Background/Objectives: Giant pituitary adenomas (GPAs) pose significant surgical challenges due to their large size, parasellar/suprasellar extensions, and proximity to critical neurovascular structures. Although the endoscopic endonasal approach (EEA) is preferred for pituitary tumors, achieving gross total resection (GTR) in GPAs remains difficult. Additional transcranial approaches may improve resection rates while minimizing morbidity. This study evaluates the impact of endoscopic and combined surgical approaches on resection outcomes using a classification system previously defined in GPA patients treated over the past year. Methods: Among 517 pituitary adenomas treated in our clinic between September 2023 and September 2024, 49 GPA patients underwent endoscopic endonasal, transcranial, or combined surgery. Their medical records and surgical videos were retrospectively reviewed. Data included demographics, symptoms, imaging, surgical details, and follow-up outcomes. Tumor resection rates were analyzed based on the “landmark-based classification”, considering radiological and pathological features and surgical approach. Results: The mean age was 45.5 years (female/male: 14/35). Zone distribution was 8 (Zone 1), 21 (Zone 2), and 20 (Zone 3). GTR was achieved in 34.6%, near-total resection in 36.7%, and subtotal resection in 28.5%. Endoscopic surgery was performed in 41 patients, combined surgery in 7, and a transcranial approach in 1. Complications included diabetes insipidus (9/49), cerebrospinal fluid leakage (2/49), apoplexy (2/49), hypocortisolism (3/49), epidural hematoma (1/49), and epistaxis (1/49). Conclusions: While EEA is effective for Zone 1 and 2 GPAs, Zone 3 tumors often require combined or transcranial approaches for better resection. A multimodal strategy optimizes tumor removal while minimizing morbidity. Individualized surgical planning based on tumor classification is crucial for improving outcomes.

BACKGROUND AND OBJECTIVES: Endoscopic endonasal surgery (EES) is the preferred approach for treating sellar and parasellar lesions due to its panoramic view and detailed anatomical definition. This study aims to review major arterial injuries during EES, a rare but critical complication associated with high mortality and morbidity rates. METHODS: A retrospective analysis was conducted, including 15 patients from 5640 EES procedures performed between August 1997 and February 2024 at in our center/Department of Neurosurgery. The study focuses on perioperative and postoperative management strategies, highlighting the use of oxidized regenerated cellulose (Surgicel®)/gelatin-thrombin matrix (Floseal®) and multidisciplinary collaboration to achieve hemostasis. RESULTS: The incidence of major arterial injury was 0.2%, with a mean patient age of 38.4 years and a female-to-male ratio of 10:5. The most common tumors were adenomas (n = 7) and chordomas (n = 5). The most commonly bleeding arteries in 6 patients each are the cavernous segment of the internal carotid artery and the paraclival carotid artery. Low-flow bleeding was observed in 10 of our patients, while high-flow bleeding was seen in 5 patients, 4 of whom were recurrent cases (P < .05). In 3 patients with high-flow bleeding from segments of the carotid artery, digital subtraction angiography was performed for stent placement or coil embolization, while in 1 patient with high-flow bleeding, digital subtraction angiography was used for monitoring cerebral blood flow. One of our patients died of a myocardial infarction at the 14th month of follow-up and 1 of our patients developed left-hemiparesis. CONCLUSION: The study underscores the importance of preoperative planning, surgical expertise, and multidisciplinary teamwork in managing major arterial injuries during EES. The authors advocate for the development of standardized treatment algorithms to improve outcomes in these patients. The findings contribute to the limited literature on managing internal carotid artery injuries in EES, emphasizing the need for ongoing research and algorithm development.

The endoscopic endonasal approach (EEA) has become a key surgical method for managing midline skull base lesions, offering minimally invasive access with reduced morbidity. One of the most significant complications following EEA is cerebrospinal fluid (CSF) leakage, especially in high-flow cases. Based on over 2 decades of institutional experience with 6221 EEA procedures, this study aims to categorize and evaluate standardized reconstruction strategies based on intraoperative CSF flow rates in order to optimize outcomes and reduce postoperative complications. This retrospective study included 179 patients with intraoperative CSF leaks among 656 EEA surgeries performed in 2024 at a tertiary center. Intraoperative CSF leaks were classified as low- or high-flow, and patients were grouped by reconstruction strategy. Techniques included free mucosal grafts, autologous fat and fascia lata, vascularized nasoseptal flaps, and lumbar drainage (LD) where necessary. Preoperative imaging, surgical details, and postoperative complications were analyzed. Statistical comparisons were performed using appropriate parametric and nonparametric tests. Intraoperative CSF leakage occurred in 27.2% of cases (n = 179), of which 60.9% were high-flow leaks. Postoperative rhinorrhea developed in 2.1% of all patients and was significantly associated with extended approaches, third ventricular exposure, and high Evans ratio. Free mucosal graft-based reconstructions were effective in low-flow leaks, while complex multilayer closure using nasoseptal flaps and LD reduced complications in high-risk cases. Meningitis occurred in 1.1% of the cohort, rising to 14.3% in patients with postoperative rhinorrhea and 13% in those with LD. Tailored reconstruction based on intraoperative CSF flow rate and anatomical risk factors is critical to minimizing postoperative complications following EEA. A structured, risk-based approach can enhance the safety and efficacy of skull base surgery and may serve as a model for standardized reconstruction protocols in endoscopic neurosurgery.

Calcification in pituitary adenomas is a rare occurrence and its differential diagnosis typically includes other sellar masses. Common calcifications in pituitary adenomas are classified into 2 morphological forms: capsular (eggshell-like) and multiple small nodular calcifications located within the adenoma. Also, there is a pituitary stone term. This study aims to present the results of calcified pituitary adenoma case series who underwent endoscopic endonasal approach (EEA) and the clinical, histopathological characteristics and surgical outcomes of these cases. This study conducted a retrospective cohort analysis of patients with calcified pituitary adenoma operated on by EEA between August 1997 and February 2024. The inclusion criteria were as follows: proven radiological calcification on preoperative neuroimaging, intraoperative findings of calcification, and definitive histopathological diagnosis of calcification. Among these patients, 11 cases were included. The mean follow-up duration was 51.45 ± 37.24 (6-118) months. Based on the preoperative paranasal sinus computed tomography scans of patients, 9 patients (81.8%) had intratumoral calcification, 1 (9.1%) had capsular (eggshell-like) calcification, and 1 (9.1%) had both intratumoral and capsular calcification. Moreover, stone-like calcifications were observed in 4 patients (36.4%), soft-type calcifications in 3 (27.3%), hard-type calcifications in 3 (27.3%), and soft-type and hard-type calcifications in 1 (9%). Gross total resection was achieved in 9 patients (81.8%). Pathologic subtypes included nonfunctioning (n = 4), prolactin secreting (n = 3), growth hormone-secreting adenoma (n = 2), and pituitary apoplexy (n = 2). Ten patients had psammomatous-type calcifications and 1 had extensive ossification and osteoid metaplasia. Preoperative radiological evaluation, intraoperative classification of calcification, and postoperative histopathological assessments are crucial in the treatment of calcified adenomas. Bases on these findings, the EEA, with its advantages, is an approach that can be effectively used in the management of these calcified adenomas.