Simultaneous Endoscopic Endonasal and Transcranial Excision of Giant Pituitary Adenomas

Objective: To study the clinical and surgical outcomes of large and giant pituitary adenomas excised through a simultaneously performed endoscopic endonasal and transcranial approach.

Methods: Twenty patients with large and giant pituitary adenomas operated simultaneously through an endoscopic endonasal and transcranial approach between 2019 and 2022 were included. Demographic profile, clinical presentation, hormonal status, adenoma characteristics, surgical procedure, the extent of resection and complications were analyzed to determine the outcomes.

Results: The mean age at presentation was 37.5 years (range: 20–51 years). The majority were males—12 (60%). Five (25%) were growth hormone-secreting pituitary adenomas, 1 (5%) was a prolactinoma and the remaining, 14 (70%) were non-functional pituitary adenomas. 19 (95%) were giant pituitary adenomas (≥ 4 cm in maximum dimension) with a mean tumor volume of 36 cm³ (range, 14–128.2). Cavernous sinus invasion (Knosp grade ¾) was seen in 13 (65%) and subfrontal/temporal extension was seen in 14 (70%) of the adenomas. In 10 (50%) patients, the tumor was extending lateral to the supraclinoid internal carotid artery (ICA) with encasement of the vessels in 7 (35%). Gross total excision (GTR) was achieved in 2 (10%), near total excision (NTR) (90–99.9%) in 12 (60%) and subtotal excision (STR) (70–89.9%) in the remaining 6 patients. The common sites of tumor residue were around the suprasellar vessels and the perforators (10/20, 50%) and/or in the cavernous sinus (9/20, 45%). The mean duration of surgery was 317.4 ± 130 minutes. The mean intraoperative blood loss was 1210 ± 519.3 mL. Two (10%) patients had postoperative CSF leak and transient diabetes insipidus was seen in 16 (80%), of which 10 (50%) had diabetes insipidus even at 3 months follow up. One patient had osteomyelitis of the bone flap at follow-up and underwent removal of the bone flap. None of the patients had meningitis, tumor bed hematoma, motor deficits or visual deterioration. There were no deaths. 15 (75%) patients had improvement in their vision postoperatively and vision remained the same in the remaining 5 patients. New onset hypocortisolemia was seen in 12 (60%) and new onset hypothyroidism was seen in 8 (40%).

Conclusion: The simultaneous endoscopic transsphenoidal and transcranial excision is a safe surgical option for the excision of large and giant pituitary adenomas that extend laterally beyond the supraclinoid ICA.

Publication History

Article published online:
01 February 2023