Post-operative diabetes insipidus after endoscopic transsphenoidal surgery.

Diabetes insipidus (DI) after endoscopic transsphenoidal surgery (ETSS) can lead to increased morbidity, longer hospital stays, and increased medication requirements. Predicting which patients are at high risk for developing DI can help direct services to ensure adequate care and follow-up. The objective of this study was to review our institution's experience with ETSS and determine which clinical/laboratory variables are associated with DI in this patient population. The authors wanted to see if there was an easily determined single value that would help predict which patients develop DI. This represents the largest North American series of this type. We retrospectively reviewed the charts of patients who had undergone ETSS for resection of sellar and parasellar pathology between 2006 and 2011. We examined patient and tumor characteristics and their relationship to postoperative DI. Out of 172 endoscopic transsphenoidal surgeries, there were 15 cases of transient DI (8.7%) and 14 cases of permanent DI (8.1%). Statistically significant predictors of postoperative DI (p < 0.05) included tumor volume and histopathology (Rathke's cleft cyst and craniopharyngioma). Significant indicators of development of DI were postoperative serum sodium, preoperative to postoperative change in sodium level, and urine output prior to administration of 1-deamino-8-D-arginine vasopressin. An increase in serum sodium of ≥2.5 mmol/L is a positive marker of development of DI with 80% specificity, and a postoperative serum sodium of ≥145 mmol/L is a positive indicator with 98% specificity. Identifying perioperative risk factors and objective indicators of DI after ETSS will help physicians care for patients postoperatively. In this large series, we demonstrated that there were multiple perioperative risk factors for the development of DI. These findings, which are consistent with other reports from microscopic surgical series, will help identify patients at risk for diabetes insipidus, aid in planning treatment algorithms, and increase vigilance in high risk patients.

Nelson syndrome: historical perspectives and current concepts.

The appearance of an adrenocorticotropic hormone (ACTH)-producing tumor after bilateral adrenalectomy for Cushing disease was first described by Nelson in 1958. The syndrome that now bears his name was characterized by hyperpigmentation, a sellar mass, and increased plasma ACTH levels. The treatment of Cushing disease has changed drastically since the 1950s, when the choice was adrenalectomy. Thus, the occurrence, diagnosis, and treatment of Nelson syndrome have changed as well. In the modern era of high-resolution neuroimaging, transsphenoidal microneurosurgery, and stereotactic radiosurgery, Nelson syndrome has become a rare entity. The authors describe the history of the diagnosis and treatment of Nelson syndrome. In light of the changes described, the authors believe this disease must be reevaluated in the contemporary era and a modern paradigm adopted.

Hemifacial spasm in a patient with Marfan syndrome and Chiari I malformation. Case report.

Marfan syndrome, hemifacial spasm, and Chiari malformation are all relatively rare and seemingly separate entities. Marfan syndrome is caused by a defect in the gene that encodes fibrillin and leads to weakness of the artery wall. Hemifacial spasm results from compression of the facial nerve by an abnormal artery. Chiari malformation is characterized by a small posterior fossa. The authors report the case of a patient with Marfan syndrome who presented with hemifacial spasm and was also found to have a Chiari malformation Type I. The patient's Chiari malformation and hemifacial spasm were successfully treated by performing suboccipital and microvascular decompression surgeries, respectively. The pathophysiological characteristics of Marfan syndrome, hemifacial spasm, and Chiari malformation are discussed, and the authors propose a link between these conditions in this patient. The authors hypothesize that the patient's Marfan syndrome contributed to the abnormal shape of his vertebral artery and that, given the lack of space in his crowded posterior fossa due to the Chiari malformation, the artery caused compression of his facial nerve, resulting in hemifacial spasm.

Multimodality treatment for invasive pituitary adenomas.

Most pituitary adenomas are slow-growing, benign tumors that do not exhibit aggressive behavior but instead grow by expansion. The majority of these adenomas can be treated successfully with transsphenoidal resection. However, more than one-third of adenomas are invasive, making complete surgical resection without unacceptable neurological deficits difficult. These more complicated adenomas require multimodal treatment and long-term follow-up for continued favorable outcomes. Initial surgical resection is indicated for decompression of the optic apparatus or cytoreduction before adjuvant therapy, even when gross total resection is not anticipated. Medical therapy is an option for most endocrinologically active adenomas, but nonfunctioning and functional adenomas that do not respond to medical therapy require a multidisciplinary approach. Radiation is often beneficial and can be delivered either as fractionated therapy or in a single dose. Conformal dose planning can be used in most cases to maximize therapeutic benefits. This article reviews the evaluation and treatment of invasive pituitary adenomas and discusses promising new therapies.

Neuro-ophthalmologic manifestations of benign anterior skull base lesions.

Visual disturbance is a common presenting symptom of anterior skull base lesions. These lesions cause deterioration in visual acuity, restriction of the visual field, or reduction of ocular mobility. Common pathological entities that affect the skull base and involve vision include meningioma, pituitary adenoma, tumors of the bone, malignancy, and infection. Benign lesions are typically treated surgically with acceptable long-term results. In this article, we review the presentation, evaluation, and surgical treatment of patients with benign skull base lesions presenting with visual disturbance.

Giant-cell tumors of the cervical spine: case report.

OBJECTIVE: Giant-cell tumors of bone are rare, benign neoplasms that occur infrequently in the spine above the sacrum, and their presence in the cervical vertebrae is even more exceptional. Although complete en bloc surgical resection is difficult in the cervical spine, treatment with adjuvant radiotherapy has been considered controversial because of a small risk of malignant transformation. The authors report two cases of giant-cell tumors in the cervical vertebrae that were treated successfully with surgical excision and postoperative radiation as well as long-term follow-up. CLINICAL PRESENTATION: Both patients presented with neck pain radiating into the upper extremities. In both cases, plain radiography, computed tomographic scanning, and magnetic resonance imaging revealed a large destructive process in the vertebral body. INTERVENTION: In one case, the tumor was treated by anterior resection, then by laminectomy and instrumented fusion, and finally by adjuvant postoperative radiotherapy. In the second case, treatment consisted of radical anterior and posterior resection with instrumented fusion. However, the tumor recurred, and, after several surgical procedures, external beam radiotherapy was administered. The patients have been followed for 17 and 11 years, respectively, with no evidence of tumor recurrence. CONCLUSION: Radical resection of giant-cell tumors is generally agreed to be the best treatment option. However, complete resection is often not a feasible option for tumors in the cervical spine because of involvement of critical neurovascular structures. In these cases, the benefits of radiotherapy to reduce the risk of local recurrence may well outweigh concerns about the treatment's theoretical risks.