Complications of endoscopic surgery of the pituitary adenomas: analysis of 570 patients and review of the literature.

Endoscopic transsphenoidal surgery is emerging as a minimally invasive and maximally effective procedure for pituitary adenomas. In this report we analyzed the complications in 624 procedures of endonasal transsphenoidal endoscopic surgery in the treatment of 570 patients with pituitary adenomas. The leading author (MB) operated pituitary adenomas via pure endoscopic endonasal transsphenoidal surgery between January 2006 and August 2011 at the Hacettepe University, Department of Neurosurgery in Ankara. Complications were assessed in 624 surgical procedures under five groups; rhinological, CSF leaks, infection, vascular and endocrinologic complications. We observed a total of 76 complications (12.1%). Rhinological complications occurred in 8 patients (1.3%): 4 epistaxis (0.6%) and 4 hyposmia (0.6%). Postoperative CSF leaks occurred in 8 patients (1.3%), and infectious complications occurred in 8 patients: 3 cases of sphenoidal sinusitis (0.4%), 5 cases of meningitis (0.8%). Only 1 case of internal carotid aneurysm rupture during the opening of sellar floor (0.16%) was observed. Endocrinologic complications occurred in 51 (8.1%) patients: Anterior pituitary deficiency in 12 (1.9%), transient diabetes insipidus (DI) in 29 (4.6%), permanent DI in 3 (0.4%) and inappropriate antidiuretic hormone secretion syndrome occurred in 7 (1.1%). There was no mortality directly related to the surgical procedure. The complication rates observed in our study suggests that the endoscopic pituitary surgery is at least as safe as microscopic transphenoidal surgery. These rates were obtained with due experience and well-coordinated teamwork. To further improve these rates, new technological developments will be helpful.

Spinal low-grade neoplasm with leptomeningeal dissemination mimicking tuberculous meningitis in a child.

Spinal seeding of primary malignant intracranial tumors via CSF is common. However, this is rare in low-grade glial tumors. Cranial leptomeningeal metastasis of primary spinal cord low-grade gliomas at diagnosis or relapse is extremely rare. Leptomeningeal metastasis of spinal cord low-grade tumors may mimic tuberculous meningitis in children. A patient with primary spinal cord low-grade neoplasm mimicked tuberculous meningitis is presented. The patient successfully treated with chemoradiotherapy. At the end of 19-month follow-up, diffuse leptomeningeal infiltration and a dural mass compatible with relapse developed. Chemoradiotherapy was started.

Pineal cyst apoplexy: report of an unusual case managed conservatively.

Pineal cyst apoplexy is a very rare entity with previously reported symptoms of severe frontal or occipital headache, gaze paresis and visual field defects, nausea or vomiting, syncope, ataxia, hearing loss and sudden death. The treatment options for symptomatic pineal cysts are observation, shunting, aspiration via stereotactic guidance or endoscopy, third ventriculostomy, ventriculocysternostomy, and/or surgical resection by craniotomy and microsurgery. Here, the authors report an unusual case of a 28-year-old male patient with pineal cyst apoplexy, presenting with headache, insomnia, and sexual dysfunction symptoms who is being managed conservatively and observed for two years by an academic tertiary care unit.

Intravascular lymphoma masquerading as multiembolic stroke developing after coronary artery by-pass surgery.

BACKGROUND: Intravascular lymphoma (IVL) is a very rare non-Hodgkin type lymphoproliferative disorder characterized by neoplastic growth of lymphoid cells within the lumen of capillaries, small veins, and arterioles. The neoplastic cells cannot reach the parenchyma because of the loss of adhesion molecules during malignant transformation. Multifocal vascular occlusions caused by proliferation of malignant lymphocytes in the lumen result in diffuse thrombosis and tissue infarction. The clinical symptoms of the disease are dependent on the specific organ involvement which most often includes the central nervous system and skin. Neurologic presentation includes focal sensory or motor deficits, altered sensorium, rapidly progressive dementia, seizures, ataxia, and vertigo. CASE REPORT: We report a patient with IVL whose symptoms developed on the second postoperative day of coronary artery-bypass surgery imitating a multiembolic stroke. Magnetic resonance imaging showed widespread ischemic subcortical lesions. The patient's clinical status worsened irrespective of supportive medical treatment. The diagnosis was established by autopsy. CONCLUSION: IVL may mimic ischemic stroke. IVL is not often diagnosed before death because of the intravascular growth pattern of the tumor cells and a fulminant clinical course. IVL may be considered in the differential diagnosis of ischemic stroke patients with progressive worsening despite medical management.

The effect of clozapine on regional cerebral blood flow and brain metabolite ratios in schizophrenia: relationship with treatment response.

The purpose of this study was to investigate the effect of clozapine on regional cerebral blood flow (rCBF) and its relationship with response to treatment. In addition, we aimed to study the influence of clozapine on proton magnetic resonance spectroscopy ((1)H-MRS) findings in the dorsolateral prefrontal cortex (DLPFC) in a subgroup of patients. Psychopathology, neurocognitive functioning, and SPECT imaging of 22 patients were assessed at the baseline and 8 weeks after the initiation of clozapine treatment. In 10 of these patients intermediate-echo (TE: 135 ms) single-voxel (1)H-MRS was also performed at the baseline and after 8 weeks. Clozapine treatment increased the right frontal (superior and medial)/caudate perfusion ratio in the whole group, while it increased bilateral frontal (superior and medial)/caudate perfusion ratios in treatment responders. In addition, percentage changes in left and right frontal (superior and medial)/caudate perfusion ratios compared to the baseline were higher in treatment responders than in non-responders. The improvement in attention was related to the increase in percentage change in the right frontal (superior and medial)/caudate perfusion ratio, while the improvement in verbal fluency was related to the increase in percentage changes in both right and left frontal (superior and medial)/caudate perfusion ratios and to right frontal (superior and medial)/thalamus perfusion. Baseline frontal (superior and medial)/thalamus perfusion could explain 32% of the variability of percentage improvements in psychopathology. (1)H-MRS showed that the baseline PANSS general psychopathology score was inversely correlated with the baseline NAA/Cre ratio. An increased NAA/Cre ratio in DLPFC after 8 weeks of clozapine treatment was also revealed by (1)H-MRS. Our SPECT imaging results suggest the presence of an imbalance in fronto-striato-thalamic circuitry that changes with clozapine, especially in the responders, while (1)H-MRS results indicate a supportive effect of clozapine on neuronal integrity.

Surgery for epilepsy in children with dysembryoplastic neuroepithelial tumor: clinical spectrum, seizure outcome, neuroradiology, and pathology.

INTRODUCTION: Dysembryoplastic neuroepithelial tumors (DNTs) were first described by Daumas-Duport et al. in 1988 as a typically cortical tumor affecting young patients with long-standing, drug-resistant epilepsy. METHODS: We reviewed the medical records of 29 patients with DNT between 1994 and 2007 at Hacettepe University Children's Hospital retrospectively; age at the time of surgery, age at seizure onset, electroencephalography (EEG), MRI, medical treatment, surgical procedure, seizure outcome, and pathological findings were documented. RESULTS: Male to female ratio was 15/14. Age at the time of evaluation ranged 4-24 years. Twenty-seven patients (93.1%) had complex partial seizures, one (3.44%) had simple partial seizures, and one patient had generalized seizures. Preop interictal EEG showed epileptiform discharges in 24 patients, while in five patients interictal EEG before surgery showed no epileptiform discharges. Pathologically, 24 of our patients were classified as complex type and five as simple type. MRI showed temporal lesion in 20 (68.9%) patients and nine patients had extratemporal DNT. We choose the type of surgery according to lesion and the epileptojenic zone. Finally, 27 patients had Engel Class IA and two patients had Engel Class IB outcome. CONCLUSION: Complete resection of the lesion with epileptojenic zone is important for seizure-free outcome. Timing of surgery, extent of surgery, and stopping antiepileptic drugs are still important factors.

Intraventricular dysembryoplastic neuroepithelial tumor-like neoplasm with disseminated spinal tumor.

Dysembryoplastic neuroepithelial tumor (DNT)- like lesions arise in extracortical locations and behave in a benign fashion similar to that of cortical DNTs. They usually come to attention by symptoms and signs of increased intracranial pressure rather than focal neurological impairment. Here we report a case of 9-year-old boy with a complaint of headache and back pain. A third ventricular mass lesion with disseminated spinal tumor was detected on his magnetic resonance imaging. The presence of floating neurons in a mucinous matrix, oligodendrocyte-like cells (OLCs) aligning axonal columns and vessels, immunohistochemical profile of the neoplasm in addition to the clinical and radiological manifestations of the patient led to the diagnosis of "DNT-like neoplasm of the third ventricle".

Hyperhomocysteinemia due to pernicious anemia leading to pulmonary thromboembolism in a heterozygous mutation carrier.

Pulmonary thromboembolism is a life-threatening condition resulting mostly from lower extremity deep-vein or pelvic-vein thrombosis. A 46-year-old woman was admitted to hospital with pain on the right side of the chest and hemoptysis. On laboratory analysis, D-dimer level was elevated. Computed tomographic pulmonary angiography revealed intravascular filling defects due to thrombi in right lower lobe pulmonary segmental arteries. Screening for thrombophilic states was normal except for heterozygous mutations of both prothrombin and methylene tetrahydrofolate reductase (MTHFR 677) genes. Homocysteine level was high, and vitamin B12 level and serum ferritin level were reduced. Serum antiparietal antibody was positive, and therefore, pernicious anemia was diagnosed along with iron-deficiency anemia. After the diagnoses were established, enoxaparin followed by warfarin was started in addition to oral vitamin B12, pyridoxine, thiamine, folic acid, and ferroglycine sulfate supplementation. At the end of 8 weeks of the replacement therapy, vitamin B12, folate, and homocysteine levels and red cell volume were found to be normal, with complete resolution of the thrombus confirmed by repeat computed tomographic pulmonary angiography. We conclude that hyperhomocysteinemia due to vitamin B12 deficiency associated with pernicious anemia might have decreased the threshold for thrombosis. In addition, the presence of heterozygous prothrombin and methylene tetrahydrofolate reductase mutations might serve as synergistic cofactors triggering pulmonary thromboembolism.

Intracranial desmoid tumor with familial adenomatous polyposis coli.

Intracranial desmoid tumors are extremely rare. The association of desmoid tumors with familial adenomatous polyposis coli was reported previously, with the tumors involving trunk and extremities. We report a 3.5-year-old girl with intracranial desmoid tumor with familial adenomatous polyposis coli. This condition in a child is rarely reported. Follow-up of the patient after cranial surgery and of the family for this premalignant inherited condition is necessary.

Radiological evaluation of patients with pituitary langerhans cell histiocytosis at diagnosis and at follow-up.

This study evaluated pituitary imaging findings in 13 patients with Langerhans cell histiocytosis (LCH) with diabetes insipidus. Nine patients were evaluated with pituitary magnetic resonance imaging (MRI), 3 with brain computed tomography, and 1 with brain MRI. The infundibulum was thickened in 11 (84.6%) patients, thread-like in 1 (7.7%), and normal in 1 (7.7%). Posterior pituitary intensity was absent in 10 patients (76.9%); in 4 patients, the pituitary gland was small in size, and 2 patients had atrophic pituitary. Three had a small sella. Infundibular thickening and absence of posterior pituitary intensity were the most common radiological findings. MRI imaging should be used to follow up patients with pituitary histiocytosis, and patients with LCH and diabetes insipidus should be followed for pituitary atrophy.

Impact of recent seizures on cerebral blood flow in patients with sturge-weber syndrome: study of 2 cases.

Patients with refractory seizures, including those with Sturge-Weber syndrome, undergo functional studies in preparation for surgery. Perfusion studies in Sturge-Weber syndrome by single photon emission computed tomography and positron emission tomography generally demonstrate hypoperfusion in the diseased tissue. We report perfusion-weighted magnetic resonance imaging results in 2 cases of Sturge-Weber syndrome with recent seizures. The affected cerebral tissue showed increased relative cerebral blood flow and volume with prolonged mean transit time and time to peak. Elevated relative cerebral blood flow could be attributed to seizures, whereas increased relative cerebral blood volume might have resulted from vasodilation due to seizure activity or chronic ischemia. These findings point to the variable results of functional studies in Sturge-Weber syndrome that might lead to miscalculations of the lesion area before surgery.

Neurologic outcome in patients with MRI pattern of damage typical for neonatal hypoglycemia.

Imaging features of infants who suffered from brain damage as a result of neonatal hypoglycemia were shown to have similar patterns, and to affect the parietal and occipital lobes most severely. Long term follow up regarding clinical outcome of patients with neonatal hypoglycemia and this pattern of damage are limited. We reviewed the medical records of 24 patients with typical neuroimaging features seen following neonatal hypoglycemia; we report neurological outcome in 13 of them who have documented hypoglycemia. Except for one patient, all patients had prenatal and perinatal problems including prematurity, perinatal hypoxia, intrauterine growth retardation, sepsis, indirect hyperbilirubinemia. All but one patient had symptomatic partial epilepsy, five of them were medically intractable. Other neurologic problems included developmental delays, learning and behavior problems, hyperactivity and attention difficulties, autistic features, microcephaly and cortical blindness. We conclude that early diagnosis and treatment of neonatal hypoglycemia is crucial to prevent future neurological sequelae, especially in patients with additional perinatal risk factors.

Evaluation of parenchymal changes at the operation site with early postoperative brain diffusion-weighted magnetic resonance imaging.

PURPOSE: To evaluate diffusion changes in the brain parenchyma at the operation site during the first 24 hours following surgery. MATERIALS AND METHODS: The study group consisted of 52 patients, 39 who had tumor resection surgery and 13 who had epilepsy surgery. Early postoperative magnetic resonance imaging (MRI) included diffusion-weighted imaging (DWI) and routine contrast-enhanced cranial MRI, together with T2* weighted images on a 3T system. DWI findings and the presence of hemorrhage in the brain parenchyma were evaluated. Correlation between the findings, the primary lesion leading to surgery, and operation site were evaluated. RESULTS: Diffusion restriction in the parenchyma surrounding the resection cavity was seen in 17 tumor patients (32.7%, n=52) and in 8 epilepsy patients (15.4%, n=52). DWI showed increased diffusion in 7 patients and no abnormality in 4 patients. Twenty patients showed restricted diffusion pattern related to hemorrhage (38.5%, n=52). CONCLUSION: Restricted diffusion was the most common abnormality observed in the early postoperative DWI of brain parenchyma at the operation site after surgery, which suggested tissue injury caused by surgery. Yet, hemorrhaging in the operation bed can constitute another cause of a reduced apparent diffusion coefficient (ADC) value. Increased diffusion and normal diffusion can also be observed, though rarely.

Multilevel myelopathy in Maroteaux-Lamy syndrome and review of the literature.

An 18-year-old male with Maroteaux-Lamy syndrome was presented with spastic quadriparesis. Magnetic resonance imaging of whole spinal canal revealed stenosis at multiple levels of cervical, thoracic and lumbar regions. By the guidance of combined evaluations of neurological examination, neuroradiological and electrophysiological findings, the most responsible spinal segment was detected each time he developed myelopathy and he underwent craniocervical, cervical and thoracolumbar decompressions consecutively. Ligamentum flavum hypertrophy was found to be the principal pathology responsible for the cord compression and myelopathy for all levels. The etiology of myelopathy and priority of the level for which decompression should be done in diffuse spinal stenosis were discussed with the literature review of Maroteaux-Lamy syndrome.

Diethylstilbestrol-induced prolactinoma: dose-related tumor growth and effect of catecholaminergic cells on prolactin tumor cells.

BACKGROUND: Prolactinoma is a pituitary adenoma originating from prolactin-secreting epithelial cells of the adenohypophysis. Unfortunately, there appears to be a relatively high recurrence rate despite all pharmacological, radiological, and surgical therapeutic interventions. The aim of the present study was to evaluate the extent of involvement of the dopaminergic dysregulation hypothesis of prolactinomas. We transplanted, in rats, DES-induced prolactinoma cells into the adrenal medulla or under the renal capsule, two tissues rich and poor in catecholaminergic innervation, respectively. METHODS: Prolactinoma was dose-dependently induced in ovariectomized female rats implanted with 10 and 20 mg DES, and tumor cells taken from prolactinoma induced by 20 mg DES were either transplanted under the renal capsule or into the adrenal medulla. RESULTS: Although the adrenal medulla, with its high dopamine content to inhibit prolactin secretion, was devoid of any tumoral development, a significant tumoral development was evident under the renal capsule, seemingly because of no inhibitory control over prolactin secretion coexisting with the dopamine deficiency of the tissue. Results are discussed for an alternatively possible regression and prevention of any relapse of prolactinoma, most possibly occurring because of tuberoinfundibular dopamine deficiency, by the implantation of another dopamine-rich tissue beside the tumoral mass. CONCLUSION: Regression and prevention of any relapse of a tumoral outgrowth, most possibly occurring because of tuberoinfundibular dopamine deficiency, can well be alternatively achieved by the implantation of another dopamine-rich tissue beside the tumoral mass prolactinoma.

Multislice mapping and quantification of brain perfusion MR imaging data: a comparative study of homemade and commercial software.

PURPOSE: We developed a homemade computer program for analysis of perfusion weighted MR imaging (PW-MRI) data in order to produce colored multislice rCBV, rCBF, and MTT maps. We then compared those maps with others produced by a commercially available program, obtained from the same PW-MRI data, to determine the feasibility of using our program in clinical practice. MATERIALS AND METHODS: Studies of 20 patients were performed on a high field MR scanner. Imaging protocol consisted of perfusion study (EPI, TR/TE: 1430/46 msec, 10 mm gap, matrix: 128x128, FOV: 240 cm, NEX: 1). Twenty ml of Gd-DTPA was administered at a rate of 4-5 ml/sec beginning at the 5th acquisition of 50 dynamic series. MATLAB software was used for writing codes of both mathematical equations and the graphical user interface. All images were in DICOM standard. For validation of the results, all maps were compared with another commercially available program, which is widely being used in daily practice, and was installed on the MR scanner. Ability to define the lesion contours and extension, and artifacts at the bone-soft tissue interface were the criteria used for statistical evaluation. RESULTS: Field definition was equally good in 38% of the patient scans for both software programs; our homemade software was better in 23% of the cases and the commercial software was better in 31%. In 6% of the results, either software program was not sufficient. For the elimination of artifacts, our homemade software was 100% successful in every case. CONCLUSION: Our homemade program is a user friendly one that gives comparable results with those of a commonly used commercial one. However, this program should be tested with different categories of diseases and a larger patient population and then compared with different commercial software programs to be validated more clearly.

Diffuse spinal and intercostal nerve involvement in chronic inflammatory demyelinating polyradiculoneuropathy: MRI findings.

Chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) is an uncommon demyelinating disorder with a relapsing and remitting or continuously progressive course. Hypertrophic nerve roots, sometimes associated with gadolinium enhancement, has been reported more commonly in lumbar spine and less commonly in the brachial plexus and cervical roots; however, diffuse involvement of intercostal nerves bilaterally has never been reported previously. We present MRI findings which include diffuse enlargement and mild enhancement of roots and extraforaminal segments of nerves in all segments except a short segment between T12-L2 as well as all the intercostal nerves in a case of CIPD with a 10-year history.

Stroke owing to noncompaction of myocardium.

Noncompaction of myocardium is a rare and recently defined entity that may cause cardioembolism during childhood. We report an 18-month-old girl with noncompaction of the left ventricular myocardium presenting with fatal cardioembolic stroke. The patient had a high factor VIII level, which is known to cause an increased tendency to thromboembolic events. To our knowledge, this is the youngest case with stroke associated with noncompaction of the myocardium. Patients with noncompaction should be considered for prophylactic antithrombotic treatment to prevent mortality and morbidity owing to systemic thromboembolic events, especially if they carry additional risk factors that make them prone to hypercoagulation.