Transsphenoidal Surgery Research Articles

From darkness to light: Reversible bitemporal hemianopia

Aims/Purpose: The purpose of this case study is to describe the diagnostic process, surgical treatment, and subsequent recovery in a patient who was being monitored for strabismus due to previous thyroid orbitopathy. This case aims to underscore the importance of early diagnosis and timely surgical intervention in the resolution of visual impairments associated with pituitary adenomas.Methods: A 53‐year‐old female, under follow‐up for strabismus due to previous thyroid orbitopathy, was noted to have limitations in certain eye movements and diplopia during a routine consultation. Suspecting an exacerbation of orbitopathy, a computed tomography (CT) scan was ordered. The CT revealed a sellar and suprasellar mass, an incidentaloma not seen in a CT performed five years earlier. Visual field testing was then conducted, revealing bitemporal hemianopia. Further evaluation with magnetic resonance imaging (MRI) was performed to better characterize the lesion. The patient was subsequently scheduled for transsphenoidal surgery to excise the tumor.Results: The patient underwent successful transsphenoidal resection of the pituitary adenoma. Postoperative assessments, including regular visual field testing and MRI scans, indicated a gradual but complete restoration of the visual fields over a three‐month period. Follow‐up showed no recurrence of the tumor, and the patient remained free of visual symptoms.Conclusions: This case illustrates that bitemporal hemianopia caused by pituitary adenomas can be effectively reversed through surgical intervention. Early identification and prompt surgical treatment are essential to prevent permanent visual deficits and ensure full recovery of visual function. This case also highlights the importance of a multidisciplinary approach in the management of complex neuro‐ophthalmological conditions.

From darkness to light: Reversible bitemporal hemianopia

Aims/Purpose: The purpose of this case study is to describe the diagnostic process, surgical treatment, and subsequent recovery in a patient who was being monitored for strabismus due to previous thyroid orbitopathy. This case aims to underscore the importance of early diagnosis and timely surgical intervention in the resolution of visual impairments associated with pituitary adenomas.Methods: A 53‐year‐old female, under follow‐up for strabismus due to previous thyroid orbitopathy, was noted to have limitations in certain eye movements and diplopia during a routine consultation. Suspecting an exacerbation of orbitopathy, a computed tomography (CT) scan was ordered. The CT revealed a sellar and suprasellar mass, an incidentaloma not seen in a CT performed five years earlier. Visual field testing was then conducted, revealing bitemporal hemianopia. Further evaluation with magnetic resonance imaging (MRI) was performed to better characterize the lesion. The patient was subsequently scheduled for transsphenoidal surgery to excise the tumor.Results: The patient underwent successful transsphenoidal resection of the pituitary adenoma. Postoperative assessments, including regular visual field testing and MRI scans, indicated a gradual but complete restoration of the visual fields over a three‐month period. Follow‐up showed no recurrence of the tumor, and the patient remained free of visual symptoms.Conclusions: This case illustrates that bitemporal hemianopia caused by pituitary adenomas can be effectively reversed through surgical intervention. Early identification and prompt surgical treatment are essential to prevent permanent visual deficits and ensure full recovery of visual function. This case also highlights the importance of a multidisciplinary approach in the management of complex neuro‐ophthalmological conditions.

Person-centered support for patients with a pituitary tumor following surgery.

To evaluate whether a person-centered care practice following surgery for pituitary tumors increased psychological well-being. Secondary aims were to study whether person-centered care would lead to better health status, less fatigue, and better self-efficacy. The study is a prospective, single center study using a quasi-experimental design to evaluate the effect of a 12-month person-centered practice by means of a name-given nurse care manager, an interdisciplinary team, and peer-support against usual care. All patients (≥ 18 years) with a benign pituitary tumor and planned for endoscopic transsphenoidal surgery were consecutively invited to participate. Psychological well-being, self-reported health, fatigue, and self-efficacy were assessed before surgery, at discharge, and at 3-6 and 12 months after surgery. In total, 82 patients in the intervention group and 66 patients in the control group were included. Psychological well-being improved 12 months following surgery in both groups to comparable levels. The intervention group had greater improvement in anxiety compared to the control group (P = 0.02). No differences were seen between groups in self-reported health status, fatigue, or self-efficacy. Patients in the intervention group with other types of pituitary tumors than non-functioning pituitary adenomas showed greater improvement in psychological well-being than the control group. The intervention did not result in major advantages in terms of health or psychological well-being. The study does, however, suggest that the intervention may reduce anxiety 12 months after surgery and that certain subgroups of patients may benefit more from a structured person-centered practice following pituitary surgery.

Recurrent Pericarditis in a Woman with Acromegaly Responding Favorably to Transsphenoidal Surgery

Recurrent Pericarditis in a Woman with Acromegaly Responding Favorably to Transsphenoidal Surgery

Cerebral Pseudoaneurysms: A review of the current literature

Cerebral pseudoaneurysms are focal dilatations of an artery that involve all three layers of the vessel wall, unlike true aneurysms. They typically arise after trauma, iatrogenic (ventricular drain insertion, transsphenoidal surgery, etc.), or infections. Common presentations include headache, subarachnoid hemorrhage, or focal neurological deficits depending on the location and size of the pseudoaneurysm. Diagnosis often involves imaging techniques such as computed tomography angiography (CTA) or magnetic resonance angiography (MRA). Treatment options vary depending on the size, location, and clinical presentation and may include conservative observation, endovascular embolization, or surgical intervention.

A Comparison of Dexmedetomidine and Magnesium Sulfate as an Anesthetic Adjuvant in Trans-Sphenoidal Pituitary Surgery

Background: Trans-sphenoidal pituitary surgery is a minimally invasive procedure used for pituitary disorders. Objectives: This study aims to investigate the effects of dexmedetomidine and magnesium sulfate in improving anaesthesia conditions and pain control during trans-sphenoidal pituitary surgery. Methods: This prospective randomised clinical trial included 90 patients between 18 and 65 years of age, with American Society of Anaesthesiologists (ASA) physical status I and II, who were undergoing elective trans-sphenoidal pituitary surgery. Exclusion criteria included a change in surgical technique during surgery and patients who were transferred directly to the ICU with a tracheal tube. Patients were randomly assigned to three groups (group D: Dexmedetomidine, group M: Magnesium sulfate, and group C: Control), and various parameters such as haemodynamics, surgical field evaluation, and pain were assessed. Results: Ninety consecutive patients were included in this study. Forty-seven males (52.2%) and 43 females (47.8%) were evaluated. There were no significant differences among the three groups regarding gender distribution, age, or Body Mass Index (BMI). The mean age of the included patients was 46.27 ± 12.47 years. The measured mean arterial pressure was lower in group D compared to group M (P-value = 0.005). The other variable that statistically differed between the two groups was the numerical rating scale, which was lower in group D (P-value = 0.02). All measured variables in group D and group M were significantly lower compared to the control group, except for the extubation time. Conclusions: Adding dexmedetomidine as an adjuvant anaesthetic medication during trans-sphenoidal pituitary surgery could potentially enhance haemodynamic stability and improve surgeon satisfaction scores.

Predictors of biochemical remission after transsphenoidal surgery in a large cohort of acromegaly patients.

The objective of this study was to characterize the clinical characteristics and factors predictive of biochemical remission in patients with symptomatic acromegaly undergoing transsphenoidal surgery (TSS) at an academic tertiary care center, as defined by the 2022 Acromegaly Consensus Conference guidelines. In this single institution, longitudinal, retrospective study, a large cohort of 158 patients with a preoperative diagnosis of acromegaly undergoing surgery at a large, academic, tertiary care center were examined. We excluded 38 patients as IGF-1 testing was performed less than 12 weeks postoperatively. The majority of tumors were intrasellar macroadenomas (75%), receiving endoscopic surgery (98.3%). Patients who failed remission appeared to have higher raw IGF-1 levels preoperatively (732 ± 313 ng/mL) compared to those who attained remission (278 ± 313 ng/mL), and trended towards higher rates of GH hypersecretion (93.1% vs. 78.4%). Patients failing remission had higher GH levels and IGF-1 levels postoperatively and experienced a lower percentage reduction in raw IGF-1 levels. Multivariable logistic regression demonstrated that the magnitude of preoperative IGF-1 (OR: 1.001, 95% CI: 1.00, 1.003) and the percentage change in IGF-1 (OR: 1.021, 95% CI: 1.01, 1.04) were predictive of remission failure. Radiographic characteristics such as tumor size, suprasellar extension, and location were not necessarily predictive of worse postoperative outcomes. Lesions which failed to achieve biochemical remission appeared to display distinctive preoperative endocrinological characteristics, with preoperative IGF-1 levels and percentage changes in IGF-1 levels being predictive of biochemical remission status.

Predictors of growth hormone level on postoperative day one in patients with acromegaly.

The growth hormone (GH) level on postoperative day one (POD1), i.e., POD1GH, holds significant value in assessing surgical efficacy and predicting long-term remission in patients with acromegaly. This study aims to explore the factors that influence the GH level of POD1 after microscopic transsphenoidal surgery (mTSS) in patients with acromegaly, providing insights for preoperative clinical decisions. A total of 85 acromegaly patients undergoing mTSS were included in this study. Sex; age; body mass index (BMI); preoperative serum hormone levels and tumor characteristics were assessed for their correlation with POD1GH levels. POD1GH level non-remission, defined as POD1GH > 2.5 ng/mL, was considered an outcome. The patients with acromegaly were divided into two groups: adult males (43 cases) and adult females (42 cases), with mean ages of 43.33 ± 11.92 years and 47.02 ± 14.18 years, respectively. Correlation and multivariate linear regression analyses revealed positive correlations of preoperative GH and prolactin (PRL) levels in females with POD1GH levels, while preoperative FT3 and TT levels in males were negatively correlated with POD1GH levels. Binary logistic regression and receiver operating characteristic (ROC) analyses identified preoperative GH levels ≥30.25 ng/mL (OR = 2.236, 95%CI = 1.402-3.567, p < 0.001), FT3 levels ≤4.415 pmol/L (OR = 0.329, 95%CI = 0.167-0.648, p < 0.001), and age ≤51 years (OR = 0.566, 95%CI = 0.352-0.911, p = 0.019) as independent risk factors for POD1GH level non-remission. Preoperative GH, FT3, TT, and PRL levels are correlated with POD1GH levels, with variations observed between sex. Age, preoperative GH, and FT3 levels can predict POD1GH level non-remission. Therefore, the comprehensive consideration of multiple hormone axes is necessary for predicting postoperative efficacy.

Urinary oxytocin secretion after pituitary surgery, early arginine vasopressin deficiency and syndrome of inappropriate antidiuresis.

Transient arginine vasopressin deficiency (AVP-D), previously called diabetes insipidus, is a well-known complication of transsphenoidal pituitary surgery (TPS) with no definite predictive biomarker to date making it difficult to anticipate. While oxytocin (OXT) was previously suggested as a possible biomarker to predict syndrome of inappropriate diuresis (SIAD)-related hyponatraemia after TPS, its secretion in patients presenting with AVP-D remains poorly understood. We therefore hypothesized that OXT might present a different secretion in the case of AVP-D which would support its potential as an early biomarker of AVP-D. Moreover, we hypothesized that abnormal secretion of OXT might occur later on, notably with SIAD. We measured the urinary output of OXT in 67 consecutive patients subjected to TPS and compared the values of oxytocin between time-points and OXT ratio between groups. The primary endpoint of our study was to identify a difference in urinary OXT excretion in patients suffering from AVP-D compared to patients remaining normonatraemic. As a secondary endpoint, we compared the evolution of OXT secretion after the diagnosis of AVP-D in both groups, comparing the patients that later developed SIAD with the ones that did not. Patients developing AVP-D showed a delay in the increase of OXT secretion after TPS as shown by a significantly lower ratio of OXT between the first postoperative day and the day of surgery (0.88 VS 1.68, p = 0.0162, IC:0.2979-0.2642) but a significantly higher ratio of OXT between the fourth and the first postoperative days (1.17 VS 0.53, p = 0.0006, IC:-2.109-0.6092). Moreover, normonatraemic patients that did not show normalization of OXT levels at day 4 after surgery tended to develop SIAD later on. Taken together, these results show for the first time that OXT release might help predict AVP-D after TPS and differentiate it from other pathologies of water-sodium balance.

Lateralization outcomes of bilateral inferior petrosal sinus sampling: desmopressin vs CRH.

Bilateral inferior petrosal sinus sampling (BIPSS) is the gold standard for localizing ACTH-dependent Cushing's syndrome (CS). While corticotropin-releasing hormone (CRH) was initially used for stimulation, desmopressin has become a common alternative. This research evaluates desmopressin's effectiveness in lateralizing Cushing's disease (CD) during BIPSS compared to CRH stimulation. The study included 33 individuals with ACTH-dependent CS who underwent BIPSS and had diagnoses confirmed by endoscopic endonasal transsphenoidal pituitary surgery (EETPS). Fourteen participants underwent BIPSS with CRH and 19 with desmopressin. A comparative analysis was conducted. BIPSS accurately lateralized 76% of cases, specifically, 71% with CRH and 79% with desmopressin (p = 0.2). For tumors < 6mm on MRI, overall accuracy was 82%, namely, 75% with CRH and 90% with desmopressin (p = 0.4). IPSS achieved 100% accuracy in the four cases with no lesion on preoperative MRI. This study demonstrates no significant difference in lateralization accuracy between desmopressin and CRH for IPSS. In challenging cases, especially those with microadenomas or non-lesional CD, desmopressin with IPSS aids in preoperative lateralization.

Proposal of a predictive score for the occurrence of postoperative cerebral vasospasm: analysis of a large single institution retrospective series and literature review.

Despite being uncommon, postoperative vasospasm (PoVS) present notably high morbidity and mortality rates. Our aim was to identify prognostic factors associated with this condition and introduce a scoring system to improve subsequent clinical and radiological surveillance strategies. We conducted a retrospective analysis of our institutional database covering patients aged over 18 who underwent craniotomic or transsphenoidal surgery for elective tumor removal at the Neurosurgical Unit of our institution between January 2016 and August 2023. A comprehensive search was conducted using the Cochrane Database of Systematic Reviews and PubMed database to identify the most correlated risk factors. Literature review included a final group of 32 studies (52 patients) and identified SAH, vessel encasement or vessel manipulation, hypothalamic disfunction, meningitis, younger age, tumor size > 3 cm, and long operative time as predictive factors for PoVS. Our cohort included 2132 patients, with only 13 individuals (0.61%) presenting PoVS. To predict the occurrence of PoVS, we developed a logistic multivariate regression model that identified thick (defined as Fisher grade ≥ 3) subarachnoid hemorrhage (coeff. 6.7, p < 0.001), intraparenchymal hemorrhage (coeff. 3.44, p < 0.001), lesion located in the parasellar region (coeff. 2.1, p = 0.064), and lesion size ≥ 4 cm (coeff. 2.0, p = 0.069) as potential independent predictors of PoVS. Based on statistical model for these variables was assigned a score: thick SAH 7 points, intraparenchymal hemorrhage 3 points, parasellar lesion site 2 points, and lesion size ≥ 4 cm 2 points. The cumulative scores ranged from 0 to 14. PoVS is a rare complication but its association with significant morbidity and mortality underscores the importance of early identification and treatment. In our study we proposed a stratified risk score to identify high risk patients. However, due to rarity of this condition, our score proposal should be considered as a training set a to be validated in future studies with a multicenter setting.

Socioeconomic Disparities in the Utilization of Endoscopic Transsphenoidal Pituitary Surgery: A Retrospective Analysis of the National Inpatient Sample

Introduction Pituitary neoplasms account for 15% of all intracranial neoplasms and affect 20% of the population. Objective We aim to use the National Inpatient Sample (NIS) to ascertain disparities in utilization and outcomes among endoscopic endonasal pituitary surgery patients. Methods NIS was used from 2010 to 2020. Pearson's v2, Fisher's Exact, and independent 2-tailed t-tests were used to assess patient characteristics and outcomes. A logistic regression model was used to compare in-hospital mortality and post-operative complications between Racial groups. Statistically significant postoperative complications were analyzed with a multivariable logistic regression to determine the independent impact of obesity on postoperative outcomes. Results Hospitalization rates for this procedure declined significantly over the decade, from 10,279 in 2010 to 5,875 in 2020 (trend p value &lt; 0.001). The majority of patients were between 25 and 64 years old (72.16%), with 60.73% having no comorbidities. While the gender distribution was nearly even, disparities emerged across racial and socioeconomic groups. Black and Hispanic patients were more likely to reside in lower income zip codes and depend on Medicaid compared to White patients. Black patients had higher odds of any postoperative complication (adjusted OR: 1.14, p=0.003) and specific complications like diabetes insipidus, fluid/electrolyte disorders, and renal/urinary issues compared to White patients. Both Black and Hispanic patients faced higher mortality risks post-surgery compared to White patients (adjusted OR: 2.62 and 2.44, respectively, p&lt;0.05). Medicaid coverage was associated with higher odds of any complication (adjusted OR: 1.18, p=0.016), while private insurance was linked to lower odds (adjusted OR: 0.88, p=0.015).Patients in the lowest income quartile had higher odds of complications compared to those in higher quartiles. Obesity independently predicted increased odds of pulmonary, renal, and hemorrhagic complications. Conclusion Despite advancements in endoscopic endonasal pituitary surgery, disparities in access and outcomes persist across racial, socioeconomic, and insurance groups. These findings underscore the need for targeted interventions to address these inequalities and ensure equitable access to quality care.

The rate of postoperative hematoma following risk-adapted cessation of oral anticoagulation in patients undergoing endoscopic endonasal surgery for pituitary adenomas.

This study describes the management of patients on oral anticoagulation (OAC) undergoing endoscopic endonasal transsphenoidal surgery (EETS) and analyzes the risk of postoperative hematoma and epistaxis following treatment of pituitary adenoma (PA). Patients with OAC prior to EETS for PA were analyzed in a single center retrospective case series of consecutive patients with PA, who were treated between December 2008 and July 2022. Patient data (age, sex, clinical, endocrinology, tumor histology) were entered into a SPSS® database. The rate of postoperative hemorrhage (intracranial and epistaxis) and other perioperative complications were assessed. Of 305 patients, 20 patients were on OAC prior to EETS for PA. Indications included non-valvular atrial fibrillation (AF) in 10 patients and previous venous thromboembolic event (VTE) in 8 patients, in 2 patients had overlapping indications. Twelve patients on direct oral anticoagulants (DOAC) paused medication 1-3 days (43.6 ± 23.6h) before surgery, while phenprocoumon was paused 234 ± 123.55h (min 6, max 22 days) before surgery. Baseline characteristics such as age, sex, tumor growth direction, tumor volume, and largest diameter showed no significant differences. No significant increase in postoperative hemorrhage was observed in patients with OAC compared to those without. One patient on apixaban paused 48h before surgery experienced postoperative epistaxis. Among patients without OAC, one experienced intracranial hemorrhage and seven experienced epistaxis. Patients with OAC prior to EETS for PA have no increased risk for postoperative hematoma when OAC is paused based on individual risk assessment and recent general recommendations.

Nomogram for predicting diabetes insipidus following endoscopic transsphenoidal surgery in pituitary adenomas.

Postoperative diabetes insipidus (DI) frequently complicates endoscopic transsphenoidal surgery (TSS) in pituitary adenoma (PA) patients, yet reliable predictive methods for DI risk remain lacking. This study aims to identify risk factors associated with DI following endoscopic transsphenoidal resection of PA and to develop a predictive nomogram for assessing postoperative DI risk. This study involved 600 PA patients underwent endoscopic TSS at Shandong Provincial Hospital from 2021 to 2023. Among these patients, 82 developed postoperative DI while 518 did not. The cohort was randomly divided into training (n = 360) and validation (n = 240) groups at 6:4 ratios by R software. Clinical parameters and radiographic features were evaluated using univariable and multivariable logistic regression to construct a predictive nomogram for post-endoscopic TSS DI risk. Model performance was assessed using ROC curves, calibration plots, and decision curve analysis. Subgroup analysis was used to evaluate the model's ability to discriminate between transient and permanent DI. Univariable and multivariable logistic regression analyses on the training group identified several independent risk factors for post-endoscopic TSS DI, including maximum tumor diameter, Knosp grade, Esposito grade, recurrent PA, and pituitary stalk deviation angle. A nomogram was developed based on these factors, demonstrating robust predictive accuracy with ROC areas under curve of 0.840 for the training group and 0.815 for the validation group. Calibration plots indicated excellent agreement between predicted and observed probabilities of postoperative DI. DCA curves highlighted the nomogram's efficacy in guiding clinical decision-making. Subgroup analysis showed that the model was able to discriminate between transient and permanent DI, and the AUC was 0.652 (95% CI 0.525-0.794). This study presents a nomogram designed to predict postoperative DI risk in patients undergoing endoscopic TSS for PA. Internal and external validations underscored the model's high accuracy, calibration, and clinical utility. Simultaneously, the model can also assess the development risk of permanent DI. This predictive tool offers clinicians valuable support in identifying high-risk DI patients, optimizing postoperative care strategies, and tailoring treatment plans to improve patient outcomes.

Endoscopic transsphenoidal surgery for infradiaphragmatic craniopharyngiomas and impact of diaphragm sellae competence on hypothalamic injury

Investigate the impact of diaphragm sellae competence on surgical outcomes and risk factors for postoperative hypothalamic injury (HI) in patients undergoing endoscopic transsphenoidal surgery (ETS) for infradiaphragmatic craniopharyngiomas (ICs). A retrospective analysis of 54 consecutive patients (2016–2023) with ICs treated by ETS was conducted. All tumors originated from the sellar region inferior to the diaphragm sellae and were classified into two subtypes in terms of diaphragm sellae competence: IC with competent diaphragm sellae (IC-CDS) and IC with incompetent diaphragm sellae (IC-IDS). Clinical features, intraoperative findings, and follow-up data were compared between subtypes. Postoperative HI was assessed using an magnetic resonance imaging-based scoring system. Fifty-four patients (29 males, 25 females) were included in this study, with 12 (22.2%) under 18 years old. Overall, 35 cases were IC-CDS, while 19 were IC-IDS. Compared with IC-CDS, patients with IC-IDS tended to have hormone hypofunction before surgery (p = 0.03). Tumor volume in IC-IDS group (9.0 ± 8.6 cm3) was also higher than that in IC-CDS group (3.3 ± 3.4 cm3, p = 0.011). Thirty-seven patients underwent standard endoscopic transsphenoidal approach (SEA) and 17 underwent an extended endoscopic transsphenoidal approach (EEA). Gross total resection (GTR) was achieved in 50 cases (92.6%). Postoperative CSF leak was observed in four patients (7.4%). Permanent diabetes insipidus (DI) occurred in 13 patients (27.7%), six in IC-CDS and seven in IC-IDS. Postoperative HI occurred in 38.9% of patients. Univariate analysis revealed that large tumor size (p = 0.014), prior hypopituitarism(p = 0.048) and IC-IDS (p < 0.001) were significantly associated with postoperative HI. Multivariate analysis revealed that IC- IDS was the sole predictor of postoperative HI. To our knowledge, this is the largest case series in the literature to describe IC resected by endoscopic surgery in a single institution. Classification based on diaphragm sellae competence highlights distinct clinical features and surgical outcomes between IC-CDS and IC-IDS subtypes. Notably, IC-IDS is an independent risk factor for postoperative HI. Preoperative identification of subtype can guide surgical strategy and potentially minimize complications.

Growth Hormone-Secreting Pituitary Adenoma: Dura Mater Invasion Is Not a Predictor of Acromegaly Persistence After Trans-Sphenoidal Surgery.

Objectives: In pituitary adenomas, examinations of surgical specimens have shown that dural invasion occurs in 42-85% of cases. No studies about dura mater invasion have been conducted specifically in acromegaly patients. The aim of the present study was to evaluate the relationship between histologically dural invasion and the main features of GH-secreting adenomas. Methods: This retrospective study included all consecutive acromegaly patients who underwent neurosurgery at our university hospital between 2017 and 2020. The following data were collected: (1) clinical, biochemical and morphological data at diagnosis, at three months, one year after neurosurgery, and at last follow-up; (2) pathological features (dura mater invasion, immunohistochemical analyses, proliferation index Ki-67, p53, and granulation pattern); and (3) radiological features on magnetic resonance images. Results: Of 35 acromegaly patients, 11 had dural invasion (INV+ 31%) and 24 did not (INV- 69%). GH levels at diagnosis were greater in INV+ patients (p = 0.02), and a GH value > 27 ng/mL was able to distinguish INV+ patients (Sensitivity 80%, Specificity 73%, AUC 0.760, p = 0.006). Indeed, patients with GH > 27 ng/mL at diagnosis had a tenfold greater risk of dura mater invasion (OR 10.7; 95% CI 1.74-65.27, p = 0.005). No differences were found in the other clinical, biochemical, morphological, radiological and pathological features. Regarding remission likelihood, IGF-1 levels at diagnosis were lower in cured patients (p = 0.03). Conclusions: The GH level at diagnosis is the only parameter significantly associated with dura mater invasion. Lower IGF-1 levels at diagnosis are significantly associated with remission one year after surgery.

Prolactinomas

Prolactinomas are the most common type of pituitary adenomas and the most common cause of hyperprolactinemia. There are several pitfalls in the evaluation of hyperprolactinemia, which should be recognized as they affect management decisions. Medical therapy with dopamine agonists is the first-line treatment for prolactinomas. Transsphenoidal surgery is indicated in cases of intolerance or resistance to dopamine agonist therapy.

Incidence of postoperative cerebrospinal fluid leaks in endoscopic endonasal transsphenoidal surgery for pituitary adenomas without sellar floor reconstruction: A retrospective observational study from a low-middle-income country.

To determine the incidence of postoperative cerebrospinal fluid (CSF) leaks after endoscopic endonasal transsphenoidal surgery (EETS) for pituitary adenomas without sellar floor reconstruction (SFR). This retrospective observational study was conducted at Department of Neurosurgery, Punjab Institute of Neurosciences (PINS), Lahore, Pakistan from January, 2018 to December, 2022. It is a non-probability based consecutive case series. A total of 316 patients meeting the inclusion criteria were selected. Among the 316 patients, 102 (32.3%) were male, while 214 (67.7%) were female. Mean age was 40.98 ± 7.8 SD (range 23 to 65 years). Regarding size of pituitary adenomas, 19 (6%) were microadenomas and 297 (94%) were macroadenomas. Overall postoperative CSF (poCSF) leak in our patients was 2.8%. Among cases with poCSF leak, 4 (3.9%) were male and five were female (2.3%) with the P-value of 0.477. Regarding size of pituitary adenomas, only one (5.3%) microadenoma had poCSF leak whereas 8 (2.7%) macroadenomas had poCSF leak with the P-value of 0.432. Pituitary adenomas can be successfully treated with EETS without SFR in patients who do not experience intraoperative CSF leak.

Patient diagnosed with acromegaly and pituitary apoplexy after breast carcinoma treatment: challenges in diagnosis and management

The clinical case presented describes a 44-year-old woman with a history of mucinous carcinoma in the right breast, who is diagnosed with a pituitary adenoma. Physical examination revealed signs of acromegaly, such as macroglossia and palmar hyperhidrosis. Hormonal tests were performed and showed elevated levels of insulin-like growth factor type 1 (IGF-1). The patient received GnRH analogues for breast cancer; and started medical treatment with somatostatin analogues for acromegaly, which provided improvement in symptoms. Pituitary bleeding was detected during hormone treatment, which caused the growth of the adenoma, causing it to contact the optic chiasm, although no symptoms of pituitary apoplexy were present. Transsphenoidal endoscopic surgery was performed to remove the adenoma, and the diagnosis of pituitary adenoma was confirmed by pathology. The importance of the evaluation of comorbidities in patients with acromegaly is discussed. Pituitary apoplexy as an uncommon complication of pituitary adenomas, which may be associated with the use of GnRH analogues, is addressed. Pre-surgical medical treatment in acromegaly is also discussed, highlighting the importance of a comprehensive assessment of prognostic factors and appropriate treatment selection to improve clinical outcomes. In conclusion, the importance of a multidisciplinary and personalized approach in the management of patients with GH-producing pituitary adenomas to improve quality of life and clinical outcomes is highlighted.

Relationship of anatomical variations of sphenoid sinus and the outcomes of endoscopic endonasal transsphenoidal surgeries: a systematic review.

The sphenoid sinus features many anatomical variations between individuals from different populations in the world. The understanding of these variations is important for the surgeons to plan for surgeries which involve intervention through the nasal approach. The aim of the present systematic review was to perform a qualitative synthesis of available studies which assess the effect of sphenoid sinus (SS) anatomical variations on the outcomes of endoscopic endonasal transsphenoidal surgeries (ETSS). The current review followed PRISMA 2020 guidelines. A systematic advanced electronic search was performed in four databases Medline (via PubMed), Scopus, Web of Science (WoS) and Lilacs in December 2023. Studies that assessed the anatomical variations of the SS that affect the outcomes of ETSS were eligible for inclusion. A qualitative synthesis of the methodology and results of the included studies was carried out. Quality assessment was performed using the National Institute of Health (NIH) quality assessment tool (last accessed on December 24, 2023). A total of 14 studies were included in the qualitative synthesis. Most of the studies included in the review found that the sellar pneumatization was the commonest followed by the postsellar type. Single intersphenoid sinus septum (ISS) was found to be the most common variation, which is more frequently found in males compared to females. There was sex difference seen in the attachment of the ISS to the carotid canal. It is more commonly attached to the posterolateral wall of the sinus in males compared to the females. Though complicated cases were less compared to uncomplicated ones, cerebrospinal fluid (CSF) leak was the leading post operative complication amongst the complicated cases and paranasal sinus (PNS) computed tomography (CT) scan showed ISS findings differed from intraoperative findings. It is concluded that the ISS poses the commonest anatomical variations encountered during the ETSS. During planning for transsphenoidal endoscopic procedure, the ISS should thoroughly be assessed to minimize potential surgical complications.