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Neuroendoscopy pp 57–64Cite as

Current Status and Future Developments of Neuroendoscopic Management of Pituitary Tumours and Craniopharyngiomas

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Abstract

The endoscopic endonasal technique has been applied for the surgical excision of pituitary adenomas and craniopharyngiomas with encouraging results and low morbidity.

Excision of hormonally inactive adenomas leads to an improvement of visual symptoms in the majority of cases. In patients with macroadenomas and normal pituitary function, the endoscopic close-up view may increase the chance to preserve residual pituitary gland. Patients with hormonally active prolactinomas are referred to surgery for cystic lesions, after failure of medical treatment or for complications related to it or when they refuse long-term medical therapy. In patients with acromegaly, despite advances in suppression of GH levels with somatostatin analogues or GH-receptor antagonists, transphenoidal surgery remains the first-line therapy, as it achieves immediate lowering of the growth hormone excess, with endocrine remission rates of 70 % for microadenomas and 50 % for macroadenomas. In recurrences of GH-secreting pituitary adenomas, 48 % of cases can achieve remission with repeat transsphenoidal surgery. In ACTH-secreting pituitary adenomas, surgery is offered as a primary therapy. Management of recurrences is still controversial. We favour repeat surgery and, in case of failure, radiosurgery, with reported encouraging results. Medical therapy with cabergoline has been proposed as an adjuvant therapy in selected patients.

An endoscopic transnasal binostril approach with a partial posterior septectomy is preferred as it allows for more than one instrument to be inserted in addition to the endoscope, which is used freehand during the whole procedure (“two nostrils-four hands technique”). Even wide parasellar adenomatous extensions can be removed. When the pituitary adenoma extends to the lateral cavernous sinus, it can be delivered through an ipsilateral transethmoid transpterygoid route.

The management of craniopharyngioma aims for complete resection, which remains the gold standard, although recurrence is common. In the majority of cases of intra-suprasellar infradiaphragmatic lesions, a standard transsphenoidal approach allows the removal of the lesion. In case of suprasellar craniopharyngiomas, some selected cases can be treated using the transtuberculum-transplanum approach. Supradiaphragmatic lesions can be removed from the endonasal route. Suprasellar prechiasmatic preinfundibular lesions can be removed with the transtuberculum-transplanum sphenoidale approach.

After tumour removal, reconstruction of the skull base comprises arachnoid sealing with fibrin glue and reconstruction of the osteodural defect with dural substitute which exceeds the bone defect, held in place with a fragment of bone substitute, which fits the bone opening. The whole skull base defect is then covered with a vascularized nasoseptal flap.

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Authors and Affiliations

  1. Department of Neurosciences and Reproductive and Odontostomatological Sciences, Division of Neurosurgery, Università degli Studi di Napoli Federico II, Naples, Italy

    Paolo Cappabianca MD, Luigi Maria Cavallo MD, Isabella Esposito MD & Felice Esposito MD

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  1. Paolo Cappabianca MD
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  2. Luigi Maria Cavallo MD
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  3. Isabella Esposito MD
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  4. Felice Esposito MD
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Correspondence to Paolo Cappabianca MD .

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Editors and Affiliations

  1. Dept. of Pediatric Neurosurgery, Mitera Children´s Hospital, Athens, Greece

    Spyros Sgouros

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Cappabianca, P., Cavallo, L.M., Esposito, I., Esposito, F. (2014). Current Status and Future Developments of Neuroendoscopic Management of Pituitary Tumours and Craniopharyngiomas. In: Sgouros, S. (eds) Neuroendoscopy. Springer, Berlin, Heidelberg. https://doi.org/10.1007/978-3-642-39085-2_5

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  • DOI: https://doi.org/10.1007/978-3-642-39085-2_5

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