Endoscopic surgical treatment for pituitary apoplexy in three elderly patients over the age of 80.

OBJECTIVES: As the population continues to live longer, the diagnosis of pituitary adenoma-induced apoplexy becomes more common in the elderly. The standard treatment options for pituitary apoplexy are debatable. Although there is little information regarding the treatment of pituitary apoplexy in elderly patients, the optimal treatment needs to be determined for this age group. The current study examined the surgical treatment of pituitary apoplexy in three patients over the age of 80. CASE DESCRIPTION: Three patients over the age of 80 with pituitary apoplexy were admitted to our hospital. Some symptoms caused by pituitary apoplexy, including decreased visual acuity, double vision and oculomotor paresis, had persisted for more than 14 days. Magnetic resonance imaging revealed suprasellar mass lesions extending into the cavernous sinus. The general condition of the patients was good, and we performed endoscopic transsphenoidal surgery in each of these cases. The masses were removed, and the histological findings were diagnosed as non-functioning pituitary adenoma with presence of hemorrhagic or ischemic necrosis. Perioperative courses and general conditions were good, and the neurological deficits of each patient improved immediately. CONCLUSIONS: Endoscopic transsphenoidal surgery has the advantage of visualization of the structures surrounding the pituitary gland. Moreover, the complication rate is relatively low because stress on the pituitary gland can be reduced by using this procedure. Even in patients over 80 years of age during the subacute phase, endoscopic surgical management is a good treatment candidate for pituitary apoplexy with mass lesion extension into the cavernous sinus.

Secondary cervical dystonia following stereotactic radiosurgery in a patient with thalamic glioma.

BACKGROUND: Cervical dystonia associated with structural lesion is uncommon. We report the first patient with secondary CD after stereotactic radiosurgery for thalamic glioma. Possible network abnormalities relevant to manifestation of CD were discussed. CASE DESCRIPTION: A 27-year-old woman complaining of headache and left motor weakness was found to have a thalamic tumor on the right side. The lesion was totally removed using transventricular approach. Histopathologically, tumor samples manifested features of anaplastic astrocytoma. She underwent stereotactic radiosurgery in addition to the conventional radiation and chemotherapy. Afterward, she returned to her usual life without any neurological deficits. Sixteen months postoperatively, the patient developed forced head tilting to the left side combined with chin lift. On the TWSTRS, she registered 15 for torticollis severity. The abnormal head posturing was alleviated by the sensory trick of touching her face with her right hand. Irregular-shaped lesion involving the thalamus, lenticular nuclei, midbrain, pons, and cerebellum was presented on magnetic resonance images. Steroid therapy effectively diminished the lesion size, and her abnormal head posturing was gradually ameliorated (TWSTRS severity scale = 3). CONCLUSION: The clinical-neuroradiological course of the present case strongly suggested that the lesion detected long after the surgery was due to radiation necrosis. The present study may provide a critical information in understanding pathophysiological mechanisms of CD that may involve substantial interactions between olivocerebellar and basal ganglia-thalamocortical circuits.

Spontaneous arteriovenous fistula of the orbit: case report.

BACKGROUND: A spontaneous arteriovenous fistula of the orbit is exceedingly rare. We report the first case of such condition treated with direct surgical exposure of the superior ophthalmic vein (SOV) followed by embolization. CASE DESCRIPTION: A 55-year-old man presented with upper lid swelling, conjunctival chemosis, and proptosis of the right eye. Angiography revealed an intraorbital shunt supplied by the ophthalmic artery whose venous drainage curved anteriorly to the SOV. Because transarterial and transvenous endovascular approaches to treat the fistula were impossible, we performed direct surgical exposure of the SOV followed by the embolization of the fistula. Postoperative angiograms demonstrated complete closure of the fistula. All symptoms had disappeared by 2 months after surgery. CONCLUSIONS: For appropriate treatment planning, it is necessary to identify the location of the shunt. In cases where transarterial and transvenous endovascular approaches to treat the fistula are difficult or impossible, direct surgical exposure of the SOV followed by embolization may accomplish complete closure of the fistula without significant risk for iatrogenic injury.

Coil embolization of an aneurysm located at the trunk of the persistent primitive trigeminal artery.

A 71-year-old woman presented with an aneurysm at the trunk of the persistent primitive trigeminal artery (PPTA) manifesting as subarachnoid hemorrhage. Angiography and three-dimensional computed tomography revealed a wide-necked saccular aneurysm at the trunk of the left PPTA. Coil embolization with the balloon-assist technique was successful and PPTA patency was preserved. Preoperative conventional angiography should be performed to check for cross-filling of the PPTA. This case demonstrates that an aneurysm of the trunk of the PPTA can be successfully treated by coil embolization using the balloon-assist technique.