The transphenoidal procedure has become the preferred approach in the surgical management of sellar/parasellar
tumors. Nevertheless, specific indications remain for the transcranial approach and the objective of this review is to evaluate the available data on outcomes following transcranial or transphenoidal approaches to sellar/parasellar
tumors. We assess the indications used for each approach and parameters that favor one over the other. Factors such as
tumor size, consistency and configuration are important variables in choosing the transcranial approach. Other important considerations include persistent visual loss after incomplete
decompression via the transphenoidal route, ectatic midline carotid arteries, co-existent
intracranial aneurysms and
sphenoid sinusitis. We review the data on visual and endocrinological outcomes following the transcranial or transphenoidal approach and provide an argument that, while there appears to be a trend towards greater visual improvement after transcranial surgery for large-to-giant
pituitary adenomas, this benefit is offset by a greater risk of postoperative pituitary dysfunction. There is no difference in the rate of recurrence between the two procedures in the published literature. Overall,
craniotomies will continue to play a role in the management of patients with sellar/parasellar
tumors, although patient selection and careful preoperative evaluation are key elements in choosing the most appropriate approach.