Far-lateral approach and modifications
• Along the clivus
• First encountrered structure VA
• Navigation
• Endoscopy

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Chondrosarcoma
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Chondrosarcoma
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Optochiasmatic Region Surgery

• Choice of the Patient
• Surgery x Other Modalities
• Preop Planning
• Navigation
• Closure
• Perop and Postop Care

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Two point technique and planning
Navigation useful in all approaches Endoscopy
assistance important
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Optochiasmatic Region Surgery

• Sellar region lesions usually benign
• Very variable and rewarding surgery
• Dangerous surgery

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Skull Base SurgeryDangers

• Insufficient experience
• Low number of surgeries
• Inability to brake
• Passion for trophy MRs
• Absence of common sense

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Science and art of medicine

• Science - simple
• (cave only the best series from limited
  number of authors get published)
• Art - difficult
• (individual assessment of not only the
  patient but that of own capabilities as well)

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