Selective resection of the medial wall of the cavernous sinus in acromegaly: patient series

BACKGROUND: Transsphenoidal surgery (TSS) is the primary treatment of choice in acromegaly. Tumor invasion into the medial wall of the cavernous sinus (MWCS) has been observed, even in Knosp grades 0-2, and may lead to suboptimal surgical results if not additionally resected. Removal of the MWCS may enhance the surgical outcome and result in improved endocrine remission rates. The aim of this study was to evaluate the impact of additional MWCS resection during TSS for acromegaly on endocrine remission and complication rates. The authors prospectively collected the data of acromegaly patients at a large tertiary pituitary referral center. Between January 2023 and January 2025, patients treated with TSS and additional selective resection of the MWCS were included. Patient demographics, tumor characteristics, surgical outcome, and postoperative complications were reviewed. OBSERVATIONS: Twelve patients were included (9 primary TSS, 3 re-TSS). Tumor invasion of the MWCS was confirmed in 91.7%. The median follow-up was 19 months (range 3-27 months). After primary TSS, 8 of 9 patients (88.9%) were in endocrine remission. Following re-TSS, remission was observed in 33.3%. Ultimately, disease control was achieved in 11 of 12 patients (91.7%). No carotid injuries or permanent neurological deficits were observed. LESSONS: Additional selective resection of the MWCS during TSS in acromegaly is a technique that can be safely executed, and it seems to enhance endocrine remission rates especially in primary TSS. https://thejns.org/doi/10.3171/CASE2665.