title: Combined trans-sphenoidal and simultaneous trans-ventricular-endoscopic decompression of a giant pituitary adenoma: case report.
abstract: OBJECTIVE
  This is the first report of the simultaneous combined use of trans-sphenoidal and trans-ventricular-endoscopic route for decompression of a giant pituitary adenoma.
  
  
  METHODS
  A 38 year old man presented to us with symptoms of raised intracranial pressure along with visual and hypothalamic disturbances. The CT scan revealed destruction of the sella by a large (5 x 3.5 x 2.5 cm) well defined enhancing mass in the sella and suprasellar region extending laterally up to the cavernous sinuses and both carotid arteries and superiorly into the lumen of the 3rd ventricle producing obstructive hydrocephalus. On T2WI of the non-contrast MRI scan the mass was iso-intense to grey matter suggesting the possibility of a firm nature of the adenoma. The tumour was first approached by the standard trans-sphenoidal route and as predicted from the pre-operative MRI, the tumour was found to be firm and not amenable to suction. After decompression of the intra-sellar part of the tumour, the intracranial pressure was raised in an attempt to make the remainder of the tumour descend into the sella but without success. The suprasellar part of the tumour was then simultaneously addressed via a trans-ventricular-endoscopic route but the firm tumour did not yield to endoscopic instruments viz. biopsy forceps, angiographic catheter and electrosurgical probes. It was then gently pushed down towards the sella and decompressed piecemeal by using trans-sphenoidal instruments. The sellar cavity was reconstructed using fat, fascia lata graft and a piece of septal bone.
  
  
  RESULTS
  Post-operatively, the patient showed a remarkable improvement of his symptoms of raised intracranial pressure, hypothalamic dysfunction and visual disturbances. Follow-up imaging at 2 months and 1 year, did not show any residual or recurrent tumour.
  
  
  CONCLUSIONS
  This novel technique of the combined trans-sphenoidal and simultaneous trans-ventricular-endoscopic approach is a viable option for patients with giant fibrous pituitary adenoma when the tumour is not yielding to the trans-sphenoidal route alone.
authors.affiliation: Department of Neurosurgery, CSM (Earlier King George's) Medical University, Lucknow 226003, India. bkojha@rediffmail.com
authors.forename: Bal Krishna
authors.initials: BK
authors.lastname: Ojha
authors.forename: Mazhar
authors.initials: M
authors.lastname: Husain
authors.forename: Manu
authors.initials: M
authors.lastname: Rastogi
authors.forename: Anil
authors.initials: A
authors.lastname: Chandra
authors.forename: Ashish
authors.initials: A
authors.lastname: Chugh
authors.forename: Nuzahat
authors.initials: N
authors.lastname: Husain
mesh_terms: D000236:Adenoma / Q000473:pathology / Q000601:surgery*; D000328:Adult; D003399:Craniotomy / Q000295:instrumentation / Q000379:methods*; D019299:Decompression, Surgical / Q000295:instrumentation / Q000379:methods*; D004724:Endoscopy / Q000379:methods*; D006801:Humans; D007027:Hypothalamic Diseases / Q000209:etiology / Q000473:pathology / Q000503:physiopathology; D019586:Intracranial Hypertension / Q000209:etiology; D007431:Intraoperative Complications / Q000209:etiology / Q000473:pathology / Q000503:physiopathology; D020547:Lateral Ventricles / Q000033:anatomy & histology / Q000601:surgery; D008279:Magnetic Resonance Imaging; D008297:Male; D010911:Pituitary Neoplasms / Q000473:pathology / Q000601:surgery*; D011183:Postoperative Complications / Q000517:prevention & control; D012658:Sella Turcica / Q000033:anatomy & histology / Q000473:pathology / Q000601:surgery; D013100:Sphenoid Bone / Q000033:anatomy & histology / Q000473:pathology / Q000601:surgery; D020542:Third Ventricle / Q000033:anatomy & histology / Q000473:pathology / Q000601:surgery; D016896:Treatment Outcome; D014696:Ventriculostomy / Q000295:instrumentation / Q000379:methods*; D015354:Vision, Low / Q000209:etiology / Q000473:pathology / Q000503:physiopathology