THE ENDOSCOPIC ENDONASAL TRANSSPHENOIDAL approach is a minimally invasive surgical technique for the removal of sellar and parasellar lesions. The procedure is performed via an anterior sphenoidotomy. The two main characteristics of the endoscopic approach, when compared with the standard microsurgical operation, arise from the use of the endoscope as a unique optical device and from the absence of a transsphenoidal retractor. More convenient straight surgical instruments are employed, whereas bayonet-shaped tools are used in the microsurgical procedure, to avoid any interference with the light beam generated by the microscope. The standard surgical technique is composed of three main time phases: the nasal, sphenoid, and sellar phase. During the nasal phase, the scope is introduced through the chosen nostril and advanced up to the sphenoethmoid recess, where the sphenoidotomy is performed. The sphenoid phase consists of the detachment of the nasal septum from the sphenoid rostrum, the anterior sphenoidotomy, removal of the sphenoid septum or septa, and identification of the landmarks inside the sphenoid sinus. In the sellar phase, an opening of the sellar floor is performed for removal of the lesion. A wide view of the sellar environment is obtained through angled scopes to detect eventual tumor remnants. The procedure ends with the reconstruction of the sella and removal of the endoscope from the nostril, without any postoperative nasal packing.

OBJECTIVE. The widespread use of the endoscope in transsphenoidal pituitary surgery has recently contributed to the extension of the approach beyond the

Tuberculum sellae meningiomas represent 5 to 10% of all intracranial meningiomas. Such lesions are classically removed through a variety of well-standardized transcranial approaches. The extended endonasal transsphenoidal route, under either microscopic or endoscopic visualization, has only recently been proposed as a viable surgical technique for the management of such tumors. A total of 51 consecutive patients with tuberculum sellae meningiomas were treated at our institution during a 21-year period. Forty-four patients had transcranial surgery, and the last seven were treated via the extended endoscopic transsphenoidal approach. We also compared our data with those reported in the pertinent literature related to the surgical, ophthalmological, and endocrinological outcome. The significant difference among the transcranial and transsphenoidal series, both in our experience and in the reviewed literature, did not allow us to draw statistically significant results but rather a reporting of the outcomes. In the transcranial group, 86.4% had a gross total removal of the lesion, whereas the percentage was 83.3% in the transsphenoidal group. Concerning the visual outcome, we experienced postoperative improvement in 61.4% of the transcranial patients and a worsening of 13.6%, whereas improvement was reported in 71.4% of the patients in the transsphenoidal group; in the last group, we did not observe any postoperative worsening. The main drawback of the transsphenoidal approach still remains the difficulty in reconstructing the cranial base dural and bone defects, which expose patients to a greater risk of postoperative cerebrospinal fluid leakage (28.6% in our series) and related complications. When treating a patient with a diagnosis of tuberculum sellae meningioma, a neurosurgeon should know that, aside from the classical transcranial approach, the possibility of an extended transsphenoidal approach exists. Although it is still not a standardized procedure, in carefully selected cases (i.e., small midline lesions, without major vessel encasement, or parasellar extension) and in experienced hands, it could be considered a viable alternative, especially in overcoming the reconstruction-related problems.

Object: The extended transnasal approach, a recent surgical advancements for the ventral skull base, allows excellent midline access to and visibility of the anterior cranial fossa, which was previously thought to be approachable only via a transcranial route. The extended transnasal approach allows early decompression of the optic canals, obviates the need for brain retraction, and reduces neurovascular manipulation. Methods: Between 2004 and 2007, 11 consecutive patients underwent transnasal resection of anterior cranial fossa meningiomas—4 olfactory groove (OGM) and 7 tuberculum sellae (TSM) meningiomas. Age at surgery, sex, symptoms, and imaging studies were reviewed. Tumor size and tumor extension were estimated, and the anteroposterior, vertical, and horizontal diameters were measred on MR images. Medical records, surgical complications, and outcomes of the patients were collected. Results: A gross-total removal of the lesion was achieved in 10 patients (91%), and in 1 patient with a TSM only a near-total (> 90%) resection was possible. Four patients with preoperative visual function defect had a complete recovery, whereas 3 patients experienced a transient worsening of vision, fully recovered within few days. In 3 patients (2 with TSMs and 1 with an OGM), a postoperative CSF leak occurred, requiring a endoscopic surgery for skull base defect repair. Another patient (a case involving a TSM) developed transient diabetes insipidus. The operative time ranged from 6 to 10 hours in the OGM group and from 4.5 to 9 hours in the TSM group. The mean duration of the hospital stay was 13.5 and 10 days in the OGM and TSM groups, respectively. Six patients (3 with OGMs and 3 with TSMs) required a blood transfusion. Surgery-related death occurred in 1 patient with TSM, in whom the tumor was successfully removed. Conclusions: The technique offers a minimally invasive route to the midline anterior skull base, allowing the surgeon to avoid using brain retraction and reducing manipulation of the large vessels and optic apparatus; hastens postoperative recovery; and improves patient compliance. Further assessment and refinement are required, particularly because of the potential risk of CSF leakage. Other studies and longer follow-up periods are necessary to ascertain the benefits of the technique.

Suprasellar craniopharyngiomas have been classically removed using a variety of transcranial approaches. Historically, the transsphenoidal route was reserved for intrasellar-infradiaphragmatic, and preferably cystic, lesions. With the advent of the endoscope in transsphenoidal surgery, its obvious advantages combined with neurosurgeons' increasing interest in extended transsphenoidal approaches made suprasellar and even intraventricular craniopharyngiomas accessible for removal via such a low route. Between January of 2004 and April of 2006, six men and four women (mean age, 57.2 yr; range, 26-70 yr) underwent surgery for craniopharyngioma, including two intrasuprasellar, one suprasellar, six suprasellar-intraventricular, and one that was purely intraventricular. Three patients had undergone a previous transcranial surgery via the pterional approach, whereas one patient had undergone a transsphenoidal microsurgical approach. The surgical method consisted of an extended endoscopic transsphenoidal approach with removal of the upper half of the sella, the tuberculum sellae, and the posterior part of the planum sphenoidale, using a "three-four hands" technique. Total craniopharyngioma removal was achieved for seven patients, subtotal removal was possible for two patients, and one patient had a partial removal. Two patients developed a postoperative cerebrospinal fluid leak that required a successful endoscopic revision of the cranial base reconstruction. One patient died 5 weeks later because of hypothalamic dysfunction. All patients with visual field and/or visual acuity defect improved except one patient, in which we observed a slight worsening of visual acuity in one eye. Preoperative pituitary dysfunction did not improve in any patient. In three patients, we observed the new occurrence of permanent diabetes insipidus. One patient developed a sphenoid sinus mycosis, which was treated with antimycotic therapy. We did not observe carotid injury, epistaxis from the sphenopalatine artery, or airway difficulties. For selected patients, the extended endoscopic endonasal approach for removal of suprasellar craniopharyngioma seems to provide a valid alternative to transcranial approaches.

OBJECTIVE: Tuberculum sellae meningiomas (TSMs) are surgically challenging tumors that can severely impair vision. Debate exists regarding whether the transcranial (TC) or endoscopic transsphenoidal (TS) approach is best for resecting these tumors, and there are few large series comparing these approaches. METHODS: A retrospective chart review was performed at 2 academic centers comparing TC and TS approaches with respect to vision, extent of resection, recurrence, and complications. The authors report surgical outcomes and propose a simple preoperative tumor grading scale that scores tumor size (1–2), optic canal invasion (0–2), and arterial encasement (0–2). The authors performed univariate, multivariate, and recursive partitioning analysis (RPA) to evaluate outcomes. RESULTS: The TSMs were resected in 139 patients. The median follow-up was 29 months. Ninety-five (68%) cases were resected via a TC and 44 (32%) via a TS approach. Tumors treated via a TC approach had a higher tumor (p = 0.0007), artery (p < 0.0001), and total score (p = 0.0012) on the grading scale. Preoperative visual deficits were present in 87% of patients. Vision improved in 47%, stayed the same in 35%, declined in 10%, and was not recorded in 8%. The extent of resection was 65% gross-total resection, 23% near-total resection (95%–99% resection), and 12% subtotal resection (< 95%). A lower tumor score was significantly associated with better or stable vision postoperatively (p = 0.0052). The RPA confirmed low tumor score as the key predictor of postoperative visual improvement or stability. Multivariate analysis and RPA demonstrate that lower canal score (p < 0.0001) and TC approach (p = 0.0019) are associated with gross-total resection. Complications occurred in 20 (14%) patients, including CSF leak (5%) and infection (4%). There was no difference in overall complication rates between TC and TS approaches; however, the TS approach had more CSF leaks (OR 5.96, 95% CI 1.10–32.04). The observed recurrence rate was 10%, and there was no difference between the TC and TS approaches. CONCLUSIONS: Tuberculum sellae meningiomas can be resected using either a TC or TS approach, with low morbidity and good visual outcomes in appropriately selected patients. The simple proposed grading scale provides a standard preoperative method to evaluate TSMs and can serve as a starting point for selection of the surgical approach. Higher scores were associated with worsened visual outcomes and subtotal resection, regardless of approach. The authors plan a multicenter review of this grading scale to further evaluate its utility.