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Objective Prolactinomas are treated with dopamine agonists (DAs) as first-line therapy and transsphenoidal surgery as an alternative approach for medically failed tumors. We sought to summarize the efficacy of stereotactic radiosurgery (SRS) in the medically and surgically failed prolactinomas as well as in nonsurgical candidates with medically failed prolactinomas by systematic review and meta-analysis. Method A literature search was conducted according to the Preferred Reporting Items for Systematic Review and Meta-Analyses guideline. Results A total of 11 articles (total N = 709) met inclusion criteria. Thirty-three percent of patients were able to achieve endocrine remission at a mean follow-up of 54.2 ± 42.2 months with no association between stopping DA and endocrine remission. Sixty-two percent of patients were able to achieve endocrine control with DA therapy and 34% of patients were able to decrease the dose of DA dose when compared with pre-SRS DA dose at the end of the follow-up period. However, 54% of patients required DA at the end of the follow-up to control hyperprolactinemia. Ninety percent of patients were able to achieve radiologic control at the end of the follow-up in comparison to pre-SRS imagings. Furthermore, 26% of patients newly developed hypopituitarism (one or more pituitary hormones) post-SRS throughout the follow-up period. Conclusion This systematic review and meta-analysis demonstrates SRS as an effective adjunct therapy in medically failed nonsurgical candidates or surgically and medically recalcitrant prolactinomas with a 33% chance of achieving endocrine remission, 62% of patients achieved hormonal control with DA and GKRS (gamma knife radio-surgery), with a 34% chance of decreasing DA dose and 90% chance of achieving radiologic control.
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Introduction Neurenteric cysts (NECs) are rare, congenital lesions lined by endodermal cell-derived columnar or cuboidal epithelium. Based on previous studies, gross total removal of the capsule has been presumed to be the ideal surgical goal. Objective This series was undertaken to further understand the risk of recurrence based on the extent of capsule resection. Methods Records were retrospectively reviewed for all patients with radiographic or pathological evidence of intracranial NEC from 1996 to 2021. Results A total of eight patients were identified; four of eight (50%) presented with headache, and four had signs of one or more cranial nerve syndromes. One patient (13%) presented with third nerve palsy, one (13%) had sixth nerve palsy, and two (25%) with hemifacial spasm. One patient (13%) presented with signs of obstructive hydrocephalus. Magnetic resonance imaging demonstrated T2 hyper- or isointense lesions. Diffusion-weighted imaging was negative in all patients (100%) and T1 contrast-enhanced imaging demonstrated minimal rim enhancement in two patients (25%). In three of eight (38%), a gross total resection (GTR) was achieved, while in four (50%), a near-total resection, and in one (13%), a decompression was performed. Recurrences occurred in two (25%) patients, one with decompression and another with near-total resection, among these 1/2 required repeat surgery after a mean follow-up of 77 months. Conclusion In this series, none from GTR group demonstrated recurrence, while 40% of those receiving less than GTR recurred, underpinning the importance of maximally safe resection in these patients. Overall patients did well without major morbidity from surgery.
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OBJECTIVE: To perform a population-based study of pituitary adenoma epidemiology, including longitudinal trends in disease incidence, treatment patterns, and outcomes. PATIENTS AND METHODS: In this study of incident pituitary adenomas in Olmsted County, Minnesota, from January 1, 1989, through December 31, 2019, we identified 785 patients who underwent primary screening, 435 of whom were confirmed as harboring incident pituitary adenomas and were included. Primary outcomes of interest included demographic characteristics, presenting features, and disease outcomes (tumor control, biochemical control, and complications). RESULTS: Among our 435 study patients, 438 unique pituitary adenomas were diagnosed at a median patient age of 39 years (interquartile range [IQR], 27 to 58 years). Adenomas were incidentally identified in 164 of the 438 tumors (37%). Common symptomatic presentations included hyperprolactinemia (188 of 438 [43%]) and visual field deficit (47 of 438 [11%]). Laboratory tests confirmed pituitary hormone hypersecretion in 238 of the 435 patients (55%), which was symptomatic in 222. The median tumor diameter was 8 mm (IQR, 5 to 17 mm). Primary management strategies were observation (156 of 438 tumors [36%]), medication (162 of 438 tumors [37%]), and transsphenoidal resection (120 of 438 tumors [27%]). Tumor and biochemical control were achieved in 398 (95%) and 216 (91%) secreting tumors, respectively. New posttreatment pituitary or visual deficits were noted in 43 (11%) and 8 (2%); apoplexy occurred in 28 (6%). Median clinical follow-up was 98 months (IQR, 47 to 189 months). Standardized incidence rates were 3.77 to 16.87 per 100,000 population, demonstrating linear expansion over time (R2=0.67). The mean overall standardized incidence rate was 10.1 per 100,000 population; final point prevalence was 175.1 per 100,000 population. CONCLUSION: Pituitary adenoma is a highly incident disease, with prolactin-secreting and incidental lesions representing the majority of tumors. Incidence rates and asymptomatic detection appear to be increasing over time. Presenting symptoms and treatment pathways are variable; however, most patients achieve favorable outcomes with observation or a single treatment modality.
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Adenoma , Neoplasias Hipofisárias , Adenoma/epidemiologia , Adenoma/metabolismo , Adenoma/terapia , Adulto , Humanos , Incidência , Pessoa de Meia-Idade , Hormônios Hipofisários , Neoplasias Hipofisárias/epidemiologia , Neoplasias Hipofisárias/terapia , Prolactina , Estudos Retrospectivos , Resultado do TratamentoRESUMO
OBJECTIVE: Acute postoperative sialadenitis is a potentially life-threatening complication of cranial neurosurgery characterized by swelling of the face and neck due to obstruction of salivary ducts by either mechanical obstruction or, potentially, pharmacologic stasis or gland obstruction. Given the paucity of literature surrounding this rare phenomenon, we sought to report our experience with acute sialadenitis after cranial neurosurgery. METHODS: Retrospective review of patients with acute sialadenitis after neurosurgical craniotomy or craniectomy from a single institution from January 1, 2011, through December 31, 2021. RESULTS: Seven patients (median age: 27 years; 6 female) identified meeting our inclusion criteria out of 10,014 patients who underwent craniotomy and/or craniectomy procedures during last 11 years (â¼0.006%), 5 of these cases were considered skull base procedures. Five (71%) patients required emergent airway management either via intubation or tracheostomy and 5 (71%) were treated with steroids. Additional supportive care included sialagogues, warm compress, massage, analgesics, and intravenous hydration for all 7 patients. Three patients (43%) developed concomitant transient focal neurologic deficits attributable to the sialadenitis. No mortalities occurred as a result of this complication. CONCLUSIONS: Acute post-neurosurgical sialadenitis spans a range of severity, with some patients requiring emergent airway management and prolonged ventilator support whereas other patients only require conservative supportive care. Early recognition of acute sialadenitis after cranial neurosurgery can prevent fatal outcomes and provide complete recovery from this condition. Therefore, all neurosurgeons, anesthesiologists, and intensivists should be aware of this rare, but potentially life-threatening, complication.
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Sialadenite , Adulto , Craniotomia/efeitos adversos , Craniotomia/métodos , Feminino , Humanos , Procedimentos Neurocirúrgicos/efeitos adversos , Ductos Salivares , Sialadenite/etiologia , Sialadenite/cirurgia , Base do CrânioRESUMO
INTRODUCTION: There is a clinical equipoise between burr hole drainage (BHD) or twist drill craniotomy (TDC) as initial surgical intervention in patients with chronic subdural hematoma (cSDH). Moreover, the impact of type of postoperative drainage is not well elucidated. We performed a systematic review and meta-analysis comparing outcomes following BHD and TDC for initial surgical management in cSDH and to understand the impact of negative suction drainage with TDC. METHODS: A literature search was conducted according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines for studies that directly compared TDC and BHD. The following outcomes were compared between TDC and BHD: mortality, recurrence, reoperations, complications, and cure rates. Subgroup analysis was performed to determine impact of negative suction drainage with TDC. RESULTS: Sixteen articles (n = 1,235; TDC: 663; BHD: 591) met inclusion criteria. Although complications (OR: 0.68, 95% CI: 0.38-1.23, p = 0.21; I2 = 31%), recurrence (OR: 1.16, 95% CI: 0.84-1.62, p = 0.37; I2 = 28%), cure (OR: 1.11, 95% CI: 0.72-1.72, p = 0.64, I2 = 34%), and mortality rates (OR: 1.20, 95% CI: 0.60-2.41; p = 0.61; I2 = 0%) were not significantly different between the two groups, TDC was associated with a higher reoperations than BHD (OR: 1.48, 95% CI:1.01-2.16, p = 0.04; I2 = 41%). Subgroup analysis demonstrated that TDC with negative suction drainage conferred equivalent reoperation rates as BHD (OR: 0.75, 95% CI: 0.24-2.35; p = 0.62; I2 = 65%); however, TDC without negative suction was associated with higher reoperations (OR: 1.62, 95% CI: 1.08-2.42; p = 0.02; I2 = 40%). CONCLUSION: A systematic review and meta-analysis of available literature directly comparing TDC and BHD for primary evacuation of cSDH did not demonstrate clear superiority of either technique, although reoperations may be higher following TDC. Use of negative suction drainage with TDC may lead to similar rates of reoperation as BHD.
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Hematoma Subdural Crônico , Craniotomia , Drenagem , Hematoma Subdural Crônico/cirurgia , Humanos , Recidiva , Estudos Retrospectivos , Resultado do Tratamento , TrepanaçãoRESUMO
PURPOSE: In Prolactinomas, surgery or radiation are reserved for DA failure due to tumor resistance, intolerance to medication-induced side-effects, or patient preference. This systematic review and meta-analysis summarizes the currently available literature regarding the effectiveness of surgery to treat prolactinomas in patients who have failed DA therapy. METHOD: A literature search was conducted according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines for studies that reported outcomes of medically resistant and intolerant prolactinoma treated surgically. RESULTS: 10 articles (Total N = 816, Surgery N = 657) met the inclusion criteria. 38% of patients who underwent surgery following DA failure achieved remission without need for further treatment (p < 0.001, I2 = 67.09%) with a median follow-up of 49.2 +/- 40 months. 62% achieved remission with multimodal treatment (p < 0.001, I2 = 93.28%) with a median follow-up of 53 +/- 39.8 months. 16% of cases demonstrated recurrence after early remission (p = 0.02, I2 = 62.91%) with recurrence occurring on average at 27 +/- 9 months. Overall, 46% of patients required reinstitution of postoperative DA therapy at last follow up (p < 0.001, I2 = 82.57%). Subgroup analysis of macroprolactinoma and microprolactinoma has demonstrated that there is no statistical significance in achieving long-term remission with surgery stand-alone in macroprolactinoma group (p = 0.49) although 43% of patients were able to achieve remission with multimodal therapy at last follow-up in the same group (p < 0.001, I2 = 86.34%). CONCLUSIONS: This systematic review and meta-analysis revealed 38% of operated patients achieved remission, while 62% achieved remission when additional modes of therapy were implemented. Therefore, although surgery has not been initial therapeutic choice for prolactinoma, it plays a significant role in medically failed prolactinoma care.