Endoscopic Endonasal Surgery for Pituitary Adenomas with Cavernous Sinus Invasion: Experience with 175 Cases

Abstract

Objective: The intracavernous extension of invasive pituitary adenomas (PA) is often considered inoperable given the high density of neurovascular structures within the cavernous sinus (CS). Study Design: Retrospective chart review. Methods: Retrospective outcome review of 175 patients who underwent EES for invasive PA. CS invasion was confirmed intraoperatively in every case. Results: The majority (75%) were nonfunctioning PA. Clinical presentation included visual deficit in 69.1% of cases, hypopituitarism in 31.4%, hormone hypersecretion in 23.4%, and cranial neuropathies in 12.6%. Gross-total resection was achieved in 37.1%. Following EES, 43 patients received adjuvant treatment for CS residual. After treatment completion (including adjuvant), 83.3% of acromegalics, 50% of prolactinomas, and 33.3% of Cushing disease were in remission. Visual deficits improved in 86.8% of the cases. Cranial nerve (CN) palsies improved in 77.3%. New CN palsies developed in four patients (2.3%) due to apoplexy of residual PA in three. The CSF leak rate was 6.3%. Two patients (1.1%) suffered a carotid artery injury without neurological sequelae. Conclusion: PA invading the CS is difficult to access surgically without new neurological deficits. EES has shown incrementally greater degrees of PA removal than purely microscopic techniques representing the best modern surgical option for the treatment of invasive PA with minimal complications.