Transsphenoidal Resection Of Pituitary Macroadenomas Research Articles

Morphological Classification of Pituitary Tumors With Suprasellar Extension.

The objective of this study was to study the association among various morphological parameters and surgical outcomes in pituitary macroadenomas with suprasellar extension. MRI studies of 160 patients undergoing endoscopic transsphenoidal resection of pituitary macroadenomas with suprasellar extension were reviewed. In the coronal plane, tumors were classified into Type 1 (dome-shaped, no constriction at the level of diaphragma sellae) and Type 2 (dumbbell-shaped, with constriction at the level of diaphragma sellae). Based on the dome-to-neck ratio (D/Nr), Type 2 tumors were further classified as Type 2A (wide neck; D/Nr >1 and <1.3) and Type 2B (narrow neck; D/Nr ≥1.3). Surgical outcomes and complications were analyzed using a logistic regression model. Overall extent of resection (EOR) and presence of residual sellar-suprasellar tumor was separately assessed in all patients with available postoperative MRI (n = 149). There were 108 Type 1 tumors and 26 patients each in the Type 2A and Type 2B subgroups. Tumor subtype was significantly associated with tumor size (P < .001), intraoperative cerebrospinal fluid leak (P < .001), EOR (P < .001), postoperative suprasellar residual tumor (P < .001), and postoperative complications, including diabetes insipidus (P = .005) and visual worsening (P = .003). On multivariate analysis, after adjusting for confounders, Type 2B tumors were negatively associated with EOR (odds ratio [OR] 0.22; 95% CI 0.07-0.68; P = .008) and associated with the presence of postoperative suprasellar residual tumor (OR 18.08; 95% CI 5.20-62.89; P < .001), intraoperative cerebrospinal fluid leak (OR 5.33; 95% CI 1.89-14.99; P = .002), and postoperative diabetes insipidus (OR 4.89; 95% CI 1.67-14.35; P < .001). Preoperative tumor classification based on D/Nr is clinically and surgically relevant, and Type 2B macroadenomas are significantly associated with lower rates of gross total resection and higher rates of postoperative complications after endoscopic transsphenoidal resection.

Pre- and Postoperative Magnetic Resonance Imaging Comparative Studies of Pituitary Tissues Following Transsphenoidal Resection of Pituitary Macroadenomas.

Magnetic resonance imaging (MRI) has become the most important radiological procedure for diagnosing and following pituitary tumors. But previous MRI studies on pituitary adenomas are mainly focused on the posterior pituitary. Few research has been done on residual normal pituitary tissue before and after transsphenoidal surgery. This retrospective cohort study investigates the pre- and postoperative magnetic resonance imaging characteristics of normal pituitary tissues regarding transsphenoidal resection of pituitary macroadenomas. Pre- and postoperative magnetic resonance imaging scanning of 112 consecutive pituitary macroadenoma patients who underwent tumor resection via transsphenoidal approach was performed, and their medical records were studied. On preoperative MRI, 66 cases of pituitary stalks were identifiable, 9 of them were roughly in the middle, and 57 cases showed left or right deviation, with the angle between pituitary stalks and the sagittal plane was 5.32°-64.05° (average 21.65°). Among the 57 patients with preoperative pituitary stalk deviation, 55 of the pituitary stalk deviations improved in 1 week after surgery, and 30 cases were almost in the middle in 4-6 months after operation, with the other cases get better in varying degrees. The diameter of pituitary stalk was 1.08-3.89 mm (mean 2.36 mm) in pre-operation, and 1.29-3.43 mm (mean 2.30 mm) in 4-6 months after operation. The length of pituitary stalk was 1.41-11.74 mm (mean 6.12 mm) preoperatively, 3.61-11.63 mm (mean 6.93 mm) early postoperatively, and 5.37-17.57 mm (mean 8.83 mm) in 4-6 months after operation. Pituitary stalk was thickened or compressed on preoperative MR images, and gradually recovered to normal during postoperative period. It tended to be in the middle position and its length increased gradually until 4-6 months after operation. On preoperative MRI, 69 out of 112 patients showed residual pituitary tissues (RPT)(+) on enhanced MRI. RPT were likely located above the adenomas in somatotroph adenoma patients. Morphological restitution of postoperative normal pituitary tissues was better in lateral displacement than in superior or superolateral patterns on preoperative magnetic resonance imaging. Postoperative normal pituitary tissues usually subsided directly in superior displacement pattern on preoperative MRI, while were likely to be confined in the lateral side in lateral and superolateral displacement patients. Postoperative morphologic remodeling grade of RPT was positively correlated with the maximum diameter of pituitary adenoma (p = 0.000), but not with age. The larger the tumor diameter, the worse the pituitary morphological recovery after tumor resection. Relative locations of normal pituitary and adenoma tissues may be related to adenoma type and may affect postoperative reconstruction of residual normal pituitary tissues. These findings enable surgeons to distinguish pituitary tissue from residual or recurring tumor tissue on postoperative magnetic resonance imaging.

The Knosp Criteria Revisited: 3-Dimensional Volumetric Analysis as a Predictive Tool for Extent of Resection in Complex Endoscopic Pituitary Surgery.

The Knosp criteria have been the historical standard for predicting cavernous sinus invasion, and therefore extent of surgical resection, of pituitary macroadenomas. Few studies have sought to reappraise the utility of this tool after recent advances in visualization and modeling of tumors in complex endoscopic surgery. To evaluate our proposed alternative method, using 3-dimensional (3D) volumetric imaging, and whether it can better predict extent of resection in nonfunctional pituitary adenomas. Patients who underwent endoscopic transsphenoidal resection of pituitary macroadenomas at our institution were reviewed. Information was collected on neurological, endocrine, and visual function. Volumetric segmentation was performed using 3D Slicer software. Relationship of tumor volume, clinical features, and Knosp grade on extent of resection was examined. One hundred forty patients were identified who had transsphenoidal resection of nonfunctional pituitary adenomas. Macroadenomas had a median volume of 6 cm 3 (IQR 3.4-8.7), and 17% had a unilateral Knosp grade of at least 3B. On multiple logistic regression, only smaller log-transformed preoperative tumor volume was independently associated with increased odds of gross total resection (GTR; odds ratio: 0.27, 95% CI: 0.07-0.89, P < .05) when controlling for tumor proliferative status, age, and sex (area under the curve 0.67). The Knosp criteria did not independently predict GTR in this cohort ( P > .05, area under the curve 0.46). Increasing use of volumetric 3D imaging may better anticipate extent of resection compared with the Knosp grade metric and may have a greater positive predictive value for GTR. More research is needed to validate these findings and implement them using automated methods.

Internal Carotid Injury during Transsphenoidal Resection of Pituitary Macroadenoma Managed with Neurointervention Technique

AbstractIatrogenic internal carotid artery (ICA) injuries during transsphenoidal pituitary tumor surgery are extremely rare but are associated with potentially disabling or life-threatening complications. Management options of ICA injuries are sacrifice, embolization, and endoluminal reconstruction. We report a case of ICA injury during transsphenoidal pituitary macroadenoma surgery, which was managed with endovascular covered stent placement for left carotid-ophthalmic pseudoaneurysm.

Vision improvement after trans-sphenoidal resection of pituitary macroadenoma

Introduction: Pituitary adenomas are tumours that occur in the Pituitary gland. Depending on the size it can be divided into Microadenoma (10mm). It can present with endocrine manifestations secondary to hypo or hyper function of pituitary gland and ophthalmological manifestations due to mass effect. Case Report: A 36-year-old female was admitted to our institution with complaints of loss of vision of right eye, headache and amenorrhea for 3 months, which were progressive in nature. Her MRI Scan revealed a well-defined sellar mass, measuring 27 x 23.18 mm, with suprasellar extension, causing expansion of pituitary fossa and superiorly extending into Hypothalamus with mild compression over optic chiasma. Prolactin level was 72.16 ng/ml. Surgery was done under general anesthesias, by Endoscopic assisted transsphenoidal approach. The adenoma was completely removed. Sella opening was closed by synthetic graft. On awakening from anesthesias visual acuity in right eye was immediately and completely restored. Conclusion: Pituitary adenoma is a complex set of benign tumours that present with hypersecretory syndrome and mass effect. An appropriate imaging of pituitary region using MRI and endocrinological consultation is the standard for detection of pituitary adenoma. Although, medical management and radiotherapy offer effective treatment for these tumours in specific situations, Endoscopic Trans-sphenoidal approach continues to provide optimal outcomes with low incidence of morbidity. Keywords: Pituitary macroadenoma, Vision loss, TransSphenoidal resection.

Magnetic resonance imaging characteristics of residual pituitary tissues following transsphenoidal resection of pituitary macroadenomas.

The present study is to investigate the pre- and post-operative magnetic resonance imaging of pituitary tissues following transsphenoidal resection of pituitary macroadenomas, as well as its clinical significance. The medical records of 108 consecutive pituitary macroadenoma patients admitted at Fuzhou 900th Hospital between September 2012 and September 2014 were retrospectively reviewed. Siemens 3. 0T magnetic resonance scanner was used to perform pre- and postoperative MRI scanning, including plain scan and contrast-enhanced scan of SE sequential T1WI and T2WI in sagittal, coronal and axial views. PACS medical imaging system was used to measure the diameter of pituitary adenoma, as well as the volumes of the adenoma and pituitary tissue. Hematoxylin-eosin staining and immunohistochemical staining were also performed. Higher height of pituitary adenoma results in lower rate of posterior pituitary bright spot (PPBS) on MR T1-weighted imaging. Preoperative MR signal intensity of PPBS was negatively related to diabetes insipidus (DI). Normal pituitary tissues were likely to be above the pituitary adenomas in growth hormone-secreting adenoma patients, while mostly located aside in gonadotropin-secreting adenoma patients. Morphological restitution of postoperative pituitary tissues was better in lateral displacement than that in superior or superolateral patterns on pre-operative MR images. Positive rate of PPBS on preoperative MRI is negatively related to adenoma height, and the signal intensity of PPBS is inversely related to postoperative DI. The relative locations of pituitary tissues and adenoma tissues may be associated with the adenoma type and may affect the postoperative remodeling of residual pituitary tissues.

Case Report: Perioperative Management in Patients with Acromegaly

BACKGROUND: Acromegaly is a chronic, progressive and multisystemic disease caused by growth hormone hypersecretion by a functioning pituitary macroadenoma. Some clinical features of this disease are important for anesthetic management, especially those that affect the upper airway, and the cardiac, respiratory and metabolic systems. CASE REPORT: Male 34 year old patient, with progressive increase of feet, hands, nose, skull bone and tongue size, diagnosed with acromegaly caused by growth hormone producing pituitary macroadenoma. Later he presents with severe SAHOS, mitral and mild tricuspid insufficiency; so transsphenoidal resection of pituitary macroadenoma was programed. During preanesthetic evaluation was classified as ASA III Surgical Risk, Lee Cardiac Risk 0.04%, NYHA I, and high probability of difficult airway. The anesthetic induction scheme was: propofol 120 mg, remifentanil 0.2 mcg / kg / min, rocuronium 50 mg. Atraumatic orotracheal intubation using McCoy leaf N4, with reinforced endotracheal tube N 7.5 was achieved. EVOLUTION: The patient was taken to Intensive Care Unit for post-surgical control. The patient remained hospitalized for 7 days and was discharged in stable condition without neurological deficit. He is still in follow up of the severe SAHOS. It has been reported improvement of the episodes of night apnea. CONCLUSION: Patients with pituitary gland disease undergoing surgery can present some anesthetic challenges, from the airway management, to the important hemodynamic and ventilatory challenges during the surgical procedure. It is important to anticipate and prevent the possible complications and correct them in time in order to avoid irreversible injuries that increase the patient’s morbidity

Effect of Intraoperative Lumbar Drainage on Gross Total Resection and Cerebrospinal Fluid Leak Rates in Endoscopic Transsphenoidal Surgery of Pituitary Macroadenomas

To assess whether controlled, intraoperative lumbar drainage (LD) of cerebrospinal fluid (CSF) could facilitate resection of pituitary macroadenomas and reduce the rate of CSF leak. A retrospective cohort study from a prospective database was conducted on 189 patients with pituitary macroadenoma who received endoscopic transsphenoidal surgery between 2013-2017. Patients were classified into two groups: 119 patients received an intraoperative LD (LD group) and 70 patients underwent routine endoscopic surgery without LD (control group). In the LD group, lumbar catheters were placed preoperatively and CSF was drained intermittently during tumor resection. The rates of GTR and CSF leaks were assessed both intraoperatively and postoperatively. Intraoperative LD was associated with a higher rate of GTR (92.4% in the LD group vs. 78.6% in the control group, P=0.006), especially in macroadenomas with suprasellar extension (90.3% vs. 75.0%, P=0.012). Both intraoperative and postoperative CSF leak rates were significantly decreased in the LD group (intraoperative: 10.1% vs. 31.4%, P< 0.001; postoperative: 3.4% vs. 11.4%, P=0.035). In functioning adenomas, a better remission rate of excess-hormone secretion was observed in the LD group compared with the controls (89.1% vs. 60.6%, P=0.001). Patients in the LD group also had an enhanced recovery with a shorter postoperative length of stay (LOS) (7 d vs. 5 d, P=0.020). Intraoperative LD may assist surgeons during endoscopic transsphenoidal resection of pituitary macroadenomas by achieving a higher rate of GTR and a lower rate of perioperative CSF leaks. Validation in prospective randomized controlled studies is needed.

Diagnostic value of early postoperative MRI and diffusion-weighted imaging following trans-sphenoidal resection of non-functioning pituitary macroadenomas

To establish the value of early contrast-enhanced magnetic resonance imaging (MRI) and diffusion-weighted imaging (DWI) in differentiating residual pituitary adenoma from postoperative surgical changes. Thirty patients with non-functioning pituitary macroadenomas, who were undergoing trans-sphenoidal adenomectomy, were prospectively studied. Patients were imaged with both MRI and DWI in the early postoperative period, as well as 6-months post-surgery. Patterns of postoperative contrast enhancement were described (non-enhancement, peripheral enhancement, and nodular enhancement). Apparent diffusion coefficient (ADC) maps were utilised to select the region of interest (ROI) for ADC calculations. Seventeen patients had postoperative surgical granulation tissue and 13 had residual adenoma based on the 6 months follow-up imaging. Mean ADC values of postoperative granulation tissue and residual adenoma were 1.476±0.476×10-3mm2/s and 0.855±0.190×10-3mm2/s, respectively, in the early postoperative period, and 1.357±0.416×10-3mm2/s and 0.829±0.201×10-3mm2/s, respectively, at the 6-month follow-up. ADC values of granulation tissue were significantly different from that of residual adenoma at both time points (p<0.001). Sensitivity, specificity, positive and negative predictive values of early MRI were 84.6%, 94.1%, 91.7%, and 88.9% respectively, and of early DWI were 91%, 97%, 94.3%, and 93%, respectively. Early postoperative DWI after trans-sphenoidal resection of pituitary macroadenomas may be more helpful than early MRI in differentiating residual adenoma from post-surgical changes.

The learning curve for endoscopic trans-sphenoidal resection of pituitary macroadenomas. A single institution experience, Leeds, UK.

The object of this study was to assess whether increasing operative experience results in greater endoscopic trans-sphenoidal resection of pituitary macroadenomas and lower complications. A retrospective single institution cohort study was performed. Subjects underwent endoscopic trans-sphenoidal resection of pituitary macroadenoma between July 2009 and July 2016 by three neurosurgeons. Following data collection, statistical analysis compared percentage of tumor resection and length of hospital stay (LOS) with experience. Complications including CSF leak are reported. In total, 142 patients (87 male, 55 female) mean age 55.1 were included. Surgeon 1 performed 106 cases; surgeon 2 performed 23 cases; and surgeon 3 performed 13 cases. Mean pre-operative tumor volumes were 8.18cm3, 6.52cm3, and 3.47cm3 and post-operative volumes were 2.21, 1.74, and 1.93cm3 for surgeons 1, 2, and 3, respectively. Respective percentage resections were 74.3, 77.2, and 52.1%. Analysis demonstrated no difference in tumor resection with increasing experience for all three surgeons (p=0.11, p=0.17, and p=0.26). Tumor consistency and cavernous sinus involvement did not appear to affect tumor resection. Mean LOS was 5days, 4days, and 3days, respectively, with no significant correlation with experience for all three surgeons. Intraoperative CSF leak incidence was 19/106 (18%) for surgeon 1, 6/23(26%) for surgeon 2, and 2/13(15%) for surgeon 3. Primary closure rate was 96.3% and only three other complications occurred. This study demonstrates that in our institution there is no statistically significant learning curve for the endoscopic resection of pituitary macroadenoma. However, there is a trend of improvement in tumor resection with experience for one surgeon. These findings suggest that the surgeons in our institution were capable of performing this procedure effectively with a low complication rate since adoption of the endoscopic technique in 2009.

Factors influencing improvement of visual field after trans-sphenoidal resection of pituitary macroadenomas: a retrospective cohort study.

To investigate the influencing factors of visual field improvement after trans-sphenoidal resection of pituitary macroadenomas. This retrospective cohort study included 201 patients (366 eyes) with visual field defect induced by pituitary macroadenomas. All of them were treated with trans-sphenoidal surgery. Ophthalmologic evaluation, best-corrected visual acuity (BCVA), and visual field examination were performed before and 3mo after surgery. BCVA, visual field defect index mean deviation (MD), duration of symptoms, age, sex, and volume of tumors were compared. Expression of vascular endothelial growth factor (VEGF) and Ki-67 of tumor tissue were detected by immunohistochemical technique. The mean age of patients was 44.23±1.29y. Ninety-three patients were female and 108 were male. The mean tumor volume was 14.36±6.23 cm(3). The mean duration of preoperative symptoms was 11.50±0.88mo. Mean preoperative MD was -17.50±0.82 dB. Mean Preoperative visual acuity was 0.64±0.04. Postoperative visual field improved in 270 (73.77%) eyes, unchanged in 96 (26.23%) eyes. Multivariate logistic regression displayed that the factors independently influencing visual field improvement were young age (OR=1.71, 95%CI: 1.325-2.387, P=0.013), low preoperative MD absolute value (OR=1.277, 95%CI: 1.205-1.355, P<0.001), small volume of tumor (OR=1.458, 95%CI: 1.060-4.289, P<0.001), low expression of VEGF in tumor tissue (OR=1.554, 95%CI: 1.089-2.457, P=0.022), and low expression of Ki-67 in tumor tissue (OR=1.552, 95%CI: 1.161-2.847, P=0.026). After pituitary macroadenomas trans-sphenoidal resection, the independent influencing factors of the visual fields recovery were low preoperative MD absolute value, young age, small volume of tumor, and expression levels of VEGF/ Ki-67.

Cerebral Vasospasm After Transsphenoidal Resection of Pituitary Macroadenomas

Delayed ischemic events due to vasospasm are a well-known complication of aneurysmal subarachnoid hemorrhage (SAH). Severe vasospasm in other neurosurgical settings is not as well recognized. Delay in diagnosis and treatment of vasospasm in such settings may be associated with significant neurological morbidity. To present three cases of symptomatic delayed cerebral vasospasm after transsphenoidal resection of pituitary macroadenomas. Transsphenoidal resection in all cases was complicated by peritumoral hemorrhage with extension into the subarachnoid space. Two of the 3 patients required re-operation to evacuate the hematoma in the tumor bed because of progressive worsening neurological deficits. All 3 patients developed vasospasm of the intracranial vessels, starting as early as postoperative day 5 and appearing as late as postoperative day 10. Comparisons to the non-vascular pre-operative magnetic resonance imaging studies confirmed the "de-novo" nature of the vasospasm based on the caliber of the flow voids. Transsphenoidal surgery complicated by peritumoral hemorrhage is associated with a significant risk of neurological morbidity because of delayed cerebral vasospasm. Early recognition and management according to guidelines used for postaneurysmal SAH may help to improve outcomes in these patients.

Comparison of Intraoperative and Postoperative MRI for Endoscopic Transsphenoidal Resection of Pituitary Macroadenomas

Comparison of Intraoperative and Postoperative MRI for Endoscopic Transsphenoidal Resection of Pituitary Macroadenomas

E-029 Symptomatic cerebral vasospasm after trans-sphenoidal resection of pituitary macroadenomas

IntroductionDelayed ischemic events are recognized complications following aneurysmal subarachnoid hemorrhage (SAH). Delayed cerebral vasospasm may also occur following traumatic SAH or craniotomy for skull base tumors. The occurrence of a...

Transsphenoidal resection of pituitary adenomas in an intraoperative MRI unit.

Transsphenoidal resection is a well known surgical procedure used in the treatment of sellar and parasellar lesions. In certain cases, operative identification of the lesion and achieving a complete resection can be problematic. We describe a surgical image guidance method using an intraoperative MRI which provides definitive identification of a lesion and verification of a complete resection. Five patients with pituitary macroadenomas underwent transsphenoidal resection of their tumors in the intraoperative MRI unit at the Brigham and Women's Hospital. This unit was developed as a collaboration between General Electric and BWH and is an open configuration 0.5 Tesla MR imager in which surgery can be performed with real time, intraoperative MR guidance. The transsphenoidal resections were performed in a standard fashion in this unit. Intraoperative imaging allowed accurate localization of the lesions, identification of pertinent surrounding structures, and the evaluation of the extent of each resection. In two patients, the resection would have been considered complete based on the surgical field of view alone but MR imaging allowed remaining tissue to be identified. Developing clot was seen in one patient after a fat graft had been placed. The intraoperative MR is a surgical modality by which transsphenoidal resection of pituitary macroadenomas can be performed using real-time image guidance. It allows definitive identification of the tumor and an immediate evaluation of whether resection is complete. It also can monitor the occurrence of intraoperative complications such as hemorrhage. This revolutionary device can be an important tool for the surgical management of pituitary tumors.

Immediate recovery of pituitary function after transsphenoidal resection of pituitary macroadenomas

Immediate recovery of pituitary function after transsphenoidal resection of pituitary macroadenomas