Endoscopic Approach of Complex Pituitary Tumors with Involvement of Cavernous Sinus

Cavernous sinus (CS) is no more a “no man’s land”. CS is accessible both by open transcranial approaches and endoscopic endonasal approaches. Due to technical and instrument advances, pituitary tumors invading any compartment of cavernous sinus can be excised in a minimally invasive manner by an extended endoscopic endonasal approach focused on providing access to that compartment. Besides the availability of high-resolution angled endoscopes and angled suction for improving tumor visualization and tumor removal respectively; intraoperative microdoppler ultrasonography and neuronavigation are essential tools for accurate mapping of ICA course during such complex approaches. Difficulty in controlling the dramatic bleeding in the event of ICA injury is a major limitation of the extended endonasal transcavernous approaches, thus necessitating their performance only by highly experienced and skillful skull base teams in institutions having adequate endovascular infrastructure.