The efficacy of a visiting surgical service versus that of a hospital-based surgical service in providing endoscopic endonasal surgery to remove nonfunctioning pituitary adenomas in rural communities.

PURPOSE: To satisfy the increasing demand for endoscopic endonasal approach (EEA) to treat pituitary tumors, especially in rural areas, the "mobile EEA" system, a visiting surgical service, has been established We report this unique system for maintaining community healthcare and evaluate the surgical results of mobile EEA. METHODS: A retrospectively acquired database of 225 consecutive cases of EEA at Shinshu University Hospital (i.e., "home EEA") and its affiliated hospitals (i.e., "away EEA") between May 2018 and May 2022 was reviewed. A total of 105 consecutive patients who fulfilled the criterion of a diagnosis of new-onset nonfunctioning pituitary adenoma (PA) were included. Clinical characteristics and postoperative clinical outcomes were statistically compared between the home EEA and away EEA groups to assess the presence of a home advantage and/or an away disadvantage. RESULTS: Patients were stratified into two cohorts: patients treated at our hospital (home EEA: n = 41 [39.0%]) and those treated in the visiting surgical service at an affiliated hospital (away EEA: n = 64 [61.0%]). Postoperative clinical outcomes, such as the extent of tumor resection (p = 0.39), operation time (p = 0.80), visual function (p = 0.54), and occurrence of surgical complications (p = 0.53), were comparable between the groups. There were no visiting surgical service-related adverse events or accidents caused by physicians' driving to away hospitals. CONCLUSION: Pituitary surgeries performed via the mobile EEA system for nonfunctioning PAs may help maintain local community healthcare. Furthermore, this system can also contribute to the efficient training of surgeons by the same experienced pituitary surgeon using the same protocol.

Postoperative Intratumoral or Peritumoral Hematomas After Vestibular Schwannoma Resection.

BACKGROUND: Surgical removal of a vestibular schwannoma is a complex and challenging procedure, which may be complicated by development of postoperative hematomas, particularly after incomplete resection of the tumor. OBJECTIVE: To investigate the occurrence of postoperative intra- or peritumoral hematomas after surgery for a vestibular schwannoma. METHODS: This retrospective study evaluated 49 patients (age range 17-78 years) with a vestibular schwannoma, who were treated surgically via the lateral suboccipital approach between 2011 and 2016. The tumors ranged in size from 0 mm (in a case of an intracanalicular lesion) to 56 mm. In 30 cases (61%), total or near-total resection was accomplished, and in 19 cases (39%), subtotal or partial resection was done. On the basis of their bleeding tendency during tumor removal, the patients were divided into a "less-bleeding" (38 cases; 78%) and a "more-bleeding" (11 cases; 22%) subgroups. RESULTS: A maximal vestibular schwannoma diameter >30 mm, patient age >60 years, and more bleeding during tumor removal were significantly associated with incomplete (subtotal or partial) resection. In six cases (12%), serial computed tomography after surgery demonstrated a postoperative hematoma, which was caused by insufficient irrigation of the surgical field (in two cases) or resulted from peritumoral hemorrhage (in two cases), intratumoral hemorrhage (in one case), or both intra- and peritumoral hemorrhage (in one case). The latter patient required urgent reoperation. In all cases, postoperative hematomas occurred after incomplete (subtotal or partial) resection of a vestibular schwannoma, and their development was significantly associated with more bleeding during tumor removal. CONCLUSION: For avoidance of postoperative hematomas, careful hemostasis is required after completion of vestibular schwannoma removal, especially in cases with incomplete resection and an excessive bleeding tendency of the tumor tissue.

Endoscopic endonasal transsphenoidal surgery in acromegaly with conchal sphenoid sinus.

BACKGROUND: A conchal non-pneumatized sphenoid sinus tends to be considered as unfavorable for transsphenoidal surgery because of procedural difficulties. Especially in acromegalic patients, the proportion of the conchal type of sphenoid sinus is potentially high compared with that of other patients who have a pituitary tumor. This report investigates the characteristics and surgery of the conchal type of sphenoid sinus in acromegaly along with the internal bone properties. CLINICAL PRESENTATION: A 70-year-old man with acromegaly underwent endoscopic endonasal transsphenoidal surgery. Intraoperatively, the anterior wall of the non-pneumatized sphenoid was cortical, however, the cancellous bone was very soft, included fatty tissue, and was easily removed by suction. The sellar lesion could be reached without any problems, and finally, total tumor resection was achieved. CONCLUSION: Based on this surgical case, the conchal sphenoid sinus of acromegaly is not always homogeneous solid bone but may contain soft fatty tissue. Therefore, although the sphenoidal characteristics may have an impact on the surgical procedures, precise assessment pre- and intraoperatively can make transsphenoidal surgery with conchal sphenoid sinus feasible.

Intraspinal canal platform system for coil embolization of anterior spinal artery aneurysm associated with spinal cord arteriovenous malformation: a case report and literature review.

BACKGROUND: The prognosis for spinal artery aneurysms associated with spinal cord arteriovenous malformations (AVMs) is poor because of the high rupture rate of aneurysms. However, endovascular treatment remains technically difficult because the catheter system must be constructed via the small-caliber anterior spinal artery (ASA) or posterior spinal artery (PSA), which feeds functionally eloquent spinal cord. A 2.6F Carnelian HF-S microcatheter (Tokai Medical Products, Aichi, Japan) has been specifically designed to assist a 1.6F Carnelian MARVEL S microcatheter (Tokai Medical Products) as a small-profile 'platform catheter' close to the target lesion. Here we present a prenidal ASA aneurysm treated using a 2.6F Carnelian HF-S microcatheter as an intraspinal canal platform catheter and review related literature. CASE PRESENTATION: A 50-year-old man presented with a subarachnoid haemorrhage due to cervical spinal cord AVM. Diagnostic vertebral angiography revealed the AVM supplied by the PSA originated from the right C2 segmental artery and ASA arising from the right V4 segment. Superselective angiography for each feeder was achieved through a 2.6F Carnelian HF-S microcatheter, and a prenidal ASA aneurysm was diagnosed, which was clinically consistent with haemorrhagic origin. A 1.6F Carnelian MARVEL S microcatheter was cannulated into the aneurysm through the 2.6F Carnelian HF-S microcatheter positioned at the ASA. The aneurysm coiling was successfully performed without system instability or periprocedural complications. CONCLUSIONS: Only a few cases have described endovascular treatment for spinal artery aneurysms. To date, no reports have been published regarding the use of an intraspinal canal platform catheter to treat spinal artery aneurysms. A 2.6F Carnelian HF-S microcatheter served as a useful intraspinal canal platform catheter for coil embolization of the ASA aneurysm. This system can provide excellent accessibility and controllability for endovascular treatment of spinal artery lesions.

Sequential Development of Putaminal Hemorrhage and Corona Radiata Infarction in the Same Lenticulostriate Arterial Territory.

Putaminal hemorrhage is a common type of spontaneous cerebral hemorrhage. However, to our knowledge, there have been no reports of sequential cerebral hemorrhage and infarction in the same perforating arterial territory. Herein, we present the first reported case of the sequential development of putaminal hemorrhage and corona radiata infarction in the same lenticulostriate arterial (LSA) territory. Early intensive blood pressure lowering treatment may have aggravated ischemic damage. If a patient presents with motor weakness that cannot be explained by putaminal hemorrhage, the sequential development of corona radiata infarction in the same LSA territory should be ruled out.

Contralateral Transradial Access for Coil Embolization of Distal Anterior Cerebral Artery Aneurysm Associated With a Steep Ipsilateral A1-A2 Angle.

OBJECTIVE: Endovascular treatment of distal anterior cerebral artery aneurysms is commonly addressed via the ipsilateral A1 segment of the anterior cerebral artery. However, when the parent pericallosal artery has a sharp ipsilateral A1-A2 angle, catheterization through the ipsilateral A1 segment can potentially result in vessel injury, catheter kinking, and/or compromised/stagnant anterior cerebral artery flow. Here, we present a case of a distal anterior cerebral artery aneurysm associated with a steep ipsilateral A1-A2 angle treated with contralateral transradial coil embolization. CASE PRESENTATION: A 91-year-old woman presented with a ruptured left distal anterior cerebral artery aneurysm at the A3 segment. The parent pericallosal artery had a steep ipsilateral A1-A2 angle. To safely achieve coil embolization of the aneurysm, a contralateral transradial system via the right A1 segment was employed. Although a secondary ipsilateral transradial system was required for contrast injection, aneurysm obliteration was successfully achieved without vessel injury or system instability. CONCLUSION: The A1-A2 angle can be a key anatomical factor in the endovascular treatment of distal anterior cerebral artery aneurysms. The contralateral transradial system is a useful treatment option for distal anterior cerebral artery aneurysms associated with sharp ipsilateral A1-A2 angles. However, if the distal anterior cerebral artery aneurysm cannot be clearly visualized through the contralateral system, an ipsilateral system will be required for contrast injection.

Transradial quadraxial system for coil embolization of distal anterior cerebral artery aneurysms: A radial-first center case series and literature review.

PURPOSE: Endovascular treatment is technically challenging as distal anterior cerebral artery (DACA) aneurysms have distal location, small-caliber parent artery, and small size/wide neck. This study evaluated the feasibility and safety of the transradial approach (TRA) with a radial-specific neurointerventional guiding sheath as the first-line technique for DACA aneurysms. METHODS: We retrospectively analyzed an institutional database of consecutive patients with DACA aneurysm who underwent coil embolization using TRA. Ten consecutive patients were included in this study. After the radial-specific 6F Simmons guiding sheath (0.088″ inner diameter) was completely engaged into the target common carotid artery, a quadraxial system (6F Simmons guiding sheath/6F intermediate catheter/3.2F intermediate catheter/single microcatheter) was used for embolization. Then, we assessed for procedural success, angiographic outcomes, and procedure-related or vascular access site complications. RESULTS: Embolization procedures were conducted using simple coiling in eight and stent-assisted coiling with the trans-cell approach in two patients. The embolization procedure was successful in all patients (n = 10). Moreover, none presented with catheter kinking, parent artery flow stagnation, or system instability during the procedure. Immediate postprocedural angiography revealed complete obliteration in six and residual neck in four patients. Then, eight patients underwent follow-up angiography at a mean of 7.1 months, and none developed recanalization or required retreatment. The postprocedural course was uneventful, and there were no complications. CONCLUSION: The transradial quadraxial system had the ability to achieve sufficient stability and kink resistance in DACA aneurysm embolization. Thus, this method was feasible and safe and had a high success rate.

Effectiveness of the intraoperative magnetic resonance imaging during endoscopic endonasal approach for acromegaly.

PURPOSE: Acromegaly is an acquired disorder usually caused by growth hormone-secreting pituitary adenoma, resolution of which requires correction of the excess hormone production. Recently, intraoperative magnetic resonance imaging (iMRI) was reported to be useful during the endoscopic endonasal approach (EEA) for pituitary adenoma. The present study was performed to quantitatively assess the role of iMRI in improving surgical outcomes in EEA for acromegaly. METHODS: Twenty surgeries for acromegaly in EEA performed at Shinshu University Hospital between April 2016 and March 2020 were reviewed retrospectively. The inclusion criteria were cases without severe cavernous sinus tumor invasion (Knosp grade 0 - 3) or history of prior pituitary surgery. Fifteen consecutive patients were enrolled in this study. Clinical characteristics and postoperative clinical outcomes were compared between patients with and without use of iMRI during EEA for acromegaly. RESULTS: Conventional navigation-guided surgery was performed in nine patients, and six underwent iMRI-guided EEA for acromegaly. Gross total resection (GTR) was obtained in the six (100%) patients in the iMRI group, and in four (44.4%) patients in the conventional group without iMRI. Postoperative clinical outcomes, including hormonal remission rate and surgical complications, were comparable between the two groups. CONCLUSION: Although iMRI significantly increased the GTR rate, we found no direct evidence of increased hormonal remission rate by use of iMRI. It is important to confirm complete tumor resection carefully with not only iMRI findings, but also with intraoperative high-definition endoscopic direct visualization to increase the hormonal remission rate of acromegaly.

Correlations Among Consistency, Computed Tomography Values, and Histopathological Subtypes of Spinal Meningioma.

The consistency of spinal meningiomas is important to consider when performing tumor removal surgery. This study evaluated the correlations between spinal meningioma consistency and both preoperative computed tomography (CT) values and histopathological subtypes. Fifteen consecutive patients who underwent surgical resection of spinal meningioma at our institution were identified, and preoperative CT values and the signal intensity of T2-weighted magnetic resonance images of the tumor were determined retrospectively. The consistency of the spinal meningioma was defined based on the ultrasonic surgical aspirator output during tumor debulking. Patients were assigned to 2 groups: a soft group (n=4) and a hard group (n=11). The T2 signal intensity was significantly higher in the soft group than in the hard group (p=0.001). While the CT values were considerably higher in the hard group, the difference was not significant (p=0.19). Regarding the histopathological subtypes, psammomatous meningioma exhibited significantly higher CT values than meningothelial meningioma (p=0.019); however, there was a higher frequency of hard tumors in meningothelial meningioma cases than in psammomatous meningioma cases. Although neither robust correlations between tumor consistency and CT values nor a relationship between tumor consistency and histopathological subtype has been established, these results might help with the perioperative manegement of spinal tumors.

Petroclival tension pneumocephalus: an unrivalled life threatening complication linked to molecular-targeted therapy.

A 73-year-old man with a petroclival tumor (metastatic renal cell carcinoma) presented with a progressive consciousness disturbance attributed to tension pneumocephalus during molecular-targeted therapy following low-dose fractionated radiotherapy for a petroclival tumor. The skull base defect was successfully reconstructed vi an endoscopic endonasal approach.

Endoscopic diving technique for surgery of brain abscess.

BACKGROUND: Recent advances in neuroendoscopic surgery have led to the minimally invasive treatment of brain abscesses using various endoscopy techniques. The endoscopic diving technique (EDT) involving the formation of fluid lenses to improve the visibility of the endoscope has been reported to be useful in the endoscopic endonasal approach (EEA) for pituitary and midline cranial base lesions. Here, we report a case of brain abscess treated endoscopically using EDT in cylinder surgery. CLINICAL PRESENTATION: A 29-year-old man with 11q trisomy syndrome developed a fever and progressive right hemiparesis was observed. A diagnosis of a brain abscess was made based on neuroradiological imaging, and endoscopic irrigation and drainage with EDT via a transparent endoscopic sheath were performed, which provided a clear operative field and allowed satisfactory irrigation without bacterial contamination. The bacterium identified by PCR was Streptococcus intermedius, and antibiotic therapy was administered. Postoperatively, his symptoms gradually improved. CONCLUSION: This is the first technical case report describing the clinical experience of EDT in brain abscess surgery. EDT may be a useful technique not only in EEA but also in cylinder surgery for brain abscesses.

Pediatric Case of Life-Threatening Stroke Caused by Reversible Cerebral Vasoconstriction Syndrome with Spontaneous Cervical Internal Carotid Artery Vasospasm: A Case Report.

Pediatric reversible cerebral vasoconstriction syndrome (RCVS) and spontaneous cervical internal carotid artery (ICA) vasospasm are rare conditions; the former is commonly associated with a favorable prognosis. A healthy 13-year-old girl presented with thunderclap headache, followed by left hemiparesis, during a curling match. Six days after onset, left hemiparesis worsened to hemiplegia. Magnetic resonance imaging showed progressive cerebral infarction caused by severe right middle cerebral artery and cervical ICA stenosis. She became comatose because of impending uncal herniation. Emergent surgical decompression was performed. Then, 59 days after onset, her multiple stenoses improved, which was consistent with RCVS concomitant with spontaneous cervical ICA vasospasm. This is the first case of RCVS that concurrently developed spontaneous cervical ICA vasospasm. The patient developed life-threatening stroke due to the hemodynamic impairment of the affected intracranial and cervical arteries. Spontaneous extracranial supra-aortic artery vasospasm can be a poor prognostic predictor of RCVS.

T-Configuration Stent Placement for Carotid Bifurcation Stenosis Co-Existing with Ipsilateral Intracranial Stenosis: A Case Report and Literature Review.

In patients with carotid bifurcation stenosis co-existing with ipsilateral intracranial artery stenosis, combined treatment with carotid artery stenting (CAS)/carotid endarterectomy (CEA) and extracranial-to- intracranial (EC-IC) bypass can be a useful option to prevent future ischemic stroke events. EC-IC bypass requires a sufficient antegrade flow in the ipsilateral external carotid artery. However, standard CAS/CEA occasionally lead to external carotid artery occlusion. Herein, we present a case of successful one-stage endovascular revascularization of both the antegrade internal and external carotid artery flow using the carotid T-stent technique for carotid bifurcation stenosis co-existing with ipsilateral middle cerebral artery stenosis.

Pitfalls of skull base reconstruction in endoscopic endonasal approach.

Various skull base reconstruction techniques have been developed in endoscopic endonasal approach (EEA) for skull base lesions to prevent postoperative cerebrospinal fluid (CSF) leakage. This study was performed to evaluate the efficacy and pitfalls of our method of skull base reconstruction after EEA. A total of 123 patients who underwent EEA (127 surgeries) between October 2014 and May 2017 were reviewed. Our algorithm for skull base reconstruction in EEA was categorized based on intraoperative CSF leakage graded as follows: grade 0 was excluded from this study; grade 1, dural suturing with abdominal fat graft or packing of gelatin sponge into the cavity; grade 2, method for grade 1 with addition of mucosal flap or nasoseptal flap (NSF); and grade 3, duraplasty in fascia patchwork closure with NSF. Bony reconstruction was not mandatory, and there was no postoperative bed rest or initial lumbar drainage (LD) insertion in any of the cases. Postoperative CSF leakage after EEA was mostly prevented (96.3%) by our algorithm without postoperative initial LD or bed rest. On the other hand, reconstruction surgery was required for postoperative CSF leakage in two cases-one with prior multitranssphenoidal surgery and radiotherapy and another patient with poor compliance due to communication difficulties. Both of the latter patients were obese. Greater care with regard to postoperative CSF leakage is required in patients with prior EEA with radiotherapy and obesity. In such high-risk patients, initial LD or bed rest may be required to prevent postoperative CSF leakage. It is also important to restrict activities that result in increased intracranial pressure.

Calcified ectopic TSH-secreting pituitary adenoma mimicking craniopharyngioma: a rare case report and literature review.

Among pituitary adenomas, which are relatively common brain tumors, elements of ectopic, thyroid-stimulating hormone (TSH) secretion, and intratumoral calcification are unusual. Here, we present an extremely rare case of a calcified ectopic TSH-secreting pituitary adenoma arising from the pars tuberalis mimicking craniopharyngioma based on neuroimaging findings. To our knowledge, this is the first case report of calcified ectopic TSH-secreting pituitary adenoma without symptoms of excessive thyroid hormone secretion.

Significance of surgical management for cystic prolactinoma.

PURPOSE: It is generally accepted that dopamine agonists (DA) represent the first-line treatment for most patients with prolactinoma, and patients become candidates for surgical intervention when DA is contraindicated. Surgical indication for cystic prolactinoma remains controversial. This study was performed to investigate the significance of surgery for cystic prolactinoma. METHODS: A total of 28 patients that underwent transsphenoidal resection of prolactinoma between February 2004 and May 2016 were reviewed. Five consecutive patients with cystic prolactinoma were included in this study. Our surgical strategy for cystic prolactinoma was categorized as follows: first, when the purpose of surgical resection was normalization of the prolactin level, aggressive resection was performed; second, when volume reduction was essential to relieve the visual symptoms and headache, internal decompression was performed followed by DA therapy. The clinical outcomes were analyzed accordingly. RESULTS: All cystic prolactinoma were resected via the transsphenoidal approach without any complications, and all symptoms including visual impairment and hypogonadal activity were finally relieved combined with medication. CONCLUSIONS: Surgery for cystic prolactinoma could be a better option. Transsphenoidal surgery is relatively safe to remove the cystic prolactinoma, additionally it can normalize the prolactine level and achieve adequate and rapid decompression of optic chiasm. The risk of transsphenoidal surgery is highly dependent on the skill of the surgeon and treatment decision for cystic prolactinoma needs to be individualized for each patient.

Endoscopic endonasal transsphenoidal surgery using the iArmS operation support robot: initial experience in 43 patients.

Objective The intelligent arm-support system, iArmS, which follows the surgeon's arm and automatically fixes it at an adequate position, was developed as an operation support robot. iArmS was designed to support the surgeon's forearm to prevent hand trembling and to alleviate fatigue during surgery with a microscope. In this study, the authors report on application of this robotic device to endoscopic endonasal transsphenoidal surgery (ETSS) and evaluate their initial experiences. Methods The study population consisted of 43 patients: 29 with pituitary adenoma, 3 with meningioma, 3 with Rathke's cleft cyst, 2 with craniopharyngioma, 2 with chordoma, and 4 with other conditions. All patients underwent surgery via the endonasal transsphenoidal approach using a rigid endoscope. During the nasal and sphenoid phases, iArmS was used to support the surgeon's nondominant arm, which held the endoscope. The details of the iArmS and clinical results were collected. Results iArmS followed the surgeon's arm movement automatically. It reduced the surgeon's fatigue and stabilized the surgeon's hand during ETSS. Shaking of the video image decreased due to the steadying of the surgeon's scope-holding hand with iArmS. There were no complications related to use of the device. Conclusions The intelligent armrest, iArmS, seems to be safe and effective during ETSS. iArmS is helpful for improving the precision and safety not only for microscopic neurosurgery, but also for ETSS. Ongoing advances in robotics ensure the continued evolution of neurosurgery.

Clinical characteristics of pituitary adenomas with radiological calcification.

BACKGROUND: Radiographic detection of calcification in pituitary adenoma is relatively rare, and the clinical characteristics of pituitary adenoma with calcification remain unclear. Herein, the clinical characteristics of pituitary adenoma with radiological calcification were investigated. METHODS: A total of 160 patients who underwent surgical resection of pituitary adenomas between February 2004 and December 2016 were reviewed. Eighty-one patients had hormone-secreting pituitary adenomas, and 79 patients had nonfunctioning pituitary adenoma. Among these 160 patients, cases with radiological calcifications on preoperative neuroimaging were included in this study, and clinical characteristics with intraoperative findings were analyzed, retrospectively. RESULTS: Pituitary adenoma with calcification on preoperative neuroimaging was observed in only nine cases (5.6%). The study population consisted of these nine patients with nonfunctioning pituitary adenoma (n = 5), mixed growth hormone and prolactin-secreting pituitary adenomas (n = 3), and a prolactinoma (n = 1). In 89% of cases (n = 8), calcified pituitary adenoma was soft enough for suction despite the presence of a granular gritty texture intraoperatively. Besides, in a single patient (11%), evidence of hard thick capsular calcification was seen surrounding a soft tumor component; however, it did not interfere with adequate removal of the soft part, and tumor resection was possible in all cases without any complications. CONCLUSIONS: Pituitary adenoma presenting with calcification is relatively rare, but should be kept in mind to avoid making a wrong preoperative diagnosis. As not all pituitary adenomas with calcification are hard tumors, preoperative radiological calcification should not affect decision-making regarding surgical indications.