The patient came to the clinic 14-December-2017 complaining of blurred vision left eye for three years. The last week go almost blind left eye with decreased vision right eye. MRI done in Turkey 11-December-2017 showing huge pituitary adenoma with massive infrasellar and moderate suprasellar extension with signs of apoplexy of the tumor bed with fluid level inside the tumor. The patient is convulsion free.

On examination, the patient can feel the light in the left eye and can count the fingers around 1 meter before the right eye. The oculo-motor innervation is intact. There is no galactorrhea. Normosmia. There are manifestations of panhypoptuitarism, but no data for diabetes insipidus.

The patient was sent for thorough radio-ophthalmo-endocrine investigations. MRI of the sella with MRA done 16-December-2017 showed the tumor pushing the chiasm and optic nerves with suprasellar extension around 16.2 mm. The tumor has massive infrasellar extension reaching the naso-pharyngeal space abutting it. The tumor dimensions are 37.3x28.6 mm. There is no invasion of the cavernous sinuses. There is fluid level inside the tumor confirming the presence of apoplexy. Visual acuity of the right eye after correction 6/6. The left eye 6/0.05. There is massive scatoma left eye with less in the right eye. Prolactine 470 ng/ml, LH 1.19, testosterone 0.3. Considering the above data trans-sphenoidal approach with MRI control was advised. Mathematically speaking the volume of the tumor with the hypophysis is around 8.8 ml.  

The patient was put in setting position to perform trans-sphenoidal approach with the C-arm projecting to the sella turcica. A trial to evacuate the tumor by epidural needle 14 was attempted and brownish content was achieved. The patient was sent for MRI control. The tumor still there with new bleeding inside the evacuated cavity. The puncture site was extended and the rubbery pituitary inferior wall was incised.  The tumor was removed using curettes for biopsy and the remaining was removed by suction. It was possible to see the posterior borders of the pituitary gland. Using Omnipaque diluted  3cc was injected to the tumor cavity. It is pulsating well, manifesting the absence of suprasellar part of the tumor. The patient was sent another time for MRI control. The tumor practically resected with the pituitary stalk hanging free and the optic nerves more than 8 mm above the superior surface of the preserved pituitary gland. There is no bleeding inside the cavity. Routine closure with tampons of nostrils. 

Smooth postoperative recovery. The patient was sent to the ward.

The patient can be operated intracranially, but the massive infrasellar extension is hard to detect through such angles, even with endoscopic facilities.

This postoperative course of transphenoidal approach is smooth in comparison to subfrontal approach.

The tumor configuration dictate the proper approach.

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