Case Overview
■ Patient Information: 55-year-old male.
■ Chief Complaint and Physical Examination:
Progressive vision loss for 2 years, worsening over the past 3 months
Right eye visual acuity: 0.04
Left eye: No light perception (blind)
■ Imaging Findings: MRI revealed a large solid supra- and intrasellar mass with marked enhancement. The tumor partially encased both internal carotid arteries and the anterior cerebral arteries, consistent with a giant pituitary adenoma.
■ Diagnosis: Invasive giant pituitary adenoma.
Preoperative Imaging
Surgical Strategy
■ Approach: Endoscopic endonasal extended transsphenoidal approach (EEA).
■ Objective: Maximal safe resection while preserving critical neurovascular structures and ensuring robust skull base reconstruction.
Surgical Procedure
■ Initial Setup:
A vascularized nasoseptal mucosal flap was harvested at the beginning of the procedure.
An extended endonasal transsphenoidal corridor was established.
Single-field exposure of the sellar floor, tuberculum sellae, and planum sphenoidale was achieved.
■ Tumor Resection:
The dura of the sellar floor, tuberculum sellae, and planum sphenoidale was opened in a single field. The surgical procedure followed these steps:
（1）Initial resection of the intrasellar tumor component
（2）Progressive intratumoral debulking
（3）Careful dissection along natural anatomical interfaces:
Tumor–pituitary gland
Tumor–diaphragma sellaeDiaphragma–arachnoid
Diaphragma–arachnoid
（4）The tumor was removed piecemeal, with continuous development of peripheral dissection planes.
■ Vascular Management:
For vessels encased by the tumor, the following technique was employed:
（1）Central debulking was performed
（2）Bidirectional dissection allowed safe vascular decompression
（3）No vascular injury occurred; all major vessels were preserved
■ Resection Outcome:
（1）Gross total resection achieved in the suprasellar region.
（2）Partial opening of the third ventricular floor.
（3）Optic apparatus was well preserved.
（4）Anterior cerebral arteries and surrounding critical vasculature were protected.
Skull Base Reconstruction
A multilayer reconstruction strategy was employed to achieve a watertight closure and restore skull base integrity:
Layer | Description |
Intradural layer | Placement of an artificial dural substitute to counteract CSF pulsation |
Structural reinforcement | Autologous fascia lata sutured to dural margins |
Overlay layer | Additional fascia lata covering the defect |
Rigid support | Contoured absorbable plate used to stabilize the reconstruction |
Vascularized coverage | Nasoseptal flap positioned over the defect |
Sealant application | Dural sealant applied to ensure watertight seal |
Procedure
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Postoperative Outcome
■ The patient demonstrated an uneventful recovery:
No cerebrospinal fluid (CSF) rhinorrhea
No intracranial infection
Visual function remained stable compared to preoperative baseline
CT of the head at 1 week postoperatively
Case Discussion
■ Reconstruction Goals:
Achieve durable sealing of the dural compartment
Prevent CSF leakage and intracranial infection
■ Reconstruction Principles:
Multilayered repair
Anatomical restoration
Optimization of tissue healing environment
■ Key Considerations:
Restoration of physiological skull base anatomy
Use of vascularized tissue for enhanced healing
Tailored selection of materials and techniques based on defect characteristics