Generally accepted
contraindications to using a transsphenoidal approach for resection of
tumors that arise in or extend into the suprasellar region include a normal-sized sella turcica, normal pituitary function, and adherence of
tumor to vital intracranial structures. Thus, the transsphenoidal approach has traditionally been restricted to the removal of
tumors involving the pituitary fossa and, occasionally, to suprasellar extensions of such
tumors if the sella is enlarged. However, conventional transcranial approaches to the suprasellar region require significant brain retraction and offer limited visualization of contralateral
tumor extension and the interface between the
tumor and adjacent structures, such as the hypothalamus, third ventricle, optic apparatus, and major arteries. In this paper the authors describe successful removal of suprasellar
tumors by using a modified transsphenoidal approach that circumvents some of the traditional
contraindications to transsphenoidal surgery, while avoiding some of the disadvantages of transcranial surgery. Four patients harbored
tumors (two
craniopharyngiomas and two
hemangioblastomas) that arose in the suprasellar region and were located either entirely (three patients) or primarily (one patient) within the suprasellar space. All patients had a normal-sized sella turcica. Preoperatively, three of the four patients had significant endocrinological deficits signifying involvement of the hypothalamus, pituitary stalk, or pituitary gland. Two patients exhibited preoperative visual field defects. For
tumor excision, a recently described modification of the traditional transsphenoidal approach was used. Using this modification, one removes the posterior portion of the
planum sphenoidale, allowing access to the suprasellar region. Total resection of
tumor was achieved (including absence of
residual tumor on follow-up imaging) in three of the four patients. In the remaining patient, total removal was not possible because of adherence of
tumor to the hypothalamus and midbrain. One postoperative
cerebrospinal fluid leak occurred. Postoperative endocrinological function was worse than preoperative function in one patient. No other new postoperative endocrinological or neurological deficits were encountered. This study demonstrates the feasibility of using a modified transsphenoidal approach for resection of certain suprasellar, nonpituitary
tumors.