Clinical evaluation of the sellar mass patient

Introduction

Sellar lesions are common and encompass a wide variety of pituitary and parasellar region pathologies. Broadly speaking, they can be categorized as neoplastic, congenital, inflammatory, infectious, and vascular causes with tumors being the most common sellar mass. In a recent US population-based report, tumors of the sellar region were the second most common central nervous system tumor with an incidence of 4.55 per 100,000 population. Given the inferior descent of the sella into the sphenoid bone and the relationship between the sphenoid bone and sinus to the nasal cavity, the most common approach to sellar masses is currently via the transsphenoidal route. Historically, this was performed microsurgically and today is increasingly performed endoscopically.

Cerebrospinal fluid (CSF) leaks are an important complication of approaching the sella through the transsphenoidal route and can lead to increased morbidity (e.g., meningitis) and additional medical costs. The adoption of endoscopic endonasal approaches (EEAs) was initially limited by high rates of postoperative CSF leak and meningitis. ^, Advanced reconstruction techniques and increasing experience of surgeons have reduced the CSF leak rates across diverse pathologies. Rates of CSF leak associated with transsphenoidal pituitary surgery in large modern series are less than 10%. CSF leaks can occur intraoperatively and/or postoperatively, with an intraoperative CSF leak being a significant predictor of a postoperative leak. ^, Notably, a postoperative CSF leak can also occur in the absence of an intraoperative CSF leak, albeit to a lesser degree. ^,

A thorough history and physical examination and detailed imaging review are the main cornerstones in the assessment of a patient with a sellar mass. This chapter focuses on the preoperative evaluation of patients with a sellar mass with particular attention to considerations for intra- and postoperative CSF leaks.