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Objective: Suprasellar craniopharyngiomas have been classically removed using a variety of transcranial approaches. Historically, the transsphenoidal route was reserved for intrasellar-infradiaphragmatic, and preferably cystic, lesions. With the advent of the endoscope in transsphenoidal surgery, its obvious advantages combined with neurosurgeons' increasing interest in extended transsphenoidal approaches made suprasellar and even intraventricular craniopharyngiomas accessible for removal via such a low route., Patients and Methods: Between January of 2004 and April of 2006, six men and four women (mean age, 57.2 yr; range, 26-70 yr) underwent surgery for craniopharyngioma, including two intrasuprasellar, one suprasellar, six suprasellar-intraventricular, and one that was purely intraventricular. Three patients had undergone a previous transcranial surgery via the pterional approach, whereas one patient had undergone a transsphenoidal microsurgical approach. The surgical method consisted of an extended endoscopic transsphenoidal approach with removal of the upper half of the sella, the tuberculum sellae, and the posterior part of the planum sphenoidale, using a "three-four hands" technique., Results: Total craniopharyngioma removal was achieved for seven patients, subtotal removal was possible for two patients, and one patient had a partial removal. Two patients developed a postoperative cerebrospinal fluid leak that required a successful endoscopic revision of the cranial base reconstruction. One patient died 5 weeks later because of hypothalamic dysfunction. All patients with visual field and/or visual acuity defect improved except one patient, in which we observed a slight worsening of visual acuity in one eye. Preoperative pituitary dysfunction did not improve in any patient. In three patients, we observed the new occurrence of permanent diabetes insipidus. One patient developed a sphenoid sinus mycosis, which was treated with antimycotic therapy. We did not observe carotid injury, epistaxis from the sphenopalatine artery, or airway difficulties., Conclusion: For selected patients, the extended endoscopic endonasal approach for removal of suprasellar craniopharyngioma seems to provide a valid alternative to transcranial approaches.

Object: The extended transsphenoidal approach to the suprasellar region has the advantages of minimal invasiveness and brain manipulation in the surgical treatment of small to medium lesions. At the same time, however, it carries a higher risk of postoperative cerebrospinal fluid (CSF) leakage and related complications than those for the standard transsphenoidal approach. Effective reconstruction of large skull base defects is a major concern in such extended approaches and remains challenging., Methods: Between January 2004 and April 2006, 21 patients affected by different suprasellar lesions underwent the extended endoscopic endonasal transtuberculum-transplanum approach. Three different techniques were used for the skull base reconstructions. In all cases, dehydrated human pericardium (Tutoplast) for dural reconstruction and a copolymer of L-lactic acid and glycolic acid (LactoSorb) as a bone substitute were used. Collagen sponges, fibrin glue, and an inflated Foley balloon catheter were also used to fill the sphenoid sinus cavity., Results: Two cases of postoperative CSF leaks (9.5%) and one case of mycotic sinusitis (4.8%) occurred following the intradural (inlay) and intraextradural (inlay-overlay) graft positioning. No cases of postoperative CSF leakage occurred in cases in which the extradural-only reconstruction procedure was applied. No meningitis or other complications related to the closure were noticed., Conclusions: The rate of postoperative CSF leakage after an extended approach to the suprasellar area is higher compared with that following standard pituitary surgery. Reconstruction after craniopharyngioma surgery exposes patients to an increased risk of postoperative CSF leaks. The extradural (overlay) technique was found to be the most effective in assuring a watertight closure.

Background: Endoscopic endonasal transphenoidal surgery has been recently proposed as a minimally invasive procedure for the treatment of pituitary adenomas. The main objective of the anaesthesiologist is to induce sufficient haemodynamic control together with rapid recovery at the end of surgery. The aim of this study was to examine recovery profile, surgical operative conditions and haemodynamic differences using remifentanil infusion with either propofol target controlled infusion system or sevoflurane., Method: Forty-four adult patients were enrolled in a prospective, randomized, single-blind, two-group study: Group P received propofol target controlled infusion system and remifentanil; Group S received sevoflurane and remifentanil for maintenance of anaesthesia., Results: No statistically significant differences between the two groups with regards to the haemodynamic changes, operative conditions as assessed by a four-step bleeding score (0-3), were obtained. Recovery times were considerably shorter after remifentanil-sevoflurane in comparison with remifentanil-propofol target controlled infusion system group (7.4 vs. 12.8 min, P < 0.01)., Conclusion: This study demonstrates that sevoflurane-remifentanil gives a faster recovery and equivalent intraoperative status compared with propofol target controlled infusion system with remifentanil for the endoscopic endonasal transphenoidal approach.

The endoscopic endonasal transsphenoidal approach has been proposed in the past decade as a minimally invasive surgical technique for the removal of pituitary tumors. From January 1997 to November 1999, 100 consecutive patients with pituitary tumors underwent endoscopic endonasal surgery, according to Jho's technique. We employed 0 degrees, 30 degrees, 45 degrees, and 70 degrees rigid endoscopes, 18 - 30 cm in length, 4 mm in diameter with an outer sleeve for irrigation and secured to a holder. Among the 87 pituitary adenomas, tumor removal was total in 51, subtotal (> 80 %) in 20 and partial in 16 cases. Four craniopharyngiomas were totally removed and an intra-suprasellar arachnoid cyst was emptied; a biopsy was performed in the two patients with a clivus chordoma. The two cases of sphenoid sinusitis were cured by surgery, the three patients with spontaneous CSF rhinorrhea were successfully treated and the residual nasal meningocele was removed. The endoscopic endonasal transsphenoidal approach appeared to be less traumatic than the traditional microsurgical approach, was very effective, and was characterized by a reduced number of complications. However, the relatively small series together with the short follow-up do not allow us to draw definitive conclusions. The post-operative reduction in hospital stay (two days in 40 of 100), significantly reduced the cost of patient's management.

Object: To assess postoperative complications related to the surgical procedure, a retrospective analysis was conducted in a series of 146 consecutively treated patients who underwent an endoscopic endonasal transsphenoidal approach to the sellar region for resection of pituitary adenomas between January 1997 and July 2001., Methods: Complications were divided into groups (nasofacial, sphenoid sinus, sella turcica, supra or parasellar, and endocrine complications) according to the anatomical structures and the systems involved. Overall, a decreased incidence of complications has been observed, compared with large historical series of the traditional microsurgical transsphenoidal approach, likely because of the overview inside the anatomy facilitated by the endoscope, and the decreased surgical trauma., Conclusions: Transsphenoidal surgery, either microscopic or endoscopic, is a safe procedure in experienced hands, but serious complications still occur and must be reduced as much as possible. Additional improvement can be expected with greater experience and new technical developments. A coordinated team effort with other dedicated colleagues from different specialties is advised.

Severe hyponatremia (118 mmol/l) with natriuresis, consistent with cerebral salt wasting syndrome (CSWS), occurred 38 days after transsphenoidal surgery in a 59-year-old woman affected by a pituitary non-functioning macroadenoma. From the 35th day after surgery, she showed progressive polyuria, hypotension and hyponatremia associated with natriuresis, decreased plasma and increased urinary osmolality. The clinical examination revealed signs of dehydration and gradual decline in the level of consciousness. The anterior pituitary function was normal due to appropriate replacement of thyroid and adrenal axis. The patient was treated with saline administration until normal natremia and water balance were restored and neurological symptoms had completely disappeared. This case focuses on the unusually prolonged time of development of post-surgery hyponatremia, despite delayed symptomatic hyponatremia being reported to commonly occur 7 days after transsphenoidal surgery. Therefore, we would advise not to limit the periodic follow-up of the hydroelectrolytic balance to the first two weeks after surgery, but to prolong it until after discharge from hospital. In fact, an early diagnosis is of great importance to prevent permanent neurological damage or death. Since CSWS and syndrome of inappropriate secretion of ADH, the two disorders alternatively imputed to generate post-surgical hyponatremia, are characterized by different pathogenic mechanisms and require opposing therapeutic approaches, the occurrence of extracellular volume dilution or of increased sodium renal loss should be carefully investigated. The evidences in favor of CSWS, the possible mechanisms behind the syndrome and diagnosis and management of patients with post-transsphenoidal surgery CSWS are discussed.

The endoscopic endonasal transsphenoidal approach to the sellar region for the removal of pituitary adenomas and of other neoplasms in the same area has proved its reliability and effectiveness for the very wide vision it offers, coupled with minimal surgical trauma. Indications and advantages of such a technique are reported, focused on the treatment of lesions of the sellar and parasellar environment in pediatric age-group patients, and based on a consecutive series of 100 patients, 3 of them adolescents, treated during the last 3 years.

Despite a good cure rate after surgery, the recurrence rate in pituitary adenomas is globally high. The decision making in such cases can be problematic for the nature of the lesion, for the anatomic structures involved, for the different pharmacological, surgical, radiotherapeutic and radiosurgical options nowadays available. In the perspective of an improvement and refinement of the surgical procedure an endoscopic endonasal transsphenoidal approach to the pituitary was recently adopted in the Neurosurgical Department of the University of Naples. Its minimal invasiveness and its wider and direct anatomic control of the operative field has allowed a faster, greater and safer potential of tumour excision, with respect of the sphenoid, sellar and parasellar structures. The authors have examined the advantages provided by this technique in 12 patients with recurrent pituitary adenomas and in 2 craniopharyngiomas already treated via a transnasal transsphenoidal approach (TTA), where the anatomy of surgical field had been distorted by the first operation or the radiation therapy. They conclude that the endoscopic transsphenoidal re-operation might be considered the procedure of choice in case of recurrences and its easiness in such conditions could favour its larger use, before other more aggressive therapeutic solutions.

Technique: Endoscopic transsphenoidal surgery. New, developing, minimally invasive technique. Removal of pituitary lesions and tumors of the parasellar region., Technical Development: Endoscopic endonasal transsphenoidal surgery. Endonasal, not transnasal, procedure. Great respect of anatomy. Very wide surgical field, without intraoperative use of a nasal speculum, but with less room in which to work (only one nostril) and potential conflict between the surgeon's hands and the endoscope (both when entering the nostril and while working inside)., Instrumentation: New instrument. Secure grip. Barycenter of the instrument is the surgeon's hands. Many different tips with different functions. Elimination of the bayonet-like shape. Handle bent in the horizontal plane to avoid interference with the surgeon's hands and to allow the distal, thin part of the instrument to be used safely and comfortably.

Diaphragma sellae meningiomas are unusual tumours often not distinguished from pituitary macroadenomas. Preoperative differentiation is essential, because the trans-sphenoidal approach is used for surgical removal of adenomas, while meningiomas are approached via a craniotomy. We reviewed five patients in whom a diaphragma sellae meningioma was initially diagnosed as a nonsecreting pituitary macroadenoma. MRI criteria for differential diagnosis are discussed. The main findings considered are visibility of the pituitary gland, contrast enhancement, the centre of the lesion and sellar enlargement. These criteria, applied to a blind review, allow correct identification of the tumours.

Standard microscopical transsphenoidal surgery is used world-wide in most sellar lesions, but continuing technological progress leaves room for further possibilities. The authors have employed a slightly modified Jho-Carrau technique for endoscopic endonasal transsphenoidal removal of pituitary lesions. This approach has been successfully used in 15 consecutive patients; the preliminary results are reported. The advantages and the limitations of this technique are discussed and compared to standard transsphenoidal surgery. In consideration of the low invasiveness of this approach and of the improved respect for the inner nose and sinus structures, the authors suggest the new term of Functional Endoscopic Pituitary Surgery (FEPS) to characterize this simple one-nostril endoscopic endonasal procedure.

The effect of surgery alone or followed by radiotherapy in recovering visual abnormalities, debulking tumor mass and restoring hormone impairments was evaluated in 84 patients with clinical nonfunctioning pituitary adenomas (NFPA) subjected to 1-10 yr follow-up. All patients underwent surgery via transsphenoidal (in 69) or transcranic-pterional approach (in 15). Radiotherapy was performed after surgery in 59 of 72 patients with incomplete tumor removal. The assessment of pituitary function was performed in all patients before and every 1-2 yr after surgery and/or radiotherapy. Radiological and ophthalmologic assessment was performed before and 3, 6 and 12 months after surgery, then yearly. At diagnosis, headache and visual disturbances occurred in 63 and 58 patients, respectively, while deficiency of GH, TSH, ACTH, FSH, LH and ADH was documented in 55, 7, 19 47 and 6 patients, respectively. After surgery, gonadal function recovered in 12 women, visual disturbances improved in 43 patients (15 regained normal vision), pituitary function improved in 8 of 62 patients, worsened in 34 patients. At MRI, complete tumor removal was documented in 12 of 84 patients. After surgery alone, tumor regrowth was observed in 7 patients between 3-7 yr. After radiotherapy, vision improved in 9, remained unchanged in 49 and worsened in 1 of 59 patients. After radiotherapy, tumor regrowth was documented in 9 patients between 2-12 yr and the prevalence of hypopituitarism raised from 28.8% to 92% after 1 and 10 yr. In conclusion, surgery alone is effective only in a minority of patients (14.3%) and radiotherapy causes hypopituitarism in rather the totality of patients after 10 yr. The prevalence of tumor regrowth was similar in irradiated ones (15%) and non irradiated patients (28%; chi(2), p = 0.4). Therefore, a careful radiological followup is suggested after surgery so that radiotherapy can be performed promptly on the basis of clinical data, tumor regrowth and/or invasiveness documented at histology.

Paragangliomas are usually benign tumors which can be found in many sites of the body, from the base of the skull down to the pelvic floor. In the central nervous system the sellar region is very rarely involved; only three well studied cases have been reported to date. We present the cytological, histological, histochemical, immunocytochemical and ultrastructural features of an intrasellar and suprasellar paraganglioma in an 84-year-old man.

A ten-year experience on 36 patients bearing macroprolactinomas (MP) and 86 others bearing microprolactinomas (mP) is reported in this study. Different therapeutical approaches were used: 1) trans-sphenoidal surgery in 24 patients with MP and in 25 with mP; 2) medical therapy with the oral form of bromocriptine (BRC) in all the 24 patients with MP previously subjected to surgery, in 48 patients with mP ab initio, and in 16 out of 25 patients with mP previously subjected to surgery; 3) medical therapy with the long-acting injectable forms of BRC in 12 MP- and 13 mP-bearing patients, and 4) conventional radiotherapy in 12 of the 24 patients with MP previously subjected to surgery. The follow-up, performed five years after surgery, showed that: a) all the 24 patients with MP but one had normal PRL levels during BRC administration, with a rebound of hyperprolactinemia in all cases after withdrawal; b) during the treatment BRC caused normalization of PRL in 15 of the 16 mP-bearing patients surgically treated and in all the 48 mP-bearing patients only treated with BRC; c) in 20 of the 25 patients the treatment with injectable retard BRC caused the normalization of plasma PRL and the shrinkage of the tumor mass in all the patients with MP but one, as revealed by seriate CT scans. In conclusion, the surgical treatment of prolactinomas was ineffective to normalize plasma PRL levels in most patients whereas BRC, in standard or in retard forms, was able to normalize plasma PRL levels, reduce the tumoral mass and preserve the pituitary residual tissue. BRC should be, therefore, used as first choice therapy both for MP and mP.

Two cases of pituitary adenoma associated with a parasellar cyst are reported; only one similar case has been described previously. Even though such an association may be coincidental, a pathogenetic relationship between the two lesions in one of our cases may be assumed: shrinkage of the prolactin-secreting pituitary adenoma by means of bromocriptine therapy did, in fact, cause collapse of the cyst. Such an occurrence must not be disregarded in considering the therapeutic approach.

The technique of peri-hypophyseal phlebography is briefly described and the theoretical bases that inspire its utilizations and indications are pointed out. On the basis of 20 preliminary cases, the main applications of this investigation are illustrated, with a particular attention concerning the early diagnosis of lesions too small or too dishomogeneous to be detected with certainly on CT (i.e. intrapituitary microadenomas smaller than 5 mm; associated intrasellar lesions as empty sella + pituitary tumor).

A rare instance of pituitary invasive adenoma in a child has been reported; the unusual age of the patient and then the rarity of the orbit invasion has been emphasized. It has been further pointed out the histologically benign nature of the neoplasm, which on contrast behaves like a malignant adenoma, according to its rapid and serious anatomo-clinical evolution.

Even though the main problems of transsphenoidal surgery are encountered during the intra- and suprasellar portions of the operation, proper reconstruction of the sella turcica plays an important role in the overall results, greatly influencing the final outcome. Improper measures may bring about a complicated postoperative course, whereas a wise and precise method allows one to control any surgical condition, preventing the more dangerous consequences of the transsphenoidal approach (i.e., empty sella, cerebrospinal fluid leakage, hemorrhage, infection, etc.). The authors review the different methods of sellar plugging and, on the basis of their own experience, indicate the most suitable one for each of the more usual situations. A good result is achievable if only natural materials are used and one avoids synthetic prostheses. Extradural packing is the technique of choice whenever a hermetic closure and a particularly effective intrasellar plug are required.

Inversion and prolapse into the sella of the superior capsule and the diaphragma sellae is the only condition that warrants, at least macroscopically, radical removal of tumors with suprasellar extension operated on via the transsphenoidal route. If this does not occur spontaneously, air can be introduced into the subarachnoid space through a lumbar spinal catheter to produce forced dissection of the suprasellar cisterns and collapse of the tumor capsule ("pumping technique"). This method permits complete removal of the neoplastic tissue. In a series of 124 transsphenoidal operations for tumors with suprasellar extension, spontaneous descent of the capsule occurred in only 26 cases. Forced dissection using air distension of the cisterns was carried out in 88 cases, with complete success in 56 cases, partial success in 20, and no effect in 12. There were no complications or unwanted side effects in any patient.

The Authors review their recent experience in investigating 185 cases of sellar and parasellar lesions, using as preliminary procedure stratigraphy and CT; further examinations were performed only in cases with unclear diagnosis. Their data confirm the reliability of this non-invasive protocol that allowed the detection of pathological changes in nearly 95% of cases and was able to define with certainty the nature of the lesions in over 72% of cases. However, other investigations were performed in 116 cases (63%): in 57 (31%) for diagnostic purpose, in 59 (32%) as complementary pre-operative studies.

In primary or relapsing grossly cystic craniopharyngiomas most of the problems related to the neoplastic mass may be, even if temporarily, improved by reducing volume of the cyst. A major surgical approach is unjustified when the aim is only to empty the cyst contents. Drainage of the cyst cavity by means of derivative techniques may be as effective and less invasive; in combined management plans that such tumours often require, they are, therefore, useful complementary procedures that can achieve long-lasting relief of symptoms, provided that the cyst is unilocular. Technical features and indications for such methods, with special regard to the techniques of sump drainage and of tube ventriculocystostomy, are discussed on the basis of the few reported series and of 6 personal cases. Usually only palliative aims are achieved, waiting for more definitive treatment; in a few selected cases, however, they may be quite effective.