TRANSCRANIAL EPIDURAL APPROACH TO PITUITARY-TUMORS EXTENDING BEYOND THE SELLA

OBJECTIVE: The treatment of residual and/or recurrent pituitary tumors , initially operated on through transsphenoidal and/or transcranial ap proaches, required a new single approach that would make it possible t o excise the tumor from the sella and from the neighboring regions. Su rgical complications, such as pneumatocephalus, cerebrospinal fluid le ak, mechanical lesion of the internal carotid artery and/or visual app aratus, and failure to remove the tumor completely, supported the need for an approach that would guarantee a much higher rate of completene ss of resection of tumors and also avoid the risk of occurrence of com plications. This report does not address endocrinological disorders be fore surgical treatment of pituitary tumors nor is its aim to present the functional efficacy of surgical treatment relating to hormones. ME THODS: The anatomic relationships of the sellar and parasellar regions were studied using central cranial base specimens (8), Previous anato mic studies of the triangles of the lateral wall of the cavernous sinu s (including anteromedial, paramedial, and Parkinson's triangles) and practical experience dealing with tumors in the region led to the use of the triangular windows as key accesses to the pituitary tumors in t he enlarged sella and in the neighboring area(s). RESULTS: During the past 15 years, 210 patients with pituitary tumors extending into the p arasellar and other regions beyond the sella were operated on using th e transcranial approach. In Group I (consisting of 120 patients), comp lete removal was achieved in 66.5% of the patients by using the classi cal approach. Postoperative cerebrospinal fluid leak occurred in 8% an d impairment of the visual function in 6% of the patients. With the ne w approach being used during the last 5 years in Group II (consisting of 90 patients), postoperative impairment of the visual function occur red in only 1 patient and cerebrospinal fluid leak occurred in only 1 other patient. Complete excision was achieved in 92.5% of the patients in Group II. Postoperative improvement of the visual function(s) was achieved for 26% of the patients in Group] and 52% of the patients in Group II. There was no mortality in either the first or the second gro up. CONCLUSION: The results led to the conclusion that the new approac h to pituitary tumors extending beyond the sella (regarding the rate o f completeness of the tumor resection) is superior to the previous tra nscranial approach (6, 8). Using the new approach, the risks of surgic al complications can be avoided by preserving, intact, the diaphragm s ellae and the dura covering the central cranial base around the sella.