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Gli adenomi ipofisari, seppur classificati come lesioni istologicamente benigne, presentano un’invasività e un’aggressività biologica che talvolta rendono impegnativo il trattamento e l’efficacia chirurgica. In ragione di tali considerazioni abbiamo definito questi adenomi “non convenzionali”. Non è possibile avere una strategia chirurgica univoca, così come è indispensabile la gestione in un team multidisciplinare. Per quel che riguarda la chirurgia, gli approcci transcranici e transfenoidale, da soli combinati, vanno considerati in ragione delle caratteristiche del tumore e delle condizioni cliniche del paziente. Gli approcci transcranici sono stati per lungo tempo considerati la prima opzione chirurgica valida per questa tipologia di adenomi; tuttavia, grazie all’evoluzione degli approcci endoscopici endonasali, questa tecnica può essere considerata anche per quegli adenomi che si estendono oltre i confini della sella turcica. L’approccio endoscopico endonasale rappresenta una soluzione efficace per gli adenomi “non convenzionali” con estensione intracranica, a patto che possa essere garantita l’area di esposizione e la manovrabilità degli strumenti a livello del target chirurgico. È indispensabile, quindi, un’accurata valutazione preoperatoria per definire la migliore strategia di trattamento, eventualmente chirurgica, al fine di ottenere un eccellente risultato nell’immediato e a lungo termine.

The transorbital route has been proposed for addressing orbital and paramedian skull base lesions. It can be complemented by further marginotomies, as per “extended-transorbital approach” and combined with others ventro-basal approaches featuring the concept of “multiportal surgery”. Nevertheless, it cannot address some anatomical regions like the clinoid, carotid bifurcation and the Sylvian fissure. Therefore, we propose a combined transorbital and a supraorbital approach, attainable by a single infra-brow incision, and we called it “Uniportal multicorridor” approach.

The use of an endoscope in skull base surgery provides a panoramic close-up view over the intracranial structures from multiple angles with excellent illumination, thus permitting greater extent of resection of tumors arising at sellar area, mostly represented by PitNet - Pituitary neuroendocrine tumors, with higher likelihood of preserving vital/intact gland tissue. For this refined specialty of neurosurgery, unique skills need to be acquired along a steep learning curve.

The management of giant and large pituitary adenomas with wide intracranial extension or infrasellar involvement of nasal and paranasal cavities is a big challenge for neurosurgeons and the best surgical approach indications are still controversial. Endoscopic extended endonasal approaches have been proposed as a new surgical technique for the treatment of such selected pituitary adenomas. Surgical series coming from many centers all around the world are flourishing and results in terms of outcomes and complications seem encouraging. This technique could be considered a valid alternative to the transcranial route for the management of giant and large pituitary adenomas.

Cushing's disease is a state of chronic and excessive cortisol levels caused by a pituitary adenoma

Since the introduction of the modern, smaller endoscopes in the 1960s, neuroendoscopy has become an expanding field of neurosurgery. Neuroendoscopy reflects the tendency of modern neurosurgery to aim towards minimalism; that is, access and visualization through the narrowest practical corridor and maximum effective action at the target point with minimal disruption of normal tissue. Transventricular neuroendoscopy allows the treatment of several pathologies inside the ventricular system, such as obstructive hydrocephalus and intra-/paraventricular tumors or cysts, often avoiding the implantation of extracranial shunts or more invasive craniotomic approaches. Endoscopic endonasal transphenoidal surgery allows the treatment of pathologies of the sellar and parasellar region, with the advantage of a wider vision of the surgical field, less traumatism of the nasal structures, greater facility in the treatment of possible recurrences and reduced complications. However, an endoscope may be used to assist microsurgery in virtually any kind of neurosurgical procedures (endoscope-assisted microsurgery), particularly in aneurysm and tumor surgery. Basic principles of optical imaging and the physics of optic fibers are discussed, focusing on the neuroendoscope. The three main chapters of neuroendoscopy (transventricular, endonasal transphenoidal and endoscope-assisted microsurgery) are reviewed, concerning operative instruments, surgical procedures, main indications and results.

Introduction In the last 10 years the endoscopic endonasal transsphenoidal approach has been proposed as a minimally invasive procedure for the treatment of pathologies of the sellar region. This procedure introduces various advantages compared with the transsphenoidal microsurgical approach such as a wider vision of the surgical field, less traumatism of the nasal structures, greater facility in the treatment of possible recurrences, and reduced complications. Nevertheless, as for any new procedure, there is an initial learning curve that is somewhat steep, due to the necessity of acquiring the specific endoscopic skills. It is equally essential to be supplied with dedicated endoscopic equipment and appropriate surgical instrumentation, in order to optimize the different stages of the operation. Discussion Therefore, after our extensive experience with over 250 patients treated by means of the endoscopic endonasal transsphenoidal approach for pathologies of the sellar region, we describe herein the characteristics of the proper endoscopic instrumentation, as well as a set of surgical instruments intentionally conceived to respond to the specific characteristics of this new procedure.

Abstract: The endoscopic endonasal transsphenoidal approach to the sellar region for the removal of pituitary adenomas and of other neoplasms in the same area has proved its reliability and effectiveness for the very wide vision it offers, coupled with minimal surgical trauma. Indications and advantages of such a technique are reported, focused on the treatment of lesions of the sellar and parasellar environment in pediatric age-group patients, and based on a consecutive series of 100 patients, 3 of them adolescents, treated during the last 3 years.

A 39-year-old woman presented with right-hand tremor triggered by coughing. Her examination revealed tremor and irregular myoclonus at rest and transient right-hand tremor precipitated by coughing (video at Neurology.org). Brain MRI showed intraventricular tumor and partial foramen of Monro obstruction (figure). Intraventricular tumors in this location can cause sudden intermittent hydrocephalus,1and focal thalamic lesions may cause hand tremor.2We hypothesize that compression of the ventral intermediate nucleus of the thalamus caused by cough-induced hydrocephalus, with dysfunction of cerebello-thalamo-cortical circuit, may be the mechanism for cough-associated tremor of the contralateral hand; this disappeared after surgical removal of the subependymoma. Cough tremor may be associated with intraventricular tumors.