Endoscopic endonasal approach to primitive Meckel's cave tumors: a clinical series.

INTRODUCTION: Recently, an alternative endoscopic endonasal approach to Meckel's cave (MC) tumors has been proposed. To date, few studies have evaluated the results of this route. The aim of our study was to evaluate long-term surgical and clinical outcome associated with this technique in a cohort of patients with intrinsic MC tumors. METHODS: All patients with MC tumors treated at out institution by endoscopic endonasal approach (EEA) between 2002 and 2016 were included. Patients underwent brain MRI, CT angiography, and neurological evaluation before surgery. Complications were considered based on the surgical records. All examinations were repeated after 3 and 12 months, then annually. The median follow-up was of 44.1 months (range 16-210). RESULTS: The series included 8 patients (4 F): 5 neuromas, 1 meningioma, 1 chondrosarcoma, and 1 epidermoid cyst. The median age at treatment was 54.5 years (range 21-70). Three tumors presented with a posterior fossa extension. Radical removal of the MC portion of the tumor was achieved in 7 out of 8 cases. Two patients developed a permanent and transitory deficit of the sixth cranial nerve, respectively. No tumor recurrence was observed at follow-up. CONCLUSION: In this preliminary series, the EEA appeared an effective and safe approach to MC tumors. The technique could be advantageous to treat tumors located in the antero-medial aspects of MC displacing the trigeminal structures posteriorly and laterally. A favorable index of an adequate working space for this approach is represented by the ICA medialization, while tumor extension to the posterior fossa represents the main limitation to radical removal of this route.

The Endoscopic Endonasal Management of Anterior Skull Base Meningiomas.

Introduction The endoscopic endonasal approach (EEA) might seem an "unnatural" route for intradural lesions such as meningiomas. The aim of this study is to critically revise our management of anterior skull base meningiomas to consider, in what cases it may be advantageous. Material and Methods Each consecutive case of anterior skull base meningioma operated on through an EEA or combined endoscopic-transcranial approach at our institution, between 2003 and 2017, have been included. Tumors were classified on the basis of their location and intra or extracranial extension. Follow-up consisted of an MRI (magnetic resonance imaging) and a clinical examination 3 months after the surgery and then repeated annually. Results Fifty-seven patients were included. The most common location was the tuberculum sellae (62%), followed by olfactory groove (14%), planum sphenoidale (12%), and frontal sinus (12%). Among these, 65% were intracranial, 7% were extracranial, and 28% both intra and extracranial. Radical removal was achieved in 44 cases (77%). Complications consisted in 10 CSF (cerebrospinal fluid) leaks (17.6%), 1 overpacking (1.7%), and 1 asymptomatic brain ischemia (1.7%). Visual acuity and campimetric deficits improved respectively in 67 and 76% of patients. Recurrence rate was of 14%. Conclusions EEA presents many advantages in selected cases of anterior skull base meningioma. However, it is hampered by the relevant risk of CSF leak. We consider that it could be advantageous for planum/tuberculum sellae tumors. Conversely, for olfactory groove or frontal sinus meningiomas, it can be indicated for tumors with extracranial extension, while its role is still debatable for purely intracranial forms as considering our surgical results, it could be advantageous for midline planum/tuberculum sellae tumors. Conversely, it can be of first choice for olfactory groove or frontal sinus meningiomas with extracranial extension, while its role for purely intracranial forms is still debatable.

Limits of endoscopic endonasal approach for cranio-vertebral junction tumors.

BACKGROUND: The endoscopic endonasal approach has been recently proposed for cranio-vertebral junction lesions. The more common indication for this sagittal extension of the endonasal route is represented by odontoidectomy for irreducible ventral brainstem compression due to congenital or degenerative conditions. However, in an increasing number of studies its adoption for tumors involving the cranio-cervical junction has been reported. The aim of this study is to consider retrospectively our surgical series, focusing on the advantages and limits of this approach. METHODS: Each consecutive case of tumor involving the cranio-vertebral junction since 2007 to 2017 treated through an endoscopic endonasal approach has been included. All patients undergone preoperative neurological examination and neuroimaging (magnetic resonance imaging [MRI] and computed tomography angiography). These examinations were repeated after 3 months and then annually. Complementary treatments, recurrence rate and clinical status at mean follow-up of 18±7.3 months were considered. RESULTS: Seven patients have been included in this study, mean age was of 47±17 years; male-to-female ratio was of 3:4. Series is composed by 6 chordomas and one foramen magnum meningioma. One patient had been already posteriorly stabilized for cranio-vertebral instability. Gross tumor removal was achieved in two cases, in the others a subtotal removal was demonstrated at postoperative MRI. One patient presented a transitory worsening of CN XII palsy, resolved within 3 months. For preoperative dysphagia and inhalation pneumonia, one case undergone tracheostomy and was fed with oro-gastric tube for 10 days. Three patients died for chordoma progression and at follow-up one presented a local recurrence. CONCLUSIONS: Despite our experience is preliminary, the endoscopic endonasal approach has resulted safe for cranio-cervical junction tumor with a reduced number of complications. It can give a straight and direct trajectory to this deep region. We suggest that lateral extension of the tumor beyond the plane of cranial nerves is a limit for this approach, as well as an inferior expansion caudal to C1. Larger series and longer follow-up are required to assess the proper indications of this approach.

Clival chordomas: considerations after 16 years of endoscopic endonasal surgery.

OBJECTIVE In the past decade, the role of the endoscopic endonasal approach (EEA) has relevantly evolved for skull base tumors. In this study, the authors review their surgical experience with using an EEA in the treatment of clival chordomas, which are deep and infiltrative skull base lesions, and they highlight the advantages and limitations of this ventral approach. METHODS All consecutive cases of chordoma treated with an EEA between 1998 and 2015 at a single institution are included in this study. Preoperative assessment consisted of neuroimaging (MRI and CT with angiography sequences) and endocrinological, neurological, and ophthalmological evaluations, which were repeated 3 months after surgery and annually thereafter. Postoperative adjuvant therapies were considered. RESULTS Sixty-five patients (male/female ratio 1:0.9) were included in this study. The median age was 48 years (range 9-80 years). Gross-total resection (GTR) was achieved in 47 cases (58.7%). On univariate analysis, primary procedures (p = 0.001), location in the superior or middle third of the clivus (p = 0.043), extradural location (p = 0.035), and histology of conventional chordomas (p = 0.013) were associated with a higher rate of GTR. The complication rate was 15.1%, and there were no perioperative deaths. Most complications did not result in permanent sequelae and included 2 CSF leaks (2.5%), 5 transient cranial nerve VI palsies (6.2%), and 2 internal carotid artery injuries (2.5%), which were treated with coil occlusion of the internal carotid artery without neurological deficits. Three patients (3.8%) presented with complications resulting in permanent neurological deficits due to a postoperative hematoma (1.2%) causing a hemiparesis, and 2 permanent ophthalmoplegias (2.5%). Seventeen patients (26.2%) have died of tumor progression over the course of follow-up (median 52 months, range 7-159 months). Based on Kaplan-Meier analysis, the survival rate was 77% at 5 years and 57% at 10 years. On multivariate analysis, the extent of tumor removal (p = 0.001) and the absence of previous treatments (p = 0.001) proved to be correlated with a longer survival rate. CONCLUSIONS The EEA was associated with a high rate of tumor removal and symptom control, with low morbidity and preservation of a good quality of life. These results allow for a satisfactory overall survival rate, particularly after GTR and for primary surgery. Considering these results, the authors believe that an EEA can be a helpful tool in chordoma surgery, achieving a good balance between as much tumor removal as possible and the preservation of an acceptable patient quality of life.

Endoscopic Endonasal Surgery for Pituitary Apoplexy: Evidence On a 75-Case Series From a Tertiary Care Center.

BACKGROUND: The optimal management of pituitary apoplexy (PA) remains debated. The aim of this study was to assess the outcome of the transsphenoidal approach for PA in a large surgical experience. MATERIALS: Each consecutive case of PA consecutively operated by endoscopic endonasal approach from our tertiary care center, from 1998 to 2015, was included in this series. RESULTS: Seventy-five patients (47 male; mean age 52.4 ± 16.2 years) were included. Mean follow-up was 69.3 ± 46.7 months. On admission, all patients presented with abrupt severe headache (100%), associated with anterior hypopituitarism in 51 patients (68%), visual disturbances in 55 (73.4%), ophthalmoplegia in 38 (50.7%), and a remarkable reduction of consciousness in 2 (2.6%). Apoplexy proved to be ischemic in 35 patients (46.7%) and hemorrhagic in 40 (53.3%). Patients with hemorrhagic necrosis presented more often with major suprasellar expansion (P = 0.012) Radical removal was achieved in 60 cases (80%). Surgical morbidity consisted in one case of postoperative cerebrospinal fluid leak (1.3%). Anterior hypopituitarism worsened in 15 cases (20%), and diabetes insipidus occurred in 4 cases (5.3%). Ophthalmoplegia improved/normalized in 71% and visual symptoms in 85.5% of the patients, with better results achieved in ischemic forms (P = 0.043). The 2 comatose patients regained normal consciousness. CONCLUSIONS: The endoscopic endonasal approach represents a valid, effective, and safe technique in the management of PA. Favorable outcomes can be achieved by referring patients to dedicated pituitary centers with a multidisciplinary team. Further studies are still needed to define criteria for surgical indication and to identify outcome predictors.

Antibiotic Prophylaxis in Endoscopic Endonasal Pituitary and Skull Base Surgery.

OBJECTIVE: Postoperative infection is a potentially dramatic consequence in endoscopic endonasal surgery. The aim of this study was to assess the efficacy of our intraoperative antibiotic prophylaxis by analyzing the risk factors of postoperative meningitis in our series. METHODS: Each endoscopic endonasal procedure performed since 1998 in patients with no preoperative infections and a follow-up longer than 30 days were included and retrospectively reviewed. Antibiotic protocol consisted in single antibiotic administration of ampicillin/sulbactam 3 g or cefazolin 2 g on induction; no postoperative administrations were performed after 2005. All cases of cerebrospinal fluid (CSF) leak, meningitis, and systemic infection were recorded. RESULTS: Two thousand thirty-two procedures matched the inclusion criteria (median age 50 years; range: 1-89 years, male/female ratio: 1:1.12). Intraoperative CSF leak occurred in 32.8% of the cases and postoperative CSF leak in 3.4%. The rate of meningitis was 0.69%; other systemic infections were observed in 0.44% of cases. Meningitis was statistically associated with intra- and postoperative CSF leak (P < 0.001). Other risk factors were the intradural extension of the tumors and their malignant histology. Extended approaches producing wide osteodural defects were correlated with a greater risk of meningitis (P < 0.001). CONCLUSIONS: All surgical maneuvers to prevent, detect, and quickly repair intra- and postoperative CSF leak are crucial to avoid postoperative meningitis. The proposed prophylaxis protocol is comparable in safety to those recommended in literature as assessed by the low rate of meningitis.

Postoperative outcome of body core temperature rhythm and sleep-wake cycle in third ventricle craniopharyngiomas.

OBJECTIVE One of the more serious risks in the treatment of third ventricle craniopharyngiomas is represented by hypothalamic damage. Recently, many papers have reported the expansion of the indications for the endoscopic endonasal approach (EEA) to be used for these tumors as well. The aim of this study was to assess the outcome of sleep-wake cycle and body core temperature (BCT), both depending on hypothalamic control, in patients affected by craniopharyngiomas involving the third ventricle that were surgically treated via an EEA. METHODS All consecutive adult patients with craniopharyngiomas that were treated at one center via an EEA between 2014 and 2016 were prospectively included. Each patient underwent neuroradiological, endocrinological, and ophthalmological evaluation; 24-hour monitoring of the BCT rhythm; and the sleep-wake cycle before surgery and at follow-up of at least 6 months. RESULTS Ten patients were included in the study (male/female ratio 4:6, mean age 48.6 years, SD 15.9 years). Gross-total resection was achieved in 8 cases. Preoperative BCT rhythm was pathological in 6 patients. After surgery, these disturbances resolved in 2 cases, improved in another 3, and remained the same in 1 patient; also, 1 case of de novo onset was observed. Before surgery the sleep-wake cycle was pathological in 8 cases, and it was restored in 4 patients at follow-up. After surgery the number of patients reporting diurnal naps increased from 7 to 9. CONCLUSIONS The outcome of the sleep-wake cycle and BCT analyzed after EEA in this study is promising. Despite the short duration of the authors' experience, they consider these results encouraging; additional series are needed to confirm the preliminary findings.

Suction Filter in Endoscopic Endonasal Surgery: A Technical Note.

BACKGROUND: The collection of the greatest possible amount of pathologic tissue is of paramount importance in neurosurgery to achieve the most accurate histopathologic diagnosis, to perform all of the necessary biomolecular tests on the pathologic specimen, and to collect biological material for basic or translational science studies. This problem is particularly relevant in pituitary surgery because of the possible small size and soft consistency of tumors, which make them suitable for removal through suction, reducing the amount of available pathologic tissue. To solve this issue, we adopted a filter connected to the suction tube, which allows the surgeon to collect all of the tissue aspirated during surgery. METHODS: Our experience of 1734 endoscopic endonasal procedures, performed adopting this device since 1998 to December 2015, has been revised to assess its advantages and limitations. RESULTS: This system is easy-to-use, does not impair the surgical maneuvers, and does not add any relevant cost to the surgery. The tissue collected through the filter proved useful for diagnostic histologic and biomolecular analyses and for research purposes, without any relevant artifacts as a result of this method of collection. CONCLUSIONS: The use of a filter has allowed us to obtain the greatest amount possible of pathologic tissue at each surgery. This surgical material has revealed to be helpful both for diagnostic and basic science purposes. The use of the filter has proven to be of particular importance for microadenomas, soft tumors, and supradiaphragmatic or skull base lesions with heterogeneous features, improving the accuracy of histopathologic diagnosis.

Cavernous sinus invasion by pituitary adenomas: role of endoscopic endonasal surgery.

BACKGROUND: Cavernous sinus (CS) invasion is one of the most unfavorable features of pituitary adenomas. The most widely used classification was proposed by Knosp in 1993 and revised in 2015. The aim of this study is to extend our previous experience by comparing the pre-operative neuroradiological assessment with the intra-operative endoscopic endonasal inspection in order to evaluate the real rate of CS invasion and analyze its correlation with the surgical outcome. METHODS: Consecutive patients, who have undergone endoscopic endonasal surgery for a pituitary adenoma with Knosp grade greater than 1, have been included in this study. The intra-operative CS invasion was assesses basing on surgical reports. The surgical outcome has been evaluated with MRI, endocrinological, visual and neurological evaluation have been performed 3 months after surgery and then annually. RESULTS: The series included 402 patients. Male-female ratio was 1:1 and median age was 56 years (range 15-85). We observed that 43% of cases with Knosp grade greater than 1 presented no CS invasion on surgical inspection. Knosp grade 4 was the only one corresponding in all cases to a real CS invasion. Radical tumor removal was achieved in 60%. while endocrinological remission was obtained in 37% of functioning adenomas. Better results were observed for lower Knosp grades. CONCLUSIONS: The endoscopic endonasal inspection is the most effective technique to detect CS invasion. Indeed, it can provide a direct visualization of the medial wall, permitting the assessment of its invasion and the management of those cases with diffuse involvement. We confirm that the revision to the Knosp classification has improved its prognostic role.

Endoscopic endonasal anatomy of the ophthalmic artery in the optic canal.

BACKGROUND: The endoscopic endonasal opening of the optic canal has been recently proposed for tumors with medial invasion of this canal, such as tuberculum sellae meningiomas. Injury of the ophthalmic artery represents a dramatic risk during this maneuver. Therefore, the aim of this study was to analyze the endoscopic endonasal anatomy of the precanalicular and canalicular portion of this vessel, discussing its clinical implication. METHODS: The course of the ophthalmic artery was analyzed through five endoscopic endonasal dissections, and 40 nonpathological consecutive MRAs were reviewed. RESULTS: The ophthalmic artery arises from the intradural portion of the supraclinoid internal carotid artery, in 93 % of cases about 1.9 mm (range: 1-3) posterior to the falciform ligament. At the entrance into the optic canal, the ophthalmic artery is located infero-medially to the optic nerve in 13 % of cases. In 50 % of these cases the artery moves infero-laterally along its course, remaining in a medial position in the others. In cases with an non medial entrance of the ophthalmic artery, it runs infero-lateral to the optic nerve for its entire canalicular portion, with just one exception. CONCLUSION: The endoscopic endonasal approach gives a direct, extensive and panoramic view of the course of the precanalicular and canalicular portion of the ophthalmic artery. Dedicated high-field neuroimaging studies are of paramount importance in preoperative planning to evaluate the anatomy of the ophthalmic artery, reducing the risk of jeopardizing the vessel, particularly for those uncommon cases with an infero-medial course of the artery.

Meningocele and Meningoencephalocele of the Lateral Wall of Sphenoidal Sinus: The Role of the Endoscopic Endonasal Surgery.

BACKGROUND: Meningocele and meningoencephalocele of the lateral wall of the sphenoidal sinus (LWSS) are rare lesions, crossing the borders of multiple disciplines such as ear-nose-throat, maxillofacial, and neurologic surgery. We reviewed our surgical experience to analyze the role of the endoscopic endonasal approach and consider these pathologies from different perspectives. METHODS: All consecutive cases of meningocele and meningoencephalocele of LWSS operated through an endoscopic endonasal approach from 1998 to 2015 in our institutions were collected. Medical history, focusing on previous episodes of cerebrospinal fluid leak, meningitis or seizures, was considered. The outcome was assessed considering the medical condition and the postoperative neuroimaging. RESULTS: The series includes 23 patients (7 male, 16 female). Mean age was 52 years (26-73 years). Eleven cases were meningoencephaloceles and 12 meningoceles. A clear cerebrospinal fluid leak occurred on in 19 patients and was associated with meningitis in 3. Two were presenting a history of epilepsy. No complications were observed, but 1 case presented seizures on waking. At follow-up (mean 84 months, 4-167) each patient is in good clinical condition with no further episodes of leaking or seizures. CONCLUSIONS: Endoscopic endonasal surgery is a safe and effective approach for meningocele and meningoencephalocele of LWSS; it allows resection of herniated tissue and repair of the osteodural defect. The favorable clinical outcome and the possible effectiveness on seizures lead us to support this approach as first minimally invasive treatment also in presence of epilepsy, as a first low risk epilepsy surgical procedure.

Endoscopic Endonasal Odontoidectomy.

Odontoidectomy is the treatment of choice for irreducible ventral cervical-medullary compression. The endonasal endoscopic approach is an innovative approach for odontoidectomy. The aim of this article is to identify in which conditions this approach is indicated, discussing variants of the technique for selected cases of craniovertebral malformation with platybasia. We believe that the technical difficulties of this approach are balanced by the advantages for patients. Some conditions related to the patient and to the anatomy of the craniovertebral junction may favor adoption of the endoscopic endonasal approach, which should be considered complementary and not alternative to standard approaches.

Targeted BRAF and CTNNB1 next-generation sequencing allows proper classification of nonadenomatous lesions of the sellar region in samples with limiting amounts of lesional cells.

PURPOSE: To assess the role of high sensitivity next-generation sequencing (NGS) of CTNNB1 for the diagnosis of adamantinomatous craniopharyngiomas (aCPs) and of BRAF for that of papillary CPs (pCPs) in routinely processed surgical samples of non-adenomatous sellar lesions. METHODS: Forty-five cases of patients operated for non-adenomatous masses of the sellar region between 2004 and 2014 were retrieved from the files of the Anatomic Pathology unit of the Bellaria Hospital in Bologna, Italy. BRAF and CTNNB1 mutation status was analyzed by NGS in samples smaller than 1 cm(3) and histological re-evaluation was performed on all cases. RESULTS: CTNNB1 mutation analysis showed a sensitivity of 86.7 % and a specificity of 96.2 % for the diagnosis of aCPs. The specificity increased to 100 % considering that in one case, initially classified as a non-CP lesion (xanthogranuloma), the identification of a CTNNB1 S47R lead to histological re-evaluation and reclassification of the lesion as aCP. BRAF mutation analysis had a sensitivity of 76.9 % and a specificity of 96.4 % for the diagnosis of pCPs. The specificity increased to 100 % considering that in one case, initially classified as a Rathke cyst, the identification of BRAF V600E lead to histological re-evaluation and reclassification of the lesion as pCP. CONCLUSIONS: This study confirms the diagnostic relevance of the molecular alterations recently identified in aCPs and pCPs and shows how the identification of BRAF and CTNNB1 mutations can be instrumental for the proper classification of samples that contain limiting amounts of diagnostic lesional tissue.

Cesare Cavina (1888-1935): a father of transsphenoidal surgery.

Among the fathers of transsphenoidal surgery, a relevant role should be reserved for Cesare Cavina (1888-1935). He had the merit to develop and popularize in Italy this approach for pituitary tumors, performing 47 transsphenoidal hypophysectomies out of his personal series of 66 patients between 1927 and 1935. He contributed to this surgery by introducing radiological control of the surgical trajectory to reduce the risk of complications and increase the safety of this approach. We think that both his short lifespan (he died when he was 47 years old) and the language of his papers (Italian and not English) are two important factors that have contributed to forgetting his role in the history of transsphenoidal surgery. We think that Prof. Cesare Cavina is definitively one of the fathers of transsphenoidal surgery and that it is important to preserve his memory.

ACTH adenomas transforming their clinical expression: report of 5 cases.

OBJECT Adrenocorticotropic hormone (ACTH) adenomas have been recognized as a more aggressive and invasive subtype of pituitary adenomas. An additional and clinically relevant peculiarity of these tumors is their ability to modify their clinical expression from a silent form to Cushing disease or vice versa. The aim of this study was to review a series of patients with pituitary adenomas and analyze the clinical implications of the transformation of clinical expression in 5 cases that showed this phenomenon. METHODS The authors retrospectively reviewed a series of patients with pituitary adenoma and collected clinical, biohumoral, and neuroradiological data of those who presented with a transformation from silent ACTH adenomas to functioning tumors or vice versa. In all the cases, preoperative assessment consisted of brain MRI, ophthalmological examination, and complete baseline endocrinological investigation. In patients with clinical and/or biochemical findings suspicious for Cushing syndrome, a low-dose dexamethasone suppression test was performed to rule in or out this diagnosis. Endocrinological evaluations were repeated 1 month after surgery, 3 months after surgery, and every 6 months or annually thereafter. Ophthalmological evaluations and brain MRIs were repeated after 3 months and then every 6 or 12 months thereafter. RESULTS Five patients (2 men and 3 women) included in this series had corticotropic tumors that showed transformation from an endocrinologically silent form to manifest Cushing disease and vice versa. The mean age at presentation was 40 years (range 18-51 years). In 3 of these patients, a transformation from silent to functioning ACTH adenoma with manifest Cushing disease occurred. In 1 patient, the authors observed the transition from a functioning to a silent adenoma with spontaneous resolution of hypercortisolism. Another patient's silent adenoma "shifted" to a functioning adenoma and then regressed back to a silent form with spontaneous resolution of Cushing disease. This patient again developed hypercortisolism, which finally resolved spontaneously. In this series, the transformation occurred after a mean of 3.5 years (range 6 months to 7 years). The shift from an ACTH-silent to a functioning adenoma was observed in 9% of the ACTH-silent adenomas in this series (4 of 44 cases), and the spontaneous remission of Cushing disease to a silent corticotroph cell adenoma occurred in 1.5% of cases of this series (2 of 132 functioning ACTH adenomas). At follow-up (mean 107 months; range 60-177 months), cortisol levels were within normal limits in all 5 cases. However, 1 patient required Gamma Knife radiosurgery and eventually adrenalectomy for disease control to be achieved. CONCLUSIONS The ability of silent ACTH adenomas to transform their secretion pattern poses a challenge for neurosurgeons and endocrinologists. Because the transformation is often unexpected, the clinical and biochemical data can be underestimated. Furthermore, this bizarre and unpredictable postoperative tumor behavior can lead to misinterpretation of clinical and endocrinological outcomes. Even if these cases are very rare, they are not anecdotal in large series. Thus, ACTH adenomas require careful biohumoral and neuroradiological follow-up to detect possible transformations.

Expanding indications for the extended endoscopic endonasal approach to hypothalamic gliomas: preliminary report.

Object In the last decade the indications for the endoscopic endonasal approach have been progressively expanded to include lesions that have not been traditionally considered amenable to resection through the transsphenoidal route. In this study, the authors analyze their experience with hypothalamic gliomas treated via the endoscopic endonasal approach. Methods Consecutive cases of hypothalamic gliomas treated since 2007 via an endoscopic endonasal approach were reviewed. Preoperative and postoperative neuroimaging as well as endocrinological, neurological, and visual symptoms were analyzed to assess the surgical outcome. Signs and symptoms of hypothalamic dysfunction including body mass index (BMI), memory, sleep-wake rhythm, and polyphagia were prospectively collected pre- and postoperatively to assess hypothalamic function. Quality of life was evaluated using the Katz scale. Results In the initial phase the endoscopic endonasal approach was adopted in 3 cases with a palliative intent, to obtain a biopsy sample or for debulking of the mass followed by radio- or chemotherapy. In 2 later cases it was successfully adopted to achieve gross-total tumor resection. Complications consisted of 2 postoperative CSF leaks, which required an endoscopic endonasal reintervention. Visual deficit improved in 3 cases and normalized in the other 2. Four patients developed diabetes insipidus, and 3 an anterior panhypopituitarism. All patients had a moderate increase in BMI. No patients presented with any other signs of hypothalamic damage, and their quality of life at follow-up is normal. Conclusions Despite the limitations of a short follow-up and small sample, the authors' early experience with the endoscopic endonasal approach has revealed it to be a direct, straightforward, and safe approach to third ventricle astrocytomas. It allowed the authors to perform tumor resection with the same microsurgical technique: dissecting the tumor with 2 hands, performing a central debulking, and controlling the bleeding with bipolar coagulation. The main limitations were represented by some anatomical conditions, such as the position of the chiasm and the anterior communicating artery complex and, finally, by the challenge of watertight plastic repair. To definitively evaluate the role of this approach in hypothalamic gliomas, a comparison with transcranial series would be necessary, but due to the rarity of these cases such a study is still lacking. The authors observed that more aggressive surgery is associated with a worse endocrinological outcome; thus they consider it to be an open question (in particular in prepubertal patients) whether radical removal is an advisable goal for hypothalamic gliomas.