Lateral Approaches

Transcranial Epidural

Dolenc has applied his extensive experience of the cavernous sinus to a transcavernous approach to the sella (10).

The operation involves the exposure of the lateral wall of the cavernous sinus via a pterional craniotomy with extensive bone removal of the lesser sphenoid wing and the anterior clinoid process. Direct visualization is made of the cranial nerves in the lateral wall of the cavernous sinus, and the approach to the sella is made between these structures (11).

For the reasons stated in the previous section, a careful assessment of the benefits of this approach must be made before applying it to a case of pituitary adenoma. In particular, the operator must be sure that the morbidity of the operation will not outweigh any benefits gained by an attempt at radical resection.

Subtemporal and Transtemporal

The subtemporal route to the pituitary gland was the first transcranial route employed by Victor Horsley and Harvey Cushing. It was done via a subtemporal decompressive craniectomy and had the advantage of a short trajectory but the disadvantage of incurring morbidity from temporal lobe retraction. Cushing applied the approach in 100 dogs, and both he and Horsley were probably falsely encouraged in attempting this route by the shallow canine middle fossa. After eight attempts at the approach in humans, Cushing concluded that it was impractical (29). The intradural subtemporal approach is now effectively obsolete.

Symon has used a transtemporal operation to approach craniopharyngiomas (30) and also a giant pituitary adenoma (31,32). In this procedure 2 cm of the temporal pole was removed to permit access to the interpeduncular fossa and to allow radical removal of the tumor.

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