Transsphenoidal approaches for the extracapsular resection of midline suprasellar and anterior cranial base lesions

OBJECTIVE: The transsphenoidal approach is an effective method for treating tumors contained within the sella or extending into the suprasellar cister n. The technique of tumor dissection is predicated on preservation of the i ntegrity of the diaphragma, i.e., intracapsular removal. Gross total extrac apsular dissection may, however, be accomplished either by using a standard approach to the pituitary fossa or by extending the exposure to include re moval of a portion of the planum sphenoidale and division of the superior i ntercavernous sinus. METHODS: Included in this series were 14 patients with parasellar or sellar tumors with extension into the anterior fossa and/or suprasellar cistern. For 4 of 14 patients (29%), extracapsular access was gained by broaching th e tumor capsule from within the pituitary fossa. For the remaining 10 of 14 patients (71%), the dura of the floor of the sella and the planum sphenoid ale was exposed, using neuronavigation to verify the limits of bony dissect ion; extracapsular tumor resection was performed using the operating micros cope and endoscopy as indicated. The dural defect was repaired with abdomin al fat, the sellar floor and planum sphenoidale were reconstructed, and in selected cases a lumbar drain was placed. RESULTS: Seven of 14 tumors (50%) were craniopharyngiomas, 3 of 14 (21%) we re pituitary adenomas, and 2 of 14 (14%) were meningiomas. There was one ca se of lymphocytic hypophysitis and one yolk sac tumor. Cross total resectio n was possible in 11 of 14 cases (79%). Immediate postoperative visual func tion worsened in 2 of 14 cases (14%), improved in 3 of 14 cases (21%), and was stable in the remainder of cases. Postoperatively, 2 of 14 patients (14 %) developed bacterial meningitis. Overt postoperative cerebrospinal fluid rhinorrhea was not observed. CONCLUSION: Cross total extracapsular resection of midline suprasellar tumo rs via a transsphenoidal approach is possible but is associated with a high er risk of complications than is standard transsphenoidal surgery.