Endoscopic Endonasal Cavernous Sinus Surgery, with Special Reference to Pituitary Adenomas

TLDR

Cavernous sinus surgery is notoriously difficult due to the region’s functional importance and high morbidity, but endoscopic approaches have improved exposure and reduced complications. The authors argue that surgery plays a central role in treating cavernous sinus tumors by enabling accurate assessment of invasion, histopathologic diagnosis, and tumor debulking to enhance adjuvant therapy response. From 1998 onward, 65 pituitary adenoma patients with intraoperative cavernous sinus invasion were treated exclusively endoscopically, with a mean follow‑up of 51.2 months. The series showed no perioperative deaths, very low morbidity, radical resection in 21 of 35 nonfunctioning adenomas, hormonal remission in 13 of 30 functioning adenomas, and only a few complications such as hypopituitarism, diabetes insipidus, CSF leaks, and one craniotomy for hemorrhagic infarction.

Abstract

Cavernous sinus surgery has always been a surgical challenge because of the high functional importance of this region and the associated high morbidity. The augmented peripheral vision of the endoscope has led to the development of surgical approaches that allow adequate exposure of the cavernous sinus, with a reduction in surgical morbidity. Since 1998, 65 patients with pituitary adenomas and intraoperative evidence of cavernous sinus invasion were treated with a purely endoscopic approach. Follow-up was of at least 6 (mean 51.2) months. There was no perioperative mortality and extremely low morbidity. Radical tumor removal was obtained in 21/35 cases with nonfunctioning adenomas. Hormonal remission was obtained in 13/30 functioning adenomas. One patient with partial hypopituitarism and 1 patient with persistent diabetes insipidus were seen. Three patients with delayed CSF leaks required endoscopic repair. In 1 patient with hemorrhagic infarction in a residual tumor, reintervention with craniotomy was necessary. We advocate the central role of surgery in the treatment of cavernous sinus tumors, since it allows definition of true cavernous sinus involvement, histopathological diagnosis and, when cure is not feasible, tumor volume reduction, which might be an important factor in the response to adjuvant therapy.