NEUROSURGICAL

FOCUS Neurosurg Focus Video 2 (2):V10, 2020

VIDEO
Endonasal interdural pituitary transposition for resection
of a posterior clinoid process enchondroma
in a patient with Maffucci syndrome
Lei Zhao, MD, PhD,1 Shuo Zhang, MD,1 Li Gong, MD, PhD,2 Yan Qu, MD, PhD,1 and Lijun Heng, MD, PhD1

Departments of 1Neurosurgery and 2Pathology, Tangdu Hospital, Air Force Medical University, Shaanxi, China

Maffucci syndrome is an extremely rare disorder characterized by benign enchondromas, skeletal deformities, and cuta-
neous lesions composed of abnormal blood vessels. Enchondromas rarely arise in the cranial bones. Interdural pituitary
transposition is an effective way to gain access to the posterior clinoid, without affecting the function of the pituitary
gland. Here, the authors present a case of a posterior clinoid process enchondroma in a patient with Maffucci syndrome.
The tumor was resected via an interdural pituitary transposition fashion. Four months postoperatively, the patient’s oculo-
motor function had recovered to normal and the function of the pituitary gland was preserved intact.

The video can be found here: https://youtu.be/EYgVwVZuC4g.

KEYWORDS interdural pituitary transposition; posterior clinoid process; Maffucci syndrome; parasellar lesion; video

Transcript sect the lesion. The patient was placed in supine position.
This video demonstrates endoscopic endonasal inter- Neuronavigation and Doppler monitoring was set and used
dural pituitary transposition for resection of a posterior intraoperatively.
clinoid process enchondroma in a patient with Maffucci
syndrome. 1:26 The anterior and inferior walls of sphenoidal
sinus were widely opened. Subsequently, bony exposure
0:32 The patient is a 24-year-old female presented with was continued in the sellar and left parasellar regions. The
ptosis and oculomotor deficit lasting for 3 weeks. Her left bone covering the sellar floor and the anterior wall of the
hand presented with multiple hemangiomas, which is one left cavernous sinus was removed with high-speed drill.
of the critical diagnostic criteria for Maffucci syndrome.
Preoperative MRI showed a left upper clivus lesion, 1:44 The anterior wall of cavernous sinus was opened
mainly involving the posterior clinoid process. Collateral with a retractable hook knife. Venous bleeding from cav-
compensation was evaluated preoperatively using balloon ernous sinus could be stopped with hemostasis agent injec-
occlusion test. The patient showed acceptable tolerance af- tion followed by cotton pledget pressing. The paraclival
ter temporary balloon occlusion of the left internal carotid carotid artery was further exposed using eggshell tech-
artery at the petrous segment. nique.

1:11 The endoscopic endonasal transcavernous ap- 2:18 After the anterior wall was further opened, the
proach with pituitary gland transposition was used to re- medial or sphenoidal wall of cavernous sinus was retracted
to the right side with pituitary gland. The inferior hypoph-

SUBMITTED December 11, 2019. ACCEPTED January 6, 2020.

INCLUDE WHEN CITING Published online April 1, 2020; DOI: http://thejns.org/doi/abs/10.3171/2020.4.FocusVid.19801
© 2020, The Authors, CC BY 4.0 (http://creativecommons.org/licenses/by/4.0/)

Neurosurg Focus Video Volume 2 • April 2020 1

Zhao et al.

yseal artery was subsequently coagulated and transected and demonstrated the region of postoperative bony defect.
to gain access to the posterior clinoid. No significant change was indicated by the pre- and post-
operative endocrinological function comparison.
2:43 After successful creating a transcavernous corri-
dor by interdural pituitary transposition, the cortical bone 7:25 In summary, endoscopic endonasal transcavern-
of upper clivus was drilled open. The lesion involving ous approach with pituitary gland transposition could take
posterior clinoid process was identified and removed in advantage of the corridor provided by the cavernous sinus
a piecemeal-by-piecemeal fashion. Microsurgical curette to gain access to the posterior clinoid area safely. Appro-
was useful for blunt dissection at this stage. The texture priate venous bleeding control with hemostatic agent in-
of the lesion was not homogenous. Mixture of both bony jection is essential for maintaining a clear surgical field
and cartilage components could be found inside the mass. and improving the safety of the operation. Unilateral re-
The magnified view of the endoscope and the bimanual section of the inferior hypophyseal artery does not influ-
four-hand technique improved the safety of resection. The ence the pituitary function.
involved clival and petrous bone should be removed to the
maximum extent to prevent recurrence. Acknowledgments
The technique used in this case was funded by the Annual Novel
3:52 Some parts of the lesion were with tight adhesion Technical Project of Tangdu Hospital; Creativity and Development
to the surrounding soft tissue. In situ sharp dissection with Funding of Tangdu Hospital (2016LCYJ008, 2018LCYJ006);
microscissors should be used to detach the lesion before its and Young Scientific and Technological Star Project of Shaanxi
removal. The tip of the posterior clinoid process was usu- (2016KJXX-17).
ally sharp and irregular due to the ligament attachment. It
was also necessary to be detached first and removed care- References
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Wang EW, Snyderman CH, et al: Bilateral coagulation of
prevent relapse for this young patient. The corner behind inferior hypophyseal artery and pituitary transposition dur-
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2019
6:14 The pan view under endoscope showed gross-to-
tal resection of the lesion. The dura graft was placed under
the dura mater as inlay. The nasal septal flap was covered Correspondence
as onlay. The BioGlue was evenly applied at last. Lijun Heng, Tangdu Hospital, Air Force Medical University,
Shaanxi, China. [email protected].
6:36 The pathological examination indicated the lesion
as an enchondroma. Disclosures
The authors report no conflict of interest concerning the mate-
6:43 On postoperative day 1, the patient’s left eye could rials or methods used in this study or the findings specified in this
perform a slight medial movement. Four months postoper- publication.
atively, the oculomotor function of the left eye had dramati-
cally recovered to normal and the ptosis was completely
resolved. MRI, at this stage, suggested the gross-total re-
section of the tumor without recurrence. Three-dimension-
al CT skull base reconstruction also confirmed the result

2 Neurosurg Focus Video Volume 2 • April 2020