The changing sella: internal carotid artery shift during transsphenoidal pituitary surgery

Injuries to the internal carotid artery (ICA) are potentially lethal complications in transsphenoidal surgery (TSS) for pituitary lesions. The intercarotid distance (ICD) is thus a major parameter, determining the width of the surgical corridor in TSS. The purpose of the study is to investigate changes in ICD at different levels of the ICA during and after TSS using high definition intraoperative MRI (3T-iMRI).

Pre-, intra- and 3 months postoperative MRI images of 85 TSS patients were reviewed. ICD was measured at the horizontal (ICDC4h) and vertical (ICDC4v) intracavernous C4 segment as well as at the C6 segment (ICDC6). Association between ICD change at different levels and time points were compared and potential factors predicting ICD reduction were analyzed.

ICD decreased intraoperatively at all three segments of ICA by -3% (median decreases: ICDC4h: -0.5 mm, ICDC4v: -0.7 mm ICDC6: -0.4 mm). At 3 months postoperative MRI, ICD reduced by a further -4%, -2% and -4% respectively (median decreases ICDC4h: -0.7, ICDC4v: -0.4 mm, ICDC6: -0.5 mm). Postoperative narrowing in ICD occurred independent of further resection after 3T-iMRI. ICD change correlated between different levels of the ICA indicating a uniform shift perioperatively. Preoperative ICD was significantly associated with the intraoperative reduction in ICDC4v and ICDC6.

We have demonstrated a uniform narrowing in ICD at different levels of the ICA during and after TSS adenoma resection. Surgeons should be aware of this change since it determines the width of the surgical corridor and can thus influence the ease of surgery.