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Background: Cavernous sinus (CS) tumors often are considered inoperable. We present our experience with endoscopic endonasal surgery (EES) and compare the outcomes for different tumor., Methods: EES (medial or lateral approach) was used in 234 patients with CS tumors. The cohort included 175 (75%) pituitary adenomas and 59 (25%) nonadenomatous lesions., Results: Presenting symptoms were significantly different between the 2 groups, with cranial neuropathies occurring mainly in nonadenomas (P < 0.0001). The overall gross total tumor resection rate from the CS was 37.3% (37.1% in adenomas, 38.1% in non-adenomas). In total, preexisting cranial nerve (CN) dysfunction improved in 56.4% of the patients. After treatment completion (including radiation of residual tumor), 83.3% of acromegalic patients, 50% of prolactinomas and 33.3% of Cushing's disease, were in remission. Visual loss improved in 86.8% of adenomas and in 70.8% of nonadenomas. Intracavernous CN palsies improved in 77.3% of adenomas and 42.4% of nonadenomas. New permanent CN palsies occurred in 7 nonadenomas, which is significantly greater than in adenomas (P = 0.007). The leak rate of cerebrospinal fluid was 6.3% for adenomas and 11.9% for nonadenomas. Four patients suffered an internal carotid artery injury with no neurologic sequelae in 3 cases and 1 death (0.4%)., Conclusions: EES provides an easily accessible midline corridor to the CS with equivalent or superior results to transcranial approaches in the management of select tumors. Symptomatology due to CS invasion is more likely to improve in pituitary adenomas and the rate of surgical complications is greater in nonadenomas. Using a team approach, the overall mortality due to vascular injury is low., (Copyright © 2017 Elsevier Inc. All rights reserved.)

To identify factors associated with successful use of free tissue grafting versus vascularized reconstruction after resection of pituitary tumors. A retrospective chart review of 2 tertiary academic medical centers over 3.5 years was conducted. Variables assessed included age, sex, body mass index, pathology, extent of surgical exposure, cavernous sinus or suprasellar extension, intraoperative cerebrospinal fluid (CSF) leak, grade of leak, previous radiation, and previous surgery. Reconstructive techniques were divided into no reconstruction, free tissue grafts, and vascularized flaps. A total of 485 patients were included. Free grafts were used in 299/485 cases (61.6%) and were more commonly used with smaller approaches (P < 0.001). Larger exposure size and CSF leak grades 2 and 3 were associated with vascularized flap use (P < 0.001 and P = 0.012, respectively). Using multivariate regression, type of reconstruction could be predicted by increasing extent of approach, intraoperative CSF leak grade, and suprasellar extension (odds ratio [OR], 2.014, P < 0.001, 95% confidence interval [CI], 1.335–3.039; OR, 1.636, P = 0.025, 95% CI, 1.064–2.517; OR, 1.975, P < 0.001, 95% CI, 1.554–2.510, respectively). Postoperative CSF leak occurred in 9 of 173 patients (5.2%) with intraoperative leak and was not associated with any factors on analysis. We propose an algorithm whereby grade 1 CSF leaks in sellar and parasellar resections can be successfully reconstructed with a free graft. Vascularized flaps may be reserved for grade 2 or 3 intraoperative CSF leaks, extended approaches, or tumors with suprasellar extension. [ABSTRACT FROM AUTHOR]