Transcranial Approach to Invasive Giant Pituitary Adenoma: 2-Dimensional Operative Video.

Abstract

“…not knowing just what was the correct procedure, whether to go at the gland from above or below” -Harvey Cushing, cited by Cohen-Gadol et al1 Large and invasive pituitary tumors can be aggressive with extensive parasellar involvement and brain compression.2 Nowadays, most pituitary adenomas with suprasellar extensions are approached through a nasal transsphenoidal route with an excellent result; endoscope is particularly helpful in the visualization of parasellar extensions. There are, however, some cases where parasellar extensions with critical neurovascular encasement are beyond the axis of transsphenoidal route despite the advantageous use of endoscopy. In such cases, radical surgical removal cannot be achieved with transnasal approach, and the risk of infarct and hemorrhage of the residual tumor is considerable. A cranial approach allows extradural and intradural microsurgical dissection of the tumor involving the internal carotid artery and its branches and permits radical resection of laterally extending tumor and total decompression of the optic pathways.2,3 It is also more efficacious in recurrent cases4 We demonstrate this technique in a 28-year-old man with a giant tumor extending into the left hemisphere and right cavernous sinus operated in 1999 when radical resection was achieved. The patient presented in 2002 with growth in the remnant tumor in the right cavernous sinus. The tumor was resected with neurological function preservation including ocular movements. The transcranial approach to the giant and invasive pituitary adenomas is a safe option in selected cases to deal with these defiant tumors.4,5 The patient consented to surgery and publication of his images. Image at 2:06 reused from Surgical Neurology, 50(6), Arnautović KI, Al-Mefty O, and Angtuaco E, A combined microsurgical skull-base and endovascular approach to giant and large paraclinoid aneurysms, p 17, ©1998, with permission from Elsevier Science Inc. Images at 2:17 and 2:27 reused with permission from Al-Mefty O, Operative Atlas of Meningiomas, Vol 1, ©LWW, 1998. Images at 2:43 reused with permission from Krisht and Tyndall, Pituitary Disorders: Comprehensive Management, Vol 1, ©LWW, 1999. {"href":"Single Video Player","role":"media-player-id","content-type":"play-in-place","position":"float","orientation":"portrait","label":"","caption":"","object-id":[{"pub-id-type":"doi","id":""},{"pub-id-type":"other","content-type":"media-stream-id","id":"1_v58ijph3"},{"pub-id-type":"other","content-type":"media-source","id":"Kaltura"}]}