title: Cavernous Sinus Invasion in Pituitary Adenomas: Systematic Review and Pooled Data Meta-Analysis of Radiologic Criteria and Comparison of Endoscopic and Microscopic Surgery.
abstract: BACKGROUND
  Despite the substantial impact of cavernous sinus invasion (CSI) in pituitary adenoma surgery, its radiologic determination has been inconsistent and variable, and the role of endonasal endoscopic surgery has been unclear. This is a systematic review and pooled data meta-analysis of the literature to ascertain the best radiologic criteria for CSI and verify the efficacy and safety of an endonasal endoscopic approach.
  
  
  METHODS
  We searched the MEDLINE database (1993-2015) to identify studies on radiologic criteria for CSI and endonasal surgery. Using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, the studies included were reviewed for CSI criteria, gross total resection (GTR), endocrine remission, cranial nerve deficits, carotid injury, and other complications.
  
  
  RESULTS
  The prevalence of CSI was 43% radiographically compared with 18% intraoperatively (P < 0.001). The radiologic criteria of inferolateral venous compartment obliteration and Knosp 3-4 had the highest correlation with intraoperative CSI and the lowest correlation with GTR. Microscopy had significantly overestimated intraoperative CSI compared with endoscopy (P < 0.001) for each Knosp grade. Endoscopy had significantly higher GTR than did microscopy particularly for Knosp 3-4 (47% vs. 21%; P = 0.001). Carotid injury and cranial nerve deficits occurred in 0.9% and 5%, respectively, with endoscopy. Among endoscopic series with CSI, GTR% showed significant correlation with number of patients in the series (P ≤ 0.01) but no correlation with complications, indicating the relative safety of endonasal endoscopy in experienced hands for removing tumors with CSI.
  
  
  CONCLUSIONS
  Knosp 3-4 remains the best objective indicator of CSI. Microscopy tends to overestimate intraoperative CSI compared with endoscopy. Among pituitary adenomas with CSI, GTR in endoscopic series is higher than microscopy and improves with experience without significant additional morbidity.
authors: Department of Neurosurgery, Weill Cornell Medical College, New York Presbyterian Hospital, New York, New York, USA; Department of Neurosurgery, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India.
authors: Sivashanmugam
authors: S
authors: Dhandapani
authors: Department of Neurosurgery, Weill Cornell Medical College, New York Presbyterian Hospital, New York, New York, USA; Department of Neurosurgery, Stanford University School of Medicine, Stanford, California, USA.
authors: Harminder
authors: H
authors: Singh
authors: Department of Neurosurgery, Weill Cornell Medical College, New York Presbyterian Hospital, New York, New York, USA; Department of Neurosurgery, Menoufia University, Shebeen El Kom, Egypt.
authors: Hazem M
authors: HM
authors: Negm
authors: Department of Neurosurgery, Weill Cornell Medical College, New York Presbyterian Hospital, New York, New York, USA; Department of Neurosurgery, National Institute of Neurology and Neurosurgery, Mexico City, Mexico.
authors: Salomon
authors: S
authors: Cohen
authors: Department of Otolaryngology, Weill Cornell Medical College, New York Presbyterian Hospital, New York, New York, USA.
authors: Vijay K
authors: VK
authors: Anand
authors: Department of Neurosurgery, Weill Cornell Medical College, New York Presbyterian Hospital, New York, New York, USA; Department of Otolaryngology, Weill Cornell Medical College, New York Presbyterian Hospital, New York, New York, USA; Department of Neuroscience, Weill Cornell Medical College, New York Presbyterian Hospital, New York, New York, USA. Electronic address: schwarh@med.cornell.edu.
authors: Theodore H
authors: TH
authors: Schwartz
mesh_terms: D000236:Adenoma / Q000000981:diagnostic imaging* / Q000473:pathology / Q000601:surgery; D002426:Cavernous Sinus / Q000000981:diagnostic imaging* / Q000473:pathology / Q000601:surgery; D006801:Humans; D008866:Microsurgery; D057605:Natural Orifice Endoscopic Surgery; D009361:Neoplasm Invasiveness; D044583:Neuroendoscopy; D019635:Neurosurgical Procedures; D009666:Nose; D010911:Pituitary Neoplasms / Q000000981:diagnostic imaging* / Q000473:pathology / Q000601:surgery
keywords: Cavernous sinus invasion; Complications; Endonasal endoscopy; GTR; Pituitary adenoma; Radiological criteria; Remission; Systematic review