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Background: Endoscopic transnasal approach to pituitary adenoma surgery has been recently introduced as an efficient alternative for traditional transcranial and conventional microscopic transnasal approaches. Recent studies have shown the advantages of this technique such as better cosmetic outcomes, low complication rate, lower duration of the surgery, higher patient satisfaction, and better tumor resection, compared to microscopic technique especially in large tumors with extensions into adjacent structures and tissues. Surgery for secreting microadenoma has been always a big surgical challenge in term of achieving full treatment especially in Cushing’s syndrome. Methods: A total of 12 cases secretory microadenoma was performed during 2011. Transplanum trans-intercavernous sinus approaches were used for better searching of the gland for microadenoma and checking the dural side adjacent for microadenoma since they were very useful in multi microadenoma and bilateral cases detections. In this approach, conventional techniques step by step were followed until the sellar floor was perforated. At this step, more resection of sellar bone was performed both anteriorly and posteriorly toward planum sphenoidale to expose intercavernous sinuses. Then, following careful bipolar cautery of the intercavernous sinuses, they were incised along with dura of the sellar floor. This approach makes an excellent view of the sella and pituitary adenoma as well as the pituitary gland itself and its stalk. Results: A total of 330 cases of pituitary adenoma underwent the endoscopic transsphenoidal (ETSS) surgery during 2005-2012. Of them, there were 27 cases of microadenoma, 15 of which underwent the surgery through classic ETSS and the rest (12 patients) were operated using ETPTICS. In the first group (conventional ETSS), 11 patients (73%) were completely recovered and only 2 cases showed recurrence after one year (both were Cushing’s syndrome). In the second group (ETPTICS), postoperative follow-up (5 months) assessments showed that all of 12 patients showed remission criteria with no recurrence. There was no postoperative cerebrospinal fluid (CSF) leak or any complication in both groups. There were 2 cases of transient diabetes insipidus (DI, unrelated to diabetes mellitus) in the ETSS group, while the other group showed 4 cases. However no permanent DI was observed in both groups. Conclusions: Findings of the present study showed that application of ETPTICS approach can increase the endocrinological remission rate that was a formidable task in cases with multiple microadenoma or Cushing’s syndrome with normal MRI and microadenoma touching the cavernous sinus or invading the dura. Hypothetically, the chance of CSF leak might be higher in this novel technique that was efficiently controlled using meticulous repair. Furthermore, meticulous care by pituitary stalk blood supply should be implemented to avoid anterior pituitary insufficiency and permanent DI. Tin tituitary insufficiency and permanent DI are to be avoided. Keywords: Endoscopic Transplanum Tran intercavernous sinus (ETPTICS), Pituitary, Endocrinological

Background: Cerebrospinal fluid (CSF) leak is a devastating complication after transsphenoidal surgical approach to pituitary adenoma and sellar repair has been postulated as crucial step in this approach. In this study, we describe our experience regarding sellar repair in pure endoscopic endonasal approach in 240 patients with pituitary adenoma. Methods: During April 2005 to April 2011, a total of 240 patients with pituitary adenomas underwent endoscopic endonasal approaches for tumor removal. The degree of intra-operative CFS leak was graded as followed: Grade 0: no leakage was observed; grade 1: leakage in form of drops; and grade 3: flow of CSF was observed. Repair was done according to degree of leak e.g. surgicel for grade 0, fat and fascia for grade 1, with adding synthetic sealant and/or lumbar drain for grade 2. The method of repair is discussed in each group and exceptions were also bolded. No sphenoid sinus obliteration was needed. Results: There were 208 macroadenomas and 32 microadenomas. One hundred and thirteen patients (55.4%) had grade 0 CSF leaks, 78 patients (32.5%) grade 1 CSF leaks, and 29 patients (12%) showed grade 2 leaks. There were 2 documented post operative CSF leak (0.8%) one of them was treated by lumbar drainage and the other with revision endoscopic repair. There was also one case of pneumocephalus (0.4%) with no obvious leak in nasal endoscopic exam which managed medically. There were also 2 cases of post-operation meningitis (0.8%) with no leak that one of them was due to outbreak of acinetobacter in ICU. Conclusions: Findings of this study showed that intra-operative CSF leak is an important factor determining the need and extend of sellar repair in endoscopic endonasal approach for pituitary adenoma. The low rate of post-operative CSF leak is in favor of the applicability of grading system and method chosen for repair. Keywords: Sellar repair, Endoscopic endonasal transsphenoidal surgery, Pituitary adenoma,Intra-operative Cerebrospinal fluid leak

Although apoplexy and cystic formation are common inside the pituitary adenoma and hemorrhage with different times of occurrence as revealed by magnetic resonance imaging sequences can be seen within a pituitary macroadenoma, a classic saccular aneurysm and its association with carotid artery haven’t been yet reported. Case: A 52 years old woman was referred for visual loss and headache accompanied by pituitary adenoma. She has no particular past medical history was operated her huge pituitary macroadenoma was resected by endoscopic endonasal transsphenoidal surgery. During surgery we encountered a tough saccular mass and checking imaging brought the conjecture of a thrombosed aneurysm. By careful dissection and use of intranasal Doppler sonography its association with left internal carotid was revealed. After coagulation of its main branch that was probably a tumor feeder aneurysm resected totally and we proceed for further tumor removal. Up to our knowledge and review of the related literatures it is the first time that intra adenoma thrombosed aneurysm is reported. Keywords: Intra adenoma thrombosed aneurysm, Classic saccular aneurysm, Case report, Doppler Sonography