5 Suprasellar Pathology

  • Sacit Bulent Omay
  • Vijay K. Anand
  • Theodore H. SchwartzEmail author


Suprasellar lesions are varied in pathology, but are challenging due to the proximity to the optic apparatus, pituitary gland, infundibulum, hypothalamus, and third ventricle. Surgical interventions to remove these lesions may result in visual field loss, endocrine dysfunction, and hydrocephalus. The endoscopic endonasal transplanum and transtuberculum approach is the defining endonasal endoscopic approach to the suprasellar lesions and is the most direct route to the region that avoids manipulation of the optic nerves and carotid artery that obviates the need for brain retraction. Meningiomas, craniopharyngiomas, and pituitary adenomas are common examples of lesions that can be resected using these approaches. These approaches differ from traditional microneurosurgical approaches with the instruments and endoscopic techniques that are utilized. Safety and success of these procedures require careful patient selection and expertise in the endonasal endoscopic method.


Suprasellar lesions Meningioma Craniopharyngioma Pituitary adenoma Endoscopic endonasal surgery 


  1. 1.
    Patel CR, Fernandez-Miranda JC, Wang WH, Wang EW. Skull Base Anatomy. Otolaryngol Clin N Am. 2016;49(1):9–20.Google Scholar
  2. 2.
    McCrea HJ, George E, Settler A, Schwartz TH, Greenfield JP. Pediatric Suprasellar tumors. J Child Neurol. 2016 Oct;31(12):1367–76.PubMedGoogle Scholar
  3. 3.
    Patel SG, Singh B, Polluri A, Bridger PG, Cantu G, Cheesman AD, et al. Craniofacial surgery for malignant skull base tumors: report of an international collaborative study. Cancer. 2003;98(6):1179–87.PubMedGoogle Scholar
  4. 4.
    Origitano TC, Petruzzelli GJ, Leonetti JP, Vandevender D. Combined anterior and anterolateral approaches to the cranial base: complication analysis, avoidance, and management. Neurosurgery. 2006;58(4 Suppl 2):ONS-327–36; discussion ONS-36-7.Google Scholar
  5. 5.
    Schwartz TH, Fraser JF, Brown S, Tabaee A, Kacker A, Anand VK. Endoscopic cranial base surgery: classification of operative approaches. Neurosurgery. 2008;62(5):991–1002; discussion −5.Google Scholar
  6. 6.
    Silva D, Attia M, Kandasamy J, Alimi M, Anand VK, Schwartz TH. Endoscopic endonasal transsphenoidal “above and below” approach to the retroinfundibular area and interpeduncular cistern – cadaveric study and case illustrations. World Neurosurg. 2014;81(2):374–84.PubMedGoogle Scholar
  7. 7.
    Khan OH, Raithatha R, Anand VK, Schwartz TH. Endoscopic surgery of the Sella and Suprasellar region. In: Sataloff RT, editor. Sataloff’s comprehensive textbook of otolaryngology: head and neck surgery, vol. 2. New Delhi: Jaypee Brothers Medical Publishers; 2015. p. 805–21.Google Scholar
  8. 8.
    McCrea HJ, Yang T, Schwartz TH. Controversies: endoscopic resection. In: Evans JJ, Kenning TJ, editors. Craniopharyngiomas. Cambridge, MA: Academic Press; 2015.Google Scholar
  9. 9.
    Schwartz TH, Anand VK. The endoscopic endonasal transsphenoidal approach to the suprasellar cistern. Clin Neurosurg. 2007;54:226–35.PubMedGoogle Scholar
  10. 10.
    Harris AE, Lee JY, Omalu B, Flickinger JC, Kondziolka D, Lunsford LD. The effect of radiosurgery during management of aggressive meningiomas. Surg Neurol. 2003;60(4):298–305; discussion.Google Scholar
  11. 11.
    Kreil W, Luggin J, Fuchs I, Weigl V, Eustacchio S, Papaefthymiou G. Long term experience of gamma knife radiosurgery for benign skull base meningiomas. J Neurol Neurosurg Psychiatry. 2005;76(10):1425–30.PubMedPubMedCentralGoogle Scholar
  12. 12.
    Paravati AJ, Heron DE, Gardner PA, Snyderman C, Ozhasoglu C, Quinn A, et al. Combined endoscopic endonasal surgery and fractionated stereotactic radiosurgery (fSRS) for complex cranial base tumors-early clinical outcomes. Technol Cancer Res Treat. 2010;9(5):489–98.PubMedGoogle Scholar
  13. 13.
    Pollock BE, Stafford SL, Utter A, Giannini C, Schreiner SA. Stereotactic radiosurgery provides equivalent tumor control to Simpson grade 1 resection for patients with small- to medium-size meningiomas. Int J Radiat Oncol Biol Phys. 2003;55(4):1000–5.PubMedGoogle Scholar
  14. 14.
    Milker-Zabel S, Zabel-du Bois A, Huber P, Schlegel W, Debus J. Fractionated stereotactic radiation therapy in the management of benign cavernous sinus meningiomas: long-term experience and review of the literature. Strahlenther Onkol. 2006;182(11):635–40.PubMedGoogle Scholar
  15. 15.
    Jho HD, Ha HG. Endoscopic endonasal skull base surgery: part 1 – the midline anterior fossa skull base. Minim Invasive Neurosurg. 2004;47(1):1–8.PubMedGoogle Scholar
  16. 16.
    Schwartz TH, Anand VJ. Endonasal transplanum approach to the anterior cranial fossa. In: Snyderman C, Gardner P, editors. Master techniques in otolaryngology-head and neck surgery. Philadelphia: Lippincott Williams & Wilkins; 2014.Google Scholar
  17. 17.
    Placantonakis DG, Tabaee A, Anand VK, Hiltzik D, Schwartz TH. Safety of low-dose intrathecal fluorescein in endoscopic cranial base surgery. Neurosurgery 2007;61(3 Suppl):161–5; discussion 5–6.Google Scholar
  18. 18.
    Banu MA, Kim JH, Shin BJ, Woodworth GF, Anand VK, Schwartz TH. Low-dose intrathecal fluorescein and etiology-based graft choice in endoscopic endonasal closure of CSF leaks. Clin Neurol Neurosurg. 2014;116:28–34.PubMedGoogle Scholar
  19. 19.
    Woodworth G, McCoul E, Anand V, Greenfiled J, Schwartz T. Endoscopic management of anterior cranial fossa meningiomas. Oper Tech Otolaryngol Head Neck Surg. 2011;22(4):Issue 4.Google Scholar
  20. 20.
    Laufer I, Anand VK, Schwartz TH. Endoscopic, endonasal extended transsphenoidal, transplanum transtuberculum approach for resection of suprasellar lesions. J Neurosurg. 2007;106(3):400–6.PubMedGoogle Scholar
  21. 21.
    Leng LZ, Brown S, Anand VK, Schwartz TH. “Gasket-seal” watertight closure in minimal-access endoscopic cranial base surgery. Neurosurgery. 2008;62(5 Suppl 2):ONSE342–3; discussion ONSE3.Google Scholar
  22. 22.
    Patel KS, Komotar RJ, Szentirmai O, Moussazadeh N, Raper DM, Starke RM, et al. Case-specific protocol to reduce cerebrospinal fluid leakage after endonasal endoscopic surgery. J Neurosurg. 2013;119(3):661–8.PubMedGoogle Scholar
  23. 23.
    Kovacs K, Horvath E. Pathology of pituitary tumors. Endocrinol Metab Clin N Am. 1987;16(3):529–51.Google Scholar
  24. 24.
    Hofstetter CP, Mannaa RH, Mubita L, Anand VK, Kennedy JW, Dehdashti AR, et al. Endoscopic endonasal transsphenoidal surgery for growth hormone-secreting pituitary adenomas. Neurosurg Focus. 2010;29(4):E6.PubMedGoogle Scholar
  25. 25.
    Messerer M, De Battista JC, Raverot G, Kassis S, Dubourg J, Lapras V, et al. Evidence of improved surgical outcome following endoscopy for nonfunctioning pituitary adenoma removal. Neurosurg Focus. 2011;30(4):E11.PubMedGoogle Scholar
  26. 26.
    Farrell CJ, Nyquist GG, Farag AA, Rosen MR, Evans JJ. Principles of pituitary surgery. Otolaryngol Clin N Am. 2016;49(1):95–106.Google Scholar
  27. 27.
    Kouri JG, Chen MY, Watson JC, Oldfield EH. Resection of suprasellar tumors by using a modified transsphenoidal approach. Report of four cases. J Neurosurg. 2000;92(6):1028–35.PubMedGoogle Scholar
  28. 28.
    Komotar RJ, Starke RM, Raper DM, Anand VK, Schwartz TH. Endoscopic endonasal compared with microscopic transsphenoidal and open transcranial resection of giant pituitary adenomas. Pituitary. 2012;15(2):150–9.PubMedGoogle Scholar
  29. 29.
    Hofstetter CP, Shin BJ, Mubita L, Huang C, Anand VK, Boockvar JA, et al. Endoscopic endonasal transsphenoidal surgery for functional pituitary adenomas. Neurosurg Focus. 2011;30(4):E10.PubMedGoogle Scholar
  30. 30.
    Fahlbusch R, Honegger J, Paulus W, Huk W, Buchfelder M. Surgical treatment of craniopharyngiomas: experience with 168 patients. J Neurosurg. 1999;90(2):237–50.PubMedGoogle Scholar
  31. 31.
    Yaşargil MG, Curcic M, Kis M, Siegenthaler G, Teddy PJ, Roth P. Total removal of craniopharyngiomas. Approaches and long-term results in 144 patients. J Neurosurg. 1990;73(1):3–11.PubMedGoogle Scholar
  32. 32.
    Honegger J, Buchfelder M, Fahlbusch R. Surgical treatment of craniopharyngiomas: endocrinological results. J Neurosurg. 1999;90(2):251–7.PubMedGoogle Scholar
  33. 33.
    Chakrabarti I, Amar AP, Couldwell W, Weiss MH. Long-term neurological, visual, and endocrine outcomes following transnasal resection of craniopharyngioma. J Neurosurg. 2005;102(4):650–7.PubMedGoogle Scholar
  34. 34.
    Benjamin V, Russell SM. The microsurgical nuances of resecting tuberculum sellae meningiomas. Neurosurgery. 2005;56(2 Suppl):411–7; discussion −7.Google Scholar
  35. 35.
    Buslei R, Nolde M, Hofmann B, Meissner S, Eyupoglu IY, Siebzehnrubl F, et al. Common mutations of beta-catenin in adamantinomatous craniopharyngiomas but not in other tumours originating from the sellar region. Acta Neuropathol. 2005;109(6):589–97.PubMedGoogle Scholar
  36. 36.
    Schaberg MR, Anand VK, Schwartz TH, Cobb W. Microscopic versus endoscopic transnasal pituitary surgery. Curr Opin Otolaryngol Head Neck Surg. 2010;18(1):8–14.PubMedGoogle Scholar
  37. 37.
    Bresson D, Herman P, Polivka M, Froelich S. Sellar lesions/pathology. Otolaryngol Clin N Am. 2016;49(1):63–93.Google Scholar
  38. 38.
    Frank G, Sciarretta V, Mazzatenta D, Farneti G, Modugno GC, Pasquini E. Transsphenoidal endoscopic approach in the treatment of Rathke’s cleft cyst. Neurosurgery. 2005;56(1):124–8; discussion 9.Google Scholar
  39. 39.
    Zada G, Lin N, Ojerholm E, Ramkissoon S, Laws ER. Craniopharyngioma and other cystic epithelial lesions of the sellar region: a review of clinical, imaging, and histopathological relationships. Neurosurg Focus. 2010;28(4):E4.PubMedGoogle Scholar
  40. 40.
    Aho CJ, Liu C, Zelman V, Couldwell WT, Weiss MH. Surgical outcomes in 118 patients with Rathke cleft cysts. J Neurosurg. 2005;102(2):189–93.PubMedGoogle Scholar
  41. 41.
    Tzortzidis F, Elahi F, Wright D, Natarajan SK, Sekhar LN. Patient outcome at long-term follow-up after aggressive microsurgical resection of cranial base chordomas. Neurosurgery. 2006;59(2):230–7; discussion −7.Google Scholar
  42. 42.
    Chibbaro S, Cornelius JF, Froelich S, Tigan L, Kehrli P, Debry C, et al. Endoscopic endonasal approach in the management of skull base chordomas – clinical experience on a large series, technique, outcome, and pitfalls. Neurosurg Rev. 2014;37(2):217–24; discussion 24–5.Google Scholar
  43. 43.
    Koutourousiou M, Gardner PA, Tormenti MJ, Henry SL, Stefko ST, Kassam AB, et al. Endoscopic endonasal approach for resection of cranial base chordomas: outcomes and learning curve. Neurosurgery. 2012;71(3):614–24; discussion 24–5.Google Scholar
  44. 44.
    DMS R, Komotar RJ, Starke RM, Anand VK, Schwartz TH. Endoscopic versus open approaches to the skull base: a comprehensive literature review. Oper Tech Otolaryngol Head Neck Surg. 2011;22(4):302–7.Google Scholar
  45. 45.
    Komotar RJ, Starke RM, Raper DM, Anand VK, Schwartz TH. The endoscope-assisted ventral approach compared with open microscope-assisted surgery for clival chordomas. World Neurosurg. 2011;76(3–4):318–27; discussion 259–62.Google Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2019

Authors and Affiliations

  • Sacit Bulent Omay
    • 1
    • 2
  • Vijay K. Anand
    • 3
  • Theodore H. Schwartz
    • 4
    Email author
  1. 1.Department of NeurosurgeryWeill Cornell Medical College, NewYork-Presbyterian HospitalNew YorkUSA
  2. 2.Department of NeurosurgeryYale School of MedicineNew HavenUSA
  3. 3.Department of OtolaryngologyWeill Cornell Medical College, NewYork-Presbyterian HospitalNew YorkUSA
  4. 4.Departments of Neurosurgery, Otolaryngology, and NeuroscienceWeill Cornell Medical College, NewYork-Presbyterian HospitalNew YorkUSA

Personalised recommendations