• Yuichi Nagata, Kazuhito Takeuchi, Taiki Yamamoto, Takayuki Ishikawa, Teppei Kawabata, Yoshie Shimoyama, and Toshihiko Wakabayashi.
• Department of Neurosurgery, Nagoya University Graduate School of Medicine, Aichi, Japan. Electronic address: you1ngta@gmail.com.
• World Neurosurg. 2019 Jun 1; 126: 53-58.

BackgroundRemoval of the medial wall of the cavernous sinus (MW) is challenging for neurosurgeons. We describe a practical method of endoscopic MW removal via endonasal transsphenoidal approach to minimalize intraoperative blood loss and postoperative morbidities. We also present the pathologic significance of this technique for functional pituitary adenomas (FPAs).MethodsWe performed MW removal in patients with FPA with no well-defined pseudocapsule and a tumor in direct contact with the MW. The MW was judged to have tumor invasion based on the intraoperative appearance, and it was removed regardless of the appearance of MW involvement. Intraoperative findings and postoperative clinical, endocrinologic, and pathologic outcomes were retrospectively reviewed.ResultsFourteen patients underwent MW removal for FPA, including 12 patients with acromegaly and 2 with Cushing disease. Mean intraoperative blood loss was 170 mL (range, 32-400 mL), and none of the patients required blood transfusion. Among the 7 patients without intraoperative apparent MW involvement, 4 (57.1%) had pathologically confirmed tumor invasion into the MW (occult invasion). Biochemical remission by surgery alone was achieved in 13 patients (92.9%). Transient oculomotor palsy occurred in 1 patient (7.1%).ConclusionsOccult tumor invasion into the MW was often detected in patients with FPA without a well-defined pseudocapsule but in direct contact with the MW. Our technique can enhance the effectiveness of surgery with minimal postoperative morbidities.Copyright © 2019 Elsevier Inc. All rights reserved.

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