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Transcranial Surgery for Pituitary Adenomas

Youssef, A Samy M.D., Ph.D.; Agazzi, Siviero M.D.; van Loveren, Harry R. M.D.

doi: 10.1227/01.NEU.0000163602.05663.86
Operative Nuances: SURGICAL APPROACH: SURGICAL TECHNIQUE: TUMOR

ALTHOUGH THE TRANSSPHENOIDAL approach is the preferred approach to the vast majority of pituitary tumors with or without suprasellar extension, the transcranial approach remains a vital part of the neurosurgical armamentarium for 1 to 4% of these tumors. The transcranial approach is effective when resection becomes necessary for a portion of a pituitary macroadenoma that is judged to be inaccessible from the transsphenoidal route because of isolation by a narrow waist at the diaphragma sellae, containment within the cavernous sinus lateral to the carotid artery, projection anteriorly onto the planum sphenoidale, or projection laterally into the middle fossa. The application of a transcranial approach in these circumstances may still be mitigated by response to prolactin inhibition of prolactinomas, the frequent lack of necessity to remove asymptomatic nonsecretory adenomas from the cavernous sinus, and the lack of evidence that sustained chemical cures can be reliably achieved by removal of secretory adenomas (adrenocorticotropic hormone, growth hormone) from the cavernous sinus. Cranial base surgical techniques have refined the surgical approach to pituitary adenomas but have had less effect on actual surgical indications than anticipated. Because application of the transcranial approach to pituitary adenomas is and should be rare in clinical practice, it is useful to standardize the technique to a default mode with which the surgical team is most experienced and, therefore, most comfortable. Our default mode for transcranial pituitary surgery is the frontotemporal-orbitozygomatic approach.

Department of Neurosurgery, University of South Florida, Tampa, Florida

Reprint requests: Harry R. van Loveren, M.D., Department of Neurosurgery, University of South Florida, Harbourside Medical Tower, 4 Columbia Drive, Suite 850, Tampa, FL 33606.

Received, October 22, 2004.

Accepted, December 16, 2004.

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