title: Is Complex Sphenoidal Sinus Anatomy a Contraindication to a Transsphenoidal Approach for Resection of Sellar Lesions? Case Series and Review of the Literature.
abstract: BACKGROUND
  The transsphenoidal approach is considered the gold standard for resection of pituitary adenomas and other sellar region lesions. This approach is guided by a few fundamental anatomic landmarks that conduct the surgeon toward the sellar floor. Some anatomic structures may vary a lot (e.g., intrasphenoidal septa, intercarotid distance) and may be difficult to identify. Pneumatization and conformation of the sphenoidal sinus (SS) plays a key role in accessing the floor of the sella and other skull base structures. A poorly pneumatized SS may be a relative contraindication to the transsphenoidal approach. We analyzed outcome and complications in transsphenoidal surgery for sellar lesions with a difficult SS.
  
  
  METHODS
  We analyzed 243 consecutive patients who underwent a transsphenoidal approach for sellar lesions. Patients with poor pneumatization of the SS were included. Neurosurgical and endocrinologic outcomes were reported.
  
  
  RESULTS
  Successful treatment using a transsphenoidal approach with neuronavigation and Doppler ultrasound was achieved in 15 patients with a low degree of pneumatization of the SS. A pituitary adenoma was present in 13 of 15 patients. Endocrinologic and neurosurgical outcomes were similar to patients with normal pneumatization of the SS, showing a cure of disease in 6 of 9 patients with functioning adenomas and an improvement of symptoms in cases of nonfunctioning adenomas.
  
  
  CONCLUSIONS
  Patients with a poorly pneumatized SS can be treated safely with a transsphenoidal approach using image guidance techniques to avoid major neurovascular complications.
authors.affiliation: Unit of Neurosurgery, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.
authors.forename: Marco
authors.initials: M
authors.lastname: Locatelli
authors.affiliation: Unit of Neurosurgery, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; Department of Pathophysiology and Organ Transplantation, University of Milan, Milan, Italy. Electronic address: andrea.dicristofori@gmail.com.
authors.forename: Andrea
authors.initials: A
authors.lastname: Di Cristofori
authors.affiliation: Unit of Neurosurgery, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; Department of Pathophysiology and Organ Transplantation, University of Milan, Milan, Italy.
authors.forename: Riccardo
authors.initials: R
authors.lastname: Draghi
authors.affiliation: Unit of Neurosurgery, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.
authors.forename: Giulio
authors.initials: G
authors.lastname: Bertani
authors.affiliation: Unit of Otolaryngology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.
authors.forename: Claudio
authors.initials: C
authors.lastname: Guastella
authors.affiliation: Unit of Otolaryngology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; Department of Biomedical, Surgical and Dental Sciences, University of Milan, Milan, Italy.
authors.forename: Lorenzo
authors.initials: L
authors.lastname: Pignataro
authors.affiliation: Department of Clinical Sciences and Community Health, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; Endocrinology and Diabetology Unit, University of Milan, Milan, Italy.
authors.forename: Giovanna
authors.initials: G
authors.lastname: Mantovani
authors.affiliation: Unit of Neurosurgery, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.
authors.forename: Paolo
authors.initials: P
authors.lastname: Rampini
authors.affiliation: Unit of Neurosurgery, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.
authors.forename: Giorgio
authors.initials: G
authors.lastname: Carrabba
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D014890:Granulomatosis with Polyangiitis / Q000601:surgery; D006801:Humans; D008579:Meningioma / Q000601:surgery*; D008875:Middle Aged; D038361:Neuronavigation / Q000379:methods*; D010900:Pituitary Diseases / Q000601:surgery*; D010911:Pituitary Neoplasms / Q000601:surgery; D012658:Sella Turcica / Q000601:surgery*; D019291:Skull Base / Q000000981:diagnostic imaging / Q000601:surgery*; D013101:Sphenoid Sinus / Q000033:anatomy & histology* / Q000000981:diagnostic imaging / Q000601:surgery*
keywords: Image-guided surgery; Pituitary adenomas; Sphenoidal sinus; Sphenoidal sinus pneumatization; Transsphenoidal surgery