• Limin Xiao, Taohui Ouyang, Bowen Wu, Shenhao Xie, Bin Tang, Yulin He, Han Ding, Xiao Wu, and Tao Hong.
• Department of Neurosurgery, The First Affiliated Hospital of Nanchang University, Nanchang, China.
• Neurosurgery. 2023 Jan 1; 92 (1): 213222213-222.

BackgroundUnderstanding the growth pathway of Knosp grade 4 pituitary adenoma (KG4PA) has a direct impact on surgical planning and safety for tumor eviction.ObjectiveTo analyze the different characteristics between KG4PAs with a focus on the tumor growth pathway and its relationship to the cavernous segment of internal carotid artery.MethodsClinical data from 129 patients with KG4PAs who underwent endoscopic endonasal surgery were retrospectively reviewed. A subclassification scheme was proposed based on the tumor growth pathway and its relevant features. The clinical connotation of the subclassification on surgical outcomes was also analyzed.ResultsThe KG4PAs were classified into 3 types based on the tumor growth pathway and its relevant features: groups A, B, and AB. The gross total resection rate in group A (51.2%) was much lower than that in group B (87.5%) and AB (87%) with a significant difference between the 3 groups ( P = .0004). The overall rate of visual function improvement, preoperative cranial nerve (CN) palsy improvement, and postoperative hormonal remission was 85.1%, 83.3%, and 85.7%, respectively. The rate of transient CN palsy, permanent CN palsy, permanent diabetes insipidus, panhypopituitarism, CSF leakage, and internal carotid artery injury was 7.8%, 3.9%, 4.7%, 2.3%, 1.5%, and 0.7%, respectively.ConclusionThe subclassification strengthens our understanding of KG4PAs on tumor growth corridors and topographic relations of tumor and cavernous segment of internal carotid artery. Furthermore, the distinction into groups 4A, 4B, and 4AB is of benefits for selecting approaches, predicting risk and avoiding complications, and generating more tailored individualized surgical strategies for KG4PAs with better outcomes.Copyright © Congress of Neurological Surgeons 2022. All rights reserved.

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