Endoscopic Endonasal Transtubercular Approach for Resection of Giant Pituitary Adenomas With Subarachnoid Extension: The “Second Floor” Strategy to Avoid Postoperative Apoplexy

Abstract

Giant pituitary adenomas (GPAs) with subarachnoid extension can be challenging to achieve a gross total resection through a single endonasal or transcranial approach, and any residual tumor is at risk for postoperative apoplexy. Intraoperative venous congestion of the suprasellar tumor can occur following resection of the sellar tumor, limiting tumor descent, and leading to suprasellar residual. We propose a technique for resecting the suprasellar component first, which we call the "second floor" strategy (SFS) for GPA. A retrospective review of cases from 2010-2020 identified 586 endoscopic endonasal approaches (EEAs) for pituitary adenoma resection. We report the rate of postoperative apoplexy and describe the SFS technique used in 2 cases. Of 586 cases, 2 developed symptomatic postoperative apoplexy (0.3%), and a third transferred to our care after undergoing postoperative apoplexy. All 3 cases had subarachnoid extension of a pituitary adenoma, underwent EEA, and had residual suprasellar tumor. All 3 had permanent morbidity due to the postoperative apoplexy including blindness, stroke, or death, despite undergoing reoperation. The SFS was used for reoperation on 1 of these patients and as a primary strategy in a fourth patient who presented with a GPA with subarachnoid extension. We describe the SFS technique and demonstrate it with a 2-dimensional operative video. Postoperative apoplexy of residual adenoma is a rare but serious complication after GPA resection. The proposed SFS allows early access to the suprasellar tumor and may improve the ability to safely achieve a gross total resection without need for additional procedures.