Assessment of anterior pituitary reserve capacity based on growth hormone response to growth hormone-releasing peptide-2 test in the elderly.

OBJECTIVE: The growth hormone (GH)-releasing peptide-2 (GHRP-2) test is relatively safe among endocrine stimulation tests for the elderly. We investigated whether anterior pituitary function in elderly patients could be assessed on the basis of GH response to the GHRP-2 test. DESIGN: Sixty-five elderly patients aged 65 years and older with non-functioning pituitary neuroendocrine tumor (PitNET) who underwent pituitary surgery and preoperative endocrine stimulation tests were classified into the "GH normal group" and "GH deficiency group" based on GH response to the GHRP-2 test. The baseline characteristics and anterior pituitary function were compared between the groups. RESULTS: Thirty-two patients were assigned to the GH normal group and 33 to the GH deficiency group. The cortisol and adrenocorticotropic hormone (ACTH) results in the corticotropin-releasing hormone test were significantly higher in the GH normal group than in the GH deficiency group (p < 0.001). The relationship between the cortisol and ACTH results and the GH response revealed significant correlations (p < 0.001). In addition, receiver operating characteristic curve analysis identified that the optimal cut-off point for a peak GH level in the correlation between adrenocortical function and GH response to the GHRP-2 test was 8.08 ng/mL (specificity 0.868, sensitivity 0.852). CONCLUSION: The present study indicated that adrenocortical function was significantly correlated with GH response to the GHRP-2 test in elderly patients before pituitary surgery. For elderly patients with non-functioning PitNET, GH response to the GHRP-2 test may support in diagnosing adrenocortical insufficiency.

Creation of low cost, simple, and easy-to-use training kit for the dura mater suturing in endoscopic transnasal pituitary/skull base surgery.

Training kits for laparoscopes for deep suturing under endoscopes are commercially available; however, previously reported training kits for endoscopic transnasal transsphenoidal pituitary/skull base surgery (eTSS) were not available in the market. Moreover, the previously reported low cost, self-made kit has the drawback of being unrealistic. This study aimed to create a low cost training kit for eTSS dura mater suturing that was as close to real as possible. Most necessary items were obtained from the 100-yen store ($1 store) or from everyday supplies. As an alternative to the endoscope, a stick-type camera was used. Through the assembly of the materials, a simple and easy-to-use training kit was created, which is almost identical to the actual dural suturing situation. In eTSS, a simple and easy-to-use training kit for dural suturing was successfully created at a low cost. This kit is expected to be used for deep suture operations and the development of surgical instruments for training.

Use of a Contest Format for Objective Assessment of Microsurgical Technique: An Observational Study.

BACKGROUND: Few studies have used simulation models to examine long-term improvement in microsurgical technique. We investigated whether improvement in surgical technique could be assessed by continuous, objective, contest-format evaluation of the same microsurgical task. METHODS: Since 2014, neurosurgeons with 1-10 years of experience participated in a biannual competition-format test. The task involved creating as many sutures as possible during the 5-minute interval after arteriotomy of a 1-mm artificial vessel. A modified version of the Objective Structured Assessment of Technical Skills examination was created and used. Changes and differences in scores over time were examined for each evaluator. RESULTS: Overall, 103 neurosurgeons participated in the study at least once, and those who participated more than once were divided into two groups: those who had the highest score in each contest and those who had the lowest score. The linear regression equations for the highest and lowest scorers were y=7.62x+81.56 (R2=0.628) and y=1.94x+67.93 (R2=0.0433), respectively. High scorers had high scores from the first time they participated, and their scores tended to increase further, while scores for low scorers tended not to increase with additional experience. Scores for the four evaluators did not significantly differ. CONCLUSIONS: Our results suggest that technical improvement in surgery can be assessed by long-term, continuous evaluation of microsurgical technique and that the present evaluation system might help increase surgical safety.

Accurate assessment of estrogen receptor profiles in non-functioning pituitary adenomas using RT-digital PCR and immunohistochemistry.

BACKGROUND: Non-functioning pituitary adenomas (NFPAs) are common pituitary tumors, and surgery is generally the only treatment option. Few attempts have been made to explore target molecules for the development of NFPA pharmacological treatments. METHOD: We quantitatively assessed the expression profiles of estrogen receptor (ER) transcripts and proteins in NFPA samples, using reverse transcription-digital polymerase chain reaction (RT-dPCR) and immunohistochemistry, and further investigated the correlations between the expression levels of ER and those of downstream responsive genes. All patients had undergone surgery at the same high-volume hospital. A total of 20 patients with NFPAs were included. All patients were new-onset, and none were diagnosed with intratumoral hemorrhages or cysts. RESULTS: NFPA samples exhibited a bimodal ESR1 expression pattern and were categorized into significantly different high- and low-ESR1 expression level groups (P < 0.05). In contrast, expression levels of ESR1 variants and ESR2 could barely be detected. Similar results were obtained through the immunohistochemical staining of NFPAs, using well-validated antibodies against ERs. The expression levels of ESR1 positively correlated with those of GREB1, an estrogen-responsive gene [correlation coefficient (r) = 0.623, P = 0.003]. CONCLUSIONS: ESR1 expression levels in NFPAs exhibited a bimodal pattern and were positively correlated with GREB1 expression levels. The accurate assessment of ER expression levels may further advance future NFPA-related research.

Risk Management of Aneurysmal Subarachnoid Hemorrhage by Age and Treatment Method from a Nationwide Database in Japan.

OBJECTIVE: There has been no precise guide for treatment management of aneurysmal subarachnoid hemorrhage (aSAH) based on the patient's age and treatment method. This study clarifies each risk management for aSAH according to age and treatment method listed in a nationwide database. METHODS: We compared 2 groups of patients (nonelderly, <65 years; elderly, ≥65 years) who underwent surgical clipping or endovascular coiling and were registered in a nationwide database in Japan from 2010 to 2015. The odds ratio (OR) and 95% confidence interval (CI) of each risk factor were calculated through multivariate logistic regression analysis for poor outcome according to a modified Rankin Scale score >2 at discharge for each group. RESULTS: In all groups, the risk factors for poor outcome were older age, male sex, neurologic grade on admission, diabetes mellitus, and use of anticoagulation drugs. Inverse risk factors were a high-volume hospital, academic hospital, hypertension, and use of an antiplatelet drug (OR, 0.63-0.81; 95% CI, 0.56-0.88). Chronic heart disease was also a risk factor, but use of a statin drug (OR, 0.85-0.87; 95% CI, 0.76-0.97) and location other than on the anterior communicating artery (OR, 0.74-0.80; 95% CI, 0.67-0.91) were inverse risks in both the elderly and the endovascular coiling groups. CONCLUSIONS: Management for patients with aneurysmal subarachnoid hemorrhage was recommended in high-volume and academic institutes with the administration of antiplatelet drugs and consideration of several risk factors. Elderly patients undergoing endovascular coiling might be better given a statin drug, and patients with chronic heart failure or an anterior communicating artery aneurysm should be treated more carefully.

Multidisciplinary consensus on assessment of unruptured intracranial aneurysms: proposal of an international research group.

BACKGROUND AND PURPOSE: To address the increasing need to counsel patients about treatment indications for unruptured intracranial aneurysms (UIA), we endeavored to develop a consensus on assessment of UIAs among a group of specialists from diverse fields involved in research and treatment of UIAs. METHODS: After composition of the research group, a Delphi consensus was initiated to identify and rate all features, which may be relevant to assess UIAs and their treatment by using ranking scales and analysis of inter-rater agreement (IRA) for each factor. IRA was categorized as very high, high, moderate, or low. RESULTS: Ultimately, 39 specialists from 4 specialties agreed (high or very high IRAs) on the following key factors for or against UIA treatment decisions: (1) patient age, life expectancy, and comorbid diseases; (2) previous subarachnoid hemorrhage from a different aneurysm, family history for UIA or subarachnoid hemorrhage, nicotine use; (3) UIA size, location, and lobulation; (4) UIA growth or de novo formation on serial imaging; (5) clinical symptoms (cranial nerve deficit, mass effect, and thromboembolic events from UIAs); and (6) risk factors for UIA treatment (patient age and life expectancy, UIA size, and estimated risk of treatment). However, IRAs for features rated with low relevance were also generally low, which underlined the existing controversy about the natural history of UIAs. CONCLUSIONS: Our results highlight that neurovascular specialists currently consider many features as important when evaluating UIAs but also highlight that the appreciation of natural history of UIAs remains uncertain, even within a group of highly informed individuals.

Prospective assessment of concomitant lumbar and chronic subdural hematoma: is migration from the intracranial space involved in their manifestation?

OBJECT: Spinal subdural hematomas (SDHs) are rare and some are concomitant with intracranial SDH. Their pathogenesis and etiology remain to be elucidated although their migration from the intracranial space has been suggested. The authors postulated that if migration plays a major role, patients with intracranial SDH may harbor asymptomatic lumbar SDH. The authors performed a prospective study on the incidence of spinal SDH in patients with intracranial SDH to determine whether migration is a key factor in their concomitance. METHODS: The authors evaluated lumbar MR images obtained in 168 patients (125 males, 43 females, mean age 75.6 years) with intracranial chronic SDH to identify cases of concomitant lumbar SDH. In all cases, the lumbar MRI studies were performed within the 1st week after surgical irrigation of the intracranial SDH. RESULTS: Of the 168 patients, 2 (1.2%) harbored a concomitant lumbar SDH; both had a history of trauma to both the head and the hip and/or lumbar area. One was an 83-year-old man with prostate cancer and myelodysplastic syndrome who suffered trauma to his head and lumbar area in a fall from his bed. The other was a 70-year-old man who had hit his head and lumbar area in a fall. Neither patient manifested neurological deficits and their hematomas disappeared under observation. None of the patients with concomitant lumbar SDH had sustained head trauma only, indicating that trauma to the hip or lumbar region is significantly related to the concomitance of SDH (p < 0.05). CONCLUSIONS: As the incidence of concomitant lumbar and intracranial chronic SDH is rare and both patients in this study had sustained a direct impact to the head and hips, the authors suggest that the major mechanism underlying their concomitant SDH was double trauma. Another possible explanation is hemorrhagic diathesis and low CSF syndrome.

Endoscopic microneurosurgery: usefulness and cost-effectiveness in the consecutive experience of 210 patients.

OBJECTIVE: Indications, usefulness, and cost-effectiveness of the endoscope in routine microneurosurgery are not clear. To delineate such aspects, we assessed our experience of endoscopic application and additional cost to use an endoscope. METHODS: Endoscopes were used in 210 patients with cranial base and cisternal pathological features in the previous 7 years. Lesions were located in the extradural cranial base in 78 patients and in the cistern in 132 patients. Rigid lens endoscopes 2.7 to 4 mm in width, 11 to 20 cm in length, and 0 to 70 degrees in angle were used. RESULTS: Endoscopes were used for primary or a significant part of the surgery in 64% of the extradural cranial base procedures. Although endoscopes were used only for visual assistance in 82% of cisternal pathological features, significant benefit was noted in 9% and was not different from cranial base lesions. Eleven patients may have had complications if the endoscope had not been used, and 10 procedures would have been impossible without endoscopic use. Therefore, the number of patients need to treat to experience significant benefits by endoscope was 10. Endoscopic equipment costs an additional US $326 per patient and, hence, significant benefit was the equivalent of US $3260. No permanent complications resulted from the use of the endoscope. CONCLUSION: The endoscope can be applied safely in routine microsurgery with specific equipment and has proven useful in 1 of 10 patients. To perform more effective procedures using endoscopes, we need to develop specially designed instruments usable through a narrow corridor and in an angled field.

Endoscopic microneurosurgery: usefulness and cost-effectiveness in the consecutive experience of 210 patients.

OBJECTIVE: Indications, usefulness, and cost-effectiveness of the endoscope in routine microneurosurgery are not clear. To delineate such aspects, we assessed our experience of endoscopic application and additional cost to use an endoscope. METHODS: Endoscopes were used in 210 patients with cranial base and cisternal pathological features in the previous 7 years. Lesions were located in the extradural cranial base in 78 patients and in the cistern in 132 patients. Rigid lens endoscopes 2.7 to 4 mm in width, 11 to 20 cm in length, and 0 to 70 degrees in angle were used. RESULTS: Endoscopes were used for primary or a significant part of the surgery in 64% of the extradural cranial base procedures. Although endoscopes were used only for visual assistance in 82% of cisternal pathological features, significant benefit was noted in 9% and was not different from cranial base lesions. Eleven patients may have had complications if the endoscope had not been used, and 10 procedures would have been impossible without endoscopic use. Therefore, the number of patients need to treat to experience significant benefits by endoscope was 10. Endoscopic equipment costs an additional 326 US dollars per patient and, hence, significant benefit was the equivalent of 3260 US dollars. No permanent complications resulted from the use of the endoscope. CONCLUSION: The endoscope can be applied safely in routine microsurgery with specific equipment and has proven useful in 1 of 10 patients. To perform more effective procedures using endoscopes, we need to develop specially designed instruments usable through a narrow corridor and in an angled field.