Endoscopic Endonasal Transsphenoidal Approach Research Articles

Platelet rich fibrin three-layer reconstruction of the sellar floor after endoscopic endonasal transsphenoidal approach: technical note and initial experience.

Cerebrospinal fluid (CSF) leakage frequently complicates endoscopic endonasal transsphenoidal pituitary resections, despite the use of lumbar drains, nasoseptal flaps, or commercial dura sealants. Managing this complication often requires revision surgery and increases the risk of infection. Platelet-rich fibrin (PRF), an affordable autologous biomaterial derived from the patient's blood through short, angulated centrifugation, contains growth factors and leukocytes embedded in a fibrin matrix. PRF exhibits regenerative properties in various surgical disciplines. This study assesses a three-layer sellar reconstruction method employing solid membranous (s-PRF) and high-viscosity injectable (i-PRF) forms of PRF. We present our initial experience on a series of 22 patients with pituitary macroadenomas. For all patients, an endoscopic transnasal transsphenoidal approach was selected. Following the resection of the pathology, sellar reconstruction was accomplished using a three-layer orthobiologic technique. A membranous s-PRF was utilized as an inlay inside the opened sellar floor, followed by a layer of injectable i-PRF finally covered with another s-PRF membrane over the top to the sellar corridor. In all cases the implementation of the proposed three-layer PRF reconstruction strategy was feasible and safe. During the 12-month follow-up period there were no adverse effects reported associated with the PRF application. 77% (17/22) of the patients demonstrated intraoperatively a cerebrospinal fluid (CSF) leak (Esposito Grade 1-3). In total, the proposed PRF reconstruction effectively prevented postoperative CSF leaks in 95% of the patients and in 94% of those with an Esposito Grade 1-3. One of the two patients with intraoperative Esposito Grade 3 developed a CSF leak on the first postoperative day, which was successfully managed with a lumbar drain for 5 days. Sellar reconstruction after endoscopic endonasal transsphenoidal resection of pituitary adenomas with PRF is feasible and safe. The three layer PRF augmentation is a novel technique to prevent CSF-leakage.

Variable anatomical features of acromegaly in the nasal cavity and paranasal sinuses: implications for endoscopic endonasal transsphenoidal surgery.

Growth hormone (GH)-secreting pituitary neuroendocrine tumors (PitNETs) are the most common cause of acromegaly. The endoscopic endonasal transsphenoidal approach (EEA) is commonly employed to remove them. Although morphological differences in the nasal cavity exist between acromegaly patients and those with other types of PitNET, few quantitative studies have been performed. This study aimed to evaluate the anatomical features of the nasal cavity and paranasal sinuses in patients with acromegaly. Preoperative computed tomography images of the nasal cavity and paranasal sinuses were compared between 20 patients with a GH-secreting PitNET (acromegaly group) and 22 with a non-functioning PitNET (control group). In the acromegaly group, the relationships between preoperative GH and/or insulin-like growth factor 1 (IGF-1) levels and anatomical characteristics were assessed. In the acromegaly group, the distance between the nostril and dorsum sellae was significantly longer and the distance between the parasellar internal carotid arteries was significantly shorter (p = 0.0022 and 0.0092, respectively). Pneumatization volume in the nasal cavity did not differ between the groups. Nasal mucosa and bony hypertrophy were observed in the acromegaly group. Preoperative GH level was correlated with the width of the piriform aperture (p = 0.0171). The nasal and paranasal changes associated with acromegaly can make EEA challenging to perform. Widening the surgical corridor anterior to the sphenoid sinus is important in these patients.

8301 A Rare Case of IgG4-Related Hypophysitis

Abstract Disclosure: P. Kesavan Chary: None. J.M. Silverstein: None. Background: IgG4-related disease (IgG4-RD) is an immune-mediated condition that presents as systemic inflammation and fibrosis of tissues, often affecting multiple organs. Isolated IgG4-related Hypophysitis is rare and characterized by lymphoplasmacytic infiltration of the pituitary gland by IgG4-positive plasma cells. A combination of clinical, serologic, radiologic, and histopathologic findings is used for diagnosis of IgG4-RD and approximately two-thirds of all patients have elevated serum IgG4 levels. We report a case of isolated IgG4-related Hypophysitis in a middle-aged woman serologically negative for IgG4-related disease. Case Report: A 52 year old female with history of steroid dependent severe persistent asthma, allergic rhinitis, and chronic sinusitis presented with one month of headache, polyuria, and polydipsia. MRI Brain demonstrated an enlarged, rounded pituitary gland 16 x 11 x 9 mm, with homogeneous enhancement, extension into the suprasellar cistern, and mild thickening of the infundibulum suspected to represent a pituitary adenoma. Lab evaluation revealed mild hyperprolactinemia (prolactin 83.2, normal 4.8-23.3 ng/mL) and secondary adrenal insufficiency based on an abnormal high-dose cosyntropin stimulation test in the setting of a low adrenocorticotrophic hormone (ACTH) level (<2.0 pg/mL). Remaining pituitary hormone levels were normal. Inpatient work-up for polyuria and polydipsia showed a low urine specific gravity of 1.003. An overnight water deprivation test was performed. Baseline urine osmolality (UOsm) was 95 mOsm/kg and serum sodium was 144 mmol/L; after 3 hours of water deprivation, serum Osm increased to 301 mOsm/kg (275-300 mOsm/kg) and UOsm only to 215 mOsm/kg, while her sodium increased to 145 mmol/L. Results were felt to be consistent with AVP deficiency (Central Diabetes Insipidus) and the patient was started on desmopressin. Because of the presence of AVP deficiency, further work-up was done to evaluate for an infiltrative process or malignancy. ANA, RPR, ESR, CRP, CBC, ACE level, T-SPOT, and IgG subclasses were unremarkable. Further imaging studies yielded a negative nuclear bone scan and PET/CT scan. For diagnostic purposes, the patient underwent biopsy via an endoscopic endonasal transsphenoidal approach. Pathology showed the presence of >10 IgG4+ plasma cells in a single high-power field, consistent with a diagnosis of IgG4-related Hypophysitis. Conclusion: Isolated IgG4-related Hypophysitis is the least common clinical presentation of IgG4-RD, which is itself a rare and relatively newly recognized condition. IgG4-related Hypophysitis should be suspected in patients presenting with AVP deficiency and pituitary stalk enlargement with an otherwise negative work up. Presentation: 6/2/2024

Pediatric abscessed craniopharyngioma: A case report and review of literature

BackgroundCraniopharyngiomas are rare sellar and suprasellar tumors affecting children and adults. The spontaneous abscessation of this lesion is an extremely rare occurrence with a total of 10 cases reported in the literature including 2 cases in the pediatric population. ObservationWe report a case of abscessed craniopharyngioma in a 10-year-old girl, revealed by intracranial hypertension and diabetes insipidus with a double component (solid and cystic) lesion of the sella visualized on cerebral MRI. The patient underwent surgical decompression via endoscopic endonasal transsphenoidal approach coupled with antibiotic treatment with an uneventful postoperative course and improvement of her symptoms. ConclusionAbscessed craniopharyngiomas are rare and challenging entities. We highlight through our case and literature review the importance of an in-depth patient’s history as well as a clinical-radiological correlation in allowing for a positive preoperative diagnosis even in patients with no meningeal or infection signs.

Comparison of Surgical Modalities for Giant Pituitary Adenoma: A Systematic Review and Meta-Analysis of 1413 Patients.

Giant pituitary adenomas (GPAs) are a challenging clinical entity, composing 5% to 15% of all pituitary adenomas. While the endoscopic endonasal transsphenoidal (EET) approach has surpassed the microsurgical transsphenoidal (MT) and transcranial (TC) approaches as the first-line surgical modality in most institutions, a systematic review comparing the 3 approaches has not been undertaken since 2012. Given growing adoption of EET and development of novel operative techniques over the past decade, an updated comparison of GPA surgical modalities is warranted. We identified all studies related to the surgical management of GPAs in PubMed, Embase, and Web of Science from inception to December 31, 2021. End points assessed included gross total resection (GTR) rates, postoperative visual improvement, mortality, and perioperative complications. After screening of 1701 studies, we identified 45 studies on the surgical management of GPAs for meta-analysis. Thirty-one used the EET approach (n = 1413), 11 studies used the MT approach (n = 601), and 10 used the TC approach (n = 416). The cumulative number of patients treated by EET did not exceed that of patients treated by the TC or MT approaches until 2014 and 2015, respectively. Despite patients undergoing EET having the highest average tumor diameter, pooled rates for GTR were significantly higher for EET (42%) than MT (33%, P < .001) and TC (8%, P < .001) and EET similarly exhibited superior rates of visual improvement (85%) than MT (73%, P < .001) and TC (56%, P < .001). Mortality rates were comparable between EET (0.6%) and MT (1.6%), but EET had significantly lower mortality than TC (2.7%, P < .001). Compared with MT, EET had lower rates of hypopituitarism (8.5% vs 14.9%, P = .012) but higher rates of diabetes insipidus (3.1% vs 0.5%, P = .001). In an updated meta-analysis of 1413 patients with GPA, EET resection conferred significantly higher rates of visual improvement and GTR, when compared with the MT and TC approaches.

Pituitary surgery and COVID.

An effect of the COVID-19 pandemic was the disruption of healthcare systems, especially surgical services provided to the community. Pituitary surgery was especially impacted, given the majority of cases were deemed non-urgent with very few exceptions, and the high risk of viral transmission conferred by the endoscopic endonasal transsphenoidal approach. Patients suffering from pituitary lesions with resultant endocrinopathy or visual symptoms saw their treatment delayed or altered, which had implications on their outcomes and care. This disruption extended to surgical training and the usual functioning of academic units, necessitating changes to curricula and implementation of novel methods of progressing surgical education. This review will explore the effect of the COVID pandemic on pituitary surgery, the experiences of various surgeons as well as the adaptations implemented on the frontlines. The lessons learned from the experience of the pandemic may assist specialists in gleaning insights regarding the care of patients in the future.

Surgical Outcome of the Endoscopic Endonasal Approach in Giant Pituitary Adenomas: A Systematic Review

Abstract Background Pituitary adenomas are the third most common intracranial tumors comprising about 10%–15% of all tumors. Giant pituitary adenomas (GPAs) are a subset of pituitary tumors. Most giant adenomas are slowly growing and histologically benign in nature despite the giant in size and difficulties to manage. Diverse surgical techniques including microscopic transsphenoidal, endoscopic transsphenoidal, transcranial transcavernous, and a combination of both suprasellar and infrasellar techniques have been developed to treat giant tumors with extension into surrounding structures. The development of the endonasal endoscopic approach for the resection of pituitary adenomas has been one of the most important advances for the treatment of pituitary tumors in the last decades since 1997. Aim of the Work analyze the collective outcomes from studies discussing endoscopic endonasal transsphenoidal approach in managing giant pituitary adenomas regarding extent of tumor resection, visual improvement and hormonal control. Methodology This systematic review included a discussion of all available studies meeting the eligible criteriaincluding: well conducted descriptive studies, cohort, articles, analytic studies and the literature of reviews. Results Surgical intent of gross or near total resection, primarily for the purpose of improving outcome, can be complicated by injuries that lead to a worse outcome and protracted clinical course. In this respect, patient-oriented outcomes (POEMs) are a point of emphasis in this review. Conclusion The endoscopic endonasal approach is an effective approach for giant pituitary adenomas with high rates of near or complete resection, visual improvement, and low rate of complications.

Morphometric Analysis of the Sella Turcica on Cone-Beam Computed Tomography Images.

Sella turcica is an important anatomic formation that contains the pituitary gland and is in a close neighborhood with many vital structures. It is important to know the morphometry of the sella turcica, as it is a transition point during surgical interventions such as the endoscopic endonasal transsphenoidal approach to the region. The findings obtained are thought to be useful in the examination of sella turcica and surrounding structures and will contribute to the literature by knowing the morphometry of the region for the surgical method. In this study, cone-beam computed tomography images of 400 individuals, 200 females and 200 males, aged between 18 and 65 years, who did not have craniofacial pathology, who applied to Gaziantep University, Faculty of Dentistry between 2015 and 2020 for any reason, were evaluated retrospectively. In the sagittal section, 8 parameters were examined, 6 of which were transverse. The length () of the sella turcica in the sagittal plane is 10.19±1.77mm, the diameter of the sella turcica is 11.6±1.69mm, the anterior height of the sella turcica is 7.88±1.56mm, the median height of the sella turcica 8.18±1.42mm, posterior height of sella turcica 6.98±1.31mm, width of sella turcica 11.10±1.6mm. The distance between anterior clinoid processes in the transverse plane was 24.93±2.57mm, and the distance between posterior clinoid processes was 14.92±2.46mm. It was determined that there was an increase in many parameters with age, and length of the sella turcica and anterior clinoid processes were statistically significantly higher in males.

The learning curve in endoscopic transsphenoidal skull-base surgery: a systematic review

BackgroundThe endoscopic endonasal transsphenoidal approach (EETA) has revolutionized skull-base surgery; however, it is associated with a steep learning curve (LC), necessitating additional attention from surgeons to ensure patient safety and surgical efficacy. The current literature is constrained by the small sample sizes of studies and their observational nature. This systematic review aims to evaluate the literature and identify strengths and weaknesses related to the assessment of EETA-LC.MethodsA systematic review was conducted following the PRISMA guidelines. PubMed and Google Scholar were searched for clinical studies on EETA-LC using detailed search strategies, including pertinent keywords and Medical Subject Headings. The selection criteria included studies comparing the outcomes of skull-base surgeries involving pure EETA in the early and late stages of surgeons’ experience, studies that assessed the learning curve of at least one surgical parameter, and articles published in English.ResultsThe systematic review identified 34 studies encompassing 5,648 patients published between 2002 and 2022, focusing on the EETA learning curve. Most studies were retrospective cohort designs (88%). Various patient assortment methods were noted, including group-based and case-based analyses. Statistical analyses included descriptive and comparative methods, along with regression analyses and curve modeling techniques. Pituitary adenoma (PA) being the most studied pathology (82%). Among the evaluated variables, improvements in outcomes across variables like EC, OT, postoperative CSF leak, and GTR. Overcoming the initial EETA learning curve was associated with sustained outcome improvements, with a median estimated case requirement of 32, ranging from 9 to 120 cases. These findings underscore the complexity of EETA-LC assessment and the importance of sustained outcome improvement as a marker of proficiency.ConclusionsThe review highlights the complexity of assessing the learning curve in EETA and underscores the need for standardized reporting and prospective studies to enhance the reliability of findings and guide clinical practice effectively.

Management of growth hormone-secreting pituitary adenomas causing acromegaly: a practical review of surgical and multimodal management strategies for neurosurgeons.

This review aimed to highlight the history, diagnostic criteria, preoperative prognostic factors, surgical management, and multimodal adjuvant therapies recommended to provide a comprehensive and multifaceted understanding of and clinical approach to treating growth hormone-secreting pituitary adenomas (GHPAs) in patients with acromegaly. The authors collated and reviewed published studies, many written by skull base neurosurgeons, endocrinologists, and radiation oncologists with expertise in pituitary adenoma management, to produce a practical and contemporary update pertaining to the optimal management of acromegaly for neurosurgeons. Acromegaly is a debilitating disease for which surgery can be curative in more than two-thirds of patients. Recent rates of hormonal remission by the authors' group and others following the resection of GHPAs are on the order of 70%-80%, and these increase to more than 85% with the addition of medical therapy in a minority of patients who do not achieve remission with surgery alone. Most tumors are accessible via a direct endoscopic endonasal transsphenoidal approach, which can be augmented with a variety of extended approaches to gain access to suprasellar, clival, and parasellar compartments as needed. Preoperative growth hormone levels, cavernous sinus invasion, and pituitary adenoma consistency are important factors in determining the extent of resection. In most patients with residual or recurrent disease, medical therapy (e.g., somatostatin analogs and dopamine agonists) can be used to help achieve hormonal remission. Repeat surgery can be safely performed in most cases if needed, whereas stereotactic radiosurgery is usually reserved for medically resistant tumors in surgically inaccessible compartments. The neurosurgeon has a primary and often definitive role in the management of acromegaly. The involvement of an integrated and multidisciplinary team consisting of experts from neurosurgery, otolaryngology, endocrinology, and radiation oncology optimizes the chances for a biochemical cure, even in large and aggressive GHPAs.

Efficacy of the Craniopharyngioma Resection via Expanded Endoscopic Endonasal Transsphenoidal Approach in the Treatment of Complex Craniopharyngioma and Its Effect on Pituitary Function and Complications of Patients.

Surgical resection is the most effective method for craniopharyngioma, with complex operations and a high incidence of complications, especially for complex craniopharyngioma. The study focuses on selecting a proper surgical method to treat complex craniopharyngioma. A clinical study was conducted in this direction to explore the efficacy of expanded endoscopic endonasal transsphenoidal approach (EETS) and transcranial approach (TCA) in the treatment of complex craniopharyngioma and their effects on pituitary function and complications of patients. The clinical data of 73 patients with complex craniopharyngioma in Baoding No.2 Central Hospital from December 2017 to December 2022 were retrospectively analyzed. 13 patients who did not meet the admission criteria were excluded, and 60 patients were finally included. The included patients were divided into the TCA and EETS groups according to the treatment method. The surgical conditions, total tumor resection rate, clinical remission rate, and complications of patients in two groups were compared. The pituitary function of all patients, including thyroid stimulating hormone (TSH), adrenocorticotropic hormone (ACTH), and human growth hormone (hGH), was compared. A total of 60 patients were finally included in the study, including 30 cases in the EETS group and 30 cases in the TCA group. The two groups had no statistical difference in baseline demographic characteristics and pathological types (p > 0.05). Compared with the TCA group, the EETS group had less intraoperative blood loss, operation time, tumor resection time, and hospitalization time (p < 0.001) and had a significantly higher total tumor resection rate and clinical remission rate (p < 0.05). The EETS group had higher ACTH and hGH levels than the TCA group (p < 0.05). There was no statistical difference between the two groups incidence of complications and disease recurrence rate (p > 0.05). The craniopharyngioma resection via EETS has a significant therapeutic effect in complex craniopharyngioma with a high total tumor resection rate and clinical remission rate, which can protect the pituitary function of patients and provide more benefits for patients.

The Evolution of Pituitary Surgery in an Australian Health Care Framework

Abstract Background The outcomes in pituitary surgery have dramatically changed over the past 130 years. Endoscopic endonasal transsphenoidal approaches are now an accepted method for operating on pituitary tumors, a skillset which takes time to develop. The Australian health care framework provides a unique mixture of public and private care for a geographically dispersed population. In this article, we aim to examine how outcomes for patients in South Australia changed as endoscopic pituitary surgery was adopted and how the Australian health care framework influenced the development of a skull base team. Methods The case notes of all patients undergoing pituitary surgery between 2006 and 2020 in South Australia. All patients treated by this author group were included. Results A total of 428 pituitary adenomas were surgically treated. Overall, 182 out of 249 patients (70%) had a complete resection with no recurrence at follow-up, and 49 patients (19%) had a residual that was observed and did not require treatment. Therefore, 89% of patients between the years 2006 and 2020 did not require any further treatment following their pituitary surgery. Upon examination of the 142 patients with functional adenomas, 112 (79%) patients had no recurrence in hormonal dysfunction following surgery, and the remaining 30 (21%) patients required further treatment. Conclusion We have demonstrated that acceptable outcomes can be achieved in a low-to-moderate volume setting across multiple hospitals when a coordinated effort is made to consolidate these cases within a small group of subspeciality-trained surgeons, as opposed to a more generalist approach.

Endoscopic Endonasal Transsphenoidal Resection of Pituitary Adenomas in Patients Presenting With Monocular Blindness.

Suprasellar tumors, particularly pituitary adenomas (PAs), commonly present with visual decline, and the endoscopic endonasal transsphenoidal approach (EETA) is the primary management for optic apparatus decompression. Patients presenting with complete preoperative monocular blindness comprise a high-risk subgroup, given concern for complete blindness. This retrospective cohort study evaluates outcomes after EETA for patients with PA presenting with monocular blindness. Retrospective analysis of all EETA cases at our institution from June 2012 to August 2023 was performed. Inclusion criteria included adults with confirmed PA and complete monocular blindness, defined as no light perception, and a relative afferent pupillary defect secondary to tumor mass effect. Our cohort includes 15 patients (9 males, 6 females), comprising 2.4% of the overall PA cohort screened. The mean tumor diameter was 3.8 cm, with 6 being giant PAs (>4 cm). The mean duration of preoperative monocular blindness was 568 days. Additional symptoms included contralateral visual field defects (n = 11) and headaches (n = 10). Two patients presented with subacute PA apoplexy. Gross total resection was achieved in 46% of patients, reflecting tumor size and invasiveness. Postoperatively, 2 patients experienced improvement in their effectively blind eye and 2 had improved visual fields of the contralateral eye. Those with improvements were operated within 10 days of presentation, and no patients experienced worsened vision. This is the first series of EETA outcomes in patients with higher-risk PA with monocular blindness on presentation. In these extensive lesions, vision remained stable for most without further decline and improvement from monocular blindness was observed in a small subset of patients with no light perception and relative afferent pupillary defect. Timing from vision loss to surgical intervention seemed to be associated with improvement. From a surgical perspective, caution is warranted to protect remaining vision and we conclude that EETA is safe in the management of these patients.

Development and validation of a prediction model for consistency of pituitary adenoma: the PiTCon score.

Pituitary adenomas (PAs) usually have a soft consistency, facilitating gross total resection. However, 5-13% of PAs with fibrous consistency are challenging to remove entirely and are accompanied by greater morbimortality. This study aims to identify the clinical and radiological characteristics that correlate with PA fibrous consistency preoperatively. A simple scoring system has been proposed to predict incidence of fibrous PAs. Consecutive interventions (226) were analyzed, all performed through an endoscopic endonasal transsphenoidal approach. Univariable and multivariable logistic regression analysis was performed. Hosmer-Lemeshow test and receiver operating characteristic (ROC) curves were assessed to evaluate the model. A point scoring system (PiTCon) was derived based on the multivariable regression model. Our study aimed to identify the clinical and radiological characteristics that correlate with fibrous tumor consistency preoperatively. The best diagnostic accuracy for predicting PA consistency consisted of five predictive factors: age, compressive symptoms, panhypopituitarism, craniocaudal extension of the PA in mm, and prior surgery. The multivariable model achieved good discrimination with an area under the curve (AUC) of the ROC curve being 0.82 and the 95% CI 0.76 to 0.88. Internal validation yielded an optimism-adjusted C-statistic of 0.80 (95% CI 0.74 to 0.86). A point scoring system (PiTCon score) was designed using the best predictive model. PA consistency can be estimated preoperatively regarding clinical and radiological characteristics. We propose a point-based scoring system (PiTCon score) that can better guide neurosurgeons in clinical decision-making and surgical risk assessment and help establish and describe patient prognosis.

ENDOSCOPIC ENDONASAL TRANS-SPHENOIDAL SURGERY IN PATIENTS WITH MACRO-ADENOMA EXTENT OF SURGICAL RESECTION AND RECURRENCE RATE.

Endoscopic Endonasal Trans-Sphenoidal Approach has been employed for skull base tumours especially macro-adenomas, for the last decade in our setup. Here we are sharing our experience with the EETA for patients with micro-adenomas in terms of extent of tumour resection and its recurrence. The objective was to assess endoscopic endonasal trans-sphenoidal surgery in patients with macro-adenoma for extent of surgical resection and recurrence rate. This descriptive case series study was carried out from May 2021 till April 2023. Male and female patients with macroadenoma were enrolled which was diagnosed with contrast enhanced volumetric MRI brain. EETA and resection was performed. Extent of resection recurrence was confirmed on post-op MRI and follow up at 6 months respectively. A total of 58 patients were enrolled. Mean age of the patients was 47.51±7.93 years and male to female ratio was 1.3: 1. 42 (72.4%) tumours were non-functional. Somatotropin releasing tumour was the most common functional tumour (n=09, 15.5%). Total resection was performed in 49 (84.4%) patients. Recurrence was observed in 9 (15.6%) cases. EETA has been shown to be a safe and effective technique for the resection of macroadenoma of the skull base.

Predictive value of suprasellar extension for intracranial infection after endoscopic transsphenoidal pituitary adenoma resection

ObjectiveTo investigate the relationship between suprasellar extension (SSE) and intracranial infection after endoscopic endonasal transsphenoidal approach (EETA) for pituitary adenoma resection.MethodsWe retrospectively analyzed 94 patients with suprasellar extended pituitary adenoma admitted to the Department of Neurosurgery of the Affiliated Hospital of Guilin Medical College from January 2018 to December 2021. We measured the preoperative magnetic resonance sagittal SSE and collected clinical data and divided the patients into groups according to the presence of postoperative intracranial infection. The critical value for the SSE was calculated by using a working characteristic curve for the subjects. The risk factors for intracranial infection after EETA resection of pituitary adenomas were analyzed by multivariate regression analysis.ResultsAmong the 94 patients, 12 cases (12.8%) were placed in the infection group and 82 cases (87.2%) in the non-infection group. The cut-off value for the SSE in the sagittal position was 15.6 mm, the sensitivity was 75%, the specificity was 87.8%, and the area under the curve (AUC) was 0.801. The coronary cut-off value for the SSE was 15.8 mm, the sensitivity was 66.7%, the specificity was 79.3%, and the AUC was 0.787. The SSE values in the sagittal and coronal positions were correlated with postoperative intracranial infection (P < 0.05). After univariate analysis, those with significant differences were included in the multivariate regression analysis. It was concluded that the extension distance of the tumor above the sella in the sagittal position was ≥ 15.6 mm, the tumor texture was hard, and the postoperative cerebrospinal fluid leakage were the independent risk factors for intracranial infection after EETA resection of suprasellar extended pituitary tumors (P < 0.05).ConclusionsThe value of SSE on sagittal MRI can predict intracranial infection in patients with suprasellar extended pituitary adenoma after endoscopic endonasal transsphenoidal resection. This finding recommends neurosurgeons pay more attention to the imaging characteristics of pituitary adenomas and select appropriate treatment plans in combination with the intraoperative conditions to reduce the incidence of intracranial infection.

Effectiveness of endoscopic endonasal surgery for pituitary apoplexy: A comprehensive evaluation of presentation and clinical outcomes from a tertiary care center

BackgroundThe management of pituitary apoplexy (PA) is under debate. Therefore, we studied the clinical manifestations and neuroendocrine outcomes of PA after surgical management, as well as the efficacy and safety of the endoscopic endonasal transsphenoidal approach (EETA). MethodsThis retrospective study was conducted between January 2013 and May 2021, and included 62 cases of pituitary adenoma apoplexy that were managed with EETA. ResultsData from 62 patients were analyzed with a mean age of 50.7 ± 10.9 years, 90.3 % of whom were female. On admission, most patients presented with abrupt onset severe headache and vomiting, associated with endocrine dysfunction in 43.5 % and deteriorated visual acuity in 92 %. Third nerve palsy was the most noted ocular nerve palsy. After using EETA, the adenoma was resected totally, subtotally, and partially in 59.7 %, 29 %, and 11.3 % of the cases, respectively. Postoperative improvement in visual acuity was achieved in 90.3 % of patients, unchanged in 6.5 % with vision defects, and deteriorated in 3.2 %. Endocrine dysfunction improved to 19.3 % after being 43.5 %. Six patients (9.6 %) experienced transient diabetes insipidus (DI) that responded completely to desmopressin therapy for a time, and three cases were complicated with CSF leakage after the operation, but it resolved completely. No intracranial infection, carotid artery injury, or death occurred. ConclusionDespite the availability of alternative treatment options, the surgical intervention by EETA remains the most effective and reliable method for managing patients with PA who present with sudden visual or endocrine symptoms. EETA has been shown to result in significant improvements in both visual and endocrine function, with an acceptable complication rate that can be managed effectively in many cases. As such, EETA continues to represent the cornerstone in the management of PA and should be considered the first-line treatment option for amenable patients.

Comparing the efficacy of endoscopic endonasal versus microscopic transsphenoidal approach for the management of sellar and suprasellar tumors: a systematic review and meta-analysis protocol

Abstract Managing sellar and suprasellar tumors is challenging due to their diverse origins and proximity to critical structures. The transsphenoidal surgical approach has become the preferred method, evolving from transcranial attempts to reduce morbidity. Microscopic transsphenoidal techniques have been refined over time, with endoscopic endonasal surgery emerging as a significant advancement. Due to the multifaceted nature of these approaches, the complexities of the pathology and the paucity of data from specific regions, understanding the prevalence, characteristics and management outcomes of sellar and suprasellar tumors is crucial for informing healthcare practices and resource allocation. This study aims to collate evidence-based insights into the efficacy of the endoscopic endonasal approach compared with the microscopic transsphenoidal approach as a surgical intervention for sellar and suprasellar tumors, following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines for 2020. To source pertinent information, we will rely on four primary central databases: PubMed, EMBASE, SCOPUS and the Cochrane Central Register of Controlled Trials. The primary outcome measure will be the surgical outcome’s effectiveness in achieving tumor resection and preserving pituitary function. The study protocol is duly registered with the International Prospective Register of Systematic Reviews (PROSPERO), with no requirement for ethical approval as it exclusively relies on previously published research. We aim to publish our findings in scientific journals and present the abstract at conferences to guide clinical practice. PROSPERO Registration Number: CRD42023461972: available via https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42023461972.

Endocrinologic Outcome Following Endonasal Transphenoidal Excision of Growth Hormone Secreting Pituitary Adenomas

Background: Endonasal Transphenoidal Approach for excision of pituitary adenomas has been gaining popularity over the traditional microsurgical approach. The objective of this study is to assess the rate of hormonal recovery following endonasal transphenoidal excision of growth hormone secreting pituitary macroadenoma in out center. Methods: In this prospective observational study all cases subjected to endonasal transphenoidal excision of growth hormone secreting pituitary adenoma, during the study period from January 2019 to December 2020 at National Neurosurgical Referral Center, Bir Hospital, Kathmandu were included in this study. Preoperative and postoperative patient characteristics were recorded. Hormonal remission was defined as normal insulin-like growth factor-1 level at 3 months follow-up. Results: A total of 24 cases were included. The mean age of acromegaly cases was 39.42±10.41 years (24-56 years), with male to female ratio of 0.71:1. Majority (9) of cases had a Knosp grade 1.Thirteen cases had a Wilson-Hardy Extension Grade 0. Majority (11) of cases had a Wilson-Hardy Invasion Grade I. Three cases developed post-operative CSF leak, which recovered after lumbar drainage with no sequel. Five cases developed epistaxis which resolved with nasal packing. Sixty three percent (15 cases) had normal IGF-1 levels at 3 months follow up. Conclusion: Endoscopic endonasal transphenoidal approach to excision of growth hormone secreting pituitary adenomas is a safe and effective modality at achieving hormonal control in our setting.

Leukocyte- and platelet-rich fibrin in endoscopic endonasal skull base reconstruction: study protocol for a multicenter prospective, parallel-group, single-blinded randomized controlled non-inferiority trial

BackgroundRecent advances in endoscopic endonasal transsphenoidal approaches (EETA) for skull base lesions have resulted in a significant increase in extent and complexity of skull base defects, demanding more elaborate and novel reconstruction techniques to prevent cerebrospinal fluid (CSF) leakage and to improve healing. Currently, commercially available fibrin sealants are often used to reinforce the skull base reconstruction. However, problems have been reported regarding hypersensitivity reactions, efficacy, and costs. This trial aims to investigate autologous leukocyte- and platelet-rich fibrin (L-PRF) membranes as an alternative for commercially available fibrin glues in EETA-related skull base reconstruction reinforcement.Methods/designThis multicenter, prospective randomized controlled trial aims to demonstrate non-inferiority of L-PRF membranes compared to commercially available fibrin sealants in EETA cases (1) without intra-operative CSF-leak as dural or sellar floor closure reinforcement and (2) in EETA cases with intra-operative CSF-leak (or very large defects) in which a classic multilayer reconstruction has been made, as an additional sealing. The trial includes patients undergoing EETA in three different centers in Belgium. Patients are randomized in a 1:1 fashion comparing L-PRF with commercially available fibrin sealants. The primary endpoint is postoperative CSF leakage. Secondary endpoints are identification of risk factors for reconstruction failure, assessment of rhinological symptoms, and interference with postoperative imaging. Additionally, a cost-effectiveness analysis is performed.DiscussionWith this trial, we will evaluate the safety and efficacy of L-PRF compared to commercially available fibrin sealants.Trial registrationClinicalTrials.gov NCT03910374. Registered on 10 April 2019.