Expanded Endonasal Endoscopic Surgery in Suprasellar Craniopharyngiomas: A Retrospective Analysis of 43 Surgeries Including Recurrent Cases.

BACKGROUND: The role of expanded endonasal endoscopic surgery for primary and recurrent craniopharyngioma is not yet fully established. OBJECTIVE: To report and evaluate our experience with the endoscopic endonasal approach (EEA) for the resection of primary and recurrent craniopharyngiomas. METHODS: This is a retrospective cohort analysis of 43 consecutive EEA procedures in 40 patients operated from September 2006 to February 2012 for suprasellar craniopharyngiomas. In 21 patients (48.8%) the disease was recurrent. We have assessed the surgical results, visual, endocrinological, and functional outcomes and resection rates in this patient cohort. RESULTS: At presentation, 31 (72.1%) patients had visual deficits, 15 patients (34.9%) complained of headaches, 25 patients (58.1%) had anterior pituitary insufficiency, and 14 (32.5%) had diabetes insipidus. Total resection was achieved in 44.2% surgeries, of which 77.3% were in primary lesions and 9.5% in recurrent lesions (P < .001). Vision improved in 92.6% patients and worsened in 2.3%. Complications other than vision were encountered in 25.6% including 9/43 cerebrospinal fluid leak, 2/43 meningitis. A total of 51.9% of patients with preoperative residual anterior pituitary function had new anterior pituitary deficiencies and 42.8% had new diabetes insipidus. There was no mortality. Six patients (14%) had recurrence of disease during the follow-up period (mean 56.8 mo), 5 of which required repeat surgery. CONCLUSION: The EEA can be integrated in the overall management of both primary and recurrent craniopharyngiomas with good results; however, in our series recurrent surgery was associated with significantly lower rates of gross total resection.

Exploratory Analysis into Reasonable Timeframes for the Provision of Neurosurgical Care in Low- and Middle-Income Countries.

BACKGROUND: In low- and middle-income countries (LMICs), 11.8% of the need for neurosurgical care is met. Delays in seeking and receiving care may further exacerbate this situation. Objective analysis of delay and its consequences is contingent on reference to established resource-appropriate acceptable timeframes. This study sought to 1) establish an estimate of the landscape of care provided in LMICs and 2) explore reasonable timeframes for various stages of patient-health care interaction. METHODS: Consensus input from neurosurgeons in select LMICs was collected; 1 high-income country was included for comparison. In phase 1, participants were asked to select neurosurgical procedures performed at their centers. In phase 2, based on procedures shared among all LMICs, representative case scenarios were generated and participants provided input on acceptable timeframes for each stage of patient-health care interaction: 1) presentation to health services, 2) diagnosis by primary care physician, 3) referral to neurosurgical specialist care, and 4) definitive neurosurgical management. RESULTS: Twenty neurosurgeons across 18 centers were identified; 12 participated in phase 1 and 7 in phase 2. The range of procedures offered was broad, similar in scope to high-income countries, and included pediatric and adult neurosurgery, trauma, degenerative spine, and hemorrhagic stroke. Acceptable timeframes had wide ranges in certain cases; however, the overall trend showed agreement between the participants. CONCLUSIONS: This exploratory analysis identified reasonable timeframes for the provision of neurosurgical care in LMICs. If validated, these data can be used to more objectively assess the prevalence of delay in neurosurgical care in individual LMICs, along with its consequences.

Endoscopic endonasal transsphenoidal approach to large and giant pituitary adenomas: institutional experience and predictors of extent of resection.

UNLABELLED: OBJECT.: While the use of endoscopic approaches has become increasingly accepted in the resection of pituitary adenomas, limited evidence exists regarding the success of this technique for patients with large and giant pituitary adenomas. This study reviews the outcomes of a large cohort of patients with large and giant pituitary adenomas who underwent endoscopic endonasal transsphenoidal surgery at the authors' institution and focuses on identifying factors that can predict extent of resection and hence aid in developing guidelines and indications for the use of endoscopic endonasal transsphenoidal surgery versus open craniotomy approaches to large and giant pituitary adenomas. METHODS: The authors reviewed 487 patients who underwent endoscopic endonasal transsphenoidal resection of sellar masses. From this group, 73 consecutive patients with large and giant pituitary adenomas (defined as maximum diameter ≥ 3 cm and tumor volume ≥ 10 cm(3)) who underwent endoscopic endonasal transsphenoidal surgery between January 1, 2006, and June 6, 2012, were included in the study. Clinical presentation, radiological studies, laboratory investigations, tumor pathology data, clinical outcomes, extent of resection measured by volumetric analysis, and complications were analyzed. RESULTS: The mean preoperative tumor diameter in this series was 4.1 cm and the volume was 18 cm(3). The average resection rate was 82.9%, corresponding with a mean residual volume of 3 cm(3). Gross-total resection was achieved in 16 patients (24%), near-total in 11 (17%), subtotal in 24 (36%), and partial in 15 (23%). Seventy-three percent of patients experienced improvement in visual acuity, while 24% were unchanged. Visual fields were improved in 61.8% and unchanged in 5.5%. Overall, 27 patients (37%) experienced a total of 32 complications. The most common complications were sinusitis (14%) and CSF leak (10%). Six patients underwent subsequent radiation therapy because of aggressive tumor histopathology. No deaths occurred in this cohort of patients. Statistically significant predictors of extent of resection included highest Knosp grade (p = 0.001), preoperative tumor volume (p = 0.025), preoperative maximum tumor diameter (p = 0.002), hemorrhagic component (p = 0.027), posterior extension (p = 0.001), and sphenoid sinus invasion (p = 0.005). CONCLUSIONS: Endoscopic endonasal transsphenoidal surgery is an effective treatment method for patients with large and giant pituitary adenomas, which results in high (> 80%) rates of resection and improvement in visual function. It is not associated with high rates of major complications and is safe when performed by experienced surgeons. The preoperative Knosp grade, tumor volume, tumor diameter, hemorrhagic components on MRI, posterior extension, and sphenoid sinus invasion may allow a prediction of extent of resection and in these patients a staged operation may be required to maximize extent of resection.

Spontaneous cerebrospinal fluid rhinorrhea secondary to anterior fossa osteoradionecrosis.

Osteoradionecrosis (ORN) after radiation therapy of head and neck or brain tumor most often presents in the mandible, followed by the maxillary bone. This case report describes a patient who presented with spontaneous cerebrospinal fluid (CSF) rhinorrhea 12 months after conventional external beam radiotherapy for frontotemporal anaplastic astrocytoma, and was diagnosed with anterior fossa ORN. Osteolysis in the anterior fossa on CT scan confirmed the diagnosis. A prompt temporal muscle graft with pericranial flap seal treated both the ORN and the CSF rhinorrhea, but observation would have been a suitable conservative option if ORN presented without CSF rhinorrhea.