Video Article Primary Endoscopic Management of Apoplexy in a Giant Pituitary Adenoma Antonio Romano1, Mario Ganau2, Ismail Zaed2, Antonino Scibilia2, Gabriele Oretti1, Salvatore Chibbaro2 Key words - BACKGROUND: Sellar lesions with large suprasellar extension represent a - Endoscopic approach neurosurgical challenge because of their nature and anatomic complexity. The goal of the extended transphenoidal-transtuberculum approach is enlarging the transsphenoidal route superiorly and laterally allowing for a surgical adequate exposure and offering a remarkable versatility in many sellar pathologies. - Giant adenoma - Pituitary apoplexy From the 1Neurosurgery Hub&Spoke, Parma-Reggio Emilia, Parma, Italy; and 2Department of Neurosurgery, University of Strasbourg, Strasbourg, France To whom correspondence should be addressed: Ismail Zaed, M.D. [E-mail: ismailzaed1@gmail.com] Supplementary digital content available online. Citation: World Neurosurg. (2020) 142:312-313. https://doi.org/10.1016/j.wneu.2020.07.059 Journal homepage: www.journals.elsevier.com/worldneurosurgery Available online: www.sciencedirect.com 1878-8750/$ - see front matter ª 2020 Elsevier Inc. All rights reserved. INTRODUCTION Sellar lesions with large suprasellar extension represent a neurosurgical challenge because of their nature and anatomic complexity. The goal of the extended transphenoidal-transtuberculum approach is enlarging the transsphenoidal route superiorly and laterally allowing for a surgical adequate exposure and offering a - CASE DESCRIPTION: We present the case of a 65-year-old man who suddenly developed blindness, right hemiparesis, and decreased alertness. The initial head computed tomography scan revealed a pituitary apoplexy of a giant adenoma associated with hydrocephalus resulting from obstruction of the foramen of Monro. The video shows a complete lesion removal through the sole endoscopic approach, with opening of the dural layer of sphenoidal plane and successful decompression of the third ventricle. Visual and functional improvement occurred in the immediate postoperative course. No lumbar drain has been used. - CONCLUSIONS: This case demonstrates how the endoscopic approach can be attempted as a first and possibly stand-alone option for the surgical management of large sellar-suprasellar lesions. The endoscopic route is not associated with high rates of major complications and is safe when performed by experienced surgeons. In fact, it guarantees an enhanced control of the vascular feeders reaching the tumor from the anterior and middle fossa and results in a satisfactory manipulation of lesions invaginating into the floor of the third ventricle. A careful preoperative assessment of Knosp grade, tumor volume, hemorrhagic components, suprasellar extension, and sphenoid sinus invasion should always guide the management plan and suggest a staged or a combined (with transventricular or pterional approach) removal in particularly challenging cases. Figure 1. Computed tomography scan (A) showing pituitary apoplexy of a giant adenoma associated with hydrocephalus 312 www.SCIENCEDIRECT.com resulting from obstruction of the foramen of Monro. Postoperative results (B). WORLD NEUROSURGERY, https://doi.org/10.1016/j.wneu.2020.07.059 VIDEO ARTICLE ANTONIO ROMANO ET AL. APOPLEXY IN A GIANT PITUITARY ADENOMA assessment of Knosp grade, tumor volume, hemorrhagic components, suprasellar extension, and sphenoid sinus invasion should always guide the management plan and suggest a staged or a combined (with transventricular or pterional approach) removal in particularly challenging cases.3,4 REFERENCES 1. Cavallo LM, Prevedello D, Esposito F, et al. The role of the endoscope in the transsphenoidal management of cystic lesions of the sellar region. Neurosurg Rev. 2008;31:55-64. 2. Cavallo LM, Prevedello DM, Solari D, et al. Extended endoscopic endonasal transsphenoidal approach for residual or recurrent craniopharyngiomas. J Neurosurg. 2009;111:578-589. Figure 2. Caption from the video showing a complete lesion removal through the sole endoscopic approach, with opening of the dural layer of sphenoidal plane and successful decompression of the third ventricle. remarkable versatility in many sellar pathologies.1,2 improvement occurred in the immediate postoperative course. No lumbar drain has been used. CASE DESCRIPTION CONCLUSIONS We present the case of a 65This case demonstrates how year-old man (Video 1) who the endoscopic approach can suddenly developed be attempted as a first and blindness, right hemiparesis, possibly stand-alone option for and decreased alertness. The Video available at www.sciencedirect.com the surgical management of initial head computed large sellar-suprasellar lesions. tomography scan (Figure 1) The endoscopic route is not associated with revealed a pituitary apoplexy of a giant high rates of major complications and is adenoma associated with hydrocephalus safe when performed by experienced surresulting from obstruction of the geons. In fact, it guarantees an enhanced foramen of Monro. The video shows a control of the vascular feeders reaching the complete lesion removal through the sole tumor from the anterior and middle fossa endoscopic approach, with opening of and results in a satisfactory manipulation of the dural layer of sphenoidal plane and lesions invaginating into the floor of the successful decompression of the third third ventricle. A careful preoperative ventricle (Figure 2). Visual and functional WORLD NEUROSURGERY 142: 312-313, OCTOBER 2020 3. Romano A, Chibbaro S, Marsella M, et al. Combined endoscopic transsphenoidal-transventricular approach for resection of a giant pituitary macroadenoma. World Neurosurg. 2010;74:161-164. 4. Juraschka K, Khan OH, Godoy BL, et al. Endoscopic endonasal transsphenoidal approach to large and giant pituitary adenomas: institutional experience and predictors of extent of resection. J Neurosurg. 2014;121:75-83. Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. Received 25 April 2020; accepted 9 July 2020 Citation: World Neurosurg. (2020) 142:312-313. https://doi.org/10.1016/j.wneu.2020.07.059 Journal homepage: www.journals.elsevier.com/worldneurosurgery Available online: www.sciencedirect.com 1878-8750/$ - see front matter ª 2020 Elsevier Inc. All rights reserved. www.journals.elsevier.com/world-neurosurgery 313