Novel Use of Biodissolvable Stent in Treatment of Recurrent Rathke Cleft Cyst.

BACKGROUND: Rathke cleft cysts (RCCs) are benign cysts arising from the pars intermedia as a result of incomplete obliteration of the Rathke pouch during development of the pituitary gland. The most common presenting symptoms are headaches, visual disturbances, and endocrinopathies. Recurrence of RCCs after surgical treatment is a well-known phenomenon after surgery with reported recurrence rates as high as 30%. Various methods have been employed to reduce the rate of recurrence. Complete cyst wall resection has been associated with increased rates of perioperative cerebrospinal fluid leak, diabetes insipidus, and carotid injury, while inconsistently demonstrating reduced recurrence rates. Marsupialization, in which the cyst cavity is widely exposed and left open with or without a fat graft suspension, has similarly shown increased morbidity without clear improvement in outcomes. We report here the use of a steroid-eluting sinus stent to maintain patency of the cyst opening. CASE DESCRIPTION: A 39-year-old female presented with a symptomatic RCC. She underwent 4 different surgeries including cyst wall resection, marsupialization, and fat graft placement. She developed short-term symptomatic and radiographic recurrence within 3 months of each surgery. She then underwent placement of a steroid-eluting sinus stent. At 3 months, the patient remained symptom free, without radiographic recurrence and with patent cyst fenestration on nasal endoscopy. CONCLUSIONS: Recurrent RCCs are challenging to manage. Strategies to reduce recurrence are typically associated with higher risk and varying success. Stent placement represents a simple, low-risk method of potentially maintaining patency of cyst fenestration.

Minimally Invasive Transsulcal Resection of Intraventricular and Periventricular Lesions Through a Tubular Retractor System: Multicentric Experience and Results.

BACKGROUND: Conventional approaches to deep-seated cerebral lesions range from biopsy to transcortical or transcallosal resection. Although the former does not reduce tumor burden, the latter are more invasive and associated with greater potential for irreparable injury to normal brain. Disconnection syndrome, hemiparesis, hemianesthesia, or aphasia is not uncommon after such surgery, especially when lesion is large. By contrast, the transsulcal parafascicular approach uses naturally existing corridors and a tubular retractor to minimize brain injury. METHODS: A retrospective review of patients undergoing minimally invasive transsulcal parafascicular resection of ventricular and periventricular lesions, across 5 independent centers, was conducted. RESULTS: Twenty patients with lesions located in the lateral ventricle (n = 9), the third ventricle (n = 6) and periventricular region (n = 4) are described in this report. Average age was 64 years (8 male/12 female). The average depth from cortical surface was 4.37 cm. A 13.5-mm-diameter tubular retractor (BrainPath [NICO Corporation, Indianapolis, Indiana, USA]) of differing lengths was used, aided by neuronavigation. Gross total resection was obtained in 17 patients. Pathologies included colloid cyst, subependymoma, glioma, meningioma, central neurocytoma, lymphoma, and metastasis. Three patients experienced transient morbidity: memory loss (2), hemiparesis (1). One patient died 3 months postoperatively as a result of unrelated pulmonary illness. Follow-up ranged from 6 to 27 months (average, 12 months). CONCLUSIONS: This technique is safe and effective for the treatment of intraventricular and periventricular lesions. Surgery-related morbidity is minimal and often transient. Lesions are satisfactorily resected and residuum occurs only when the neoplasm involves vital structures. The tubular retractor minimizes trauma to brain incident in the surgeon's path.

Short-term outcome of endoscopic versus microscopic pituitary adenoma surgery: a systematic review and meta-analysis.

Endoscopic transsphenoidal pituitary surgery has become increasingly more popular for the removal of pituitary adenomas. It is also widely recognised that transsphenoidal microscopic removal of pituitary adenomas is a well-established procedure with good outcomes. Our objective was to meta-analyse the short-term results of endoscopic and microscopic pituitary adenoma surgery. We undertook a systematic review of the English literature on results of transsphenoidal surgery, both microscopic and endoscopic from 1990 to 2011. Series with less than 10 patients were excluded. Pooled data were analysed using meta-analysis techniques to obtain estimate of death, complication rates and extent of tumour removal. Complications evaluated included cerebrospinal fluid leak, meningitis, vascular complications, visual complications, diabetes insipidus, hypopituitarism and cranial nerve injury. Data were also analysed for tumour size and sex. 38 studies met the inclusion criteria yielding 24 endoscopic and 22 microscopic datasets (eight studies included both endoscopic and microscopic series). Meta-analysis of the available literature showed that the endoscopic transsphenoidal technique was associated with a higher incidence of vascular complications (p<0.0001). No difference was found between the two techniques in all other variables examined. Meta-analysis of the available literature reveals that endoscopic removal of pituitary adenoma, in the short term, does not seem to confer any advantages over the microscopic technique and the incidence of reported vascular complications was higher with endoscopic than with microscopic removal of pituitary adenomas. While we recognise the limitations of meta-analysis, our study suggests that a multicentre, randomised, comparative effectiveness study of the microscopic and endoscopic transsphenoidal techniques may be a reasonable approach towards establishing a true valuation of these techniques.

Transsphenoidal surgery for Cushing disease: experience with 136 patients.

BACKGROUND: This is a retrospective study of 136 patients with Cushing disease treated with transsphenoidal microsurgery. OBJECTIVE: To evaluate factors influencing immediate postoperative results and long-term outcomes. METHODS: Data regarding clinical presentation, endocrine evaluation, imaging studies, surgical technique, immediate postoperative biochemical remission (IPBR), and long-term results were entered into a database and analyzed statistically. IPBR was based on biochemical evidence of adrenal cortical insufficiency and clinical evidence of such insufficiency. RESULTS: IPBR for the entire series was 83.4%. In microadenomas, IPBR was 89.8% with a mean immediate postoperative plasma cortisol (IPPC) of 2.1 µg/dL (range, <0.5-5.3). Positive magnetic resonance imaging (MRI) was associated with 18 times greater odds of finding microadenoma at surgery (P < .001) and with 4.1 times greater odds of IPBR (P = .07). In patients with a negative MRI, a positive inferior petrosal sinus sampling (IPSS) test was associated with 93% of IPBR (P = .004). IPBR in macroadenomas was 30.7%. Of patients followed for 12 months or longer, 34.8% required glucocorticoid replacement for the duration of follow-up. The mean follow-up in microadenomas was 68.4 months with a 9.67% incidence of recurrences. The estimated actuarial incidence of recurrences increased with the passage of time and IPPC of greater than 2 µg/dL was associated with higher incidence of recurrences, although without statistical significance (P = .08). CONCLUSION: In microadenomas, a positive MRI and positive IPSS test were associated with a higher incidence of IPBR. Recurrences increased with the passage of time, and an IPPC of greater than 2 µg/dL may be associated with higher incidence of recurrences.

Pituitary tumor apoplexy in patients with Cushing's disease: endocrinologic and visual outcomes after transsphenoidal surgery.

Pituitary apoplexy in patients with adrenocorticotropic hormone (ACTH) producing tumors is a rare occurrence. We report four patients with Cushing's disease harboring ACTH-secreting macroadenomas who presented with pituitary apoplexy. We report the endocrinologic and visual outcomes of these patients after emergent transsphenoidal surgery. A retrospective chart review was performed in 4 patients who presented with pituitary apoplexy from hemorrhage into an ACTH-secreting pituitary adenoma. The patient charts were reviewed for clinical presentation, neuroimaging findings, intraoperative surgical findings, pathologic findings, and postoperative endocrinologic and visual outcomes. All patients presented with acute headaches, nausea, vomiting, and visual loss from optic compression. MR imaging demonstrated a hemorrhagic macroadenoma that was confirmed at surgery. All patients underwent emergent transsphenoidal decompression (within 24 h of presentation). One of these underwent an additional craniotomy to resect residual tumor. Postoperatively, all patients showed significant improvement in visual acuity and visual fields with biochemical remission confirmed on laboratory testing. Significant weight loss as well as resolution of diabetes and hypertension was noted in all cases. All four patients remained in biochemical remission at their most recent follow-up visit (mean 40 months, range: 24-72 months). Excellent endocrine and visual outcomes can be achieved after emergent transsphenoidal surgery in patients with Cushing's disease presenting with pituitary apoplexy. Although the cure rates of non-apoplectic ACTH macroadenomas are generally poor, higher rates of remission can be achieved in cases of pituitary apoplexy. This may be partly due to the effects of tumor infarction.

Treatment options for Cushing disease after unsuccessful transsphenoidal surgery.

Cushing disease is considered an aggressive pituitary endocrinopathy because of the devastating effects from untreated hypercortisolemia. Although they are histologically benign, these adrenocorticotropic hormone (ACTH)-secreting pituitary tumors are associated with significant morbidity and premature death. Currently, transsphenoidal surgery is the primary treatment of Cushing disease associated with an ACTH-secreting pituitary tumor, resulting in remission rates ranging from about 50 to 90%. Some patients, however, will not achieve sustained remission after transsphenoidal surgery and can exhibit persistent or recurrent Cushing disease that requires multimodal treatment to achieve remission. In these patients, options for treatment include repeat transsphenoidal resection, radiation therapy (including conventional fractionated radiation therapy and stereotactic radiosurgery), and medical therapy. Despite undergoing multiple treatment modalities, some patients may ultimately require bilateral adrenalectomy for definitive treatment to eliminate hypercortisolemia associated with Cushing disease. In this article, the authors review the treatment options for patients who have persistent or recurrent Cushing disease after unsuccessful transsphenoidal surgery. The indications, current results reported in the literature, and complications of each treatment modality are discussed.

Transsphenoidal microsurgery: past, present and future.

In this report, we first describe the history of transsphenoidal surgery. We further elaborate on three fundamental surgical anatomy principles of transsphenoidal surgery for pituitary adenomas. First, the pituitary gland and, therefore, pituitary adenomas are extra-arachnoid structures, therefore the operation should be executed without penetration into the subarachnoid space. Second, the pituitary gland and, therefore, pituitary adenomas are midline structures, thus, veering off midline can result in potentially serious complications. Third, pituitary adenomas commence inside the pituitary gland, which distends around them as they grow. Thus, pituitary macroadenomas are surrounded on their surface by a layer of attenuated residual normal anterior pituitary. The operative technique for pituitary micro- and macroadenomas is described in detail. Finally, we discuss the likely future treatment methods for pituitary adenomas.

Acoustic neuroma (vestibular schwannoma) revision.

The authors present their experience of more than 25 years, now in excess of 1200 patients, with cerebellopontine angle tumors. This article focuses on the management of planned subtotal resection of acoustic tumors in five subjects, and unexpected "residual" discovered by MRI scanning in 10 cases, which represents, to the best of the authors' knowledge, a residual rate of 1% of operated patients. The rate of residual tumor is as high as 19% in some series and, in part, depends on the surgical approach. For the purpose of this article, the authors did not include their cases of neurofibromatosis, because these tumors behave differently than unilateral sporadic schwannomas.

Suboccipital retrosigmoid approach for removal of vestibular schwannomas: facial nerve function and hearing preservation.

In this report, we discuss the pertinent bony, arachnoid, and neurovascular anatomy of vestibular schwannomas that has an impact on the surgical technique for removal of these tumors, with the goal of facial nerve and hearing preservation. The surgical technique is described in detail starting with anesthesia, positioning, and neurophysiological monitoring and continuing with the exposure, technical nuances of tumor removal, hemostasis, and closure. Positive prognostic factors for hearing preservation are also highlighted.

Long-term management and outcome for pituitary tumors.

As we enter the twenty-first century, neurosurgeons and endocrinologists are armed with a greater variety of treatment options for pituitary adenomas, both secreting and nonsecreting. These include an ever-increased availability of different drugs that can be used for suppression of hypersecretion of pituitary adenomas in conjunction with their shrinkage (at least for the duration of the treatment), surgical techniques that have greatly improved, and newer techniques, such as endoscopic microsurgery, that have been added to the surgeon's armamentarium. Radiation therapy techniques have also improved in terms of structuring the radiation field as well as in terms of dosimetry and delivery.