The current role of transcranial surgery in the management of pituitary adenomas

Pratheesh, Ravindran; Rajaratnam, Simon; Prabhu, Krishna; Mani, Sunithi; Chacko, Geeta; Chacko, Ari G

doi:10.1007/s11102-012-0439-z

Cited by 39 publications

(31 citation statements)

References 48 publications

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“…patients with pituitary adenomas, Pratheesh et al 30 operatively approached the sella transcranially in 23 instances. They found several common characteristics among their cases: extension lateral to the supraclinoid internal carotid artery (ICA), asymmetrical subfrontal tumor extension, a small sella in relation to the entire tumor volume, and diaphragmatic constriction of the tumor at its waist.…”

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confidence: 99%

“…A volumetric threshold greater than 10 cm 3 was found for lesions that demonstrated high perioperative morbidity and a high rate of subtotal resection following endonasal endoscopic surgery. 18 The tumor characteristics that are independent predictors of subtotal resection include significant vertical intracranial extension, 15,19,42 irregular and multilobular configuration, fibrous and firm consistency, 29,30 and cavernous sinus invasion.…”

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confidence: 99%

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Pituitary macroadenomas with oculomotor cistern extension and tracking: implications for surgical management

Hoang¹,

Tran²,

Herde

et al. 2016

JNS

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T reaTmenT management strategies for pituitary macroadenomas depend on numerous factors that guide the determination of medical management, surgical approach, and/or adjuvant therapeutic options. Maximal resection and adequate decompression of the neurological structures is the paradigm of care for symptomatic pituitary macroadenomas, with the exception of medically responsive prolactinomas.Since its inception by Schloffer in 1907 and then refinement and popularization by Hirsch, Guiot, and Hardy, the transsphenoidal approach has become the preferred route to the sella because of its relative safety profile. 9,14,16,17 The transcranial route still plays an important role in providing access to the sella in 1% to 4% of pituitary macroadenomas where direct visualization and accessibility via the transsphenoidal approach are limited. 38A transcranial approach should be considered in the surgical management of pituitary adenomas that display constriction at the diaphragma sellae, parasellar extension or inaccessible suprasellar extension off the midline, tumors of fibrous consistency with large suprasellar extension, and in patients with an active sinus infection or a coexisting adjacent aneurysm. Other cases that should be approached transcranially include those patients with ectatic intrasellar carotid arteries, 40 retrosellar extension, brain invasion with edema, involvement or vasospasm of the arteries of the circle of Willis, or encasement of the optic apparatus or invasion of the optic foramina. obJective Oculomotor cistern extension of pituitary adenomas is an overlooked feature within the literature. In this study, 7 cases of pituitary macroadenoma with oculomotor cistern extension and tracking are highlighted, and the implications of surgical and medical management are discussed. methods The records of patients diagnosed with pituitary macroadenomas who underwent resection and in whom preoperative pituitary protocol MRI scans were available for review were retrospectively reviewed. The patient and tumor characteristics were reviewed along with the operative outcomes and complications. results Seven patients (4.1%) with oculomotor cistern extension and tracking were identified in a cohort of 170 patients with pituitary macroadenoma. The most common presenting symptoms were visual deficit (6 patients; 86%), apoplexy (3 patients; 43%), and oculomotor nerve palsy (3 patients; 43%). Lone oculomotor nerve palsy was seen in 2 patients without apoplexy and 1 patient with an apoplectic event. Gross-total resection was achieved via a microscopic endonasal transsphenoidal approach with or without endoscopic aid to the sella in 14%, near-total resection in 29%, and subtotal resection in 57% of patients in the data set. coNclusioNs Pituitary adenoma extension along the oculomotor cistern is uncommon; however, preoperatively recognizing such extension should play an important role in the surgeon's operative considerations and postoperative clinical management because this extension can limit gross-total resection using t...

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confidence: 99%

Pituitary macroadenomas with oculomotor cistern extension and tracking: implications for surgical management

Hoang¹,

Tran²,

Herde

et al. 2016

JNS

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“…Pterional surgery is applied to tumors extending to one side, making full use of the anterior area of optic chiasma, the space between optic nerve and internal carotid artery, and between internal carotid artery and oculomotor nerve. This approach could not only remove tumors but also avoid excessive traction of frontal lobe, as well as protect surrounding structures such as pituitary stalk, optic nerve and internal carotid artery [ 30 , 31 ]. In the present case series, 4 cases (40%) achieved GTR via pterional approach, involving 2 patients of recurrent adenomas after transsphenoidal approach.…”

Section: Discussionmentioning

confidence: 99%

Clinical features and management of nonfunctioning giant pituitary adenomas causing hydrocephalus

et al. 2018

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We evaluated the features of clinically nonfunctioning giant pituitary adenomas (NFGPAs) causing hydrocephalus to highlight the timing of hydrocephalus management and surgical approaches. A total of 24 patients with NFGPAs and hydrocephalus were included. Eighteen patients underwent endoscopic transsphenoidal surgery. Ten patients received pterional surgery, including 6 patients as first treatment and 4 cases with recurrence after transsphenoidal approach. Gross total resection was achieved in 10 patients, including 6 cases (6/18, 33.3%) with endoscopic transsphenoidal surgery and 4 cases (4/10, 40%) with pterional surgery. All patients were divided into preoperative EVD group and non-preopoerative EVD group. The proportion of patients receiving postoperative EVD or shunt was significantly higher in non-preoperative EVD group than that in preoperative EVD group (9/15 vs. 1/9, P = 0.033). Visual impairment score (VIS) was evaluated for each patient. We detected significant vision improvement according to the preoperative and postoperative VIS (median, interquartile range: 62, 48.25–77 vs. 36.5, 0–50.75, P < 0.001). Conclusively, for patients with NFGPAs and hydrocephalus, preoperative EVD might reduce the need for a second shunt or EVD. Surgical approach should be decided based on the clinicoradiological features and surgeons’ experience for individualized treatment, and endoscopic transsphenoidal resection of pituitary adenomas was suggested for most NFGPAs.

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“…In these cases also the transcranial route may be the best surgical approach. In only about 5% of the cases, the transcranial approach is necessary 20) . Pituitary stalk (PS) preservation is important during surgery of pituitary adenomas in order to reduce the risk of post-operative diabetes insipidus (DI).…”

Section: Introductionmentioning

confidence: 99%

Correlation between the Position of the Pituitary Stalk as Determined by Diffusion Tensor Imaging and Its Location as Determined at the Time of Surgical Resection of Pituitary Adenomas

Wang

Yang

et al. 2020

J Korean Neurosurg Soc

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Objective : An important factor during pituitary adenoma surgery is to preserve pituitary stalk (PS) as this plays a role in reduction of the risk of postoperative diabetes insipidus. The hypothalamic-hypophyseal tract (HHT) projects through the PS to the posterior pituitary gland. To reconstruct white matter fiber pathways, methods like diffusion tensor imaging (DTI) tractography have been widely used. In this report we attempted to predict the position of PS using DTI tractography and to assess its intraoperative correlation during surgery of pituitary adenomas. Methods : DTI tractography was used to tract the HHT in nine patients before craniotomy for pituitary adenomas. The DTI location of the HHT was compared with the PS position identified at the time of surgery. DTI fiber tracking was carried out in nine patients prior to the planned craniotomy for pituitary adenomas. In one patient, the PS could not be identified during the surgery. In the other eight patients, a comparison was made between the location of the HHT identified by DTI and the position of the PS visualized at the time of surgery. Results : The position of the HHT identified by DTI showed consistency with the intraoperative position of the PS in seven patients (88.9% concordance). Conclusion : This study shows that DTI can identify the position of the HHT and thus the position of the PS with a high degree of reliability.

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The current role of transcranial surgery in the management of pituitary adenomas

Cited by 39 publications

References 48 publications

Pituitary macroadenomas with oculomotor cistern extension and tracking: implications for surgical management

Pituitary macroadenomas with oculomotor cistern extension and tracking: implications for surgical management

Clinical features and management of nonfunctioning giant pituitary adenomas causing hydrocephalus

Correlation between the Position of the Pituitary Stalk as Determined by Diffusion Tensor Imaging and Its Location as Determined at the Time of Surgical Resection of Pituitary Adenomas

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