Endoscopic Endonasal Transsphenoidal Surgery for Patients with Prolactinomas: Indications and Outcomes.

OBJECTIVE: Clinical paradigms and consensus recommend dopamine agonists (DAs) as the primary treatment for prolactinomas. However, medically treated patients also encounter challenges such as DA resistance, intolerable side effects, and recurrence of hyperprolactinemia after DA withdrawal. Technical advances in transsphenoidal resection, with an endoscopic endonasal approach, have led to improved visualization of tumor, decreased postoperative morbidity, and shortened length of stay. We examined the indications and outcomes in patients with prolactinomas who underwent surgical resection at our center. METHODS: A retrospective analysis was performed of 60 consecutive patients with prolactinomas who underwent endoscopic endonasal transsphenoidal resection between August 2010 and July 2019 and were followed by the same multidisciplinary team. RESULTS: Women comprised 73% of surgical cases, and 60% of the tumors were macroadenomas. The most common primary surgical indication was patient preference (26.6%) followed by DA intolerance (25%) and DA failure (18.3% inadequate shrinkage, 15% persistent hyperprolactinemia, 11.7% both). Gross total resection was noted in 83% and length of stay was 1 day in 92% of patients. Early remission (postoperative day 1 normalization of prolactin off DA therapy) was seen in 71% of all patients, 91% of microadenomas, 56% of macroadenomas, 65% of Knosp grade 0-2 macroadenomas, and 75% of macroadenomas operated on with expectation of a cure. Only 3 patients had recurrence, at 4.3, 3.3, and 1.6 years of follow-up, respectively. CONCLUSIONS: Endoscopic endonasal resection is a viable option for management of patients with prolactinomas in the setting of a high-volume pituitary center, with minimal postoperative complications.

A Remarkable Response of Granulomatous Hypophysitis to Infliximab in a Patient With a Background of Crohn's Disease-A Case Report.

Background: Hypophysitis is primary or idiopathic or secondary to another disease process. The histologic subtypes of hypophysitis are lymphocytic, granulomatous, xanthomatous, xanthogranulomatous, or IgG4-related. Granulomatous hypophysitis is the second most common form and is characterized by multinucleated giant cells with granulomas and histiocytes. It can be idiopathic or secondary to another process such as infection, sarcoidosis, vasculitis, dendritic cell disorders, Crohn's disease (CD) or a reaction to rupture of a Rathke's cyst or pituitary adenoma. We present a case of granulomatous hypophysitis in a patient with CD who had resistance to corticosteroids but a dramatic response to immunosuppressive therapy with anti-tumor necrosis factor (TNF)-α therapy. Case description: A 43-year-old woman with a 9-year history of ileal and colonic CD presented to the Pituitary Center with headaches, visual disturbance, fatigue, nausea, and secondary amenorrhea. She was not on active therapy for her CD at the time of presentation and had no gastrointestinal symptoms. Hormonal evaluation revealed hyperprolactinemia, secondary hypothyroidism and adrenal insufficiency. MRI revealed a 12 × 12 × 19 mm sellar lesion abutting the optic chiasm, reported as a macroadenoma. The patient underwent endoscopic transsphenoidal biopsy of the pituitary mass. Pathology revealed granulomatous hypophysitis. Evaluation for secondary causes of hypophysitis, apart from CD, was negative. Despite a course of high dose prednisone, her symptoms and MRI findings worsened and she developed symptoms consistent with diabetes insipidus. Using a personalized medicine approach, she was started on anti-(TNF)-α therapy with infliximab combined with azathioprine, which are indicated for treatment of CD. Her headaches and polyuria resolved and her menstrual cycles resumed. MRI at 3 months and more than 1.5 years after initiation of anti-TNF-α therapy revealed durable resolution of the pituitary mass. Conclusion: To our knowledge, this is the first report of successful use of anti-TNF-α therapy for a patient with granulomatous hypophysitis, in this case associated with a previous diagnosis of CD. Although glucocorticoids are used frequently as first-line therapy for primary hypophysitis, granulomatous hypophysitis can be corticosteroid resistant and other immunosuppressive approaches may need to be considered within the context of the patient.

An Effective and Practical Fluid Restriction Protocol to Decrease the Risk of Hyponatremia and Readmissions After Transsphenoidal Surgery.

BACKGROUND: Delayed hyponatremia is a common complication following transsphenoidal surgery (TSS) of pituitary lesions, which leads to significant patient morbidity, as well as increased hospital costs associated with readmission. OBJECTIVE: To report the effects of fluid restriction, during a postoperative period of 4 d, to decrease rates and readmissions for hyponatremia in a cohort of patients undergoing TSS. METHODS: Because of our observed postoperative rates of hyponatremia, we implemented 1000-mL fluid restriction limited to postoperative days (POD) 4 to 8 in consecutive patients undergoing surgery at our center between March 2018 and January 2019. Patients were monitored for the development of hyponatremia and readmissions. We compared outcomes with those of patients who had undergone TSS prior to fluid restriction. RESULTS: Data from 57 patients who underwent TSS following implementation of fluid restriction were compared to prior patients who underwent TSS without restriction. The rate of hyponatremia in patients (n = 57) prior to fluid restriction was 12.3%. Following implementation of fluid restriction, we had zero cases of hyponatremia or readmissions. We found body mass index to be inversely related to the risk of hyponatremia and readmissions. Furthermore, male gender, follicle stimulating hormone and/or luteinizing hormone staining on pathology, and administration of preoperative and intraoperative glucocorticoids were associated with decreased risk of hyponatremia readmissions. CONCLUSION: The implementation of 1000-mL fluid restriction between POD 4 and 8 is a highly successful and simple approach to decrease the risk of delayed hyponatremia after TSS.

Molecular profiling predicts meningioma recurrence and reveals loss of DREAM complex repression in aggressive tumors.

Meningiomas account for one-third of all primary brain tumors. Although typically benign, about 20% of meningiomas are aggressive, and despite the rigor of the current histopathological classification system there remains considerable uncertainty in predicting tumor behavior. Here, we analyzed 160 tumors from all 3 World Health Organization (WHO) grades (I through III) using clinical, gene expression, and sequencing data. Unsupervised clustering analysis identified 3 molecular types (A, B, and C) that reliably predicted recurrence. These groups did not directly correlate with the WHO grading system, which classifies more than half of the tumors in the most aggressive molecular type as benign. Transcriptional and biochemical analyses revealed that aggressive meningiomas involve loss of the repressor function of the DREAM complex, which results in cell-cycle activation; only tumors in this category tend to recur after full resection. These findings should improve our ability to predict recurrence and develop targeted treatments for these clinically challenging tumors.

Intraoperative Computed Tomography Angiography: A Novel Completion Imaging Modality for Carotid Endarterectomy.

BACKGROUND: Intraoperative computed tomography angiography (ICTA) is a novel completion imaging modality for carotid endarterectomy (CEA). No studies exist in the literature describing ICTA use in CEA. OBJECTIVE: To evaluate the feasibility and efficacy of ICTA as a method of immediately evaluating the technical results of CEA. METHODS: Twenty-three consecutive CEAs were performed by a single neurosurgeon over an 8-month period. Of this series, 12 utilized ICTA for completion imaging, 10 utilized duplex ultrasonography (US), and 1 utilized no intraoperative completion imaging. Electronic medical records were reviewed to assess demographics, CTA results, US results, and need for revisions. RESULTS: Patients included 13 men (62%) and 8 women (38%). All patients had symptomatic internal carotid artery stenosis. Polytetrafluoroethylene (PTFE) patch angioplasty was used in 16 cases (70%). Average operative times were comparable between cases that utilized CTA and US, 180 and 175 min, respectively. Major technical defects were identified in one of the 12 cases utilizing ICTA and none of the 10 cases utilizing intraoperative US. The technical defect was revised without subsequent neurological complication. One patient had a postoperative intracerebral hemorrhage requiring surgical evacuation. Fifteen patients were followed for up to 3 months with no postoperative stroke or transient ischemic attacks. CONCLUSION: ICTA is a potentially safe and effective completion imaging modality compared to traditional alternatives, enabling the identification of technical deficits intraoperatively. While no statistically significant difference in operative times were noted between intraoperative CTA and US use, numerous steps must be taken to maximize the efficiency of ICTA.

Does preoperative scalp shaving result in fewer postoperative wound infections when compared with no scalp shaving? A systematic review.

Preoperative scalp shaving has been a well-established practice among neurosurgeons based on the belief that hair removal prevents postoperative infections. Apart from aiding in improved visualization of the incision line, ease of closure, and dressing application, there are concerns that the presence of hair at the surgical site may interfere with the surgical procedure. Preoperative scalp shaving is a controversial practice, and many neurosurgeons are moving toward not removing any hair or clipping minimal hair along the incision line rather than shaving the scalp. The following is a systematic review of articles related to preoperative scalp shaving before cranial surgeries and the implications for postoperative wound infections. Eighteen articles were identified as potentially relevant based on the search criteria. These articles were selected based on the inclusion and exclusion criteria to provide concise background information and an explanation of scalp-shaving practices in neurosurgery leading to the clinical question posed. An evidence table was compiled to organize the study data and identify key points. The review brings strong evidence that preoperative scalp shaving does not confer any benefit against postoperative wound infection and, paradoxically, may lead to higher rates of infection. Because hair removal neither contributes benefits to the surgery itself nor decreases the risk of wound infection but has considerable cosmetic value for the patient, many of the authors recommended that cranial surgeries should be done without hair shaving.

Nurses' perceptions of open visiting hours in neuroscience intensive care unit.

A quality improvement project was undertaken by Neuro-ICU nurses to determine possible effects from open visitation. From a quality improvement perspective, nurses' concerns were investigated along with their perceptions about open visitation to determine a need for visitation policy revision. Vast variability in nurses' interpretation and implementation of individualized open visitation policy suggested a need for the following: staff education about the policy and its implementation, a review of the literature to determine the validity of concerns about deleterious physiologic effects on neuroscience patients from visitation, and improved communication among nurses about visitation.

Pentobarbital sodium coma for refractory intracranial hypertension.

Refractory intracranial hypertension (RICH) is defined as intracranial pressures that exceed 25 mm Hg for 30 minutes, 30 mm Hg for 15 minutes, or 40 mm Hg for 1 minute. RICH occurs in approximately 15% of patients with traumatic brain injury. If it is not aggressively treated, RICH can result in cerebral herniation and death. Pentobarbital sodium coma is a second-tier treatment that can be used to treat RICH. Understanding the principal mechanics of this therapy is key to the successful management of RICH and quality patient care.