Giant Recurrence Pituitary Adenoma After Three Times Transphenoidal Removal Surgery, One Craniotomy Procedure, and 30 Doses of External Radiotherapy.

This is a case of 42nd year-old woman with history of sight loss in her both eyes. She experienced headache and visual field decrease gradually since 2014. After several laboratory and imaging examinations, from her dynamic pituitary magnetic resonance imaging (MRI), it is concluded that she had a giant adenoma of the pituitary gland which compressed to her optic chiasm. From her pituitary laboratory hormone panel, it is revealed that the tumor is a non-functioning pituitary adenoma. From the neuro-ophthalmology (campimetry) examinations, she had papillae atrophy in her both eyes and also bilateral temporal hemianopia.

Cerebral Amyloidoma.

Cerebral amyloidoma is the rarest presentation of amyloid-related diseases of the central nervous system. We present the case of a patient with visual difficulty and an infiltrating lesion in the temporal lobe, shown by magnetic resonance imaging. In as much as a benign clinical course is expected, a knowledge of this entity, along with state-of-the-art imaging and close follow-up, could avoid invasive procedures such as biopsy.

A case of relapsing-remitting tumour-like inflammation of the central nervous system.

The case of a 37-year-old woman suffering from a relapsing-remitting tumefactive inflammatory disease of the central nervous system (CNS) is described. The patient had four severe relapses over eight years, and was treated with steroids, immunosuppression and plasma-exchange with modest benefit. No magnetic resonance imaging or cerebrospinal spinal fluid findings suggestive of multiple sclerosis emerged during the eight-year follow-up. 'Relapsing-remitting tumefactive inflammation' seems to have the features of a distinct inflammatory CNS disease.

Tumefactive demyelinating lesions: Characteristics of individual lesions, individual patients, or a unique disease entity?

Whether or not recurrent tumefactive demyelinating lesions are a unique form of CNS demyelinating disease or part of the continuum of multiple sclerosis is a question raised by the case report on which this commentary is based. Detailed review and immunopathologic study of biopsy material may not only confirm or refute a diagnosis of demyelinating disease, but potentially uncover unique features that may assist in understanding pathophysiology and nosology of rare cases with recurrent tumefactive demyelination.

Endoscopic Endonasal Approach to the Optic Canal: Anatomic Considerations and Surgical Relevance.

BACKGROUND: Increasing use of endoscopic endonasal surgery for suprasellar lesions with extension into the optic canal (OC) has necessitated a better endonasal description of the OC. OBJECTIVE: To identify the osseous OC transcranially and then investigate its anatomic relationship to the key endonasal intrasphenoidal landmarks. We also aimed to determine and describe the technical nuances for safely opening the falciform ligament and intracanalicular dura (surrounding the optic nerve [ON]) endonasally. METHODS: Ten fresh human head silicon-injected specimens underwent an endoscopic transtuberculum/transplanum approach followed by 2-piece orbitozygomatic craniotomy to allow identification of 20 OCs. After completing up to 270° of endonasal bony decompression of the OC, a dural incision started at the sella and continued superiorly across the superior intercavernous sinus. Subsequently the dural opening was extended anterolaterally across the dura of the prechiasmatic sulcus, limbus sphenoidale, and planum. RESULTS: Endonasally, the length of the osseous OC was approximately 6 mm and equivalent to the length of the lateral opticocarotid recess, as measured anteroposteriorly. The ophthalmic artery arose from the supraclinoidal carotid artery at approximately 2.5 mm from the medial osseous OC entrance. Transcranial correlation of the endonasal dural incision confirmed medial detachment of the falciform ligament and exposure of the preforaminal ON. CONCLUSION: The lateral opticocarotid recess allows distinction of the preforaminal ON, roofed by the falciform ligament from the intracanalicular segment in the osseous OC. This facilitates the preoperative surgical strategy regarding the extent of OC decompression and dural opening. Extensive endonasal decompression of the OC and division of the falciform ligament is feasible.

"Unusual brain stone": heavily calcified primary neoplasm with some features suggestive of angiocentric glioma.

This 40-year-old man presented with a 5-month history of progressive right-sided headache associated with visual blurring. He also had a history of epilepsy but had been seizure free with medication for the past 10 years. An initial CT scan of his brain performed 16 years previously had revealed a small area of calcification in the right parietal region. In the current presentation, he had a left-sided homonymous hemianopia but no other neurological deficits. A CT scan of his brain showed a much larger calcified, partly cystic lesion in the right parietal region. Because he was symptomatic, the lesion was excised and the cyst was drained. Histological examination of the excised tissue showed an unusual primary tumor that was difficult to classify but had some features of angiocentric glioma. The heavy calcification, mixed-density cell population, and regions with features of angiocentric glioma were most unusual. The patient remained asymptomatic 5 years after surgery, and follow-up scans did not show recurrence.

Intermittent visual field defects caused by a dilated Virchow-Robin space close to the optic radiation: Therapeutic and pathomechanical considerations.

OBJECTIVE: Virchow-Robin spaces (VRSs) are extensions of subarachnoid spaces that accompany vessels entering the brain. T2-weighted magnetic resonance imaging detects VRS in about 95 percent of patients in a recent study. VRSs are considered a normal variant with benign prognosis. Occasionally, VRS might become symptomatic causing neurological deficits depending on their location. CASE DESCRIPTION: We report the case of a 55-year-old female patient with dilated VRS presenting with visual field disturbances and cognitive deficits. The patient underwent endoscopic fenestration of a large periventricular VRS located next to the visual radiation into the posterior horn of the right lateral ventricle. During the postoperative course, visual field disturbances were resolved but cognitive deficits remained unchanged. CONCLUSION: Dilated VRSs can cause a variety of neurological deficits depending on their size and location. Therefore, patients harboring dilated VRS should undergo early close inspection and in case of progressive neurological deficits, an operative therapy should be done; as valve mechanisms can cause a reduction of size when brain scans are conducted and later lead to occurrence of severe neurological deficits during phase of dilation.

Imaging of the optic chiasm and retrochiasmal visual pathways.

The exploration of the chiasmal and retrochiasmal visual pathways is based on magnetic resonance imaging. A bitemporal hemianopsis suggests a lesion of the optic chiasm while homonymous lateral hemianopsis should lead to a search for a lesion of the retrochiasmal visual pathways. The causes of chiasmal impairment are mainly tumoral. The exploration protocol is based on MRI with T1-weighted sagittal sections, then T2- and T1-weighted coronal sections with and without injection. In case of a retrochiasmal syndrome, the MRI exploration protocol is a function of the type of occurrence of the deficiency and the context.

Uncommon cavernous malformation of the optic chiasm: a case report.

Cavernous malformation (CM) is a vascular malformation disorder characterized by a berry-like mass of expanded blood vessels. CM, originating from the optic chiasm. usually leads to chiasma syndrome presenting with bitemporal hemianopsia. We report a 28-year-old male presenting with left homonymous hemianopsia. Magnetic resonance imaging (MRI) revealed an occupied lesion located in the right side of the optic chiasm, and a clinical diagnosis of chiasmal CM was made. Microsurgical excision was performed via anterolateral pterional craniotomy. The patient showed good recovery with slight improvement of the visual field deficits after the operation. No CM recurrence was discovered during the follow-up MRI scans.

Acute cerebrovascular accident after cisplatin treatment in a patient taking letrozole.

Vascular thrombotic events are common in patients with cancer and chemotherapy is considered a contributing factor. Venous thrombotic events are more common than arterial ones which are less documented. In this report, we describe a patient with right homonymous hemianopsia following treatment with cisplatin for small cell lung carcinoma while also taking letrozole. A brief review of the literature on arterial thrombotic events after chemotherapy follows.

Pre-existing chiasma syndromes do not entirely remit following transsphenoidal surgery for pituitary adenomas.

BACKGROUND: It is not known whether following transsphenoidal surgery for pituitary adenomas the vision of patients with preoperative chiasma syndromes (CS) does improve to the degree of vision of patients without preoperative CS. OBJECTIVE: The purpose of this study is to answer the question above. METHODS: Pertinent data of a successive series of patients operated transsphenoidally for the first time for pituitary adenoma were retrospectively analysed. RESULTS: Of the 304 patients, 35.1% presented preoperatively with CS. The median visual acuity (VA) of these patients improved significantly from preoperative (right eye, 0.63 (0; 1.25); left eye, 0.56 (0; 1.4)) to postoperative (right eye, 0.8 (0; 1.25); left eye, 0.74 (0; 1.25)). The median number of impaired quadrants of the binocular visual fields (VF) improved significantly from preoperative (2 (0; 8)) to postoperative CS (0 (0; 4)). In patients without preoperative CS, postoperative vision (VA as well as VF) remained unchanged. Postoperatively, VA of patients with preoperative CS remained significantly lower than that of patients without preoperative CS (right eye, 0.96 (0.2; 1.4); left eye, 0.94 (0.05; 1.4)). Postoperatively, the number of impaired quadrants of the binocular VF of patients with preoperative CS remained significantly higher than in patients without preoperative CS (0 (0; 1)). CONCLUSION: In this unselected patient series, the vision (VA as well as VF) of patients with preoperative CS did not improved postoperatively to the degree of the vision of patients without preoperative CS. Thus, in patients with adenomatous chiasma compression transsphenoidal surgery may be indicated before CS develops.

Relationship between visual field sensitivity loss and quadrantic macular thickness measured with Stratus-Optical coherence tomography in patients with chiasmal syndrome / Correlação entre defeito de campo visual e espessura macular quadrântica avaliada através da tomografia de coerência óptica em pacientes com compressão quiasmática

PURPOSE: To correlate visual field sensitivity (VFS) loss on standard automated perimetry (SAP) and quadrantic macular thickness on optical coherence tomography (OCT) in patients with permanent temporal hemianopia from chiasmal compression. METHODS: Forty eyes from 40 patients with chiasmal compression and 40 healthy eyes were submitted to standard automated perimetry and Stratus-OCT scanning. Raw data of the fast macular thickness scanning protocol were exported and macular thickness measurements were recorded and averaged for each quadrant and half of the central area. The correlation between visual field sensitivity loss and optical coherence tomography measurements was tested with Pearson's correlation coefficients and with linear regression analysis. RESULTS: A significant association was found between each macular thickness parameter and the corresponding central VF mean sensitivity. The strongest association was observed between superonasal macular thickness and the inferotemporal mean defect measured both in decibel (R=0.47; p=0.001) and in 1/Lambert (R=0.59; p<0.0001) units. CONCLUSION: Stratus-OCT-measured macular thickness was topographically related with visual field sensitivity loss in patients with temporal hemianopia from chiasmal compression. Such measurements could prove clinically useful in the diagnosis and follow-up of patients with chiasmal compression. ClinicalTrial.gov identifier number: NCT0039122.

OBJETIVO: Avaliar a correlação entre o defeito de campo visual ao exame de perimetria computadorizada e a espessura macular quadrântica ao exame de tomografia de coerência óptica (OCT) em pacientes com hemianopsia temporal permanente causada por compressão quiasmática. MÉTODOS: Quarenta olhos de 40 pacientes com compressão quiasmática e 40 olhos de 40 indivíduos controles foram submetidos aos exames de perimetria computadorizada e tomografia de coerência óptica. Dados não processados foram exportados e as medidas de espessura macular foram calculadas para cada quadrante e metade da área macular central. A correlação entre o defeito campimétrico e as medidas de espessura macular foi avaliada por coeficiente de correlação de Pearson e por análise de regressão linear. RESULTADOS: Associação significante foi encontrada entre os parâmetros de espessura macular e seus respectivos defeitos campimétricos. A correlação mais forte foi encontrada entre o parâmetro espessura macular nasal superior e o defeito campimétrico médio temporal inferior medido em decibel (R=0,47; p=0,001) e em 1/Lambert (R=0,59; p<0,0001). CONCLUSÃO: Medidas de espessura macular avaliada através da tomografia de coerência óptica foi topograficamente relacionada ao defeito campimétrico em pacientes com hemianopsia temporal por compressão quiasmática. Estas medidas podem provar a importância clínica no diagnóstico e seguimento dos pacientes com compressão quiasmática. ClinicalTrial.gov identifier number: NCT0039122.

Reversible hemianopsia caused by mechanical compression of the visual pathway by the dilated draining vein of an arteriovenous malformation--case report.

A 41-year-old woman presented with progressive hemianopsia caused by compression of the lateral geniculate body by the dilated basal vein draining a contralateral frontal arteriovenous malformation (AVM). Magnetic resonance (MR) imaging revealed left frontal AVM and right lateral geniculate body compression due to the dilated basal vein. Emergent presurgical transarterial embolization and surgical removal were performed. Left hemianopsia completely recovered 3 months after surgery and MR imaging indicated improvement of the compression of the lateral geniculate body. Direct mechanical compression of the enlarged drainage vein is one of the causes of homonymous hemianopsia. Early surgical treatment is recommended to obtain a rapid recovery.

Visual field defects after selective amygdalohippocampectomy and standard temporal lobectomy.

BACKGROUND: Selective amygdalohippocampectomy (SelAH) is increasingly performed in patients with mesial temporal lobe epilepsy and hippocampal sclerosis. To determine whether visual field defects are less pronounced after SelAH than after standard temporal lobectomy (StTL), we retrospectively analyzed postoperative quantitative visual fields after the 2 procedures. METHODS: Humphrey visual field analysis was obtained postoperatively in 18 patients who had undergone SelAH and in 33 patients who had undergone StTL. The SelAH was performed via a transcortical approach through the middle temporal gyrus and included the amygdala, 3 cm of the hippocampus, and the parahippocampal gyrus. The visual field pattern deviation was used for analysis. We considered a defect clinically significant if there were 3 contiguous coordinates affected at the 5% level or 2 at the 1% level. RESULTS: All but 2 of 18 patients who had undergone SelAH had homonymous superior quadrantic visual field defects contralateral to the side of the surgery. One patient had no defects by our criteria, and one had a mild defect that reached significance only in the ipsilateral eye. The averaged defect affected mostly coordinates close to the vertical meridian with relative sparing of points close to the horizontal meridian. All but 3 of the 33 patients who had undergone StTL had homonymous superior quadrantic visual field defects. One patient had no defects; 2 had defects that reached significance in only one eye. The averaged defect involved all points in the affected quadrant, but was also greater near the vertical meridian. Of 13 tested visual field coordinates, 4 were significantly less affected by SelAH in the ipsilateral eye and 3 in the contralateral eye. The coordinates close to the horizontal meridian were significantly spared by SelAH. CONCLUSIONS: Visual field defects are very common after SelAH but are significantly less pronounced than after StTL. In particular, the visual field close to the horizontal meridian is relatively spared in SelAH.