Endonasal decompression plus transcranial for a giant sellar–suprasellar tumor case-Medprin Biotech

Clinical status and initial plan (from Dr. Rajkumar):

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A 59-year-old female with hypertension and severe visual loss; in the left eye there has been only light perception for more than one year.
Imaging shows a large tumor extending from the sellar region upwards, with the long axis the left side, and associated hydrocephalus / raised intracranial pressure.
The anterior communicating artery complex (ACom) is displaced but not clearly encased; both internal carotid arteries (ICAs) are “completely encircled” by the tumor.
The initial plan at CMJAH was: first, an extended endonasal / extended transsphenoidal approach for maximal debulking and decompression; then, depending on residual tumor, a possible second-stage transcranial resection.

Prof. Zan’s perspective (from the webinar discussion):

(1) The patient “cannot wait,” but a single route is unlikely to achieve gross resection：

The patient has hydrocephalus and intracranial hypertension, so in his words, “the patient could not wait.”
However, given the large tumor volume, vessel encasement, and high intracranial pressure, it is very difficult to achieve gross resection via an endonasal-only route under acceptable risk.
At the same time, there is a risk of tumor apoplexy and intra-tumoral hemorrhage, which he described as “unpredictable.”

(2) Suggested overall strategy: endonasal decompression plus transcranial as needed:

Prof. Zan stated that he personally prefers a combined endonasal + transcranial strategy rather than an endonasal-only plan in such cases.
Endonasal / transsphenoidal surgery can be used first to debulk the tumor, relieve intracranial pressure, and open a working corridor.
When the endonasal route reaches its limit, a craniotomy can then be performed to remove additional tumor from the intracranial side, sometimes pushing residual capsule or mass back toward the sellar corridor for resection.
If vascular complications occur during this process (for example, bleeding near the ICA), a transcranial route may provide more favorable conditions for vascular control.
He emphasized that in such complex cases, endonasal and transcranial approaches are often two stages of a single treatment plan, rather than mutually exclusive alternatives.

(3) On whether to still pursue gross resection in a nearly blind patient:

Dr. Rajkumar asked whether, in a patient who has been blind or nearly blind for a long time, the primary goal should be decompression and control of intracranial pressure rather than aggressively pursuing gross total resection.
Prof. Zan replied that he “always” tends to aim for gross resection—that is, maximal safe resection—even in patients with only light perception or complete blindness.
His reasoning is that pituitary adenomas are “unstable tumors”: residual tumor carries the risk of further growth or hemorrhage.
If intraoperative conditions allow, he will try his best to achieve the maximum extent of resection, while recognizing that whether gross total resection is actually achieved ultimately depends on intraoperative findings and safety boundaries.

Key points:

For complex pituitary tumors with hydrocephalus / intracranial hypertension, large suprasellar extension, and vascular encasement, an endonasal-only approach often cannot achieve satisfactory gross resection at an acceptable risk level.
Prof. Zan recommends using an endonasal endoscopic route primarily for decompression and corridor creation, and then adding or staging a transcranial approach as needed to handle high-lying or vessel-adjacent remnants and to provide better vascular control if complications occur.
Even in patients with long-standing severe visual loss, he still prefers, under safe conditions, to pursue the maximum possible extent of tumor removal to reduce future instability (regrowth, re-bleeding), rather than being satisfied with decompression alone.

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