The Party Wall: Redefining the Indications of Transcranial Approaches for Giant Pituitary Adenomas in Endoscopic Era

Objectives: To redefine the current indications for the transcranial approaches for giant pituitary adenomas in the endoscopic era. Background: The evolution of endoscopic transsphenoidal surgery raises the question of the role of transcranial surgery for pituitary tumors, particularly with the effectiveness of adjunct irradiation. Methods: A critical appraisal of the personal series of the senior author (O.A.) was performed to characterize the patient factors and the tumor’s pathological anatomy features that endorse a cranial approach. Results: Traditional indications for transcranial approach include absent pneumatization of the sphenoid sinus, kissing/ectatic internal carotid arteries, reduced dimensions of the sella, lateral invasion to the cavernous sinus lateral to the carotid artery, dumbbell-shaped tumors caused by severe diaphragm constriction, fibrous/calcified tumor consistency, wide supra, para-, and retro-sellar extension, arterial encasement, brain invasion, coexisting cerebral aneurysms, and coexisting separate pathologies of the sphenoid sinus, especially infections. Residual/recurrent tumors and postoperative pituitary apoplexy after transsphenoidal surgery require individualized considerations. Conclusions: Transcranial approaches still have a critical role in giant and complex pituitary adenomas with wide intracranial extension, brain parenchymal involvement, and encasement of the neurovascular structures.