• Martina Cappelletti, Andrea Gennaro Ruggeri, Lorenzo Spizzichino, Alberto D'Amico, Elena D'avella, and Roberto Delfini.
• Department of Neurology and Psychiatry-Neurosurgery Unit, "Sapienza" University of Rome, Rome, Italy. Electronic address: cappelletti.marty@gmail.com.
• World Neurosurg. 2019 Jan 1; 121: e449-e457.

ObjectiveThe endoscopic technique is in many cases the technique of choice for the removal of pituitary adenomas. Extended endoscopic approaches make it possible to remove lesions with suprasellar and parasellar extension and fibrous consistency. We identify some characteristics that might point to the adoption of an expanded approach in the preoperative phase.MethodsWe considered 66 consecutive cases treated for pituitary macroadenomas. All patients underwent preoperative magnetic resonance imaging and computed tomography, as well as postoperative magnetic resonance imaging. From the analysis of surgical reports and preoperative radiologic investigations, we extracted data related to size, extension, morphologic characteristics, consistency, and type of approach used (sellar or expanded). The degree of removal was judged to be total, near total, subtotal, or partial.ResultsThe data showed that in some cases it is possible to assume in advance that there is a need for an expanded endoscopic approach. The features that led to an extended approach for extracapsular dissection of the lesion were the size of the tumor; an hourglass/dumbbell shape; lateral extension to the suprasellar carotid artery; Knosp degree 3 or 4; contrast enhancement heterogeneity; intratumoral hemorrhage, erosion, or discontinuity of the sellar floor; and increased sellar depth, which predicts increased thickness.ConclusionsThe ability to predict the consistency of pituitary adenomas allows the surgeon to design a surgical procedure tailored to the patient. This approach has advantages concerning the extent of resection and allows a radical strategy with a single surgical procedure to be pursued.Copyright © 2018 Elsevier Inc. All rights reserved.

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