Fully automated imaging protocol independent system for pituitary adenoma segmentation: a convolutional neural network-based model on sparsely annotated MRI.

This study aims to develop a fully automated imaging protocol independent system for pituitary adenoma segmentation from magnetic resonance imaging (MRI) scans that can work without user interaction and evaluate its accuracy and utility for clinical applications. We trained two independent artificial neural networks on MRI scans of 394 patients. The scans were acquired according to various imaging protocols over the course of 11 years on 1.5T and 3T MRI systems. The segmentation model assigned a class label to each input pixel (pituitary adenoma, internal carotid artery, normal pituitary gland, background). The slice segmentation model classified slices as clinically relevant (structures of interest in slice) or irrelevant (anterior or posterior to sella turcica). We used MRI data of another 99 patients to evaluate the performance of the model during training. We validated the model on a prospective cohort of 28 patients, Dice coefficients of 0.910, 0.719, and 0.240 for tumour, internal carotid artery, and normal gland labels, respectively, were achieved. The slice selection model achieved 82.5% accuracy, 88.7% sensitivity, 76.7% specificity, and an AUC of 0.904. A human expert rated 71.4% of the segmentation results as accurate, 21.4% as slightly inaccurate, and 7.1% as coarsely inaccurate. Our model achieved good results comparable with recent works of other authors on the largest dataset to date and generalized well for various imaging protocols. We discussed future clinical applications, and their considerations. Models and frameworks for clinical use have yet to be developed and evaluated.

Pituitary Adenoma Surgery Survey: Neurosurgical Centers and Pituitary Adenomas.

Objective: Pituitary adenoma surgery has evolved rapidly in recent decades. This study aims to determine current practice across a wide range of European neurosurgical centers. Methods: A list of eligible departments performing pituitary adenoma surgery was created. The survey consisted of 58 questions. For analysis, the departments were divided into four subgroups: academic/nonacademic, high-volume/low-volume, "mainly endoscopic/mainly microscopic practice," and geographical regions. Results: Data from 254 departments from 34 countries were obtained. In 108 centers (42.5%), <30 pituitary adenomas were operated per year. Twenty (7.9%) centers performed >100 adenoma surgeries per year. Number of neurosurgeons performing endonasal surgeries are as follows: 1 in 24.9% of centers and 2 in 49.8% of centers. All residents assisted endonasal surgeries in 126 centers (49.8%). In 28 centers (21.1%), all residents performed endonasal surgery under supervision during residency. In 141 centers (56.8%), the endoscopic approach was used in >90% of the surgeries. Regular pituitary board (either weekly or once a month) meetings were held in 147 centers (56.3%). Nonfunctioning adenomas represent >70% of pituitary caseload in 149 centers (58.7%). Conclusions: In our survey, most centers perform less than 100 surgeries for pituitary adenomas. In most centers, pituitary surgeries are performed by one or two neurosurgeons. Residents have a limited exposure to this type of surgery, and the formal pituitary board is not a standard. Nonfunctioning adenomas make up most of surgically treated adenomas. This study can serve as a benchmark for further analyses of pituitary adenoma centers in Europe.

Endocrinological aspects of pituitary adenoma surgery in Europe.

Hormone-secreting adenomas are treated in many neurosurgical centers within Europe. The goal of the survey is to understand variance in practice management of pituitary tumors amongst neurosurgical centers. A list of departments performing pituitary surgery was created. The survey consisted of 58 questions. This study focuses on neurosurgical care of hormone-secreting adenomas. For analysis, the departments were divided into four subgroups: academic/non-academic, high-volume/low-volume, "mainly endoscopic/mainly microscopic practice" and geographical regions. Data from 254 departments from 34 countries were obtained. Most centers surgically treat 1-5 hormone-secreting adenomas per year. In prolactinomas this is the case in 194 centers, (76.4%), in GH-secreting adenomas: 133 centers, (52.4%), ACTH-secreting adenomas: 172 centers, (69.8%). Surgery as a primary treatment of prolactinomas is considered in 64 centers (25.2%). In 47 centers (18.8%), GH-secreting microadenomas are often treated pharmacologically first. Debulking surgery for an invasive GH-secreting adenoma in which hormonal remission is not a realistic goal of the surgery and the patient has no visual deficit surgery is always or mostly indicated in 156 centers (62.9%). Routine postoperative hydrocortisone replacement therapy is administered in 147 centers (58.6%). Our survey shows that in most centers, few hormone-secreting adenomas are treated per year. In about 25% of the centers, prolactinoma surgery may be regarded as first-line treatment; in about 20% of the centers, medical treatment is the first-line treatment for GH-secreting adenomas. Pretreatment for ACTH-secreting adenomas is routinely used in 21% of centers. This survey may serve as plea for neurosurgical care centralization of hormone-secreting adenomas.

Surgical treatment of symptomatic pineal cysts without hydrocephalus-meta-analysis of the published literature.

BACKGROUND: To examine published data and assess evidence relating to safety and efficacy of surgical management of symptomatic pineal cysts without hydrocephalus (nhSPC), we performed a systematic review of the literature and meta-analysis. METHODS: Following the PRISMA guidelines, we searched Pubmed and SCOPUS for all reports with the query 'Pineal Cyst' AND 'Surgery' as of March 2021, without constraints on study design, publication year or status (PROSPERO_CRD:42,021,242,517). Assessment of 1537 hits identified 26 reports that met inclusion and exclusion criteria. RESULTS: All 26 input studies were either case reports or single-centre retrospective cohorts. The majority of outcome data were derived from routine physician-recorded notes. A total of 294 patients with surgically managed nhSPC were identified. Demographics: Mean age was 29 (range: 4-63) with 77% females. Mean cyst size was 15 mm (5-35). Supracerebellar-infratentorial approach was adopted in 90% of cases, occipital-transtentorial in 9%, and was not reported in 1%. Most patients were managed by cyst resection (96%), and the remainder by fenestration. Mean post-operative follow-up was 35 months (0-228). PRESENTATION: Headache was the commonest symptom (87%), followed by visual (54%), nausea/vomit (34%) and vertigo/dizziness (31%). Other symptoms included focal neurology (25%), sleep disturbance (17%), cognitive impairment (16%), loss of consciousness (11%), gait disturbance (11%), fatigue (10%), 'psychiatric' (2%) and seizures (1%). Mean number of symptoms reported at presentation was 3 (0-9). OUTCOMES: Improvement rate was 93% (to minimise reporting bias only consecutive cases from cohort studies were considered, N = 280) and was independent of presentation. Predictors of better outcomes were large cyst size (OR = 5.76; 95% CI: 1.74-19.02) and resection over fenestration (OR = 12.64; 3.07-52.01). Age predicted worse outcomes (OR = 0.95; 0.91-0.99). Overall complication rate was 17% and this was independent of any patient characteristics. Complications with long-term consequences occurred in 10 cases (3.6%): visual disturbance (3), chronic incisional pain (2), sensory disturbance (1), fatigue (1), cervicalgia (1), cerebellar stroke (1) and mortality due to myocardial infarction (1). CONCLUSIONS: Although the results support the role of surgery in the management of nhSPCs, they have to be interpreted with a great deal of caution as the current evidence is limited, consisting only of case reports and retrospective surgical series. Inherent to such studies are inhomogeneity and incompleteness of data, selection bias and bias related to assessment of outcome carried out by the treating surgeon in the majority of cases. Prospective studies with patient-reported and objective outcome assessment are needed to provide higher level of evidence.

What is the current clinical practice in pituitary adenoma surgery in Europe? European Pituitary Adenoma Surgery Survey (EU-PASS) results-technical part.

Pituitary adenoma surgery has evolved rapidly in recent decades, changing clinical practice markedly and raising new challenges. There is no current consensus or guidelines for perioperative care that includes possible complication management. This study aims to determine current practice across European neurosurgical centres. We created a list of eligible departments performing pituitary adenoma surgery based on cooperation with EANS, national neurosurgical societies, and personal communication with local neurosurgeons. We contacted the chairpersons from each department and asked them (or another responsible neurosurgeon) to fill out the survey. The survey consisted of 58 questions. For further analysis, departments were divided into subgroups: "academic"/ "non-academic centre", "high-volume"/"low-volume", "mainly endoscopic"/ "mainly microscopic"/ "mixed practise", and by geographical regions. Data from 254 departments from 34 countries were obtained. The average time to complete the survey was 18 min. Notably, the endoscopic approach is the predominant surgical approach in Europe, used in 56.8% of the centres. In routine cases without intraoperative cerebrospinal fluid leak, high-volume centres are less pedantic with sellar closure when compared with low-volume centres (p < 0.001). On the other hand, when a postoperative cerebrospinal fluid leak occurs, high-volume centres are more active and indicate early reoperation (p = 0.013). Less than 15% of the participating centres perform early postoperative MRI scans. Marked variation was noted among different groups of respondents and some contentious issues are discussed. Such information can encourage useful debate about the reasons for the variations seen and perhaps help develop standardised protocols to improve patient outcomes. A future research focus is to compare European results with other regions.

Pineal Apoplexy: A Case Series and Review of the Literature.

BACKGROUND: Pineal apoplexy is a rare condition, with unknown incidence and clinical significance. To elucidate this clinical condition, we analyzed our own case series and performed a review of the literature. METHODS: We enrolled all patients with a hemorrhagic pineal apoplexy who were referred to our department between January 2000 and January 2020. Hemorrhagic pineal apoplexy was defined as the presence of fluid-fluid levels inside the pineal cyst (PC) on an axial or sagittal magnetic resonance scan. In one patient, after PC apoplexy, we performed a circadian melatonin sampling from peripheral blood to determine the function of the pineal gland. The PubMed database was searched for publications using the terms "pineal" and "apoplexy." RESULTS: Eight patients were enrolled, of which three patients underwent surgical treatment and five patients were managed conservatively. One patient was tested for circadian melatonin secretion. Results confirmed melatonin secretion with preserved physiologic circadian rhythm.Our search of the literature led us to 31 studies that comprised 30 patients with apoplectic PC, 9 with apoplectic pineal tumor, and 1 with bleeding into the normal pineal gland. Most patients presented with headache, nausea, and vomiting, less frequently with acute hydrocephalus and gaze palsy. Twenty patients with a PC underwent resection or aspiration. Two patients underwent shunt placement as the only procedure and five received both shunt and surgical removal. Six patients with a PC were observed without surgical treatment. All the nine patients with a pineal tumor were operated on. In indicated cases, four patients received radiation therapy and one received chemotherapy. CONCLUSION: Clinical significance of hemorrhagic pineal apoplexy ranges from an asymptomatic course to rapid deterioration and death. In patients with mild symptoms, observation is indicated, whereas surgical treatment is reserved for severe cases presenting with obstructive hydrocephalus and includes cerebrospinal fluid diversion, resection of apoplectic pineal lesions, or both.

Long-term outcome of Simpson IV meningioma resection: Would it improve with adjuvant SRS?

OBJECTIVE: Subtotal meningioma resection (STR) is often performed to minimize surgical morbidity. Nevertheless, only a few studies have reported on patient outcome after STR. We studied the long-term outcome of SIV (Simpson grade IV) resection and identified predictive factors of overall survival (OS), progression-free survival (PFS) and time to progression (TTP). METHODS: A retrospective analysis was performed on 68 patients who underwent SIV resection of meningioma (grade I) from 2004 to 2010. Data were collected from clinical, surgical and pathology records and radiological imaging. Long-term outcomes were evaluated at least 10 years after surgery. RESULTS: Permanent morbidity was 11.8%, 30-day mortality 2.9% and progression rate 50.0% for a median follow-up duration of 126.6 months. Median TTP was 86.2 months. Adjuvant SRS was the only significant factor associated with longer PFS (p = 0.0052) and TTP (p = 0.0079). Higher age (p = 0.0022), KPS (p = 0.0182), postoperative ECOG score (p = 0.0182) were reliable predictors of shortened OS and aSRS (p = 0.0445) was reliable predictor of longer OS. CONCLUSION: STR in intracranial meningioma is still viable and often the only treatment option available in high-risk patients or high-risk tumors. Although surgical morbidity and mortality are high, the OS rate was 85.3% at 5 years and 79.4% at 10 years. Because of the considerable progression rate and rather a long term OS the adjuvant SRS should be considered following SIV resection.

Extreme Lateral Supracerebellar Infratentorial Approach: Surgical Anatomy and Review of the Literature.

OBJECTIVE: The extreme lateral supracerebellar infratentorial (ELSI) approach has the potential to access several distinct anatomical regions that are otherwise difficult to reach. We have illustrated the surgical anatomy through cadaveric dissections and provided an extensive review of the literature to highlight the versatility of this approach, its limits, and comparisons with alternative approaches. METHODS: The surgical anatomy of the ELSI has been described using 1 adult-injected cadaveric head. Formalized noninjected brain specimens were also dissected to describe the brain parenchymal anatomy of the region. An extensive review of the literature was performed according to each targeted anatomical region. Illustrative cases are also presented. RESULTS: The ELSI approach allows for wide exposure of the middle and posterolateral incisural spaces with direct access to centrally located intra-axial structures such as the splenium, pulvinar, brainstem, and mesial temporal lobe. In addition, for skull base extra-axial tumors such as petroclival meningiomas, the ELSI approach represents a rapid and adequate method of access without the use of extensive skull base approaches. CONCLUSIONS: The ELSI approach represents one of the most versatile approaches with respect to its ability to address several anatomical regions centered at the posterior and middle incisural spaces. For intra-axial pathologies, the approach allows for access to the central core of the brain with several advantages compared with alternate approaches that frequently involve significant brain retraction and cortical incisions. In specific cases of skull base lesions, the ELSI approach is an elegant alternative to traditionally used skull base approaches, thereby avoiding approach-related morbidity.

Olfactory Results of Endoscopic Endonasal Surgery for Pituitary Adenoma: A Prospective Study of 143 Patients.

BACKGROUND: Clinical examination, including pre- and postoperative assessment of olfaction function, should be included in evaluating surgical outcomes in patients with pituitary adenomas. Most of the studies are lacking assessment of olfactory function. METHODS: A prospective study of 143 patients who underwent surgical resection of pituitary adenomas from January 2014 to December 2017 was performed. Data on clinical presentation, pre- and postoperative neurologic, endocrinologic, and ophthalmologic examinations, complications, and follow-up outpatient examinations were recorded. Olfactory function was assessed using the Sniffin' Sticks odor identification test preoperatively, postoperatively (3 months), and 1 year after surgery. RESULTS: Normosmia was present preoperatively in 93.7% of patients, postoperatively in 95.8% of patients, and in 95.1% 1 year postsurgery. Hyposmia was present preoperatively in 4.2% of patients, postoperatively in 2.1% of patients, and in 1.4% 1 year after surgery. Anosmia was present preoperatively in 2.1% of patients, postoperatively in 2.1% of patients, and in 3.5% 1 year after surgery. In patients with preoperative normosmia, postoperative hyposmia and anosmia were present in 1.5% of patients. There were no differences according to age, sex, size, or type of pituitary adenoma. CONCLUSIONS: Assessment of olfactory function should be included in the analysis of pituitary adenoma surgery results. This prospective study showed low risk of olfaction deterioration if an endoscopic endonasal approach is used without any mucosal flaps for skull base reconstruction. Further studies that include objective olfaction assessment are warranted.

Burr-Hole Evacuation of Chronic Subdural Hematoma: Biophysically and Evidence-Based Technique Improvement.

Chronic subdural hematoma (CSDH) is one of the most common neurosurgical conditions. Despite ongoing efforts, recurrence and reoperation rates after surgical treatment remain high. We synthesize scientific evidence on the treatment of CSDH with biophysical principles and then propose a simple and effective surgical technique aiming to reduce the recurrence rate. Under local anesthesia, one burr hole is placed in the area above the maximum hematoma thickness. One drain is inserted into the dorsal direction to the deepest point of the hematoma cavity, and a second drain is inserted frontally into the highest point. Next, saline is gently instilled to the dorsal drain to eliminate air from the hematoma cavity through the frontal drain. Once saline has filled the frontal drain, the frontal drain is removed. The dorsal drain is left in situ for 48 h, and the pressure within the cavity may be adapted hydrostatically. We implemented evidence-based conclusions of previous studies and modified the classical burr-hole technique to reduce the recurrence rate. As a result, we developed a straightforward surgical procedure that is possible to perform under local anesthesia, suitable for everyday practice in rural and remote areas while working with limited resources. The novelty of this technique is in the purposeful reduction of postoperative pneumocephalus, a known independent factor of recurrence. Subdural air is eliminated during surgery using a two-drain system. Safety and efficacy of the technique need to be evaluated in future clinical trials.

First Case Report of Bilateral Spontaneous Otogenic Pneumocephalus.

BACKGROUND: Pneumocephalus is commonly associated with cranial trauma including surgical interventions. Spontaneous pneumocephalus on the other hand is a rare diagnosis. Reported cases were predominantly unilateral. We report a unique case of a bilateral spontaneous pneumocephalus probably related to a bilateral tegmen defect related to repeated Politzer maneuvers. CASE DESCRIPTION: A 78-year-old man suffered from vertigo, tinnitus, instability, and mild expressive aphasia. In the past 12 weeks before clinical deterioration he underwent series of Politzer maneuvers performed for repetitive inflammation of upper respiratory tract with otitis media. Brain computed tomography revealed a large bilateral collection of intracranial air with associated tegmen defects. Primarily, surgical revision of the middle fossa and multilayer reconstruction of the dura and skull base defect on the left side was performed. After 5 days, the other side was reconstructed in a similar way. Postoperative course was uneventful with brisk improvement of symptomatology. Both computed tomography scans undertaken after the first and second surgery showed satisfying regression of intracranial air. CONCLUSIONS: Spontaneous pneumocephalus represents a rare condition often associated with increased middle ear pressure, which can be caused by autoinflation (e.g., Valsalva or Politzer maneuver), sneezing, or coughing. The described case represents a unique presentation of the bilateral spontaneous pneumocephalus associated with bilateral tegmen and dura mater defects managed surgically. Despite its rarity, spontaneous pneumocephalus originating from the temporal bone should be considered as a possible diagnosis in patients with suggestive otologic presentation (e.g., tinnitus, instability, hearing loss) and associated nonspecific neurologic symptomatology.

Olfactory function in patients after transsphenoidal surgery for pituitary adenomas-a short review.

Olfaction is an important sensory input that obviously affects many daily activities. However, olfactory dysfunction (hyposmia and anosmia) leads to a pronounced decrease in quality of life. Surprisingly, little attention has been paid to olfactory changes after transsphenoidal surgery for pituitary tumors. In this review, we summarize current knowledge of the effects of transsphenoidal pituitary surgery on olfaction and compare different surgical techniques. Based on selected studies, the endoscopic approach, in comparison with the microscopic approach, seems to be superior in terms of preservation of olfactory function, although the quality of data from these studies is generally poor. The best results were observed when the endoscopic approach was used without harvesting of the nasoseptal flap.

Natural course of pineal cysts-a radiographic study.

BACKGROUND: Pineal cysts (PCs) are a benign lesion of the pineal gland that have been known to the medical community for a long time. With a prevalence rate of approximately 1% in the general population, PC is often a reason for medical counseling. The natural course of PC morphology has not been well described. In this study, we present a longitudinal magnetic resonance imaging (MRI) study of patients with PCs, with special focus on those who showed an increase or decrease in PC size. METHODS: We enrolled all patients with a PC who were referred to our department between January 2000 and January 2018. Each patient underwent a clinical examination, and the patient's age, sex, and presenting signs and symptoms were noted. MRI was performed during periodic examinations, and a clinical and radiological course was reassessed. RESULTS: In total, 133 patients (99 women, 34 men) were enrolled. The mean maximum diameter was 12.7 ± 5.2 mm (range 7-35 mm). PCs increased in size during the follow-up in seven patients (5.3%) and decreased in size in 10 (7.5%). The remaining cysts (n = 116, 87.2%) were stable over the follow-up period. Analyzing patients according to cyst size change, we found a significant difference in the mean age between the PC progression group and PC regression group (p = 0.01). The mean size of the PCs at the time of diagnosis did not differ significantly between the two groups (p = 0.81). We diagnosed two cases of pineal apoplexy. CONCLUSION: We found that PCs are a dynamic structure that may change in size during the patient's lifetime. Patients with an increase in PC size were significantly younger than patients with a decrease in size. Therefore, PC growth in the first, second, and third decennium is normal and does not justify medical intervention. Surgery is indicated in cases of hydrocephalus and Parinaud's syndrome or in atypical cysts when neoplasia is suspected. The size of a PC does not predict PC behavior in terms of a future increase or decrease in size.

Is surgery for pineal cysts safe and effective? Short review.

In this short review, the authors performed a database search and summarize current knowledge of the management of patients with pineal cysts (PCs) and investigate the role of surgical treatment. The scientific literature on the surgical treatment of PCs is sparse and encompasses only case series with little over 200 operated patients combined. All included papers reported favorable results after pineal cyst surgery with improvement of symptoms in most patients. Microsurgical resection of PCs, preferably using the supracerebellar-infratentorial approach, could be considered as a viable treatment option in symptomatic patients. Even patients with non-specific symptoms are reported to improve after surgery. However, evidence offered by this literature review is very limited and therefore our conclusions must be tempered by the restricted set of data. For ethical reasons, a randomized controlled trial is not an acceptable approach, and therefore patient registry could be a useful tool to identify a subset of symptomatic patients that might benefit from pineal cyst resection.

Conservative and Surgical Treatment of Patients with Pineal Cysts: Prospective Case Series of 110 Patients.

BACKGROUND: A pineal cyst is a relatively common benign condition of the pineal gland. The clinical management of patients with a pineal cyst remains controversial, especially when patients present with nonspecific symptoms. METHODS: We performed a prospective study between 2000 and 2016. All patients with a pineal cyst >7 mm were included. Epidemiologic data, presenting symptoms, surgical results, and radiographic and clinical follow-up were documented. RESULTS: A total of 110 patients were enrolled in the present study. The most common presenting symptoms were tension headache (62.7%), vertigo (16.4%), migraine (12.7%), syncope (10.9%), nausea (8.2%), and diplopia (8.2%). Symptoms worsened during the follow-up period in 17 patients (15.5%), improved in 13 patients (11.8%), and remained stable in 81 patients (73.6%). The mean follow-up was 79.2 months. A pineal cyst increased in size during the follow-up in 6 patients (5.5%) and decreased in size in 9 patients (8.2%). Twenty-one patients underwent pineal cyst resection; 20 patients (95.2%) reported some improvement in their presenting symptoms, and 10 patients (47.6%) were symptom free after the surgery. CONCLUSION: We present the largest clinical series of patients with pineal cysts. Surgery, if indicated properly, is a legitimate treatment modality for symptomatic patients with satisfactory results. Relief of symptoms, even nonspecific ones, is achieved in the majority of cases. Simple growth of the cyst in the first decades of life is a part of the natural course and should not be considered as an indication for surgery.

Melatonin and cortisol secretion profile in patients with pineal cyst before and after pineal cyst resection.

A pineal cyst is a benign affection of the human pineal gland on the borderline between pathology and normality. Only a small percentage of patients present with symptoms and a surgical treatment is indicated in highly selected cases. A melatonin secretion in patients with a pineal cyst before and after a pineal cyst resection has not been studied yet and the effect of surgery on human metabolism is unknown. The present study examined melatonin, cortisol and blood glucose secretion profiles perioperatively in a surgical group of 4 patients. The control group was represented by 3 asymptomatic patients with a pineal cyst. For each patient, 24-h circadian secretion curves of melatonin, cortisol and glycemia were acquired. An analysis of melatonin profiles showed an expected diurnal pattern with the night peak in patients before the surgery and in the control group. In contrast, melatonin levels in patients after the surgery were at their minimum throughout the whole 24-h period. The cortisol secretion was substantially increased in patients after the surgery. Blood glucose sampling showed no statistically significant differences. Clinical results demonstrated statistically significant headache relief measured by Visual Analogue Scale in patients after the surgery. Despite the small number of examined patients, we can conclude that patients with a pineal cyst preserved the physiological secretion of the hormone melatonin while patients who underwent the pineal cyst resection experienced a loss of endogenous pineal melatonin production, which equated with pinealectomy. Surprisingly, cortisol secretion substantially increased in patients after the surgery.

Magnetic resonance imaging and histology correlation in Cushing's disease.

INTRODUCTION: We continuously look for new techniques to improve the radicality of resection and to eliminate the negative effects of surgery. One of the methods that has been implemented in the perioperative management of Cushing's disease was the combination of three magnetic resonance imaging (MRI) sequences: SE, SPGR and fSPGR. MATERIAL AND METHODS: We enrolled 41 patients (11 males, 30 females) diagnosed with Cushing's disease. A 3D tumour model with a navigation console was developed using each SPGR, fSPGR and SE sequence. The largest model was then used. In all cases, a standard four-handed, bi-nostril endoscopic endonasal technique was used. Endocrinological follow-up evaluation using morning cortisol sampling was performed for 6-34 months in our study. RESULTS: In total, 36 patients (88%) were disease-free following surgery. Our results indicate we achieved 100% sensitivity of MR. Overall, the conformity of at least one donor site, as compared with the places designated on MR, was in 78% of patients. We searched the place of compliance in individual locations. There is a consensus in individual locations in 63 of the 123 cases (or 56%). The correlation gamma function at a 5% significance level was then 0.27. DISCUSSION: The combination of MR sequences (SE, SPGR, fSPGR), neuronavigation system and iMRI led to increased sensitivity of up to 100%. Specificity reached 56% in our study. CONCLUSION: We found a high success rate in surgical procedure in terms of the correlation between MR findings and histology, which leads to remission of Cushing's disease.

Flexible endoscope-assisted evacuation of chronic subdural hematomas.

BACKGROUND: Chronic subdural hematoma (CSDH) is a common neurosurgical condition with an increasing incidence. Standard treatment of CSDHs is surgical evacuation. The objective of this study is to present a modification of standard burr-hole hematoma evacuation using a flexible endoscope and to assess the advantages and risks. METHODS: Prospectively, 34 consecutive patients diagnosed with CSDH were included in the study. Epidemiological, clinical and radiographical data were collected and reviewed. All patients underwent a burr-hole evacuation of CSDH. A flexible endoscope was inserted and subdural space inspected during surgery. The surgeon was looking specifically for the presence of septations, draining catheter position and acute bleeding. RESULTS: Thirty-four patients underwent 37 endoscope-assisted surgeries. Presenting symptoms were hemiparesis (79%), decreased level of consciousness (18%), gait disturbances (15%), headache (12%), aphasia (6%), cognitive disturbances (6%) and epileptic seizure (3%). Average operative time was 43 min, and the average increase in operative time due to the use of the endoscope was 6 min. Recurrence rate was 8.8%, and clinical outcome was favorable (defined as mRS ≤ 2) in 97% of the cases. CONCLUSIONS: To our knowledge, the present cohort of 34 patients is the largest group of patients with CSDH treated using an endoscope. This technique allows decent visualization of the hematoma cavity while retaining the advantages of a minimally invasive approach under a local anesthesia. The main advantages are correct positioning of the catheter under visual control, identification of septations and early detection of cortex or vessel injury during surgery.

Intraoperative Magnetic Resonance Imaging During Endoscopic Transsphenoidal Surgery of Growth Hormone-Secreting Pituitary Adenomas.

BACKGROUND: The effect of intraoperative magnetic resonance imaging (iMRI) on the extent of sellar region tumors treated endonasally has been described in previous research. However, the effects of iMRI on endocrinologic outcome of growth hormone-secreting adenomas have been studied in only a few small cohort studies. METHODS: Inclusion criteria were primary transsphenoidal surgery for growth hormone-secreting adenoma from January 2009 to December 2014, a minimum follow-up of 1 year, complete endocrinologic data, at least 1 iMRI, and at least 2 postoperative magnetic resonance images. The cohort consisted of 105 patients (54 females, 51 males) with a mean age of 48.3 years (range, 7-77 years). There were 16 microadenomas and 89 macroadenomas. RESULTS: Endocrinologic remission in the whole cohort was achieved in 64 of the patients (60.9%). Resection after iMRI was attempted in 22 of the cases (20.9%). Resection after iMRI led to hormonal remission in 9 cases (8.6%). Endocrinologic postoperative deficit was observed in 10 cases (12.5%). Postoperative cerebrospinal fluid leakage indicated the necessity to reoperate in 3 cases (3.8%). No neurologic deterioration was observed. CONCLUSIONS: iMRI influences not only the morphologic extent of pituitary adenomas resection but also the endocrinologic results. We encourage the routine application of iMRI in pituitary adenoma surgery, including hormone-secreting pituitary tumors.

Clinical management of pineal cysts: a worldwide online survey.

BACKGROUND: A pineal cyst is a benign affection of a pineal gland on the borderline between a pathological lesion and a variant of normality. Clinical management of patients with a pineal cyst remains controversial, especially when patients present with non-specific symptoms. METHODS: An online questionnaire consisting of 13 questions was completed by 110 neurosurgeons worldwide. Responses were entered into a database and subsequently analysed. RESULTS: Based on data from the questionnaire, the main indication criteria for pineal cyst resection are hydrocephalus (90 % of the respondents), Parinaud's syndrome (80 %) and growth of the cyst (68 %). Only 15 % of the respondents occasionally operate on patients with non-specific symptoms. If surgery is indicated, improvement is expected in 88 % of the patients. The vast majority of the respondents favour a supracerebellar infratentorial approach to the pineal region. Most (78 %) of the respondents regarded the patient registry as a potentially useful instrument. CONCLUSIONS: This survey sheds light on the current practice of pineal cyst management across the world. Most of the respondents perform surgery on pineal cysts only if patients are presenting with symptoms attributable to a mass effect. Surgery for patients with non-specific complaints (headache, vertigo) is not widely accepted, although it may prove effective. A prospective patient registry might be useful in the decision-making process in the clinical management of pineal cysts.