Transcranial surgery for pituitary adenomas

Abstract

Following a century of evolution and refinements in standard surgical techniques, the vast majority of operations for pituitary adenoma to date are performed utilizing transsphenoidal approaches. From current large series one obtains the impression that certainly less than 10% of these tumors require craniotomies. However, still several tumors, which's volume is mainly localized outside of the sella require transcranial approaches, of which the pterional and subfrontal routes are the most widely used. The goal of surgical treatment is rapid eradication of the tumor mass, decompression of visual pathways and elimination of hormonal oversecretion whilst preserving the normal gland and avoiding potential surgical complications. Even with microsurgical techniques and standardized approaches, there is still some mortality associated with transcranial approaches and morbidity is undoubtly higher than with transsphenoidal operations. However, a selection bias must be considered, which shifts tumors with a larger size, less favourable prognosis and higher complication rate into the transcranial series. Moreover, with extended transsphenoidal approaches, lesions have become accessible for transsphenoidal surgery, which previously have been considered as contraindications. In this article current indications and limitations for transcranial surgery of pituitary adenomas, the preoperative workup, surgical techniques, results, and complications are briefly reviewed.

Microscopic surgery for pituitary adenomas to preserve the pituitary gland and stalk

“…The present The majority of pituitary tumors (with or without suprasellar extension) are removed via transnasal transphenoidal microscopic surgery. However, transcranial microscopic surgery is recommended in up to 10% of patients (5,6,20). In the present patient series, 138 patients (90.2%) underwent transphenoidal surgeries, and 15 patients (9.8%) received transcranial operations.…”

“…Regardless of the surgical approach, the treatment goals were four-fold: i) To achieve GTR whenever possible, ii) reduce intracranial pressure if present, iii) relieve neurological and endocrine manifestations, and iv) preserve normal pituitary anatomy. It is important to preserve both the gland and stalk in order to minimize new postoperative endocrinopathies and improve quality of life (5,15,21). Preoperative pituitary MRI provides invaluable information to facilitate the localization and protection of the gland and stalk during surgery.…”

“…Due to significant mortality rates associated with this approach, Schloffer explored a transphenoidal route to the sellar region in the early 1900s (3). Following the introduction of the operating microscope into transphenoidal surgery in the 1960s (4), there was a marked reduction in postoperative morbidity and mortality (5)(6)(7)(8). This microsurgical technique is still considered to be the gold standard for pituitary tumor management (9).…”

A Purely Endoscopic and Simultaneous Transsphenoidal and Transcranial Keyhole Approach for Giant Pituitary Adenoma Resection: A Technical Case Report

“…[1][2][3][4] Various modifications of transsphenoidal surgery that overcome these challenges have been reported. 3,5,6,13) For example, extended transsphenoidal surgery can be used to directly approach the suprasellar area without brain retraction and expose the suprasellar component of the tumor as well as the optic nerves and the anterior cerebral arteries. 14) However, removing a tumor with a large suprasellar component and/ or lateral extension is still challenging using this approach.…”

What Remains of Transcranial Surgery in The Treatment of Pituitaryadenomas

“…First by the re-introduction of trans-sphenoidal approach by Gérard GUIOT in (1958) under the image intensifier and there was additional finesse provided by the use of the microscope introduced by Jules HARDY to achieve a microscopic transsphenoidal surgery (2)(3). With the development of technology and the introduction of minimally invasive surgery, a pure endoscopic transsphenoidal technique was introduced in 1997, JHO reported a series of 50 cases of which 46 were treated with this approach (4-5-6) .…”