Endoscopic endonasal transcavernous approach for removal of pituitary macroadenoma with apoplexy: Technical nuances.

Background: The endoscopic endonasal transcavernous approach is an extended approach for sellar masses with cavernous invasion with negligible complications regarding permanent cranial nerve (CN) palsy or internal carotid artery (ICA) injury. With a proper understanding of surgical anatomy regarding the ICA and its relation to the cavernous sinus, an endoscopic trans-cavernous approach through the anterior wall of the cavernous sinus with lateral and superior extension can allow for safe and efficient tumor visualization and removal in the inferior and superior CS compartment. The aim is to describe the technical nuances involved during the transvenous approach.

Case description: A 67-year-old male with acute onset of left vision loss, headache, and left side complete CN III and VI palsy with large sellar mass measuring 3.1 × 2.0 × 5.6 cm extending to the left cavernous sinus encasing the ICAs with evidence of apoplexy. An endonasal transcavernous approach was done involving tumor removal from the superior and inferior compartment, resulting in gross total resection. Histological examination revealed a nonfunctioning apoplectic pituitary adenoma. The patient was discharged on Post-operative day (POD) 2 with partial palsy in CN III and CN VI and was noted to have a progressive improvement in CN palsy with complete resolution of ptosis and partial palsy of CN VI at the 3-month follow-up visit.

Conclusion: Pseudocapsular apoplectic plane identification, extracapsular dissection, identification of parasellar ligaments, and understanding of adenoma-cavernous sinus ICA relationship are key surgical highlights that we discuss in our case. The combination of these techniques, along with the use of intraoperative Doppler, helped us to maximize pituitary gland preservation, CN improvement, and gross total resection of a large pituitary adenoma with cavernous sinus invasion presenting as apoplexy. Future studies with endoscopic endonasal transvenous approaches with cavernous sinus extension for large pituitary adenoma with apoplexy are warranted to study long-term CN outcomes.