Combined Lateral and Superior Cavernous Sinus Approach for Microsurgical Resection in Large Pituitary Adenomas

Objective: To demonstrate the feasibility of the combined lateral and superior cavernous sinus approach to deal with large pituitary adenomas.

Design: We used the pretemporal approach combined with the peeling of the middle fossa to open the lateral wall of the cavernous sinus and with the opening to the oculomotor triangle and the anterior clinoidectomy, in the cavernous sinus roof, allowing the view of the pituitary adenoma all around the internal carotid artery.

Patients: We operated on 32 patients with large pituitary adenomas at the Hospital Beneficencia Portuguesa de Sao Paulo between January 2005 and December 2011, using the combined approach to the lateral wall of the cavernous sinus, the peeling of the middle fossa, and an approach to the cavernous sinus roof, performing the anterior clinoidectomy and opening the oculomotor triangle.

Results: Good exposure of the neurovascular structures was obtained in all cases compared with the well-established pterional approach. All patients had oculomotor, abducent, and ophthalmic nerve palsy.

Conclusion: The pterional approach allows only the opening of the cavernous sinus roof; the pretemporal approach combined with the peeling of the middle fossa and opening of the cavernous sinus roof facilitates the complete withdrawal of the large pituitary adenomas and the preservation of the neurovascular structures.