Surgical management of giant pituitary adenomas: institutional experience and clinical outcomes of 94 patients.

Background: Giant (with a diameter of at least 40 mm and a volume of at least 10 cm3) pituitary adenomas (GPAs) are intricate tumors that pose considerable difficulty for surgical removal. While endoscopic transsphenoidal surgery (ETS) is a commonly employed technique for these destructive tumors, its effectiveness may be restricted in cases where invasion into multiple compartments is present, leading to limited resection. Methods: A retrospective review was conducted on the clinical records of 94 patients diagnosed with GPAs who had undergone surgical resection from 2014 to 2022. An analysis was conducted on the outcomes of the surgical and clinical procedures. Results: In this group, the average size of the tumor before surgery was 44.6 ± 5.6 mm (range, 40-73 mm), and the volume was 25. 5± 16.6 cm3 (range, 10-20.67 cm3). Of the total number of patients, 72 (76.6%) underwent a single ETS, 12 (12.8%) opted for transcranial surgery (TCS), and 10 (10.6%) chose a combined method. Gross total resection (GTR) was successfully performed in 49 (68.1%), 3 (25.0%), and 8 (80.0%) patients who underwent each surgical approach. Seventy-four (78.7%) patients had improved vision, 20 (21.3%) were unchanged, and none had deterioration. Twenty-two patients (23.4%) experienced a total of 43 complications, which comprised hormonal insufficiency (11/94, 11.7%), diabetic insipidus (6/88, 6.8%), electrolyte disorders (7/94, 7.4%), cerebrospinal fluid leakage (5/94, 5.3%), meningitis (8/94, 8.5%), and hydrocephalus (6/94, 6.4%). The GTR, subtotal resection (STR), and partial resection (PTR) rates were 63.8% (60/94), 21.3% (20/94), and 14.9% (14/94), respectively. Throughout the follow-up duration, 18.1% (17/94) of patients required reoperation and/or adjuvant radiation treatment as a result of tumor regrowth or inadequate biochemical remission of functioning GPAs. Conclusion: ETS remains the optimal surgical option for most GPAs and generally offers safe and efficient tumor resection. However, a combined approach with TCS remains a requirement in cases that are not suitable for treatment with a single ETS. To achieve optimal tumor removal and minimize the occurrence of surgical complications, a flexible combination of ETS and TCS is recommended based on the characteristics of the tumor.

Risk Factors for Progression in Vestibular Schwannomas After Incomplete Resection: A Single Center Retrospective Study.

Background and Purpose: The risk factors for progression in vestibular schwannomas (VSs) after incomplete resection (IR) remain to be elucidated. The purpose of this study was to investigate the risk factors for progression in remnant VSs after surgery. Methods: From January 2009 to January 2018, 140 consecutive patients who underwent IR of VSs via suboccipital retrosigmoid approach in our institution were retrospectively analyzed. During follow-up, if progression was detected, the patient was classified into Progressive Group (PG); if the residual tumor was stable or shrank, the patient was classified into Stable Group (SG). Univariate analysis and multivariate analysis were used to evaluate the risk factors for progression after IR of VSs. Results: After a mean follow-up of 80.4 months (range, 24-134 months), 35 (25.0%) patients (PG) had a progression, and no progression was detected in 105 (75.0%) patients (SG). The average tumor size was 36.5 ± 8.9 mm in PG and 31.0 ± 9.8 mm in SG, respectively. The residual tumor volume was 304.6 ± 443.3 mm3 in PG and 75.9 ± 60.0 mm3 in SG, respectively. Univariate analysis showed that preoperative tumor size, residual tumor volume, and irregular internal auditory canal (IAC) expansion were significantly different between the two groups, whereas gender, age, cystic component, or Ki-67 labeling index (LI) did not differ significantly between the two groups. Multivariate analysis showed residual tumor volume was the independent risk factor for progression. Conclusions: VSs that underwent IR with larger preoperative size, greater residual tumor volume, or irregular IAC expansion may have a higher progression rate. Strict follow-up with shorter interval in these patients to detect early progression is necessary.

Calcified extra-axial cavernous malformation arising from lower cranial nerves: A case report and literature review.

RATIONALE: Extra-axial cavernous malformations (ECMs) arising from cranial nerves (CNs) are rare. Complete "en bloc" lesion resection and hemosiderin-stained tissue preservation remain the standard treatment, while a different strategy may be needed when the lesion is highly calcified . We report the 3rd calcified ECM-CN and review the clinical features and surgical strategy for this rare condition considering previous literature. PATIENT CONCERNS: We present a 52-year-old woman with a calcified lesion located in the right lower 1/3 of the cerebellopontine angle. DIAGNOSIS: The diagnosis was calcified ECM-CNs according to the pathological and radiological features. INTERVENTIONS: A posterior midline craniotomy was performed, and piecemeal resection of the lesion was carried out. Subtotal resection of the lesion was achieved with a small piece left in situ. OUTCOMES: No symptom or lesion-related recurrence was found during 28 months of follow-up. LESSONS: Calcified ECM-CNs are unique cavernous malformations arising from CNs. Piecemeal resection and subtotal or near-total excision are 2 major aspects that differ from the surgical strategy for general ECM-CNs.

Mixed Signal Intensity on Preoperative T1 MRI Might be Associated with Delayed Postoperative Hemorrhage in Patients with Intracranial Epidermoid Cyst.

OBJECTIVE: Delayed postoperative hemorrhage (DPOH) was a severe postoperative complication after intracranial epidermoid cyst (EC) surgery. This study was designed to investigate possible clinical data and image features related to DPOH in patients with EC. METHODS: We retrospectively investigated 186 cases of EC, and 8 cases presented an appearance of DPOH. Preoperative magnetic resonance imaging (MRI) and clinical data (age, sex, chief surgeon, tumor size, tumor location, and degree of resection) were reviewed and analyzed. The Student t test and the χ2 test were used, and statistical significance was defined as P < 0.05. RESULTS: A total of 8 patients suffered from DPOH. Seven patients (87.5%) with DPOH showed atypical mixed signal intensity on preoperative T1 MRI compared with typical low intensity in another DPOH case. Only 1 case of mixed signal intensity on T1 MRI was found in 178 patients without DPOH. The mixed signal intensity on preoperative T1 MRI was highly related to DPOH and mortality (both P < 0.001). There was no significant difference in other relative clinical data between patients with or without DPOH. CONCLUSIONS: Mixed signal intensity on preoperative T1 MRI might be associated with DPOH in patients with EC. The surgeon should pay more attention to this rarely atypical imaging before surgery. Further observations are necessary to illustrate the relationship between mixed signal intensity and DPOH in EC and to guide reasonable therapy.

Intracranial clear cell meningioma: Clinical study with long-term follow-up in 24 patients.

OBJECTIVE: Clear cell meningioma (CCM) is a rare disease, and controversy about treatment and prognosis of CCMs still exists. We aimed to clarify the natural history, radiological features, histological characteristics, management and prognosis of intracranial CCMs. PATIENTS AND METHODS: We performed a retrospective study of 24 patients with intracranial CCM who were treated at West China Hospital from January 2006 to January 2018. The clinical features, radiologic findings, diagnosis, treatment, and outcome of these patients were analyzed retrospectively. Additionally, a literature review of intracranial CCMs was performed. RESULTS: Among 3554 surgeries for intracranial meningiomas, we identified 24 (0.7%) cases of CCMs. The most common localization was the frontal lobe (n = 9, 37.5%). The mean age at diagnosis of CCMs was significantly younger than that of total meningiomas patients (46.7 ± 15.8 versus 55.4 ± 14.8 years). They had a high rate (54.2%) of atypical radiological manifestations, such as cystic component, heterogeneous enhancement, and irregular shape. During the average follow-up of 61.1 months, four patients (19.0%) suffered from tumor recurrence. Kaplan-Meier analysis showed that patients with subtotal resection (STR) or a MIB-1 index ≥3% had significantly shorter progression-free survival (PFS) compared to gross total resection (GTR) and MIB-1 index <3%. CONCLUSIONS: CCMs are rare diseases which have a predilection to affect younger patients and a high rate of recurrence and metastasis. Surgery resection is the first treatment choice. For patients underwent STR or with MIB-1 index ≥3%, we hold further radiotherapy is necessary. Close follow-up of the brain and spine for years is crucial to monitor recurrence or metastasis.