Transcranial approach in giant pituitary adenomas: results and outcome in a modern series

Today, transcranial (TC) approach indications are particularly rare in pituitary adenomas (PA), representing 1.1% of all PA surgeries in our experience. In these rare and selected cases, the complications, advantages, and disadvantages of TC approach were also analyzed.

Nineteen cases of giant PA (≥40 mm) operated via TC approach alone or combined with transsphenoidal (TS) approach between 2000 and 2016 were selected.

The most frequently observed symptom was visual disturbance. Most PA (79%) were non-secreting. Only one tumor was aggressive. Maximal diameter average was 51.5 mm. Tumor removal was total, subtotal and partial in respectively 21%, 68.5%, and 10.5% of cases. Mean follow-up was 57 months. No recurrence was observed after total tumor removal. Visual improvement was observed in 53% of patients. Visual impairment rate was 21% after TC approach. New cases of panhypopituitarism were reported in 26.5% of patients in the TC approach. Total (including definitive and transient) postoperative diabetes insipidus occurred in 42% of patients in the TC approach. Ischemic and hemorrhagic complications were observed in 16% and 10.5% of patients, respectively, in the TC approach. Preoperative neurocognitive disturbance was identified in 31.5% of patients and only 16.5% of them showed postoperative improvement. Neurocognitive examination showed impaired results in 7.5% of patients with normal preoperative examination.

TC approach remains a requirement in giant and invasive PAs non-accessible via TS approach. However, the high morbidity associated with TC approach, including ischemic complications and visual impairment, has to be balanced with patient preoperative symptoms, and benign features of the tumor.