Transfrontal pituitary surgery: clinical results, intraoperative management, and postoperative monitoring

Sixty-nine cases of pituitary tumours with suprasellar extensions are reviewed. Twenty cases were recurrent. All were removed via a frontal craniotomy and surgery was performed under moderate hypothermia in all except seven cases. In 59 cases, lumbar cerebrospinal fluid (CSF) drainage was performed in order to improve operating conditions. Amongst 42 primary cases, 29 (69%) were uncomplicated, 5 (12%) developed severe transient complications and one (2.4%) had a persistent deficit postoperatively; there were no deaths. Amongst 17 recurrent cases, 6 (35%) were uncomplicated; there were five deaths (29%) in the immediate postoperative period and one patient had a persistent deficit (6%). Acute hypertension and/or bradycardia were seen in 32 cases (54%) at the time of lumbar CSF drainage. These included all those who subsequently died and 10 of the 12 cases who developed severe complications. In 7 cases where ventricular CSF drainage was performed intraoperatively, one showed acute hypertension accompanying brain retraction but there were no postoperative complications. Two of these cases were recurrent. Postoperative intracranial pressure, measured epidurally, varied widely in both complicated and uncomplicated cases and was frequently low (less than 10-15 mm Hg) in the presence of severe complications. It is concluded that lumbar CSF drainage should not be performed in the presence of a suprasellar extension and that postoperative monitoring of the epidural pressure is of little value in these cases for the early detection of postoperative complications pertaining to the operative field.