Transsphenoidal Surgery Research Articles

Does the crafted abdominal fat grafting technique completely eliminate risk of postoperative CSF leak in endonasal pituitary surgery? Technical note and preliminary clinical outcome.

The endonasal transsphenoidal approach (ETA) developed over the years has become the standard of care for sellar and parasellar lesions. However, because it necessitates the removal of the skull base bone, it is often accompanied by CSF leakage. The authors aimed to provide technical nuances and analyze the results of their routine fat grafting technique after ETA. A consecutive patient cohort (2004-2024) of 168 patients who underwent ETA for sellar and parasellar lesions and the modified fat grafting technique for skull base repair were retrospectively reviewed. Overall, combined ETA and transcranial approach (TCA) was performed in 7 (4.2%) patients, and 4 (2.4%) patients had prior transsphenoidal surgery. The size of the lesion was < 10 mm in 24 (14.3%) patients, 10-30 mm in 93 (55.4%), and > 30 mm in 51 (30.4%). Histopathological diagnoses were as follows: 154 (91.7%) pituitary adenomas, of which 45 (26.8%) were secreting; 8 (4.8%) Rathke's cleft cysts; 2 (1.2%) inflammatory/autoimmune lesions; 2 (1.2%) craniopharyngiomas; 1 (0.6%) renal cell carcinoma metastasis; and 1 (0.6%) chordoma. Gross-total resection was achieved in 127 (75.6%) patients, near-total resection in 22 (13.1%), and subtotal resection/partial resection/biopsy in 19 (11.3%). Overall, 122 (72.6%) procedures had intraoperative CSF leakage. Postoperative CSF leakage was observed in 1 (0.6%) patient treated with a revision operation and regrafting with a slightly larger graft and lumbar drainage. Even slight modifications in contemporary surgical techniques and the addition of an innovative approach may improve the treatment of sellar and parasellar lesions via ETA and reduce the risk of CSF leakage. The authors have developed and described a modified fat grafting technique with gradual crafting and preprocessing of the abdominal fat tissue for skull base repair, and they have demonstrated its effectiveness in significantly reducing the CSF leak rate. This technique enables adequate reconstruction of skull base defects with low donor-site complication rates and obviates the need for external lumbar drainage.

The effect of first intervention on cardiac parameters in patients with acromegaly: a systematic review.

Cardiovascular disease in acromegaly patients remains a major cause of morbidity and all-cause mortality. This systematic review investigates the effect of the first growth hormone lowering intervention on cardiac parameters. Systematic review. Studies evaluating cardiac parameters following first intervention in acromegaly published up to February 25 2022 were included in this systematic review. Risk of bias was assessed using a modified Newcastle-Ottawa Scale and Joanna Briggs Institute Critical Appraisal Checklist. Primary treatment modalities included (transsphenoidal) surgery and medical treatment with first-generation somatostatin receptor ligands. Cardiac outcome measures were divided into cardiac structure [left ventricular hypertrophy (LVH), (indexed) left ventricular mass (LVM/LVMi)] and cardiac function [left ventricular ejection fraction (LVEF) and E/A ratio]. Twenty-six studies (17 cohort studies and 9 case reports) were included out of 2541 potential studies. The risk of bias analysis categorized, 24 studies as low risk and 2 studies as intermediate risk. Disease-associated changes in cardiac structure and function generally improved in most studies following primary treatment. LVM/LVMi significantly decreased in 9/15 studies and the prevalence of LVH in 3/13 studies. LVEF significantly increased in 9/14 studies and E/A ratio in 6/7 studies. Despite the limited number of studies, cardiac structure improved more in patients achieving biochemical remission than in those failing to achieve biochemical remission. Acromegaly-associated structural and functional myocardial changes improve with both medical and surgical treatment. Normalizing or even reducing GH/IGF-I levels may be key in prevention of further progression of cardiac involvement in acromegaly and adverse cardiac outcomes.

Diagnostic value of 11C-Methionine PET-CT imaging in persistent or recurrent Cushing's disease after surgery.

Equivocal or negative pituitary magnetic resonance imaging (MRI) findings raise a significant challenge in the management of persistent or recurrent Cushing's disease (CD), compromising the chances of success of a further transsphenoidal surgery (TSS). The aim of our study was to determine the diagnostic utility of 11C-methionine (MET) positron emission tomography coupled with computerized tomography (PET/CT) in localizing the residual or relapsing corticotroph adenoma. We retrospectively analyzed the results of 11C-MET PET/CT performed in two tertiary medical centers between May 2002 and November 2023 in 22 patients with a persisting or recurrent CD after initial TSS and equivocal or negative pituitary MRI findings. In 15 cases, images obtained from MET PET/CT were also co-registered with high-resolution 3D T1 or FLAIR MRI pituitary imaging. All patients had a proven CD at the time of first surgery. Twenty-two patients were included (18 females and 4 males), with a mean age of 36 years at diagnosis. Initial tumors were mostly microadenomas with a mean maximum tumor diameter of 6.5 mm. Thirteen out of the 22 patients had a suspect anomaly on conventional MRI that could however not be clearly distinguished from postsurgical changes, while the remaining 9 had a negative MRI. A maximal metabolic activity in the suspected area of the tumor residue (SUVmaxT) was found in 14 patients (63.5%; 5/9 patients with negative pituitary MRI and 9/13 with equivocal findings). On the basis of positive imaging, repeat TSS was performed in 12 patients and was successful in 7, while Gamma Knife radiosurgery (GKRS) was performed in 2 patients allowing remission in both (total remission rate of 64%). Among the 5 patients not cured by TSS, the presence of a corticotroph adenoma in the resected tissue was found in 3 cases. Therefore, when positive, 11C-MET PET/CT had a detection rate accuracy of 86% (12/14). Out of the 8 PET-negative patients, exploratory TSS was performed in 2, with no remission, and GKRS was performed in another two patients, with long-term remission in one. 11C-Methionine PET/CT imaging can provide valuable diagnostic information to detect a corticotroph microadenoma in more than half of patients with persistent or recurrent CD and equivocal or negative MRI findings, thereby allowing targeted TSS or radiosurgery with a global success rate of 64% in the selected subgroup with positive imaging.

O-04 A CASE OF FUNCTIONAL GONADOTROPINOMA PRESENTING WITH OVARIAN MASSES

Abstract Introduction Most gonadotropinomas are nonfunctional macroadenomas, usually diagnosed by immunohistochemical staining. Here, a rare case of functional gonadotropinoma will be presented. Clinical Case A 37-year-old female patient applied to the neurology clinic with a severe headache, and a macroadenoma was detected on cranial magnetic resonance imaging(MRI). She was referred to our endocrinology clinic. Her menstrual cycle was irregular, and she had frequent intermenstrual bleeding for about a year. She has never had galactorrhea, and there were no features of acromegaly or Cushing’s disease on physical examination that would suggest a functional adenoma. The biochemical evaluation showed an elevated estradiol (E2) level of 2900 ng/L (normal 12,5 –166 ng/L) and an elevated prolactin(PRL) level of 203 µg/L (normal 2,8-29,2 µg/L) with normal follicular-stimulating hormone (FSH), luteinizing hormone (LH) and beta-human chorionic gonadotropin (b-hCG) levels of 2,8 IU/L, 6,6 IU/L and 0.1 mIU/mL respectively. PRL level was 196 µg/L after dilution. The low-dose dexamethasone suppression test was 2.1 µg/dL.The patient’s laboratory results are given in Table 1. Pituitary MRI revealed a 31*20*28 mm lesion invading both cavernous sinuses and compressing the optic nerve on the left side(Figure 1A). Visual field testing showed no visual field defects. The patient was consulted with the gynecology and obstetrics clinic due to high estradiol levels. Pelvic MRI revealed 5-6 cystic lesions, the largest of which was 45*30 mm in the right ovary and 41*37 mm in the left ovary, which did not enhance contrast and did not contain solid components (Figure 1B). The patient, who was considered for surgery due to suspicion of malignancy, was planned to be closely followed up by gynecology because tumor markers were negative and the lesions did not enhance contrast. While the patient’s gynecological examinations were continuing, the patient was started on cabergoline one tablet/week. After the gynecology department decided to follow up on the lesions, the patient underwent TSS for macroadenoma. Immunohistochemical staining was positive for FSH and LH, negative for PRL and adrenocorticotropic hormone (ACTH), and the ki-67 index was %2. The patient’s E2, cortisol, and PRL levels became in the normal range after the operation, and her hormone levels are given in Table 1. A pelvic ultrasound performed six months after the operation revealed that the previously detected lesions in the ovaries had disappeared. At this stage, the patient was considered to have functional gonadotropinoma and cortisol elevation has been linked to the effect of estradiol. Conclusion In patients with pituitary macroadenoma, it would be beneficial to check pituitary-gonadal axis hormones even if they are not in the follicular phase to avoid missing functional gonadotropinomas and prevent unnecessary surgeries for ovarian pathologies that may be observed in patients with functional gonadotropinomas.Figure 1:Pituitary and pelvic MRI images of the patientA: Pituitary MRI revealed a 31*20*28 mm lesion invading both cavernous sinuses and compressing the optic nerve on the left side. B: Pelvic MRI revealed 5-6 cystic lesions, the largest of which was 45*30 mm in the right ovary and 41*37 mm in the left ovary, which did not enhance contrast and did not contain solid components. Table 1:Laboratory results of the patientTSS: transsphenoidal surgery, ACTH: Adrenocorticotropic hormone, FSH: follicle stimulating hormone, LH: luteinizing hormone, IGF-1: Insülin-like growth factor, TSH: Thyroid stimulating hormone, fT4: free thyroxie fT3: free triiodothyronine, beta HCG: beta-human chorionic gonadotropin

P-01 ADRENAL LESIONS IN A PATIENT WITH ACROMEGALY

Abstract A 41 year old woman diagnosed with acromegaly due to a pituitary somatotroph macroadenoma (3.2 x 2.2 x 2.2 cm) and bilateral adrenal lesions, presented after her first transsphenoidal debulking surgery (TSS). She initially seeked medical care due to uncontrolled hypertension and newly diagnosed diabetes mellitus. Αt the time of her first visit she was receiving octreotide. The patient complained that her symptoms persisted, specifically that her blood pressure remained high, despite therapy with 4 different agents (not including mineralocorticoid receptor antagonist) and her glycemic control was unsatisfactory, despite medication regimen (liraglutide and metformin). She underwent repetitive brain MRI which depicted residual disease (1.6 x 1.5 x 2.2 cm). Her laboratory panel revealed markedly increased levels of both GH and IGF-1 confirming disease persistence (on octreotide). Subsequently her regimen was changed to pasireotide. However, it also failed to ameliorate her symptoms leading to a second operation. After the second surgery, her glycemic control was normalized and her hypertension was improved, despite slightly elevated IGF-1 levels. At this point pasireotide was discontinued. Her initial check up had also revealed bilateral adrenal lesions, which were characterized as primary bilateral macronodular adrenocortical hyperplasia (PBMAH), with concomitant high aldosterone and suppressed renin and potassium levels. Plasma metanephrines were measured preoperatively to exclude pheochromocytoma. They were within normal limits. Her ACTH levels remained relatively low at 12.1 pg/ml (&amp;lt;46) with basal cortisol at 12 μgr/dl. Multiple dexamethasone suppression tests (1 mg) were positive for mild autonomous cortisol suppression. Due to the presence of concomitant high aldosterone and suppressed renin and potassium levels, she was submitted to a saline induced test (SIT) which was positive for primary hyperaldosteronism. Epleronone was started. Under this medication, her blood pressure remains well controlled and potassium levels have normalized. This is a rare case of a patient with concomitant acromegaly and primary hyperaldosteronism on a base of PBMAH. Adrenal lesions in acromegalic patients have been mentioned mostly as non- functioning adenomas, though increased cortisol and aldosterone secretion has been recently described. The patient's symptoms remain under control to the moment, but as she hasn’t achieved biochemical remission of acromegaly we plan on reinitiating octreotide. We also plan to proceed to genetic screening to assess syndromic presentation and exclude aberrant receptor expression.Figure 1:CT of retroperitoneal regionright adrenal: 1.35 x 2.1 cm/-3HU left adrenal: outer limp 1.6 x 2 cm/-1HU inner limp 2 x 2.5cm/-5HU

P-46 A CASE OF PITUITARY APOPLEXY PRESENTING WITH OPHTHALMOPLEGIA

Abstract Introduction Pituitary apoplexy is a rare endocrinological emergency that may be life-threatening due to pituitary hormone deficiency or compression effect, if not treated appropriately. It usually develops secondary to acute ischemia or hemorrhage in the pituitary gland and presents with headache, vomiting, ophthalmoplegia, vision loss. In this case, we aim to present a case of pituitary apoplexy who applied to the emergency service with a complaint of vomiting, and developed ophthalmoplegia while hospitalized. Clinical Case A 76-year-old male patient applied to the emergency department with complaints of nausea and vomiting that had been continuing for the last week. At admission, physical examination, blood pressure and neurologic examination were normal. The laboratory tests were as follows: Glu:141 mg/dl, Cre:0,7 mg/dl, AST:25 U/L, ALT:13 IU/L, Na:118 mmol/L, K:3.0 mmol/L. He was admitted to the service in order to investigate hyponatremia and hypokalemia. On the first day of his hospitalization, restriction of upward sight in the right eye and ptosis developed. Cranial imaging with computerized tomography revealed a contrast-enhancing mass at the level of pituitary gland. A well-frameworked, 20 mm in diameter, hyperintens at T1-weighted images, with heterogeneous contrast enhancing lesion was reported in the contrast-enhanced pituitary MRI. Preliminary diagnosis were considered to be a bleeding cyst or pituitary apoplexy. Pituitary hormone tests were as follows: TSH:0.5 mIU/L (0.27-4.8), sT4: 1,38 ng/dL (0,79-1,59), sT3: 2.1 ng/L (2,04-4,4), FSH: 2.6 IU/L (1,5-12,4), LH: 0.87 IU/L (1,7-8,6), Total Testosterone: 0.4 ng/ml (2,8-8), PRL: 1 µg/dl (4,6-21,4), ACTH: 1,5 ng/L (7-63,2), Cortisol: 1.8 µg/dl (6-19), İGF-1: 53 mg/L (50-184). Hormone replacement with methylprednisolone 2x20 mg intravenous was started with the diagnosis of anterior pituitary insufficiency. The patient underwent to transphenoidal pituitary surgery for decompression, under a steroid cover. Hemodynamics remained stable following surgical intervention. Postop urinary output was also normal. But, right side ptosis continued after surgery. The patient was discharged with oral prednisolone 5 mg 1*1. Steroid was discontinued at the second week following surgery. The entire pituitary axis was determined to be intact at the first month. Pathology was reported as a large hemorrhagic infarction of the pituitary gland compatible with pituitary apoplexy. Consultations with Neurology and ophthalmology departments were done because of the persistence of right ptosis. No additional intervention was planned, follow-up was recommended. A significant improvement of ptosis was observed after a two months period. Conclusion Although the neurological signs and symptoms of pituitary apoplexy usually improves following accurate medical or surgical interventions in majority of patients, it should be kept in mind that it may take time for ptosis to recover after surgical decompression as in our case.Figure 1:Improvement in ptosis in the second month after surgery

P-51 A RARE CASE IN WHICH ACROMEGALY IS PROVEN CLINICALLY AND BIOCHEMICALLY DESPITE NEGATIVE GH IMMUNOHISTOCHEMICAL STAINING

Abstract Introduction The diagnosis of acromegaly is confirmed by high IGF-1 and GH levels. When a GH-secreting pitNET is resected, immunocytochemistry with GH staining typically supports the diagnosis. It is very rare for these tumors to stain negatively for GH in the presence of clinical and biochemical acromegaly. We are presenting a case of growth hormone (GH)-secreting PitNET with negative immunostaining for GH. Clinical Case 50-year-old male with history of headache and visual disturbances was found to have a pituitary macroadenoma. Years before the presentation, he noticed his shoe size had increased. Physical exam was notable for enlarged nose, thick lips, mandibular prognathism, and enlarged hands and feet. Blood pressure was 140/90 mmHg. Pre-operative laboratory results were remarkable for elevated GH 5.6 ng/ml (0.03-2.47) and IGF-1 816 ng/ml (80.6-207) levels. OGTT suppressed GH nadir 3.95 ng/ml. Pituitary MRI revealed an invasive macroadenoma measuring 37x31x40 mm (Figure 1). The patient underwent transsphenoidal surgery. Although GH and IGF-1 levels decreased after surgery, they did not return to the normal range. Visual field loss improved. Surprisingly, in the histopathological examination, no immunohistochemical staining was detected with GH and other anterior pituitary hormones, and Ki-67 was found to be 2%. Due to disease activity (IGF-1:278 ng/ml; 1.3XULN), medical treatment was started first with dopamine agonist and then continued with somatostatin receptor agonist (IGF-1:322 (1.6xULN). The remaining tumor tissue remained stable under treatment. Conclusion Silent somatotrophinomas detected by immunohistochemical staining have been reported in the literature. Conversely, endocrinologists should keep in mind that there may be rare cases in which immunohistochemical GH staining is negative but clinical and hormonal acromegaly is evidenced.Figure 1Magnetic resonance imaging (MRI) revealed a pituitary macroadenoma 37x31x40 mm in size, with Knosp grade 4 on the right and grade 1 on the left

Correlates of prolonged length of stay after endoscopic transsphenoidal surgery for pituitary adenomas: varying definitions and non-clinical factors

PurposeProlonged length of stay (PLOS) can lead to resource misallocation and higher complication risks. However, there is no consensus on defining PLOS for endoscopic transsphenoidal pituitary surgery (ETPS). Therefore, we investigated the impact of varying PLOS definitions on factors associated with PLOS in patients undergoing ETPS.MethodsWe conducted a retrospective review of patients with pituitary adenomas who underwent ETPS at our institution from 2012 to 2023. Patients were divided into non-PLOS and PLOS groups based on varying definitions of PLOS: > median, > 4 days, > 75th percentile, and > 90th percentile. Bivariate statistical analyses were conducted using Fisher’s exact test, chi-square test, and t-tests. Univariate and multivariate logistic regression identified significant predictors for each PLOS definition.ResultsOur cohort (n = 808) had a mean age of 54.37 ± 16.06 years, 50.43% male, and a median LOS of 3 days. The 75th and 90th percentiles of LOS were 4 and 6 days, respectively. The way PLOS was defined influenced associated factors identified. Preoperative KPS score, non-private insurance, and non-home discharge disposition were associated with PLOS across all definitions used (p < 0.05). Increased preoperative tumor volumes and postoperative hyponatremia were associated with PLOS only when defined by the 75th and 90th percentiles (p < 0.05). Non-White race and low income were significantly associated with PLOS > median while intraoperative CSF leak was a significant predictor for PLOS > 90th percentile (p < 0.05).ConclusionOur study highlights the variability in predictors of PLOS based on its definition and emphasizes the role of non-clinical factors on LOS.

Contributing factors to postoperative surgical site infections in pituitary neuroendocrine tumors undergoing endonasal transsphenoidal resection

Pituitary Neuroendocrine Tumors (PitNETs), often treated via endonasal transsphenoidal resection, present a risk for postoperative surgical site infections (SSIs), including intracranial infections such as meningitis. Identifying the risk factors associated with these infections is crucial for improving surgical outcomes and patient care. A retrospective study was conducted at a medical center from June 2020 to June 2023. The study included 20 patients with postoperative intracranial infections and 50 controls without infections. Inclusion criteria involved adult patients diagnosed with PitNETs who underwent standard endonasal transsphenoidal surgery and provided informed consent. Exclusion criteria included previous neurosurgical procedures, preoperative infections, concurrent severe diseases, or alternative surgical approaches. Diagnostic criteria for intracranial infections were based on clinical, hematological, cerebrospinal fluid, radiological, and microbiological findings. Statistical analyses were performed using IBM SPSS, focusing on univariate and multivariate logistic regression analyses. Univariate analysis showed no significant association of intracranial infections with factors like smoking history, previous craniotomy, operation time, hypertension, preoperative sphenoid sinusitis, BMI, and age. However, postoperative CSF leaks, intracranial pneumocephalus, diabetes mellitus, and tumor extension to the third ventricle were significantly associated with infections. Multivariate logistic regression further confirmed these findings, with significant odds ratios for these factors. The study reveals a significant correlation between postoperative CSF leaks, intracranial pneumocephalus, diabetes mellitus, and tumor extension to the third ventricle with the occurrence of SSIs following endonasal transsphenoidal resection of PitNETs. Microbial analysis revealed Escherichia coli as the most prevalent pathogen in post-surgery infections, with notable antibiotic resistance patterns observed in key bacteria, necessitating careful antibiotic selection. Tailored clinical treatment strategies addressing these risk factors are essential to reduce the incidence of postoperative SSIs and enhance patient safety.

A Y-shaped sphenoidal sinus septum: a case report.

The sphenoidal sinus septum is one of the most important landmarks during endonasal endoscopic transsphe-noidal operations. During routine coronal sectioning of the face, we found a variant Y-shaped septum in the sphenoidal sinus of a female cadaver. This unusual septum was found between two sections (anterior and posterior sections) and located inferior to the pituitary gland. The sphenoid sinus was divided into three chambers by the septum, i.e., right, middle, and left. During endoscopic surgery, surgeons should be aware of these variations. To our knowledge, this report documents the first Y-shaped septum of the sphenoidal sinus. Such information can be helpful for surgeons.

Comparison of Sphenoid Sinus Morphology in Bilateral Cleft Lip and Palate and Control Groups: A CBCT Study.

To investigate and compare the morphology of the sphenoid sinus (SS) in patients with bilateral cleft lip and palate (BCLP) and the control group. A retrospective comparative study. Craniofacial rehabilitation institution. The study included 100 patients with BCLP (50 men and 50 women) in the preorthognathic period, and 100 control patients who did not have BCLP, were not syndromic and had not undergone orthognathic surgery (50 men and 50 women). The morphological type of the SS was classified as conchal, presellar, sellar, and postsellar. It was further categorized into subtypes: lateral, body, anterior, lesser wing, and clival. Finally, the septations of the SS were classified as intersphenoidal, multiple, or absent. The χ2 test was used to compare the groups and evaluate categorical variables. The most common main types in both groups were the sellar type (BCLP group: 44%, control group: 59%) and the postsellar type (BCLP group: 33%, control group: 31%). No statistically significant differences were found between the groups (P > .05). Regarding subtypes, the most common were the lateral subtype (BCLP group: 57%, control group: 59%) and the sphenoid body subtype (BCLP group: 33%, control group: 31%). The most common SS morphologies in BCLP were the sellar and postsellar types. The importance of this morphology is therefore understood in the context of surgeries in the SS region, such as orthognathic and transsphenoidal surgeries, thus helping to avoid complications during surgery.

Aggressive Super-Giant Prolactinoma in a Male Adolescent: A Case Report

Giant prolactinoma (GP) in childhood and adolescence is a rare entity with scarce litterature. We report a case of A 17-year-old adolescent Moroccan boy presented with a Rapidly progressive vision loss complicated with an incomplete Intracranial hypertension syndrome. Magnetic resonance imaging (MRI) showed a very large intrasellar mass with suprasellar extension and evidence of recent necrotic and hemorrhagic remodeling. Patient underwent an urgent transsphenoidal surgery for tumor resection. Post operative labroratory findings were in favor of a hyperprolactinemia a panhypopituitarism and transient Diabetes insipidus. Histological assessment confirmed diagnosis of prolactinoma. Pituitary MRI control revealed an intrasellar residue. Patient was then started on cabergoline.This case highlights the importance of early identification and the need for a multidisciplinary approach in managing Giant aggressive prolactinomas in young patients.

Comparison of Intraoperative Propofol-Dexmedetomidine and Ketofol-Dexmedetomidine Infusions on Recovery from Anesthesia in Patients Undergoing Endoscopic Trans-Sphenoidal Pituitary Surgeries: A Randomised Controlled Trial.

A rapid and smooth emergence is essential in patients undergoing trans-sphenoidal pituitary surgeries. Ketofol has been used as an anesthetic agent with good recovery characteristics. We conducted this study to compare the recovery profile of the patients receiving propofol-dexmedetomidine or ketofol-dexmedetomidine infusions for trans-sphenoidal excision of pituitary tumours. Forty adult patients undergoing endoscopic pituitary surgery received either an infusion of propofol (Group P) or ketofol, 1:5 (Group KP)at 0.6-0.9ml/kg/h. Dexmedetomidine (0.5 μg/kg/ h) was administered in both groups. Our aim was to assess the recovery time, extubation time, emergence time. We also assessed the intraoperative hemodynamics, cerebral oxygenation, quality of the surgical field and postoperative pain. The recovery time (Group KP v/s P; 16.5 ± 4.3 v/s 8.3 ± 2.7 mins, P <0.01), emergence time (12.9 ± 3.9 v/s 5.7 ± 2.7 mins, P<0.01) and extubation time (14.3 ± 4.2 v/s 7.2 ± 2.8 mins, P <0.01) was longer in Group KP as compared to Group P. However, the patients in Group KP had lower cough scores, and pain scores, along with better maintenance of hemodynamic stability and cerebral oxygenation. The agitation score, cognition score, and quality of the surgical field were comparable. The use of ketofol resulted in a longer recovery time compared to the use of propofol alone. However, ketofol was associated with a better quality of extubation, maintenance of hemodynamic stability, and enhanced postoperative analgesia. Further research is needed to conclusively establish its efficacy and optimal dosage in pituitary surgery.

ACTH-Dependent Cushing Syndrome Treated with Homeopathy: A Case Report

Abstract Background Cushing's disease is an endocrine disorder caused by endogenous hypercortisolism resulting from an adrenocorticotropic hormone (ACTH)-secreting pituitary tumour. The average incidence of new cases is 2.4 cases per million people per year. The first-line treatment for Cushing's disease is selective transsphenoidal pituitary surgery; however, the risk of recurrence after the initial surgery is high and remains so for many decades after surgery. There is paucity of scientific evidence regarding Cushing disease in homoeopathy. Method This case study describes a case of ACTH-dependent Cushing's syndrome with fasting plasma cortisol serum levels and 24 hours urinary free cortisol levels were 22.7 ug% and more than 1000 μg/24 hour, respectively, and decreased after 1 mg and 8 mg overnight dexamethasone. Mercurius in ascending fifty millesimal potency was prescribed as an individualised homeopathic medicine on the basis of symptoms. Result The patient improved symptomatically as evidenced by a marked reduction in weight and cortisol levels in the normal range under continued homoeopathic treatment. Conclusion Homoeopathy can be effectively used to decrease cortisol levels in Cushing disease and prevent hypercortisolism-associated comorbidities such as infection, diabetes, obesity, osteoporosis and cardiovascular disease.

Endocrine Outcome and Quality of Life After Transsphenoidal Resection of Pituitary Adenoma-A Prospective Randomized Single-Blinded Study Comparing Endoscopic Versus Microscopic Resection.

Endoscopic pituitary surgery might yield better endocrine outcomes compared to microscopic resection. We conducted a prospective, randomized, single-blinded study to compare the endocrine outcome and quality of life (QoL) of patients with newly diagnosed pituitary adenoma who underwent either endoscopic or microscopic transsphenoidal surgery (NCT03515603). Due to slow recruitment, this study had to be stopped prematurely. Out of 170 transsphenoidal pituitary surgeries performed during the study period, 36 patients were enrolled in this study. The primary endpoint was based on the development of a new hypopituitarism. Secondary endpoints included the extent of resection, complications, and QoL. Endoscopic surgery was performed in 47.2% (n = 17). A new hypopituitarism was found in 8.3% (n = 3). All these cases underwent microscopic resection. Arginine vasopressin deficiency was found in 2.7% (n = 1) after microscopic resection. Gross total resection was achieved in 94.4% (n = 34). No surgical complications or new neurological deficits were observed. QoL improved significantly after the surgery, as measured by EQ-VAS (p = 0.003). According to EQ-5D3L, QoL improved or remained unchanged in almost all patients. No significant difference was found in QoL between the endoscopic and microscopic groups. The endoscopic technique appears to offer benefits in the treatment of pituitary adenomas, particularly in terms of achieving a favorable endocrine outcome.

Machine learning algorithms for predicting delayed hyponatremia after transsphenoidal surgery for patients with pituitary adenoma

This study aimed to develop and validate machine learning (ML) models to predict the occurrence of delayed hyponatremia after transsphenoidal surgery for pituitary adenoma. We retrospectively collected clinical data on patients with pituitary adenomas treated with transsphenoidal surgery between January 2010 and December 2020. From January 2021 to December 2022, patients with pituitary adenomas were prospectively enrolled. We trained seven ML models to predict delayed hyponatremia using the clinical variables in the training set. The final model was internally validated using a test set and a prospective dataset. The SHapley Additive exPlanations (SHAP) algorithm was used to determine the significance of each variable in the occurrence of delayed hyponatremia. In the training dataset, the best predictive performance was observed for XGBoost (area under the ROC curve; AUC = 0.821), followed by Random Forest (AUC = 0.8), Logistic Regression (AUC = 0.793), Support Vector Machine (AUC = 0.776), naïve Bayes (AUC = 0.774), K-Nearest Neighbors (AUC = 0.742), and Decision Tree (AUC = 0.717). The AUC of the XGBoost model for the test and prospective datasets are 0.831 and 0.785, respectively. The differences in pituitary stalk deviation angle, the “measurable pituitary stalk” length before and after surgery, and blood sodium concentration between preoperative and postoperative day 2 were important variables for predicting delayed hyponatremia as determined by the SHAP algorithm. The XGBoost model was best able to predict delayed hyponatremia after transsphenoidal surgery for pituitary adenomas. The differences in pituitary stalk deviation angle, pre- versus postoperative “measurable pituitary stalk” length, and pre- versus postoperative day 2 blood sodium concentrations were important variables for predicting delayed hyponatremia.

Cerebral Vasospasm Following the Endoscopic Endonasal Resection of Craniopharyngioma.

Cerebral vasospasm following an endoscopic endonasal resection of a craniopharyngioma is a rare, devastating occurrence that can lead to delayed cerebral ischemia and a poor neurological outcome if not diagnosed and treated in a timely manner. The etiology of this condition is not well understood. In this chapter, we present a case of cerebral vasospasm following transsphenoidal surgery (TSS) for craniopharyngioma, review the literature, and identify common presenting symptoms, probable predisposing factors, and essential management strategies to treat this condition.

Internal Carotid Artery Injury During the Endoscopic Transsphenoidal Surgery of Pituitary Adenoma: Case Illustration, Introspection, and Systematic Review.

Advances in endoscopic technology have made the endoscopic transsphenoidal approach the preferred approach for most surgeries of pituitary adenoma. The goal of these surgeries is to achieve cure, efficacy, and safety. Ample research has deliberated on the complications of cerebrospinal fluid (CSF) leak, meningitis, visual deterioration and nasal crusting after endoscopic transsphenoidal surgery. Among these, injury to the internal carotid artery (ICA) is not common in transsphenoidal pituitary surgery and has an incidence that ranges from 0.1% to 1%. Though it is rare, the effects are devastating and associated with a high risk of mortality and morbidity. As a result, iatrogenic ICA injury is every neurosurgeon's nightmare. Available literature primarily consists of case reports on these injuries. The literature is lacking on preventive and management options. We present an unusual case of a patient who had a nonfunctioning pituitary macroadenoma and an unexpected injury to the internal carotid artery (ICA) during endoscopic transsphenoidal surgery. We share our successful experience with its management via emergency endovascular treatment with parent vessel occlusion for an iatrogenic ICA injury. We present the article to address the pragmatic questions and challenges faced by neurosurgeons experiencing this complication for the first time.

Letter to the Editor Regarding: "Effectiveness of a Sellar Reconstruction Algorithm in Transsphenoidal Pituitary Surgery: Insights from 490 Cases".

Letter to the Editor Regarding: "Effectiveness of a Sellar Reconstruction Algorithm in Transsphenoidal Pituitary Surgery: Insights from 490 Cases".

Social functioning longitudinal trajectory and its predictors in young and middle-aged postoperative pituitary tumor patients: A growth mixture model.

Pituitary adenoma and its treatments can significantly impact the social function of young and middle-aged patients. Monitoring social functioning trajectories over time provides a more holistic understanding of patients' quality of life. We aimed to study the social functional trajectories and their predictors to achieve individualized and comprehensive management. A longitudinal prospective survey was conducted from January 2021 to December 2022 in Nanjing, China. The convenience sampling method was adopted to recruit the patients with pituitary adenoma who underwent transsphenoidal surgery at the neurosurgery department in a tertiary-grade A hospital. The general information questionnaire, social disability screening scale and postoperative pituitary adenoma symptom distress scale were applied in different stages. Growth mixture modeling and the Logistic regression were utilized to identify the trajectory subgroups and their predictors of the social function. Of 225 patients, 33 (14.67%) experienced "progressively recovered function", while 192 (85.33%) exhibited "persistently impaired social function". Factors associated with persistently impaired social function included fertility status (OR=0.167, p=0.001), visual loss (OR=0.154, p=0.012), and electrolyte disturbances at 6th month (OR=0.047, p=0.003). Conversely, patients with high monthly income (OR=0.116, p=0.000), good family support (OR=3.890, p=0.006), and preoperative headache (OR=4.129, p=0.006) were more likely to show progressively recovered function after surgery. Patients with pituitary adenoma still experience social dysfunction six months after surgery. Fertility status, family support, economic status, and symptom distress were significant predictors. This study emphasizes the crucial role of symptom distress and family support, providing a basis for follow-up and intervention strategies.