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The current role of transcranial surgery in the management of pituitary adenomas

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Abstract

The aim of this study was to determine the factors influencing the use of a transcranial (TC) approach in pituitary adenomas and suggest a decision-making tree for the surgical strategy. The data for 23 (4.6 %) patients who underwent TC surgery from amongst 494 pituitary adenomas were retrospectively analyzed. Eight factors on magnetic resonance imaging (MRI) that could predict a difficult transsphenoidal (TS) surgery were noted. Adverse findings at TS surgery leading to a 2nd stage TC surgery were documented. Eighteen of the 23 cases were giant adenomas. Thirteen patients underwent TC surgery alone or as an initial approach when combined with TS while 10 underwent 2nd stage TC surgery following a TS approach. Most cases in the first group had 3 or more radiological factors in combination with a small sella. The 2nd group had higher sellar tumor volumes and fewer unfavourable radiological factors that led to the initial use of the TS approach. A hard, fibrous consistency or a significant residue obscured from the surgeon’s view, and difficulty in hemostasis were additional factors prompting the use of a TC approach. Tumor excision ≥90 % could be achieved in 13 cases (56.5 %). Post-operative RT was administered in 12 patients. There were 2 deaths (8.7 %) and the major morbidity rate was 43 %. Despite advances in endoscopic surgery the TC approach may be required in 5 % of cases. A study of the preoperative MRI for factors that predict difficulty with the TS approach might encourage the surgeon to consider a TC surgery either as an initial approach or combined with a TS surgery.

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Abbreviations

TC:

Transcranial

TS:

Transsphenoidal

MRI:

Magnetic resonance imaging

T4:

Thyroxine

FTC:

Free thyroxine concentration

TSH:

Thyroid stimulating hormone

FSH:

Follicle stimulating hormone

LH:

Luteinizing hormone

GH:

Growth hormone

IGF-1:

Insulin-like growth factor

OGTT:

Oral glucose tolerance test

PACS:

Picture archiving and communication system

ICA:

Internal carotid artery

FLAIR:

Fluid attenuated inversion recovery

CT:

Computed tomography

ACoA:

Anterior communicating artery

ETCO2 :

End tidal CO2

CSF:

Cerebrospinal fluid

RT:

Radiation therapy

SRT:

Stereotactic radiation therapy

SD:

Standard deviation

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Acknowledgments

We would like to thank Dr. KS Jacob for helping with the statistical analysis. We would also like to thank Mr. Rajkumar G. and Dr. K Srinivasa Babu for the illustrations.

Ethical standards

The authors declare that there were no ethical issues related to this study and have complied with the current laws of our country.

Conflict of interest

The authors declare that they have no conflict of interest.

Author information

Authors and Affiliations

  1. Section of Neurosurgery, Department of Neurological Sciences, Christian Medical College, Vellore, 632004, Tamil Nadu, India

    Ravindran Pratheesh, Krishna Prabhu & Ari G. Chacko

  2. Department of Endocrinology, Christian Medical College, Vellore, Tamil Nadu, India

    Simon Rajaratnam

  3. Department of Radiodiagnosis, Christian Medical College, Vellore, Tamil Nadu, India

    Sunithi E. Mani

  4. Section of Neuropathology, Department of Neurological Sciences, Christian Medical College, Vellore, Tamil Nadu, India

    Geeta Chacko

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  1. Ravindran Pratheesh
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  2. Simon Rajaratnam
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  3. Krishna Prabhu
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  4. Sunithi E. Mani
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  5. Geeta Chacko
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  6. Ari G. Chacko
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Correspondence to Ari G. Chacko.

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Pratheesh, R., Rajaratnam, S., Prabhu, K. et al. The current role of transcranial surgery in the management of pituitary adenomas. Pituitary 16, 419–434 (2013). https://doi.org/10.1007/s11102-012-0439-z

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