Anterior Microsurgical Approach to Ventral Lower Cervical Spine Meningiomas: Indications, Surgical Technique and Long Term Outcome.

Ventral lower cervical spinal meningiomas with posterior displacement of the spinal cord are rare and anterior approach has been rarely reported in the literature. The authors present their experience about eight patients operated through anterior microsurgical approach. Exposure of meningiomas was achieved through one or two corpectomies, according to meningioma extension. Tumour removal was performed thanks to the aid of a dedicated ultrasonic aspirator, and intraoperative evoked potentials were employed. Particular care was taken with the materials adopted for reconstruction of the anterior dural plane, to avoid postoperative cerebrospinal fluid leak. Vertebral fusion and stabilization were achieved by tantalum cage or titanium graft in case of one or two corpectomies respectively; anterior titanium plate fixed with screws was applied in all patients. Extent of tumour removal was related to the presence of a conserved arachnoidal plane between the tumour and the spinal cord: total removal was achieved in 2 patients, while gross total removal in the other six ones. Postoperative neurological outcome, which was favourable in all patients, was related mostly to preoperative neurologic status. No recurrence after total removal and no remnant growth after gross total removal occurred during an average follow-up period of 6, 7 years.

Extended transsphenoidal microsurgical approach for diaphragma sellae and tuberculum meningiomas.

Diaphragma sellae meningiomas represent a difficult challenge for neurosurgeons; they are generally operated on by a transcranial approach. Some authors reported transsphenoidal surgery in selected cases, but without accurately focusing the surgical technique that should be necessary for removing the typical hard fibrous tissue of the meningioma, that is not aspirable, by this approach. We present the surgical technique and the useful instrumentarium for removing a diaphragma sellae meningioma through an extended microsurgical transsphenoidal approach.

Diaphragma sellae metastasis from colon carcinoma mimicking a meningioma. A case report.

We describe a rare case of metastatic intra-suprasellar adenocarcinoma from colonic cancer mimicking a meningioma of the "diaphragma sellae". Autopsy studies indicate breast and lung carcinoma to be the most frequent primary tumor metastasizing this site, particularly in patients with systemic spread. While diabetes insipidus is reported to be one of the commonest symptoms in these cases, the only clinical manifestation of the tumor in our patient was a bitemporal hemianopia, while the primary tumor remained asymptomatic. In the available literature are reported only two pituitary metastasis from operated colon carcinoma. In both cases the diagnosis of the colon cancer preceded the pituitary operation. The clinico-pathological and neuroradiological aspects of this unusual lesion are analyzed in the light of the relevant literature on the topic focusing on recent MRI acquisitions.

The surgical treatment of pituitary adenomas in the eighth decade.

BACKGROUND: The surgical treatment of pituitary adenomas in elderly patients (i.e., over 70 years of age) is a special problem because of the increased rate of perioperative complications and the reduced tolerance of postoperative fluid and electrolyte imbalance. Therefore, the unquestionable progress in the pharmacological and radiotherapy may not allow these patients the option of radical surgical treatment. We report our experience with the transsphenoidal procedure for pituitary adenomas in aged patients in an attempt to contribute to a better definition of the actual role of surgery. METHODS: Transsphenoidal surgery was performed in 11 patients over 70 years of age affected by various histological types of pituitary micro- and macroadenomas, ranging from Hardy Grade I through IIIc. Special care was dedicated to the postoperative treatment, in particular to water and electrolyte balances, and to the immediate treatment of any pathological variation of these parameters. RESULTS: We had no mortality and no postoperative adjunctive morbidity. All the patients recovered well from the operation with an average hospital stay of 20 days. The tumor removal was complete in six cases and partial in the remaining five. With an average follow-up of 2 years, we did observe only one case of symptomatic recurrence of the disease. CONCLUSIONS: Transsphenoidal surgery in the elderly is feasible and quite safe in the hands of an experienced team, if special care is devoted to the preoperative selection of patients and to the postoperative treatment of fluid and electrolyte imbalance.

Paraganglioma of the cauda equina. Case report with 33-month recurrence free follow-up and review of the literature.

Paraganglioma of the cauda equina is an unusual tumor and do not have the secretory properties of the same tumors arising outside the nervous system. In none of the few cases reported in literature a preoperative diagnosis was possible, and the surgical findings raised questions in the differential diagnosis with ependymomas. A rare case of paraganglioma of the cauda equina studied both pre- and postoperatively by MRI, and treated with subtotal excision combined with radiotherapy is described. Results and recurrence rates of the cases reported in literature are reviewed. Though MRI imaging has proven to be more sensitive than other radiological procedures, we stress the difficulties of preoperative diagnosis of paragangliomas in this site. The correct diagnosis of the paraganglioma of the cauda equina still relies on immunochemistry and electron microscopy. Total excision is often very difficult owing the tendency of these neoplasms to infiltrate cauda's roots. A 33-month recurrence free follow-up of our patient confirms that successful treatment is achieved by subtotal resection combined with radiotherapy.

Trans-sphenoidal treatment of postsurgical cerebrospinal fluid fistula: CT-guided closure.

Cerebrospinal fluid (CSF) leakage after trans-sphenoidal surgery is a troublesome complication with a risk of meningitis and pneumocephalus. We suggest CT-guided intrasphenoidal injection of fibrin sealant through a 12-gauge needle as a simple alternative to surgical management of CSF fistulae. We treated eight patients, operated via the trans-sphenoidal route (five pituitary adenomas, three craniopharyngiomas), for a postoperative CSF leak by CT-guided intrasphenoidal injection of fibrin sealant alone in three cases and fibrin sealant and autologous blood in 5. CT was obtained 10 days after the procedure in all cases. In four patients, the CSF leak was closed successfully at the first attempt. The procedure was repeated on the four remaining patients because only a reduction in leakage was obtained at the first attempt. This procedure preserves olfaction and avoids the risk of frontal lobe damage. It could therefore represent the treatment of choice in many cases of anterior cranial fossa postsurgical CSF leaks.

The contribution of Davide Giordano (1864-1954) to pituitary surgery: the transglabellar-nasal approach.

This report describes the fundamental contribution made by Davide Giordano, proposing the transglabellar surgical approach in a period in which transfacial and transbasal operative approaches to the pituitary gland were considered inadvisable because of their risk. His idea was to gain access through bilateral paranasal and frontal skin incisions, allowing removal of the ethmoid bone and the anterior wall of the sphenoidal cube. With the anterior and inferior aspects of the sella turcica thus exposed, bone is removed and the gland is exposed by incision of the dura mater. The technique proposed by Giordano is undoubtedly a forerunner of the transsphenoidal route to the pituitary gland. The importance of his contribution was confirmed by Cushing, who reported his first use of the approach of Giordano in 1909 in a patient with a pituitary adenoma. The efforts of Giordano clearly inspired surgeons of his era to perform this operation clinically, giving impetus to the further development of neurosurgery.

Computed tomography-guided transsphenoidal closure of postsurgical cerebrospinal fluid fistula: a transmucosal needle technique.

BACKGROUND: Cerebrospinal fluid (CSF) fistula represents a fearful complication of transsphenoidal surgery and, despite careful intraoperative repair and prolonged postoperative lumbar CSF drainage, need for a new surgical intrasphenoidal plasty is not uncommon. METHODS: These cases prompted us to develop a simple, minimally invasive, harmless repeatable technique consisting of a computed tomography (CT)-guided intrasphenoidal injection of fibrin glue through a 12-gauge spinal needle. RESULTS: Five patients presenting with rhinoliquorrhea following a transsphenoidal approach for the excision of pituitary adenomas (three cases) and craniopharyngiomas (two cases) were treated successfully with the presented technique. In two cases the first attempt attained only partial success and therefore the procedure was repeated. In the last two cases, the injection of fibrin glue was preceded by 2 cc of fresh autologous blood, with the aim of enhancing the mechanisms of healing, possibly inducing adhesions and fibrosis. CONCLUSIONS: The proposed method of treatment for CSF leakage following transsphenoidal surgery may represent a valid alternative to the surgical option.

1897--celebrating the centennial--Hermann Moritz Gocht and radiation therapy in the treatment of trigeminal neuralgia.

Among German radiologists and orthopaedic surgeons Hermann Moritz Gocht (1869-1938) is one of the most prominent figures. In addition to his noteworthy contributions to the progress of orthopaedic surgery, in 1897 he introduced the use of radiotherapy for the treatment of trigeminal neuralgia. Subsequently the value of this technique was widely recognized by radiologists and neurosurgeons, and it is still acclaimed as the most brilliant intuition of this famous pioneer of radiology. Gocht made also important contributions to the technical development of X-ray apparatus and to the definition of the radiological anatomy of the skeleton, as well as to orthopaedic surgical pathology. The aim of this paper is to celebrate the centennial of Gocht's introduction of radiotherapy in the treatment of neuralgic syndromes and to express our appreciation of the work of this eminent scientist.

Effects of increasing times of incomplete cerebral ischemia upon the energy state and lipid peroxidation in the rat.

Different times of incomplete cerebral ischemia (2, 4, 6, 8, 10 and 30 min) were induced by bilateral common carotid artery occlusion in anesthetized rats to evaluate the time course of changes in lipid peroxidation and energy metabolism. Analysis of malondialdehyde (used to assess the levels of lipid peroxidation), ascorbic acid, oxypurines, nucleosides, nicotinic coenzymes and high-energy phosphates, was carried out by high-performance liquid chromatography on neutralized perchloric acid extract of brain tissue. Under the present experimental conditions, malondialdehyde, nicotinic coenzymes and ATP catabolites (oxypurines and nucleosides) were affected by increasing times of ischemia, with respect to control sham-operated rats. In particular, the concentration of malondialdehyde, undetectable in control brains, increased from 1.26 nmol/g wet weight after 2 min of carotid clamping to 13.42 nmol/g wet weight at the end of 30 min of incomplete cerebral ischemia. The presence of oxidative stress was further supported by ascorbic acid depletion, which was particularly significant after 10 and 30 min of incomplete ischemia. Carotid clamping provoked an imbalance between energy production and consumption that was evidenced by a reduction in ATP and GTP concentrations and an increase in ATP degradation products such as AMP, oxypurines and nucleosides. A decrement in the sum of adenine nucleotides and the energy charge potential indicated a progressive malfunctioning of energy-producing metabolic cycles. A possible contribution to such a severe change in energy state might be related to depletion of NAD and NADP, particularly noticeable after the longest incomplete brain ischemia times, that should have provoked a consequent lessening of oxido-reductive reactions. Bilateral carotid clamping causes a significant reduction in brain oxygen and substrate supply that results in inhibition of energy metabolism and triggering of oxygen-radical-induced lipid peroxidation.

Cellular receptors for sex steroids in human pituitary adenomas.

Cellular receptors for sex steroids (SSRs) were studied in an unselected series of 55 human pituitary tumors. Cytosolic receptors for estrogen (ERcs) and progesterone (PgRcs) were determined in all cases and cytosolic androgen receptors (ARcs) in 47 cases. Nuclear receptors (ERns, PgRns, ARns) were also studied in 33 cases. ERs and PgRs were determined by an ELISA and ARs by [3H]methyltrienolone binding. Where both cytosolic and nuclear receptors were studied (n = 33), ERs, PgRs and ARs were found in at least one subcellular fraction in 66.7, 60.6 and 81.8% of cases respectively, ERs and ARs being mainly recovered from the cytosol and PgRs from the nucleus. No linear correlation was found between pre-operative plasma steroid hormones and their specific cellular receptors. Nonetheless, the differential expression of SSRs according to sex and gonadal status at the time of surgery strongly supports their regulation by the steroid environment in vivo: PgRcs were more frequent in tumors found in women (41.4 vs 15.4%, P < 0.05), whereas a high expression of ERcs and ARcs (> 15 fmol/mg protein) was more common in tumors found in men (34.5 vs 10.3%, P < 0.05 and 54.5 vs 24.0% respectively). PgRs were positively correlated with ERns, indicating the possibility of estrogen priming of their expression, and negatively correlated with ARs in nuclear fractions. SSRs appeared to be widely distributed among pituitary tumors, although, compared with other hormone-secreting groups, prolactinomas displayed a higher ERc expression (34.8 +/- 11.3 vs 4.8 +/- 5.1 fmol/mg protein, P = 0.007) and gonadotroph cell adenomas lower ARc values (1.3 +/- 0.8 vs 38.2 +/- 10.6 fmol/mg protein, P = 0.048). Microadenomas were characterized by a higher PgR expression than macroadenomas, whereas hemorrhagic (macro)adenomas were characterized by a high ER expression (> 90%). The present results indicate that most pituitary tumors are targets for sex steroids, SSR expression being partially triggered by the steroid environment itself. Possible physiopathological and therapeutic implications of these findings are discussed.

Transmaxillosphenoidal approach to tumors invading the medial compartment of the cavernous sinus.

A transmaxillosphenoidal approach was used to remove sellar tumors invading the cavernous sinus. This procedure, a widening of the standard transsphenoidal approach to the sella turcica, uses the sublabial or transnasal route in which the medial wall of the maxillary sinus is laterally dislocated. This method provides good exposure of the prominences of bone above the carotid artery which lies on the posterolateral wall of the sphenoid sinus. This bone area is the key to opening the cavernous sinus inferomedially and removing lesions within its medial compartment. The inferomedial approach takes an entirely extracerebral route so that tumors invading the cavernous sinus through its medial wall are approached inferomedially following the direction of tumor growth. It also allows direct visualization of the intracavernous carotid artery during tumor removal, thus sparing the cranial nerves, which run on the opposite side. Adequate surgical exposure of a pituitary adenoma is achieved with a custom-made sphenoidal retractor with asymmetric blades, the shorter blade holding aside the thin medial wall of the maxillary sinus. Between October, 1989, and July, 1993, 11 patients with tumors invading the cavernous sinus underwent surgery via this approach; 10 had pituitary adenomas and one had a craniopharyngioma. Eight tumors were treated by primary operation: four tumors were totally and four subtotally (> 80%) removed; one tumor already operated on elsewhere was totally removed; and of two tumors already operated on and irradiated, one was subtotally removed and the other only partially (approximately 40%) removed owing to marked postirradiation scarring. None of the patients suffered permanent cranial nerve deficit and all but one showed marked clinical improvement.

Glossopharyngeal neuralgia with cardiac syncope.

Glossopharyngeal Neuralgia is an uncommon craniofacial pain syndrome that is occasionally associated with cardiac syncope. Involvement of the glossopharyngeal nerve may be painless or may be marked by true episodic neuralgia, and this justifies the term neuralgia reported here. We present 5 cases of this uncommon syndrome, of a total of 15 observed cases of glossopharyngeal neuralgia, successfully treated by section of the rootlets of Cranial Nerves IX and X or by microvascular decompression in the posterior cranial fossa. We also analyze the relevant literature and discuss the pathogenesis and treatment of the syndrome.

The supine position for transsphenoidal surgery.

The supine position has been routinely used for transphenoidal microsurgery in our department since 1973. We had 404 patients, 387 of whom had pituitary micro-or macroadenomas. It is always satisfactory, allowing a very good control of intraoperative arterial pressure and prevention of air embolism. It is also comfortable for both surgeons.

Unilateral reduction of head pain and facial vasodilatation after gasserian ganglion lesion.

The features of histamine-induced headache and its associated vascular responses were studied in 52 patients with different surgical lesions of the gasserian ganglion and in 12 control subjects. Certain features of headache (eg, intensity, type, and duration) were similar in patients and control subjects. However, the pain was absent on the side of the trigeminal lesion in 26 (50%) of the patients. This unilateral absence of pain was not related to the hypoesthesia that was caused by the operation, and it was associated with a decrease in vascular responses (histamine-induced facial flushing and increase in temperature) on the side operated on. These abnormalities were more prevalent in patients who had undergone thermocoagulation and presented with more severe damage of the trigeminal ganglion than in those who were subjected to trigeminal compression or glycerolization. The trigemino-vascular system seems to control headache of a vascular type and associated craniofacial vasodilatation in human subjects.

Effects of 17 beta-estradiol, progesterone and tamoxifen on in vitro proliferation of human pituitary adenomas: correlation with specific cellular receptors.

Six human pituitary adenoma cultures, characterized for estrogen and progesterone (Pg) receptors, were treated with 17 beta-estradiol (17 beta-E2), Pg and tamoxifen (TAM) at different concentrations, alone and in combination, for 2, 4 and 8 days. Cell proliferation data showed in most cases a stimulating effect of 17 beta-E2 and an inhibitory effect of Pg on cell growth, which appeared to be correlated with specific receptor expression, but independent of pituitary cell hormone content. A marked inhibitory effect of TAM on cell proliferation was present in all cases, but, on the contrary, was independent of estrogen receptor expression.

Hemorrhagic pituitary adenomas: clinicopathological features and surgical treatment.

Forty-five (9.9%) of 453 pituitary adenomas operated on between January 1973 and November 1988 demonstrated hemorrhagic changes at surgery: 24 had a blood collection, 12 had a blood collection associated with hemorrhagic necrosis, and 9 had hemorrhagic necrosis. Thirteen patients (28.9%) experienced the acute symptoms of pituitary apoplexy, whereas another 32 had an "asymptomatic" hemorrhage, that is, the clinical course was comparable to an uncomplicated adenoma. Nineteen tumors (42.2%) showed marked suprasellar extension, 8 (17.8%) showed moderate extension, and 11 (24.5%) showed slight extension; another 2 (4.4%) were laterosellar and 5 (11.1%) were intrasellar. Invasive behavior was present in 32 cases (71.1%) and this may suggest another hypothesis to explain the pathogenesis of tumoral hemorrhage. The incidence of hemorrhagic complications in invasive adenomas with marked suprasellar extension was particularly impressive; therefore, we do not suggest preoperative bromocriptine treatment in this type of tumor. Two of 14 patients operated on by the transcranial route died after surgery, whereas there was no operative mortality in the 31 patients operated on by the transsphenoidal route. It proved advantageous to operate as early as possible, even during the acute phase of pituitary apoplexy. The transsphenoidal approach gave the best results, but to achieve satisfactory late results multidisciplinary treatment was necessary, namely, postoperative radiotherapy in 23 patients, bromocriptine in 12, and endocrine replacement therapy in almost all. In an average follow-up period of 6.2 years, 5 (11.1%) symptomatic recurrences were observed.

Microsurgical treatment of glossopharyngeal neuralgia: case reports.

Three patients with excruciating glossopharyngeal neuralgia underwent microsurgical operations in the posterior cranial fossa. In each patient, neurovascular compression was found involving the posteroinferior cerebellar artery and involving the 9th and 10th cranial nerves. In two of the patients, the compression was caused by arachnoiditis and in the other by an arterial loop. In each patient, neuralgia was successfully eliminated by microvascular decompression and by section of the upper rootlets of the vagus nerve. In one patient, partial section of the 9th cranial nerve was also performed. Because of the frequent involvement of the vagus nerve in the pathogenesis of this condition, open surgery should be preferable to percutaneous thermorhizotomy, which is unable to act selectively on the 10th cranial nerve.

Chemical meningitis: unusual presentation of a cerebellar astrocytoma: case report and review of the literature.

Chemical meningitis resulting from the spillage of the contents of a cystic tumor rarely constitutes the sole manifestation of a cranial or spinal tumor. The case of a man who initially had signs and symptoms of meningitis that on computed tomographic scan was shown to be a space-occupying cerebellar lesion is reported. Thirty-five cases of cranial and spinal tumors in which the presenting symptom was chemical meningitis are also reviewed.