Endonasal Surgery For Pituitary Adenomas Research Articles

Headache alleviation with nasal irrigation following endoscopic endonasal surgery for pituitary adenomas

BackgroundHeadache is a common occurrence after endoscopic endonasal surgery (EES) for pituitary adenomas and significantly impacts the quality of life of patients. This study aims to investigate the effectiveness of nasal irrigation in relieving postoperative headache after EES.MethodsA retrospective analysis was conducted on a cohort of 101 patients (Cohort I) who underwent EES for pituitary adenomas to explore the risk factors associated with postoperative headache. Another cohort of 72 patients (Cohort II) who received adjuvant nasal irrigation following surgery was enrolled for further analysis. The Headache Impact Test (HIT-6) was used to score the severity of headache, and patients with a HIT score > 55 were classified as having headache.ResultsIn Cohort I, 21.78% of patients experienced headache one month after EES, which decreased to 5.94% at the three-month follow-up. Multivariate analysis revealed that postoperative nasal sinusitis (OR = 3.88, 95%CI 1.16–13.03, p = 0.028) and Hardy’s grade C-D (OR = 10.53, 95%CI 1.02-109.19, p = 0.049) independently predicted the presence of postoperative headache at one month. At the three-month follow-up, patients with sinusitis had higher HIT-6 scores compared to those without sinusitis (44.43 ± 9.78 vs. 39.72 ± 5.25, p = 0.017). In Cohort II, the incidence of sinusitis at three months was significantly lower than that in Cohort I (p = 0.028). Importantly, both the incidence of headache and HIT-6 scores in Cohort II were significantly lower than those in Cohort I at the one- and three-month follow-ups.ConclusionsPostoperative sinusitis is an independent risk factor for the development of headache following EES for pituitary adenomas. Prophylactic nasal irrigation helps relieve postoperative headache, possibly by preventing the occurrence of sinusitis.

Management and risk of postoperative bleeding in patients with low-dose antiplatelet aspirin medication during endoscopic endonasal surgery for pituitary adenomas.

To analyze the risk of postoperative bleeding following endoscopic endonasal transsphenoidal surgery (EETS) for treatment of pituitary adenomas (PA) in patients with short-term discontinuation of low-dose aspirin, if required for prevention of artherothrombotic disease (ATD). Patients with preoperative aspirin medication were identified in this single-center retrospective analysis of consecutive patients with PA, who underwent EETS between December 2008 and June 2022. Aspirin was discontinued perioperatively less than 2days, > 2 and < 4days, and > 4 and < 7days according to the assumed risk of perioperative ATD. For those patients, the rate of postoperative bleeding, which required surgery, was compared to patients without aspirin. Forty-five (14.8%) out of 304 patients underwent EETS with short-term perioperative aspirin discontinuation. Thirty-six (80%) patients discontinued aspirin < 2days, 6 (13.3%) patients > 2 and < 4days, and 3 patients (6.7%) > 4 but < 7days. Postoperative bleeding rate was not increased in patients with short-term perioperative aspirin discontinuation. One patient (0.3%) without perioperative aspirin medication underwent revision surgery for treatment of postoperative hemorrhage with suprasellar extension. Eight patients (2.6%) had postoperative epistaxis (1 patient (0.3%) with short-term discontinuation and 7 patients (2.3%) without aspirin). Patients with perioperative aspirin were significantly older (68.3 ± 8.6 vs. 57.9 ± 14.1; p < 0.01) and had a significantly lower rate of hormonally active tumors (11.1% vs. 25.1%; p < 0.05) compared to patients without aspirin. No differences were found for tumor characteristics (tumor extension, tumor volume, largest diameter) between both groups. Short-term discontinuation of low-dose aspirin was not associated with increased rate of postoperative bleeding in patients, who underwent EETS for treatment of PA.

Prospective evaluation of multidimensional health-related quality of life after endoscopic endonasal surgery for pituitary adenomas using the endoscopic endonasal sinus and skull base surgery questionnaire.

Social functioning is an important factor in the evaluation of postoperative health-related quality of life (HRQoL) for pituitary adenoma patients. In a prospective cohort study multidimensional HRQoL of non-functioning (NFA) and functioning (FA) pituitary adenoma patients were evaluated following endoscopic endonasal surgery using the endoscopic endonasal sinus and skull base surgery questionnaire (EES-Q). Prospectively, 101 patients were included. The EES-Q was completed preoperatively and postoperatively (2 weeks, 3months, 1year). Sinonasal complaints were completed daily during the first week postoperatively. Preoperative and postoperative scores were compared. A generalized estimating equation (uni- and multivariate) analysis was performed to identify significant HRQoL changes related to selected covariates. Two weeks postoperatively, physical (p < .05) and social (p < .05) HRQoL are worse and psychological (p < .05) HRQoL improved compared with preoperatively. Three months postoperatively, psychological HRQoL (p=.01) trended back to baseline and no differences in physical or social HRQoL were reported. One year postoperatively, psychological (p=.02) and social (p=.04) HRQoL improved while physical HRQoL remained stable. FA patients report a worse HRQoL preoperatively (social, p < .05) and 3months postoperatively (social, p < .02 and psychological, p < .02). Sinonasal complaints peak in the first days postoperatively and gradually return to presurgical levels 3months postoperatively. The EES-Q provides meaningful information on multidimensional HRQoL to improve patient-centred health care. Social functioning remains the most difficult area in which to achieve improvements. Despite the relatively modest sample size, there is some indication that the FA group continues to show a downward trend (and thus improvement) even after 3months, when most other parameters reach stability. Level II-B.

Clinical application of the "sellar barrier's concept" for predicting intraoperative CSF leak in endoscopic endonasal surgery for pituitary adenomas with a machine learning analysis.

BackgroundRecently, it was defined that the sellar barrier entity could be identified as a predictor of cerebrospinal fluid (CSF) intraoperative leakage. The aim of this study is to validate the application of the sellar barrier concept for predicting intraoperative CSF leak in endoscopic endonasal surgery for pituitary adenomas with a machine learning approach.MethodsWe conducted a prospective cohort study, from June 2019 to September 2020: data from 155 patients with pituitary subdiaphragmatic adenoma operated through endoscopic approach at the Division of Neurosurgery, Università degli Studi di Napoli “Federico II,” were included. Preoperative magnetic resonance images (MRI) and intraoperative findings were analyzed. After processing patient data, the experiment was conducted as a novelty detection problem, splitting outliers (i.e., patients with intraoperative fistula, n = 11/155) and inliers into separate datasets, the latter further separated into training (n = 115/144) and inlier test (n = 29/144) datasets. The machine learning analysis was performed using different novelty detection algorithms [isolation forest, local outlier factor, one-class support vector machine (oSVM)], whose performance was assessed separately and as an ensemble on the inlier and outlier test sets.ResultsAccording to the type of sellar barrier, patients were classified into two groups, i.e., strong and weak barrier; a third category of mixed barrier was defined when a case was neither weak nor strong. Significant differences between the three datasets were found for Knosp classification score (p = 0.0015), MRI barrier: strong (p = 1.405 × 10−6), MRI barrier: weak (p = 4.487 × 10−8), intraoperative barrier: strong (p = 2.788 × 10−7), and intraoperative barrier: weak (p = 2.191 × 10−10). We recorded 11 cases of intraoperative leakage that occurred in the majority of patients presenting a weak sellar barrier (p = 4.487 × 10−8) at preoperative MRI. Accuracy, sensitivity, and specificity for outlier detection were 0.70, 0.64, and 0.72 for IF; 0.85, 0.45, and 1.00 for LOF; 0.83, 0.64, and 0.90 for oSVM; and 0.83, 0.55, and 0.93 for the ensemble, respectively.ConclusionsThere is a true correlation between the type of sellar barrier at MRI and its in vivo features as observed during endoscopic endonasal surgery. The novelty detection models highlighted differences between patients who developed an intraoperative CSF leak and those who did not.

Risk factors and management associated with postoperative cerebrospinal fluid leak after endoscopic endonasal surgery for pituitary adenoma.

ObjectiveTo determine risk factors and management for the development of a postoperative cerebrospinal fluid (CSF) leak after an endoscopic endonasal surgery (EES) for pituitary adenomas.MethodsThe clinical data of 400 patients who underwent EES for resection of pituitary adenomas from December 2018 to November 2019 in the Department of Neurosurgery of Beijing Tiantan Hospital were retrospectively reviewed. Age, gender, body mass index (BMI), tumor size, Knosp grade, suprasellar extension grade, sellar floor erosion grade, repeated transsphenoidal surgery, intraoperative CSF leak, use of pedicled nasoseptal flap and lumbar drain were collected and analyzed.ResultsPostoperative CSF leak occurred in 14 of 400 patients (3.5%). Age, gender, BMI, tumor size, Knosp grade and repeated transsphenoidal surgery were not risk factors for CSF leak. Suprasellar extension grade (≥B 6.0% vs. <B 1.4%; p = 0.024), sellar floor erosion grade (≥III 5.7% vs. <III 0.6%; p = 0.020) and intraoperative CSF leak (Yes 7.5% vs. No 2.0%; p = 0.009) were factors associated with an increased postoperative CSF leak rate.ConclusionsHigher suprasellar extension grade, higher sellar floor erosion grade and intraoperative CSF leak were risk factors for postoperative CSF leak after endoscopic treatment of pituitary adenoma. Strict skull base reconstruction including use of a pedicled nasoseptal flap and perioperative lumbar drainage may avoid postoperative CSF leak.

Evaluation of nasal function after endoscopic endonasal surgery for pituitary adenoma: a computational fluid dynamics study

Objective To analyze the effect of different endoscopic endonasal approaches (EEAs) on nasal airflow and heating and humidification in patients with pituitary adenoma (PA) by computational fluid dynamics (CFD). Methods A three-dimensional pre-surgical model (Pre) of the nasal cavity and 6 that were post-EEA surgery were created from computed tomography scans as follows: small posterior septectomy (0.5 cm, sPS), middle posterior septectomy (1.5 cm, mPS), large posterior septectomy (2.5 cm, lPS), and sPS with middle turbinate resection (sPS-MTR), mPS-MTR, and lPS-MTR. Simulations were performed by CFD to compare the changes in different models. Results The temperature in the nasal vestibule rose more rapidly than in other parts of the nasal cavities in all models. There were no apparent differences in temperature and humidity among the models in sections anterior to the middle turbinate head (C6 section). MTR significantly influenced airflow distribution between the bilateral nasal cavities and the different parts of the nasal cavity, while changes in temperature and humidity in each section were mainly affected by MTR. The temperature and humidity of the choana and nasopharynx of each postoperative model were significantly different from those of the preoperative model and the change in values significantly correlated with the surface-to-volume ratio (SVR) of the airway. Conclusions Changes due to the different nasal structures caused different effects on nasal function following the use of EEA surgery for the treatment of PA. CFD provided a new approach to assess nasal function, promising to provide patients with individualized preoperative functional assessment and surgical planning.

Experience of Endoscopic Endonasal Approach for 803 Pituitary Tumors With Cavernous Sinus Invasion.

The aim of this study was to investigate the effectiveness, safety, complications, and prognosis of endoscopic endonasal surgery for pituitary adenomas with cavernous sinus invasion (CSI). The clinical data of 803 pituitary adenomas with CSI surgeries performed in our single ward between January 1, 2006 and December 31, 2018 were retrospectively reviewed. The resection degree, bone invasion, endocrine examination, complications, and outcome were retrospectively summarized. Gross total resection was achieved in 394 patients (49.1%) subtotal resection in 171 patients (21.3%) and partial resection in 238 patients (29.6%). Clinically variable analyses showed that there was a significant correlation between CSI and female, older age, operation history, and non-gross total resection (NGTR). Among the pituitary adenomas with CSI, there was a significant correlation between bone invasive and NGTR, Knosp classification, recurrence. K-M curves showed that young age, larger tumors, bilateral invasion, Grade 4 of Knosp classification, NGTR, and bone invasion were associated with pituitary adenomas regrowth. Multivariate analysis revealed that bone invasion, NGTR, and Grade 4 of Knosp classification were independent risk factors for pituitary adenomas regrowth. There was a significant correlation between CSI and female, older age, operation history, and tumor resection degree. There was a significant correlation between CSI and female, older age, operation history, and tumor resection degree. The patients with CSI and bone invasion were likely to recurrent. Non-gross total resection, bone invasion, and Grade 4 of Knosp classification were independent risk factors for pituitary adenomas regrowth. Endoscopic endonasal surgery is an excellent choice for pituitary adenomas with CSI.

Clinical application of the “sellar barrier’s concept” for predicting intraoperative CSF leak in endoscopic endonasal surgery for pituitary adenomas with a machine learning analysis

Clinical application of the “sellar barrier’s concept” for predicting intraoperative CSF leak in endoscopic endonasal surgery for pituitary adenomas with a machine learning analysis

Risk Factors Associated With CSF Leak Rates In Extended Approaches For Pituitary Adenomas Endoscopic Endonasal Surgery: A Systematic Review

Over the last two decades the preferred treatment of choice of pituitary adenomas has been extended endoscopic endonasal surgery. However, ongoing CSF leakage is the most common issue for some patients, and contributing to reoperation for repairing is reported. At this point is valuable to identify prognostic factors that influence the CSF leaks rates to make multi-faceted decisions; being as challenging as the technical procedures for neurosurgeons and their team. Objective: The aim of this review is to determine whether preoperative factors are associated with postoperative CSF leaks in extended endoscopic endonasal surgery for pituitary adenoma Data Sources: A systematic review of published articles undergoing extended endoscopic endonasal surgery for pituitary adenomas between 2000 and 2019 was performed. Including criteria published studies reporting on outcomes of EEEA for pituitary adenomas; 2) no limited language restriction; 3) references list on case report and review articles of extended endoscopic endonasal surgery for pituitary adenoma were also searched; 4) containing original data; 5) adult patients (> 18 years). 6) Eligible study designs include analytic study designs (case-control studies, cohort studies, analytical cross sectional studies.

Surgical management of pituitary adenomas: does age matter?

Along with increased life expectancy and improvements in the diagnostic tools and techniques, the number of elderly patients with symptomatic pituitary tumors being evaluated for surgery is increasing. To date, contrasting results of the safety and effectiveness of transsphenoidal surgery in patients over 65years old were published in the medical literature. An investigation concerning the extension of resection, post operative complications and, recovery rate from endocrinological and visual symptoms in elderly patients who underwent transsphenoidal surgery for pituitary adenoma was conducted. A retrospective review, which included a series of 81 patients 65years old or older who underwent endoscopic endonasal surgery for pituitary adenomas was analyzed. Pre operative and post operative data were collected and patients were then compared among four age groups: 65-69years old, 70-74years old, 75-79years old and 80years and over. The results were then compared with the findings from the medical literature review. The statistical analysis failed to highlight any difference in terms of clinical presentation or complications among the four age groups, however there seems to be a slightly higher risk of post operative hypopituitarism in patients over 74years old. The results of the study seem to confirm that transsphenoidal surgery for PA is safe and effective among patients that are 65 and over. Moreover, a partial resection is preferred over a gross total one in order to reduce the surgical risk.

Utility of 7 Tesla MRI for Preoperative Planning of Endoscopic Endonasal Surgery for Pituitary Adenomas.

Objective  There is increasing interest in investigating the utility of 7 Tesla (7 T) magnetic resonance imaging (MRI) for imaging of skull base tumors. The present study quantifies visualization of tumor features and adjacent skull base anatomy in a homogenous cohort of pituitary adenoma patients. Methods  Eighteen pituitary adenoma patients were scanned at 7 T in this prospective study. All patients had reference standard-of-care clinical imaging at either 3 T (7/18, 39%) or 1.5 T (11/18, 61%). Visualization of tumor features and conspicuity of arteries and cranial nerves (CNs) was rated by an expert neuroradiologist on 7 T and clinical field strength MRI. Overall image quality and severity of image artifacts were also characterized and compared. Results  Ability to visualize tumor features did not differ between 7 T and lower field MRI. Cranial nerves III, IV, and VI were better detected at 7 T compared with clinical field strength scans. Cranial nerves III, IV, and VI were also better detected at 7 T compared with only 1.5 T, and CN III was better visualized at 7 T compared with 3 T MRI. The ophthalmic arteries and posterior communicating arteries (PCOM) were better detected at 7 T compared with clinical field strength imaging. The 7 T also provided better visualization of the ophthalmic arteries compared with 1.5 T scans. Conclusion  This study demonstrates that 7 T MRI is feasible at the skull base and identifies various CNs and branches of the internal carotid artery that were better visualized at 7 T. The 7 T MRI may offer important preoperative information that can help to guide resection of pituitary adenoma and reduce operative morbidity.

Olfactory Results of Endoscopic Endonasal Surgery for Pituitary Adenoma: A Prospective Study of 143 Patients

Clinical examination, including pre- and postoperative assessment of olfaction function, should be included in evaluating surgical outcomes in patients with pituitary adenomas. Most of the studies are lacking assessment of olfactory function. A prospective study of 143 patients who underwent surgical resection of pituitary adenomas from January 2014 to December 2017 was performed. Data on clinical presentation, pre- and postoperative neurologic, endocrinologic, and ophthalmologic examinations, complications, and follow-up outpatient examinations were recorded. Olfactory function was assessed using the Sniffin' Sticks odor identification test preoperatively, postoperatively (3 months), and 1 year after surgery. Normosmia was present preoperatively in 93.7%of patients, postoperatively in 95.8% of patients, and in 95.1% 1 year postsurgery. Hyposmia was present preoperatively in 4.2% of patients, postoperatively in 2.1% of patients, and in 1.4% 1 year after surgery. Anosmia was present preoperatively in 2.1% of patients, postoperatively in 2.1% of patients, and in 3.5% 1 year after surgery. In patients with preoperative normosmia, postoperative hyposmia and anosmia were present in 1.5% of patients. There were no differences according to age, sex, size, or type of pituitary adenoma. Assessment of olfactory function should be included in the analysis of pituitary adenoma surgery results. This prospective study showed low risk of olfaction deterioration if an endoscopic endonasal approach is used without any mucosal flaps for skull base reconstruction. Further studies that include objective olfaction assessment are warranted.

Predictors of Cerebrospinal Fluid Leaks in Endoscopic Surgery for Pituitary Tumors

<i>Background</i>: Cerebrospinal fluid (CSF) leak is a serious complication of endoscopic endonasal surgery for pituitary adenoma; leading to a more serious and financial burden of the surgery. Prediction of the occurrence of such sequale and proper plaining for reconstruction can reduce its prevalence and associated morbidities. <i>Purpose</i>: To determine the predictors and risk factors associated with intra/and postoperative cerebrospinal fluid (CSF) leaks in endoscopic endonasal pituitary surgery. Methods: A retrospective study included 150 patients who underwent endoscopic endonasal approach for resection of pituitary adenomas between 2015 and 2018. We analyzed the association between CSF leaks (intra/post-operative) and perioperative variables including patients’ demographic data, medical comorbidities, tumor characteristics and operative data (rates of intraoperative leak, reconstructive techniques). <i>Results</i>: 34 patients (22.6%) out of the 150 patients had an overall, CSF leak: 26 (76.5%) patients had intraoperative leaks; 5 patients out of them continued to have a postoperative leak. 8 patients (23.5%) had postoperative leak. Based on multiple logistic regression model analysis; increased body mass index (BMI), associated hydrocephalus, suprasellar extension and recurrent tumors had a significant association with intraoperative CSF leaks, while only BMI and hydrocephalus predicted postoperative CSF leaks. <i>Conclusion</i>: Elevated BMI, suprasellar extension of the tumor, recurrence or previous radiation are all important risk factors that have been proved in this study to have statistically significant association with the incidence of CSF leak. In high risk patients for CSF leakage: adequate reconstruction planis advised to avoid such morbidity.

Pure Endoscopic Endonasal Surgery for Pituitary Adenomas: Technique and Early Results in Banha Neurosurgery Department

AbstractBackground: Surgery for pituitary adenomas passed though several stages of refinement during the past decades. During the past 20 years a major shift has been made by neurosurgeons towards endoscopic pituitary surgery. This has been aided by the great development in technologies of rod lens and high resolution video cameras. The panoramic view offered by the endoscope made the surgery more safe and radical in removing the tumor. Now it is widely accepted in most neurosurgical institutes that the endoscopic endonasal surgery should be the gold standard in pituitary surgery.Aim of Study: In this study we report our early results, challenges we faced and the problems we solved in applying the technique of pure endoscopic endonasal surgery for pituitary adenomas in Banha Neurosurgery Department.Study Design: This is a retrospective study case series of 35 patients with pituitary adenomas. All patients were treated surgically using the pure endoscopic endonasal technique. Patients had been followed after surgery for a period of time ranged from 4 to 36 months during the years from February 2012 to March 2015.Patients and Methods: Thirty five patients were included; twenty with nonfunctioning pituitary adenomas, (nine with suprasellar extension only and 11 with parasellar extension) and fifteen with functioning adenomas including 3 ACTH secreting, 8 GH secreting and 4 prolactinomas. Patients were endocrinologically, ophthalmologically and radiologically evaluated using CT paranasal sinus and MRI pituitary scans. Pre and post-operative scans as well as levels of pituitary hormones have been compared and evaluated for the degree of tumor resection, visual improvement and endocrinological cure.Results: Gross total resection of the tumor has been achieved in 23 patients (65.7%) while 12 patients (34.3%) had incomplete resection. Among 15 patients with pre operative visual deficits, 13 patients (86,6%) showed variable degrees of visual improvement and 2 only (13.3%) did not improve. Endocrinological cure was 75% in GH secreting adenomas, 75% in prolactinomas and 66.7% in ACTH secreting adenomas.The most common complications were transient post-operative DI and inrtaoperative CSF laek. No reported deaths, major vascular injury or worsening of vision.Conclusion: The pure endoscopic endonasal technique, although challenging, it is less traumatic, and associated with good outcome.

Bibliometric Analysis of Journals in the Field of Endoscopic Endonasal Surgery for Pituitary Adenomas.

Endoscopic endonasal surgery for pituitary adenomas is being performed more frequently worldwide in the recent years. This first bibliometric analysis was conducted aiming to have a microscopic view of research activities about endoscopic endonasal surgery for pituitary adenomas. The original articles about endoscopic endonasal surgery for pituitary adenomas were extracted from the Web of Science (WoS) and analyzed concerning their distributions. We also explored the potential correlations between publications of different countries and their gross domestic product (GDP) via Pearson correlation test. The total number of original articles retrieved from WoS was 307 from 1997 to 2017. The number of original articles published in the last decade has increased by 530.95% compared with that published in the former decade. The United States has published 124 articles (40.391%), followed by Italy with 40 (13.029%) and Japan with 27 articles (8.795%). The journal that published the highest number of original articles was Journal of Neurosurgery with 31 (10.098%), followed by Neurosurgery (n = 23, 7.492%), World Neurosurgery (n = 23, 7.492%), and Neurosurgical Focus (n = 15, 4.886%). There was a strong correlation between publication numbers and GDP of different countries (r = 0.889, P < 0.001). There is a skyrocket trend of endoscopic endonasal surgery for pituitary adenomas during the last 2 decades, and countries with high GDP tend to make more contributions to this field.

Endoscopic endonasal surgery for pituitary adenomas extending to the oculomotor cistern.

Extension of a pituitary adenoma to the oculomotor cistern harbors the risk of oculomotor nerve impairment and further extension into the interpeduncular cistern. The role of endoscopic endonasal surgery for those lesions was investigated. The medical records were retrospectively analyzed. Attention was paid to the oculomotor nerve function and removal rate of the tumor within the oculomotor and interpeduncular cisterns. Six patients were eligible for the study, including 2 with oculomotor nerve palsy. The tumor from the oculomotor and interpeduncular cistern was removed in all except on one side of the case with bilateral tumor extension. The oculomotor nerve palsy demonstrated partial recovery in both cases during the 3-month follow-up. The pituitary adenoma extending to the oculomotor cistern can be removed under the endoscope. Improvement of oculomotor nerve palsy can be achieved, and further tumor extension into the interpeduncular cistern can be prevented.

内視鏡下経鼻下垂体腺腫手術におけるチーム医療

下垂体腺腫に対する手術は近年経鼻内視鏡手術が多く行われ, その低侵襲性と良好な術後成績が示されている. しかし, これらの手術に耳鼻咽喉科医が関与している施設は限定され, 術後鼻副鼻腔合併症についての報告は少ない.

The Endonasal Microscopic Surgery versus Fully Endoscopic Endonasal Surgery for Pituitary Adenomas

Objective: This study aims to compare the results of traditional endonasal transsphenoidal microscope surgery for the pituitary adenomas with advancements in fully endoscopic surgery.

Management of Complications in Endoscopic Endonasal Surgery for Pituitary Adenomas

Objective: To describe a case series of patients with pituitary adenomas with endoscopic endonasal transsphenoidal approach, the technique performed and complications in our centre. Methods: The technique performed in a series of 98 consecutive patients, and description of their complications and the protocol followed to treat these complications. Results: 120 patients where submitted to Skull Base Endoscopic Surgery, of which 98 (81.66%) had diagnosis of non-functioning pituitary adenoma in a two year period. Complications described are postoperative cerebrospinal fluid leaks (6.12%), vascular injury (3.06%) and cranial nerve injury (2.04%). Conclusion: A specific protocol is followed in our institution to treat different complications in pituitary adenoma transnasal endoscopic surgery in order to improve outcomes. Prompt and diligent identification of complications is of utmost importance for their treatment.

Delayed postoperative epistaxis from the posterior lateral nasal branch of the sphenopalatine artery after endoscopic endonasal approach: Case report

Abstract Postoperative delayed epistaxis is a rare but serious complication following endoscopic endonasal surgery for pituitary adenoma. It usually originates in the septal branch of the sphenopalatine artery (SPA), whereas we experienced a case of postoperative delayed epistaxis from the posterior lateral nasal branch of the SPA after endoscopic endonasal approach with middle turbinectomy. A 38-year-old woman underwent an endoscopic transsphenoethimoidal approach combined with middle turbinectomy for the removal of recurrent atypical growth hormone-secreting adenoma invading to the left cavernous sinus. She suddenly showed delayed massive epistaxis two weeks after surgery. Emergency endoscopic endonasal surgery under general anesthesia confirmed bleeding from the posterior lateral nasal branch of the SPA. To our knowledge, this is the first case reporting that delayed epistaxis occurred due to the bleeding from the posterior lateral nasal branch of the SPA after endoscopic endonasal approach for pituitary adenoma. It is important for neurosurgeons to be aware of the possibility of delayed epistaxis from injury of the posterior lateral nasal branch of the SPA during endoscopic endonasal approach with middle turbinectomy to the lateral nasal wall.