Transcranial approach to pituitary adenomas invading the cavernous sinus: A modification of the classical technique to be used in a low-technology enviroment

OBJECTIVE: Pituitary adenomas invading the cavernous sinus represent a therapeutic challenge. Those tumours have been traditionally treated with incomplete surgical removal, observation and/or adjunctive medical therapy, and radiotherapy. In relatively recent years some authors have suggested a main direct surgical approach to cavernous sinus (CS) with the aim of complete removal of the adenoma, either by a modified trans-sphenoidal route, using or not an endoscopic-assisted approach, or by a transcranial direct approach. The latter has the advantage of allowing direct exposure of the lesion with a view of the surgical field unhindered by important neurovascular structures. MATERIAL AND METHOD: We report a technical modification of the classical epidural approach for CS adenoma removal. This was used in 14 patients. Surgical technique included a fronto-orbito-zygomatic craniotomy with extradural anterior clinoidectomy, and intradural approach to the Hakuba’s triangle for intracavernous dissection. The tumours were removed under direct vision. RESULTS: Total macroscopical removal was achieved in all but one case. This patient required postoperative radiation therapy as well as adjuvant dopaminergic regime for achieving control of preoperatively increased hormonal values. No other case required radiotherapy. Hormonal and/or clinical control was also achieved in all the remaining cases. Out of the remaining 13 cases, all appeared to be tumour-free at an average postoperative observation of 78 months (34 to 90 months). Significant surgical sequels were detected in only one case (persistent III nerve palsy and moderate hemiparesis). CONCLUSIONS: This experience, though limited, would suggest that the transcranial limited CS exposure through the Hakuba’s triangle may allow adequate removal of intracavernous pituitary adenomas with very good long-term results and acceptable complication rate.