Combined transsphenoidal and pterional craniotomy approach to giant pituitary tumors

We describe a combined simultaneous approach to giant pituitary tumors and present a review of 10 patients undergoing this procedure with emphasis on patient selection, surgical technique, and results.

A retrospective review was performed of patients who had undergone a combined, simultaneous transsphenoidal and pterional craniotomy approach to a giant pituitary adenoma. Visual findings, endocrine presentation, and tumor type were compiled. Tumor stage and grade (Hardy classification) were based on MRI and intraoperative findings.

Gross total resection of tumor was achieved in 4 of 10 patients, near total (>90%) in 2 of 10, and subtotal (80-90%) in 4. At the time of follow-up (average, 29.7 months; range, 17-44 months), stereotactic radiosurgery had been performed in 2 patients. Of the 9 patients who presented with visual field loss, all had improvement at 1-month follow-up. At 6 months follow-up, resolution was complete in 5 patients and partial in 4. No patient had worsening of vision. Hypopituitarism persisted in all 5 patients who presented with it preoperatively.

The combined, simultaneous transsphenoidal and pterional approach described is indicated for a small subset of patients with giant (>3 cm) clinically nonfunctional pituitary tumors who meet the criteria of tumor configuration outlined where the surgeon cannot achieve complete resection by a single approach. We propose adding a new Hardy's scheme subtype, Stage B-a, to describe giant pituitary tumors with a dumbbell configuration. Combining both craniotomy and transsphenoidal approaches may achieve the goal of tumor resection with less need for multiple sequential operations.