Transsphenoidal Approach Research Articles

Initial Experience with Diffusion-weighted Imaging to Predict the Tumor Consistency and Surgical Success in Solid Growth Hormone Producing Pituitary Macroadenomas.

Background:Tumor consistency is an important factor impeding transsphenoidal resection of some pituitary macroadenomas. Preoperative prediction of the tumor consistency may help neurosurgeons in preparing the patients for other therapeutic options after a subtotally resected growth hormone (GH)-producing macroadenoma. We present the preliminary results of our study about the application of the preoperative diffusion-weighted (DW) magnetic resonance imaging (MRI) to predict the consistency and resection rate of GH-producing pituitary macroadenomas.Materials and Methods:Sixteen primary patients with solid GH-producing pituitary macroadenomas were enrolled. Hormonal assays as well as standard and DW-MRI were obtained before surgery. All the patients were operated via an endoscopic transsphenoidal approach. The intraoperative tumor consistencies (suctionable versus nonsuctionable) were documented. The samples were stained for measurement of the collagen content (low, moderate, and high). Postoperative hormonal study and MRI were performed after 8 weeks to evaluate the resection ratio and the hormonal remission.Results:On DW images, the tumor diffusion was enhanced (free) in four, moderate in ten, and restricted in two patients. The tumor was suctionable in 14 cases; gross total resection and hormonal remission were achieved in 12/14 of these. All the 14 suctionable tumors had moderate to enhanced diffusion on DW imaging (DWI). The two patients with a nonsuctionable fibrous tumor had a restricted diffusion in DWI. These were the only ones to have high collagen content in the histopathologic study.Conclusion:DWI could help identify the fibrous nonsuctionable GH-producing adenomas from the others.

Surgical Robotic Technology for Developing an Endonasal Endoscopic Transsphenoidal Surgery (EETS) Robotic System

Purpose:Neurosurgical robots are acknowledged for their advantages in assisting neurosurgeons in enhancing their precision and accuracy. Here, the aim of this study is to report the first use as a robot-assisted Endonasal Endoscopic Transsphenoidal (EET) approach, applied to reach sphenoid sinus in a cadaver. The introduction of the seven tenets for the Endonasal Endoscopic Transsphenoidal approach will propel the feasibility of neurosurgical techniques and instruments for intrasellar lesions.Methods:Endonasal endoscopic transsphenoidal approach in a cadaver was performed under robot assistance with simple navigation system. This preliminary study reveals the accuracy and precision of the robot to reach a target at sphenoid sinus safely and within the shortest duration .Results:This robotic technology provided the foundation to support neurosurgeons when they are working in narrow and complicated surgical corridors with accuracy and precision.Conclusion:This article reveals the first robot-assisted Endonasal Endoscopic Transsphenoidal approach. This demonstrates the feasibility of the evolution and will augment neurosurgeons toward their limits of minimally invasive surgical techniques, manual dexterity, and spatial orientation. These tenets will be as state of the art and overcome the future challenges of Endonasal Endoscopic Transsphenoidal approach shortly.

Clinical value of QST classification in the treatment of children with craniopharyngioma

Objective To explore the clinical manifestation of children with different QST classification of craniopharyngioma (CP) and its role in prognosis. Methods We retrospectively analyzed 149 children with CP who underwent surgery at Department of Neurosurgery, Nanfang Hospital of Southern Medical University from December 1998 to December 2015. Of those, 70 (47.0%) children underwent operation through frontal base approach, 46 (30.9%) through pterional approach and 33 (22.1%) through transsphenoidal approach for tumor removal. All patients underwent clinical follow-up after surgery, including MRI review of the sellar region to determine the tumor resection and recurrence, and measurement of relevant indicators to assess the prognosis. All 149 children were classified according to the QST classification criteria, and the differences in clinical characteristics of different types of children were analyzed. Furthermore, multivariate logistic regression analysis was used to determine the clinical factors affecting the prognosis of children. Results All children in this series underwent successful operation and 138 (92.6%) out of those had total resection and 11 (7.4%) had subtotal resection. The median follow-up duration of 149 patients was 87 months (range: 11-236 months). Good outcomes were reported in 134 patients and poor outcome in 15. In this study, 91 patients were type Q (Q-group), 14 were type S (S-group) and 44 were type T (T-group) according to the QST classification criteria. There were no significant differences in age, gender, maximum diameter, tumor calcification degree, degree of tumor resection and tumor recurrence between the 3 groups (all P>0.05), while the clinical symptoms, incidence of hydrocephalus, pre- and post-operative pituitary function, operation approach and pathological types were significantly different in patients with different QST classifications among 149 children with CP (all P<0.05). The T-type was more often associated with hydrocephalus, the Q-type was more prone to have abnormal pituitary function, and the S-type was more likely to have vision and visual field damage. Multivariate logistic regression analysis showed that QST classification(OR=5.984, 95%CI: 1.529-23.417, P=0.037) and degree of tumor resection(OR=8.220, 95%CI: 2.158-31.318, P=0.002) were independent prognostic factor in children with CP. Conclusions The clinical characteristics of children with different QST classification of craniopharyngioma are different, and QST classification is one of the independent risk factors affecting the prognosis of children with craniopharyngioma. Key words: Craniopharyngioma; Child; Prognosis; Disease attributes; QST typing

Surgical Outcomes of the Endoscopic Endonasal Transsphenoidal Approach for Anterior Skull Base Lesions: Experience in Combined Military Hospital, Dhaka

Introduction:The endoscopic endonasal approach is a minimally invasive surgical technique for removal of skull base lesions by using nose and sinuses as natural corridors. This study represents our institutional experience with endoscopic endonasal trans-sphenoidal approach for anterior skull base lesions.&#x0D; Objective: To find out surgical outcomes of endoscopic endonasal trans-sphenoidal approach for treatment of anterior skull base lesions.&#x0D; Materials and Methods: Cross-sectional observational study of 38 consecutive patients who underwent endoscopic endonasal trans-sphenoidal surgery for anterior skull base lesions in Combined Military Hospital, Dhaka from July 2013 to June 2017.&#x0D; Results:This study included 16 men and 22 women, ranging from 24 to 68 years of age where median was 38 years. Common presentations were visual disorder (60%), headache (30%), features of pituitary apoplexy (5%), Cushing disease (0.35%), acromegaly (0.7 %), galactorrhoea (0.35%). Radiological evaluation revealed intrasellar (12), sellar and suprasellar (22), sellar and parasellar (1), tuberculum sella and planum sphenoidale (3), clival (1) lesions. Recurrent cases (3/38) were nonfunctioning pituitary macroadenoma, prolactinoma, and growth hormone secreting macroadenoma. The surgical resection in relation to post op imaging were 45% as gross total resection, near-total in 35%, subtotal in 15%, and partial in 5%. We found fifteen patients experienced improvement in visual acuity, while one patient worsened. Common complications were transient diabetes insipidus (53%), new pituitary deficit (35%), endonasal adhesions (20%), and cerebrospinal fluid leak (5%). Surgical mortality was (0.35%). The histological diagnoses included twenty-eight pituitary adenomas, five craniopharyngioma, three meningioma, one Rathke’s cleft cyst and one clival chordoma.&#x0D; Conclusion: Endoscopic endonasal transsphenoidal surgery is a valuable treatment option for an anterior skull base lesion.&#x0D; Journal of Armed Forces Medical College Bangladesh Vol.14(1) 2018: 66-68

Autologous Partial Thickness Calvarial Graft Sphenocranioplasty for Congenital Transsphenoidal Encephalocele

Abstract INTRODUCTION Transsphenoidal encephalocele (TSE) is a rare type of basal encephalocele (BE) with a reported incidence of 1 in 700 000 live births. Clinical presentation is often insidious with a large herniation protrudes through the nasopharynx containing neural elements. Due to the rare occurrence of these lesions, management options can be quite challenging. METHODS Authors present a case report of a 16-yr-old male who has followed for a large transsphenoidal encephalocele. The patient had obstructive sleep apnea with a recent progression of his vision and endocrinopathy symptoms. Unique is the preoperative planning and the surgical details to treat this complex developmental pathology of skull base. RESULTS The timing of mangement of the transsphenoidal encephalocele depends on the progression. Endoscopic endonasal transsphenoidal approach was utilized to address this skull base defect. A large herniation containing neural elements was encountered and was sequentially reduced. Authors discuss their novel method of closing the bone defect with an autologous calvarial partial thickness parietal bone graft. Postoperative course was uneventful. Postoperative MR brain revealed significant reduction of TSE with closure of the bony defect. CONCLUSION TSE can be closely monitored; however, surgery is recommended in lieu of progression of symptoms. Sphenocranioplasty with a partial thickness calvarial bone graft through endoscopic endonasal transsphoidal approach is a viable option to treat this rare developmental pathology of skull base.

Endoscopic Endo-nasal Trans-Sphenoidal Approach for Pituitary Adenomas: A Prospective Study.

The surgical approach for hypophysectomy has undergone sweeping revolution in the past three decades. With the advent of endoscopes, better instrumentation, better illumination and viewing cameras, endoscopic endo-nasal trans-sphenoidal approach to sella has now largely become the norm. The aim of this study is to present our experience, analysing the surgical outcomes of this approach in patients with pituitary adenoma, pertaining to entirety of tumor removal, alleviation of symptoms and rate of complications. This prospective studywas conducted at our tertiary health care centre from June 2012 to June 2015. A total of 14 patients, meeting the inclusion criteria, underwent endoscopic trans-sphenoidal hypophysectomy for pituitary adenoma. Age of presentation ranged from 19 to 73years (mean 43.6years). 9 patients were female and 5 were male. The most common presenting symptom was headache, followed by visual disturbances. Amongst those with hormonal imbalance, most common were prolactinomas and growth hormone secreting adenomas. Preoperative MRI brain showed macroadenomas in all 14 patients. 7 (50%) patients had suprasellar extension, while 5 (36%) patients had intracavernous extension too. CT paranasal sinuses provided the roadmap for surgery by identifying anatomical variations. Alleviation of headache occurred in all cases. Normalization of altered hormonal profile was seen in all cases. 83.3% of our patients with visual field defects on perimetry showed improvement post-surgery. Recidivism was directly related to the size and extent of adenoma. Transient diabetes insipidus was seen in 4 (28%) cases. Persistent diabetes insipidus occurred in 1 (7%) patient. CSF leak was seen in 2 (14%) patients, 1 (7%) patient developed postoperative meningitis. Most common nasal complication was excessive crusting. There was no incidence of any vascular complications, focal neurological deficit or hypopituitarism in our study. The pure endoscopic approach is a safe, efficacious, and minimally invasive technique for the removal of pituitary adenomas. The results have been encouraging in our prospective study. However, the importance of learning curve in endoscopic skull base surgery and use of a multi-disciplinary collaboration cannot be overemphasized.

Maximal removal of pediatric suprasellar craniopharyngioma by extended transsphenoidal approach - Reconstituted hypothalamic function and long-term tumor control

ObjectLong-term tumor control and maintenance of good quality of life are sometimes difficult to achieve in the treatment of craniopharyngioma despite modern microsurgery techniques. The transsphenoidal approach for tumors with large suprasellar extension has not been fully established for pediatric patients, because of their narrow nostrils and undeveloped sphenoidal sinus. MethodsSeventeen consecutive pediatric patients, 6 boys and 11 girls aged from 3 to 19 years (mean 12.0 years), with craniopharyngioma and extension to suprasellar cistern were treated through the extended transsphenoidal approach. Surgery was intended to achieve maximum removal without causing neurological deficits. And the closest attention was paid to preserve the lateral walls of the third ventricle. Removal rate, pituitary function, and adverse events were evaluated. ResultsGross total removal was achieved in 14 of 17 patients, and all patients were discharged without autonomic and/or thermal disturbances except for 2 patients with preoperative hypothalamic disturbance. All patients with gross total removal have remained disease-free in the follow-up period (mean 38.1 months). Anti-diuretic hormone administration was discontinued in 8 of the 17 patients in the follow-up period, although glucocorticoid administration could not be discontinued in any patient except for one patient without involvement of the pituitary stalk. No patients suffered new hypothalamic disturbance, and all patients could return to school life or obtain employment. ConclusionHigh rate of gross total removal with the compatibility of good quality of life was achieved for pediatric craniopharyngioma patients through the extended transsphenoidal approach. Long-term risk analysis is required in the future.

Surgical Outcome of Endoscopic Endonasal Surgery of Large and Giant Pituitary Adenomas: An Institutional Experience from the Middle East

Surgical treatment of large and giant pituitary adenomas is challenging and associated with higher risk of complications and lower rate of gross total resection. We present our experience with surgical management of large and giant adenomas using the extended endoscopic transsphenoidal approach (EETA). A total of 80 patients with large (30-39 mm) and giant (≥40 mm) pituitary adenomas who underwent tumor resection using EETA were studied. Radiologic data, hormonal and visual status, surgical outcomes, complications, and factors affecting the extent of resection were evaluated. Forty-five tumors (56.3%) were classified as large and 35 (43.8%) as giant adenomas. Gross total resection was achieved in 66 patients (82.5%), near-total resection in 10 (12.5%), and subtotal resection in 4 (5%). Preoperative factors including larger tumor size, multilobular shape of tumor, and higher Knosp scores significantly decrease the likelihood of gross total resection. Of patients with preoperative visual acuity impairment and visual field deficit, 76.8% and 74.1%, respectively, experienced improvement after surgery. The most common complications include new pituitary insufficiency (16.4%), permanent diabetes insipidus (7.5%), and cerebrospinal fluid leakage (5%). Two cases of meningitis (2.5%) and 3 deaths (3.8%) occurred in this cohort of patients. Mean follow-up duration was 24.2 months. EETA can be a safe and efficient approach as the first-line treatment of patients with large and giant pituitary adenomas and is associated with high rates of gross total resection or near-total resection, visual function improvement, and a relatively low rate of complications.

Long-term olfactory function outcomes after pituitary surgery by endoscopic endonasal transsphenoidal approach

ObjectivesTo evaluate long-term olfactory outcomes in patients who underwent pituitary surgery through the endoscopic endonasal transsphenoidal approach (EETSA) by T&T olfactometer. MethodsWe retrospectively reviewed 26 patients who underwent pituitary surgery via EETSA. Olfactory function was assessed by T&T olfactometer before and 6 months after surgery. The mean of recognition thresholds for five different odorants was used. The change in the mean recognition threshold values was evaluated in the entire cohort and the subgroup analysis was performed according to the age, sex, past history of pituitary surgery (primary surgery or revision surgery), histopathology (non-functioning adenoma (NFA) or functioning adenoma (FA)), reconstruction procedure (rescue flap or nasoseptal flap), and superior turbinate management (preserved or resected). ResultsOf the 26 patients (12 men and 14 women, median age 53 years), 21 patients were newly diagnosed with pituitary gland tumor (16 NFAs, 5 FAs) and the remaining 5 were diagnosed with recurrent pituitary gland tumor (4 NFAs and 1 FA). In the whole cohort, the mean recognition threshold values of T&T olfactometer significantly improved after surgery (P=0.01). Thirteen out of 26 patients (50%) showed olfactory improvement, whereas only 3 (12%) showed deterioration. In the subgroup analysis, olfactory function outcomes were not significantly different between the subgroups with respect to the age, sex, past history of pituitary surgery, histopathology, reconstruction procedure, or superior turbinate management. The olfactory function tended to worsen in the revision surgery group compared to that in the primary surgery group, but not significantly (P=0.06). ConclusionsThe olfactory function was improved or maintained after pituitary surgery via EETSA in 88% of patients, indicating the benefits of low invasiveness of our surgical treatment. On the other hand, three patients (12%) demonstrated deterioration of olfactory function, suggesting that the risk of postoperative olfactory dysfunction should be informed to patients.

Ten-Year Follow-Up of Collision Tumors Composed of Craniopharyngioma and Pituitary Adenoma: A Case Report and Literature Review

Although craniopharyngioma (CP) and pituitary adenoma (PA) are common tumors of the parasellar lesions, the coexistence of CP and PA is very rare. A 48-year-old male visited our hospital because of consciousness disturbance. The neuroimaging revealed a sellar tumor contact with a massive suprasellar cyst including calcification. Preoperative diagnosis was CP, and the patient underwent craniotomy to resolve the suprasellar mass effect. The histological examination disclosed adamantinomatous CP, and subsequently a transsphenoidal approach was chosen for the residual intrasellar tumor. Against expectations, the histological diagnosis was not CP but PA. The patient underwent gamma knife surgery for the residual tumor, and the postoperative course was good. After a 10-year follow-up, both lesions were still completely controlled. If we had suspected and diagnosed the tumor involved as not only CP but also PA at the first operation, the second operation could have been avoided because we would have chosen gamma knife surgery for the residual tumor. We should draw attention to this rare situation for differential diagnosis of parasellar tumor to avoid unnecessary surgery and to decide the best strategy for treatment. In addition, the biological behavior of collision tumors composed of CP and PA is probably the same as solitary CP or PA based on a long-term follow-up of our case.

A regional Australasian experience of extended endoscopic transsphenoidal surgery for craniopharyngioma: Progression of the mentoring model

Endoscopic endonasal transsphenoidal approaches to craniopharyngioma has become increasingly popular over the last 15 years. We present the results of our retrospective series of craniopharyngiomata resected by an endoscopic, endonasal approach at a low-volume service in Australasia. Between the years of 2009 and 2017, 11 patients underwent pure endoscopic endonasal transsphenoidal resection for a craniopharyngioma at our institutions. The medical records, histopathology, intraoperative findings and patient imaging were retrospectively assessed. 11 patients were included with 5 male and 6 female patients. The mean age was 32.0 years (range 14–68 years). Of this patient series a gross total resection of the tumour was achieved in 8 of 11 patients (73%). In the immediate postoperative phase, 10 of the 11 patients developed diabetes insipidus (91%). The pituitary stalk was formally not seen in 4 patients and all were treated with vasopressin. Of the 7 patients where the pituitary stalk was identified it was formally divided in 6 and preserved in 1 patient where the tumour was separate to the stalk. The endoscopic endonasal transsphenoidal approach for excision of craniopharyngioma, utilising and progressing the surgical mentoring model, can achieve adequate decompression of critical structures. Furthermore, our aggressive approach to divide and remove the involved pituitary stalk results in high rates of gross macroscopic resection with excellent long-term disease control with a greater risk of postoperative diabetes insipidus and panhypopituitarism.

Neuroendoscopic and microscopic transsphenoidal approach for resection of nonfunctional pituitary adenomas.

BACKGROUNDNonfunctional pituitary adenoma is a common type of pituitary adenoma, which can lead to headache, visual field disturbance, and cranial nerve damage due to increased tumor volume. Neuroendoscopic and microscopic transsphenoidal approaches have been widely used in the resection of nonfunctional pituitary adenomas. However, the clinical efficacy in neuroendoscopic and microscopic surgery is still controversial.AIMTo explore the clinical efficacy of neuroendoscopic and microscopic transsphenoidal approach for resection of nonfunctional pituitary adenomas.METHODSWe retrospectively analyzed 251 patients with nonfunctional pituitary adenomas; 138 underwent neuroendoscopic surgery via transsphenoidal approach, and 113 underwent microscopic surgery via transsphenoidal approach between July 2010 and September 2015. All patients were followed up for > 6 mo. Gender, age, course of disease, tumor diameter, tumor location, and percentage of patients with headache, visual impairment, sexual dysfunction, and menstrual disorders were contrasted between the two groups to compare the difference of preoperative data. Cure rate, symptom improvement rate, recurrence rate, the postoperative hospital stay, operating time, intraoperative blood loss, and the incidence of postoperative complications were compared in order to evaluate the advantages and disadvantages of neuroendoscopic and microscopic surgery.RESULTSThere was no significant difference in cure rate, symptom improvement rate, and recurrence rate between neuroendoscopy group and microscopy group (82.6% vs 85.8%, P > 0.05; 90.6% vs 93.8%, P > 0.05; 5.1% vs 9.7%, P > 0.05). In the neuroendoscopy group, the postoperative hospital stay was 8.4 ± 0.6 d; operating time was 167.2 ± 9.6 min; intraoperative blood loss was 83.4 ± 9.3 mL, and the rates of diabetes insipidus and electrolyte imbalance were 4.3% and 8.0%, respectively. The corresponding results in the microscopic group were 11.2 ± 0.6 d, 199.7 ± 9.3 min, 138.8 ± 13.6 mL, and 32.7% and 20.4%, respectively. There were significant differences in postoperative hospital stay, operating time, intraoperative blood loss, and the rates of diabetes insipidus and electrolyte imbalance between the two groups (P < 0.05).CONCLUSIONNeuroendoscopic and microscopic transsphenoidal approaches have similar clinical efficacy for the resection of nonfunctional pituitary adenomas. Neuroendoscopic surgery reduces operating time, intraoperative bleeding, postoperative recovery, and complications.

Interdisciplinary Management of Sellar Masses

Interdisciplinary Management of Sellar Masses Abstract. Sellar masses may present with an impairment of pituitary function (hypopituitarism), hormone hypersecretion (prolactinoma, acromegaly, glucocorticoid excess) or neurological symptoms (visual impairment, headache). An increasing number of them is discovered as an incidentaloma. Among the various entities, benign pituitary adenomas and cystic lesions are most frequently encountered. The work-up includes a laboratory evaluation for hormone hyper- or hyposecretion and an MRI of the pituitary gland. If the optic chiasm is compromised, a visual field examination is mandatory. Except for prolactinomas, symptomatic sellar masses are usually resected via an endoscopic transsphenoidal approach. If a total resection is not feasible because of the invasion of surrounding structures, debulking to relieve pressure from the optic chiasm is the primary goal and radiotherapy may be considered. Residual hormone excess can be treated medically. In the early postoperative period special attention to the development and treatment of disordered body water homeostasis and hypopituitarism is crucial. Interdisciplinary work-up and decision making are of utmost importance and will offer the best management.

Pediatric Pituitary Adenomas: Early and Long-Term Surgical Outcome in a Series of 85 Consecutive Patients.

Young age has been reported as a negative prognostic factor for pituitary adenomas (PAs). They are very uncommon in children and adolescents; therefore, surgical outcomes are poorly described. To report results of microsurgical transsphenoidal approach (MTSA) in pediatric PAs. The study retrospectively analyzed 3040 PAs treated in our institute, according to the adenoma subtype and then divided into pediatric (≤18 yr) and adult groups (>18 yr). The average follow-up after surgery was 58 mo (n = 2906). In the pediatric group, the majority of adenomas were hormone-secreting (89.5%) with a female sex prevalence (78%) in prolactinomas and nonfunctioning pituitary adenomas (NFPAs); the maximum diameter of growth hormone (GH)-secreting adenomas was greater (28.1 ± 4.1 mm) than in adults (18 ± 0.3 mm, P = .002). Surgical remission rate at 6 mo was similar in both groups for all adenoma subtypes: 72.1% and 76% in pediatric and adult Cushing's disease, 69.3% and 59.3% in prolactinomas, 55.6% and 61% in gigantism or acromegaly, 55.6% and 61.5% in NFPAs. Recurrences after remission occurred more frequently in pediatric GH-secreting adenomas compared to adults (40.0% vs 5.3%, P = .028) despite similar follow-up (38 ± 17 and 48.1 ± 2.2 mo, P = .7). Mortality was zero in the pediatric and 0.2% in the adult group (P = .7); major morbidity was 2.4% and 2.2%, respectively (P = .8). MTSA was safe and effective in children and adolescents as in adults, with the only exception of higher recurrence rate in pediatric GH-secreting adenomas. No complications related to young age appeared.

Differentiation of postoperative changes and residual tumors in dynamic contrast-enhanced sella MRI after transsphenoidal resection of pituitary adenoma.

To establish magnetic resonance imaging (MRI) features that differentiate residual tumors from postoperative surgical changes following the transsphenoidal approach of a pituitary adenoma.We analyzed residual enhancements at the tumor bed in 52 patients who underwent dynamic contrast-enhanced sella MRI within 48 hours after surgery and at 6 to 28 months. Patients were divided into 2 groups defined by either peripheral or nodular enhancement patterns. For each group, we measured the maximum thickness of the residual enhancing portion and compared differences in the residual tumor and postoperative changes.Among the tumors examined in the 52 patients, 19 residual tumors showed nodular (n = 16) and peripheral (n = 3) enhancement patterns, and 33 postoperative changes showed nodular (n = 3) and peripheral (n = 30) enhancement patterns. The mean residual tumor thickness was 7.1 mm (range, 2.9–16.8 mm) and 1.9 mm (range, 1.0–7.4 mm) in the postoperative change. Receiver operating characteristic curve analysis revealed that a 3.9-mm thickness was associated with 89% sensitivity, 97% specificity, and 94% accuracy for diagnosis of residual tumor.On immediate postoperative MRI, residual enhancement with greater than 3.9-mm thickness and nodular pattern suggest residual pituitary adenoma tumor.

Influence of Variables on Hormone Profile in Endoscopic Transsphenoidal Surgery for Pituitary Adenomas

Objective: to evaluate the hormone profiles of patients with pituitary adenomas operated on in Hospital das Clínicas, UniversidadeFederal de Goiás (HC-UFG), correlating them with the variables age, sex, and Knosp grade. Method: This is a retrospective quantitativestudy of medical records, including a total population of 20 patients diagnosed with pituitary adenomas operated on using the pureendoscopic endonasal transsphenoidal approach. The hormone profiles of the three types of pituitary adenoma prevalent in this institutionwere analyzed: nonfunctioning macroadenoma, growth hormone-secreting pituitary adenoma (acromegaly), and adrenocorticotropichormone-secreting pituitary adenoma (Cushing’s disease). Pre and postoperative hormone values were statistically paired with thevariables selected. Results: The global levels of the specific hormones of each disease decreased after surgery. However, no statisticalsignificance was found between the variables selected in this study and the pre and postoperative hormone values. Conclusion:The main surgical goal, the specific hormones decrease, was achieved in all the surgeries performed. Analyzing the relationshipbetween the variables and the hormone profiles, we conclude that age, sex, and Knosp grade did not influence the results obtained.

Comprehensive Evaluation of Rare Pituitary Lesions: A Single Tertiary Care Pituitary Center Experience and Review of the Literature.

The 2017 World Health Organization classification of central nervous system and endocrine tumors have introduced significant changes in the diagnostic criteria for pituitary lesions. The aim of our paper is to describe the epidemiological, clinico-pathological, and radiological features of a single consecutive institutional surgical series of rare pituitary lesions, using these new criteria. Of the 316 endoscopic endonasal trans-sphenoidal approaches performed for pituitary lesions between 2010 and 2018, 15 rare lesions were encountered. These included metastases, pituitary carcinomas, pituicytomas, granular cell tumor, primary pituitary lymphomas, germinoma, mixed gangliocytoma-adenoma, hypophysitis, and pituitary hyperplasia. Their clinical, radiological, and pathological features are herewith presented along with a literature review that enabled us to propose an algorithm to facilitate a diagnosis for rare pituitary lesions.

REMOVING A RETROSELLAR PITUITARY ADENOMA VIA THE ENDOSCOPIC ENDONASAL TRANSSPHENOIDAL TRANSCAVERNOUS APPROACH

The study objective is to describe the removal of the pituitary adenoma from the posterior cranial fossa through endoscopic transsphenoidal trans-cavernous approach, when the main surgical corridor was the tumor-intact cavernous sinus. Materials and methods. A 55-year-old male patient with endosupraretrosellar endocrine-inactive pituitary adenoma was admitted to N.N. Burdenko Research Center of Neurosurgery. The patient had earlier undergone two surgeries for pituitary adenoma. Using the endoscopic endonasal transsphenoidal approach, we found that these surgeries resulted in the formation of scar-altered adipose tissue in the sphenoid sinus and partly in the sella turcica; anatomical landmarks indicating the midline and the location of the internal carotid arteries were absent. We formed an access to both retro- and suprasellar portions of the tumor between the sella turcica and cavernous segment of the internal carotid artery (through the cavernous sinus); then we dissected anterior and posterior walls of the sinus and revealed a soft capsule-free pituitary adenoma, which was completely removed by a vacuum aspirator. The skull base defect was repaired using the multilayer technique with autologous tissues. Results. After surgery, neurological status and visual functions did not change. In the postoperative period, we observed no oculomotor disorders, pituitary insufficiency, diabetes insipidus, or nasal liquorrhea. Follow-up computed tomography scans revealed no signs of intracranial complications or obvious residual tumor tissue. Magnetic resonance imaging 4 month postoperatively demonstrated small laterosellar fragments of the tumor in the sella turcica. The patient was further followed up. Conclusion. Cavernous sinus is a natural anatomical corridor providing access to the structures of the posterior cranial fossa and interpeduncular cistern. The main risk (damage to the cavernous segment of the internal carotid artery) can be minimized by using intraoperative dopplerography and visual control of all manipulations.

HYPOTHALAMIC HAMARTOMA. LITERATURE REVIEW

The study objective is to analyze scientific literature on hypothalamic hamartomas’ diagnostics and treatment. Materials and methods. We studied 90 scientific sources, published between 1948 and 2019. Results. The paper describes clinical picture of hypothalamic hamartomas, their various classifications, specificity of neuroimaging and neurophysiological diagnostics and pathomorphological research, the surgical treatment. Conclusion. Transnasal resection is a promising and noninvasive method to treat hypothalamic hamartomas of IV and V types by J. Régis classification. According to the scientific literature, stereotactic destruction can be used to resect hamartomas of I–IV types; types II and III require endoscopic transventricular approach, while types IV and V can be resected using endoscopic transnasal transsphenoidal approach.

Transnasal endoscopic approach for pediatric skull base lesions: a case series.

Transnasal endoscopic transsphenoidal approaches constitute an essential technique for the resection of skull base tumors in adults. However, in the pediatric population, sellar and suprasellar lesions have historically been treated by craniotomy. Transnasal endoscopic approaches are less invasive and thus may be preferable to craniotomy, especially in children. In this case series, the authors present their institutional experience with transnasal endoscopic transsphenoidal approaches for pediatric skull base tumors. The authors retrospectively reviewed pediatric patients (age ≤ 18 years) who had undergone transnasal endoscopic transsphenoidal approaches for either biopsy or resection of sellar or suprasellar lesions between 2007 and 2016. All operations were performed jointly by a team of pediatric neurosurgeons and skull base otolaryngologists, except for 8 cases performed by one neurosurgeon. The series included 42 patients between 4 and 18 years old (average 12.5 years) who underwent 51 operations. Headache (45%), visual symptoms (69%), and symptoms related to hormonal abnormalities (71%) were the predominant presenting symptoms. Improvement in preoperative symptoms was seen in 92% of cases. Most patients had craniopharyngiomas (n = 16), followed by pituitary adenomas (n = 12), Rathke cleft cysts (n = 4), germinomas (n = 4), chordomas (n = 2), and other lesion subtypes (n = 4). Lesions ranged from 0.3 to 6.2 cm (median 2.5 cm) in their greatest dimension. Gross-total resection was primarily performed (63% of cases), with 5 subsequent recurrences. Nasoseptal flaps were used in 47% of cases, fat grafts in 37%, and lumbar drains in 47%. CSF space was entered intraoperatively in 15 cases, and postoperative CSF was observed only in lesions with suprasellar extension. There were 8 cases of new hormonal deficits and 3 cases of new cranial nerve deficits. Length of hospital stay ranged from 1 to 61 days (median 5 days). Patients were clinically followed up for a median of 46 months (range 1-120 months), accompanied by a median radiological follow-up period of 45 months (range 3.8-120 months). Most patients (76%) were offered adjuvant therapy. In this single-institution report of the transnasal endoscopic transsphenoidal approach, the authors demonstrated that this technique is generally safe and effective for different types of pediatric skull base lesions. Favorable effects of surgery were sustained during a follow-up period of 4 years. Further refinement in technology will allow for more widespread use in the pediatric population.