The transnasal-transsphenoidal approach is the first choice in treating infradiaphragmatic craniopharyngiomas with sellar enlargement and a rounded and symmetrical suprasellar extension. The important points to consider when using the transsphenoidal surgical approach in treating infradiaphragmatic craniopharyngiomas are discussed, based upon our experience with 25 patients. A transsphenoidal surgical procedure with a straight incision of the normal pituitary gland horizontally and sharply can avoid any major functional damage to the anterior pituitary gland. It is also extremely important to completely remove calcification piece by piece to prevent CSF leakage during removal of the tumor. The severe CSF leakage after total tomor resection is prevented by infiltrating of a piece of thigh-muscle and some fatty tissue into the sella and then reconstructing the sellar floor with vomer or sellar plate and ensuring lumber drainage. The concept of a subtotal tumor excision to preserve pituitary function, which avoids damage to the hypothalamic structures and limits CSF leakage, especially when treating childhood infradiaphragmatic craniopharyngiomas, seems justified. With the advances in surgical technique, intraoperative monitoring and surgical devices, the transnasal surgical results for treating infradiaphragmatic craniopharyngiomas can be continuously improved.

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Giant pituitary adenomas are defined as tumors of more than four centimetres in one plane in the suprasellar extended portion. Giant pituitary adenomas are a rare but formidable neurosurgical challenge which have long been recognized as having a high surgical complication rate, because of their proximity to the optic pathway, intracavernous invasion, and the possible injury of perforating arteries from the circle of Willis. Moreover, they are also characterized by a higher frequency of vascularity and a hard collagenous consistency, rendering surgical resection difficult. The initial surgical approach should be based on the neuroimaging indication and the surgeon's experience. In these rare instances, most neurosurgeons have preferred using the transsphenoidal approach (TSS) first and experienced surgeons can successfully remove most tumors even when large, although craniotomy may be performed before or after TSS to achieve surgical goals in some cases. Alternatively, staged TSS has been advocated by others. However, giant adenomas are at risk for fatal perioperative bleeding into the residual tumor when incompletely resected. We believe that near-total tumor removal in the initial surgery is important to avoid this critical complication. We have applied extended TSS, which was originally developed to remove suprasellar tumors via TSS, to facilitate the removal of suprasellar extending tumors in some relatively small giant adenomas. In addition, we have also performed simultaneous, combined transsphenoidal-craniotomy approaches for most giant pituitary adenomas. The operative approach is described emphasizing the benefits of simultaneous procedures with two surgeons in a single stage which allows for aggressive tumor resection and avoidance of postoperative hemorrhage.

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The first-line treatment of prolactinomas is medical therapy with dopamine receptor agonists. Bromocriptine (BC) has been used over the past 30 years, while cabergoline (CAB) is increasingly used in recent years because of its enhanced efficacy and better tolerability. Cabergoline is highly effective in normalizing elevated prolactin, recovering hypogonadism, and achieving a successful pregnancy in patients with tumoral and non-tumoral hyperprolactinemia. Also, CAB has a greater ability to shrink prolactinomas (PRLomas) than BC and often extinguishes them. Regarding the diagnosis, it requires demonstrating hyperprolactinemia on at least two separate occasions, excluding other causes of hyperprolactinemia than PRLomas, and detecting pituitary tumor on magnetic resonance imaging. Final diagnosis in non-operated cases is made empirically by attaining unequivocal tumor shrinkage or disappearance with CAB treatment.

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The diencephalo-pituitary axis is a key center in the endocrine system and plays a critical role in the maintenance of homeostasis. Hormone replacement therapy in the patients after diencephalo-pituitary tumor surgery, especially with hydrocortisone and levothyroxine must need to be tailored to the individuals, ideally based on body surface area- and/or body weight-adjusted regimen. In addition, replacement with GH and gonadotropin should be strongly considered to improve quality of life and various metabolic disorderes.

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Craniopharyngiomas are histologically benign tumors, but they are located at the pituitary-hypothalamic system and are therefore difficult lesions to resect surgerically. The present authors have attempted to resect craniopharyngiomas totally by interhemispheric trans-lamina terminalis approach (IH) or pterional approach (PT) with/without anterior temporal approach. As a result of our policy at the first operation that preservation of the pituitary function is more important than total resection, our total resection rate was low and recurrence/regrowth rate was high. Based on our limited experiences, IH is a useful approach for the large craniopharyngiomas, but has limits concerning total resection and/or preservation of the pituitary stalk. On the other hand, PT is a useful approach for treating small to medium tumors to achieve total resection and preservation of the stalk, but anatomical preservation of the stalk does not always mean good functional results.

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Microvascular decompression surgery (MVD) for trigeminal neuralgia, hemifacial spasm and glossopharyngeal neuralgia is well known to be associated with low mortality and morbidity rates when performed at specialized institutes. Although MVD is now popular and widely performed at various institutes, the surgical results are not always reliable. Satisfactory results of MVD should be a complete and permanent cure of symptoms without any complications or recurrence and accordingly, the results of such a functional neurosurgery should be judged and evaluated not only by the surgical cure rate, but also with consideration of the postoperative sequelae. Therefore, members of the Society of MVD in Japan have tried to standardize the results of MVD in order to appropriately judge the surgical results and furthermore, the Society has tried to raise the quality of surgery of all MVD surgeons. The standardized result of MVD will finally be used to inform patients and it also will make doctors, who still have a little knowledge of MVD, acquainted with the effectiveness of MVD.

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Objective: This article demonstrates the feasibility of using a videoscope system with narrow-band imaging (NBI) technology to enhance the safety of endoscopic third ventriculostomy (ETV). Methods: ETV was performed on two longstanding overt ventriculomegaly in adults (LOVA) patients using a videoscope system with narrow-band imaging technology. All procedures were digitally recorded. Images obtained from this new videoscope were compared with images from a conventional fiberscopy performed earlier. To determine the usefulness of the NBI technology, the digital photographs were organized so as to compare the conventional and NBI images. Results: The visual quality of the videoscope was far superior to the conventional fiberscope. Clear visualization of 1) the subependymal blood vessels, 2) tiny capillaries in the ventricular floor, and 3) perforators of the basilar artery on the other side of the floor, was obtained. Furthermore, when used in conjunction with narrow-band imaging technology, the videoscope was capable of producing enhanced images of the blood vessels aforementioned. Conclusion: This videoscope is effective in avoiding vessel injuries, and thus hemorrhage, during ETV. Though yet to be assessed, its usefulness in other neuroendoscopy procedures seems promising. Videoscopy with NBI technology is expected to be a new paradigm in the development of neuroendoscop.

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