Sphenoid sinus aspergilloma in trans-sphenoidal surgery for pituitary adenomas.

BACKGROUND: Simultaneous appearance of sphenoid sinus aspergilloma and pituitary adenoma is a very rare finding. METHODS: Retrospective analysis of patients with sellar and sphenoid sinus mass lesions who underwent trans-sphenoidal surgery was performed. Demographic data, medical history, predisposing factors, clinical picture, neurological status and radiological findings were reviewed. All patients underwent a trans-sphenoidal microsurgical treatment, and acquired specimens underwent both histopathological and microbiological analysis. RESULTS: Sphenoid sinus aspergilloma was encountered in seven patients. Three patients had an isolated sphenoid sinus aspergilloma and four patients with pituitary macroadenoma had a sphenoid aspergilloma as an incidental finding. CONCLUSIONS: Sphenoid sinus aspergilloma can be found during trans-sphenoidal surgery for pituitary adenomas. Sphenoid sinus extirpation followed by adenomectomy is the treatment of choice unless invasive aspergilloma is encountered requiring additional antifungal therapy.

Surgical treatment of prolactinomas--our experience.

The dilemma of whether to apply surgical or drug treatment to prolactinomas has been ongoing for the past 30 years. The aim of this study is to compare the early postoperative values of prolactin (PRL) in two groups of patients with prolactinomas: those who underwent primary surgical-treatment, and those who underwent surgery after a dopamine agonist (DA) therapy. We present the results of surgical treatment on a series of 161 patients with prolactinomas. Surgery was the primary treatment in 65 patients, while 96 patients had surgery following a long-term treatment with a DA. All surgically treated prolactinomas were operated in the standard transsphenoidal, microsurgical approach. The criteria for hyperprolactinemia remission was a PRL level under 25 ng/ml. Early normalization of PRL was achieved in 92% of those patients who underwent primary surgical-treatment, yet it was achieved in only 42% of patients who were operated on after receiving a long-term drug treatment with a DA. The highest prevalence of postoperative normalization of PRL was achieved in a group of patients with microadenomas who were primarily operated on (98%). The worst results in postoperative normalization of PRL were found in the group of patients with macroadenomas who received a long-term drug treatment with a DA first. These results show our surgical experience in treating prolactinomas. Using surgical treatment, the best clinical outcome was achieved with microprolactinomas and intrasellar, well-confined macroprolactinomas. Nevertheless, we stress the need of an individualized approach and recommend treatment in multidisciplinary centres for pituitary diseases.

[Croatian Society of Endocrinology guidelines for the diagnosis and treatment of acromegaly]. / Smjernice Hrvatskoga endokrinoloskog drustva za dijagnostiku i lijecenje akromegalije.

The working group of the Croatian Society of Endocrinology met in September 2011 to discuss the diagnostic and therapeutic dilemmas in patients with acromegaly. The group comprised 9 pituitary specialists including endocrinologists, neurosurgeons, and medical biochemistry specialist. After a critical analysis of published scientific papers the group has developed guidelines for the diagnosis and treatment of acromegaly.

Accidental finding of an anomalous spinal nerve root during lumbar-disc surgery: a case report and a review of literature.

Anomalies of lumbosacral nerve roots, even though are rare, have been well documented so far in the medical literature. The early diagnosis of these anomalies may be difficult and it is crucial to develop specific methods for depicting them. Preoperative diagnosis of anomalous lumbosacral spinal nerve roots using the magnetic resonance imaging is essential to facilitate thorough surgical planning in order to avoid unnecessary complications for the patient during surgery. The operative management of these anomalies depends on the patient's neurological problems and while asymptomatic and accidentally diagnosed cases do not require treatment, patients who suffer low back or sciatic pain need surgical intervention in order to decompress nerve roots. We report a 45-years old woman presented with severe low back pain associated with left lumboischialgia. Intraoperative finding of an aberrant L5/S1 nerve root, optimal surgical therapy and different classifications are discussed together with a review of literature.

[ISKRA guidelines for antimicrobial prophylaxis in surgery--Croatian National Guidelines]. / Smjernice ISKRA za antimikrobnu profilaksu u kirurgiji--Hrvatske Nacionalne Smjernice.

Summary. The development of the Guidelines for perioperative prophylactic use of antimicrobial agents (further on Guidelines) was initiated by the Interdisciplinary Section for Antibiotic Resistance Control (ISKRA) of the Croatian Ministry of Health and Social Welfare in accordance with the principles of AGREE (Appraisal of Guidelines for Research and Evaluation) methodology which means that the guidelines are the result of a consensus between all involved professional societies. Guidelines were composed in order to improve antibiotic use in surgical professions. Data obtained from observational studies have shown that the use of antimicrobials in surgical professions is unsatisfactory, and since around 50% of all prescribed drugs in surgical professions refer to perioperative prophylaxis, such guidelines could significantly improve current negative trend and reduce the occurrence of infections in surgical patients as well as slow down the selection of resistant bacteria. In the introductory part of the guidelines, principles of perioperative prophylaxis are presented. The advantages and risks of prophylaxis are listed as well as factors that determine prophylaxis effectiveness. For easier orientation, surgical professions have been divided into basic surgical fields. In each field, the specificity of the field has been described followed by uniform structured tables and with every listed surgical procedure there is the most probable cause of infection, the drug of choice for prophylaxis, alternative drug, remark for particular surgical procedure and finally the grade of recommendation. The Guidelines do not cover perioperative prophylaxis in immunocompromised patients nor perioperative prophylaxis in children. The Guidelines do not cover all possible surgical interventions, but can be used as a basis for most surgical procedures performed in our hospitals. At the very end of these Guidelines, a comprehensive list of references enables all those interested to find further information and details about this topic. The revision of the Guidelines is planned in three years' time.

Medical expertise as a historical phenomenon and academic discipline.

Based on secondary literature, a survey of particular forms of medical expertise over history is presented. The state-to-individual interaction in terms of personality and physical integrity protection, health care, etc., was observed. It was only after the 16th century that the development of anatomy was found to have become a decisive argument for convincing expertise in various trials. In Croatia, the course of medical expertise development was comparable to the close settings in the neighboring European countries. Major advances at the legislative, educational and professional levels took place in the second half of the 19th century. The subject of Forensic Medicine was introduced at Royal Academy of Jurisprudence as early as 1861; the book entitled Lecnicka izvesca (visa reperta) za prakticnu porabu lecnikov by Ivan Dezman (1841-1873) from 1868 offered the first systematic form of autopsy reports, whereas Kratka sudska medicina, a handbook in forensic medicine by Niko Selak (1861-1891) from 1889 denoted the beginnings of forensic medicine literature in Croatian language. It has been noted that medical expertise approach perceives man as a social being at the crossing of manifold impacts and influences, thus being always observed by physicians of various specialties. During centuries, medical expertise has been formed in conjunction with advances in medicine and science, and with the development of civil society. Medical expertise had gradually grown into a multidisciplinary field requiring high professionalism, ethical approach, continuous training and collaboration with various professions. This resulted in a compact and polyvalent discipline, in Croatia gradually formed as a special course in medical curriculum.

Oblique transsphenoethmoidal approach to the cavernous sinus.

Pituitary adenomas frequently invade the cavernous sinus. The standard transsphenoidal approach does not provide satisfactory visualization of the cavernous sinus structures. The transcranial approach has no advantages, and increases the operative trauma and complications. The oblique transsphenoethmoidal approach, a modified standard transsphenoidal approach, was used to treat 19 patients with pituitary adenomas invading the cavernous sinus. Complete tumor removal was achieved in 15 patients and subtotal removal in 4 patients. The patients tolerated this modified transsphenoethmoidal approach well and the postoperative results were satisfactory. Although the number of patients was too small to allow any statistical analysis, the results, compared with other series, are encouraging.

Reversible "brain atrophy" in patients with Cushing's disease.

During the past 25 years, we came across 60 patients with corticotroph pituitary adenomas and Cushing's disease. Neuroradiological examination showed prominent volume loss of the brain parenchyma, unexpected for the patient's age. This "brain atrophy" appeared to regress after surgical removal of pituitary adenoma and normalization of cortisol level. Observed difference between degree of "brain atrophy" in the Cushing's disease group and in the control group was statistically significant (p < 0.001). The degree of "brain atrophy" correlated well with the duration of Cushing's disease. Partial reversibility of "brain atrophy" was noticed during the 2nd, 3rd and 4th year after surgery and normalization of cortisol level. Increased cortisol level is one of the causative factors in pathogenesis of "brain atrophy". Loss of brain volume is at least partially reversible after normalization of cortisol levels.

Centenary of the first trans-sphenoidal surgery of the hypophysis (Hermann Schloffer 1907) and its echoes within Croatian neurosurgical practice.

In this paper we aim to reminisce the role of the Austrian surgeon Hermann Schloffer (1868-1937) as the pioneer of a trans-sphenoidal approach to the pituitary gland. On the 16th of March 1907 he operated a patient with pituitary tumor and published his report in the Wiener Klinische Wochenschrift on 23rd May 1907. This paper is to recall the 100th anniversary of this event. Schloffer's method was spread and modified worldwide, Croatia included, a country in which the interest in trans-sphenoidal approach to pituitary tumors has not diminished or been lost, but slowly modified. Today, almost a whole century after its introduction, it is still used to operate about 95% of sellar region tumors.

Incidence of pituitary tumors in the human population of Croatia.

Pituitary tumors are rare tumors (less then 10%) of the central nervous system (CNS), which malignicity depends on their localization, meanwhile, their biological nature is benign. The diameter they have is mostly less then 10 mm (microadenomas), but sometimes could be 10 mm (macroadenomas) to 5 cm and more and then are usually nonfunctional (about 20% of all pituitary tumors). Clinical presence depends on their localisation and hormonal activity. In the Center for Clinical Neuroendocrinology and Pituitary Diseases, in the last working 10 years, there were treated and examined 504 patients from Croatia, all with pituitary tumors: 182 patients with prolactinomas, 137 with acromegaly, 70 with Morbus Cushing (Mb. Cushing), and 115 patients with nonfunctional pituitary tumors. The patient's classification is based on regional (Mediterranean and continental region, 20 counties) and the state level. In our analysis we haven't found difference in incidence of tumors between Mediterranean and continental region.

Sellar region surgery in Croatia in the first half of 20th century.

We reconstructed the historical development of surgical approaches to the pituitary gland, which were used in Croatia in the first half of the 20th century, on the basis of earliest clinical case reports and descriptions of initial surgical attempts. The first published case report on surgical treatment of acromegaly was described, as well as the review of 11 patients with pituitary disease admitted to the Ophthalmology Clinic in Zagreb in the period 1925-1927. The earliest 5 reports on pituitary surgery dating from 1925 were analyzed to reveal the circumstances that led to the development of transsphenoidal approach as a method of choice in Croatia, when this technique was becoming obsolete in other parts of the world. Frequent modifications of surgical approaches to sellar region have been shown a suitable historical-medical model for analysis of changes in surgical trends.

[Optic nerve injury from the medical expertise point of view]. / Ozljeda vidnog zivca sa stajalista medicinskog vjestacenja.

The optic nerve can be injured directly or indirectly. Direct injury occurs in association with orbital or craniocerebral injury with interruption of anatomical and functional optic nerve integrity. Indirect injuries occur when the force of impact is transmitted to the optic nerve. In the indirect injury group the mostly false diagnosed is traumatic opticoneuropathy especially after whiplash injury. According to Quebec classification, after whiplash injury Ist to IIIrd degree, ophthalmologic examination or visual field testing is not necessary, because there is no possibility of optic nerve injury. The first signs of injured optic nerve are the loss of maximal visual acuity and the presence of pupillary defect. High doses of glucocorticoids or surgical decompression can be applied in the treatment of traumatic opticoneuropathy.

[Contemporary surgical treatment of sellar region tumors]. / Suvremeno kirursko lijecenje tumora selarne regije.

Due to improved diagnostics, and primarily neuroradiological methods, an increased incidence of sellar region tumors is marked, among which the most common are pituitary adenomas. Sellar region tumors cause dysfunctions of the hypothalamo-pituitary axis as well as surrounding neurovascular structures. Despite the development of pharmacological and radiation therapy, surgical treatment is in these cases still a dominant therapeutical method. The author displays an overview of contemporary surgical methods for the treatment of sellar region tumors, as well as an overview of other adjuvant methods, especially pharmacological. Described are the results of over 1200 patients surgically treated during the past 20 years for sellar region tumors, as well as their complications and adverse effects. The author argues for respecting modem consensus on standardization of results of treating sellar region tumors as well as the consensus on professional and technical equipment of doctors and institutions that deal with this complex work.

[80 years of hypophyseal surgery at the Sestre Milosrdnice Hospital]. / Osamdeset godina kirurgije hipofize u Klinickoj bolnici "Sestre milosrdnice".

Sestre milosrdnice University Hospital has celebrated its 155th anniversary. In this period, it has been the origin of Croatian medical masterminds and a place of numerous pioneer events. After V. Horsley, in 1904, completed the first pituitary adenoma surgery by transcranial approach, and Schloffer, in 1906 by transsphenoidal approach, numerous surgeons have accepted these procedures depending on their affinity and equipment. A. Blaskovic did the first six transsphenoidal surgeries on the pituitary tumors in 1922. A. Sercer published a paper in 1926 "When and how to operate pituitary tumors" in which he described his experience in surgically treating six pituitary tumors by transnasal approach. By arrival of a neurosurgeon, D. Riessner, transcranial approach became a dominant method in treating extrasellar pituitary tumors. At the same time, smaller intrasellar adenomas were operated at the ORL clinic by transnasal approach. In 1963 I. Padovan published a paper describing his experience in implanting radioactive gold (Au198) in pituitary tumors. Following the D. Riessner's retirement, N. Popov continued to use transcranial approach in treating pituitary tumors with admirable results. In 1970, I. Padovan published a work in which he described 26 pituitary tumors treated by transsphenoethmoidal approach. Since 1982 until today Z. Gnjidic has performed surgery on more than 1000 patients using transsphenoidal approach. The above mentioned results belong to the top ten world series.