Outcome Assessment After Surgical Treatment of Tuberculum Sellae Meningiomas- A Preliminary Report.

AIM: To evaluate the endocrinological and ophthalmological results of the tuberculum sellae meningioma surgery. MATRRIAL and METHODS: A total of 18 patients diagnosed with tuberculum sellae meningioma received surgical treatment at Neurosurgery Clinic at Military Medical Institute in Warsaw from January 2010 to July 2012. This analyzed group of patients included 15 females and 3 males at a mean age of 50.5 years (ranging from 30 to 73; SD ± 13.4). In the pre-operative and post-operative periods, all patients underwent magnetic resonance imaging of the head according to a uniform protocol, eye examinations with assessment of visual acuity and field of vision, as well as endocrine tests to evaluate the hypothalamic-pituitary axis (including urine specific gravity and osmolality as well as blood cortisol, TSH, fT3, and fT4 levels). All patients underwent surgical treatment of the tumor via unilateral subfrontal craniotomy, achieving macroscopically complete tumor removal (Simpson grade II resection). RESULTS: The use of the unilateral subfrontal approach helped improve vision in 88% of the treated patients. Endocrine tests revealed no hypothalamic-pituitary axis dysfunction. The most commonly diagnosed meningiomas of the area were meningothelial (77%) and transitional (12%) meningiomas. CONCLUSION: Surgical treatment of tuberculum sellae meningiomas via the unilateral subfrontal approach is a safe technique with no significant complications. Visual improvement was observed in 88% of the patients who had received this treatment. There were no hormonal disturbances in patients operated via the subfrontal approach either prior to or after the procedure, which suggests that surgical treatment of tuberculum sellae meningiomas has no effect on pituitary endocrine function.

The inadequacy of the Y-axis of growth (SNGn) for the vertical pattern assessment in patients with sagittal discrepancies.

AIM: The aim of this cephalometric study was to evaluate the influence of the sagittal skeletal pattern on the 'Y-axis of growth' measurement in patients with different malocclusions. MATERIALS AND METHODS: Lateral head films from 59 patients (mean age 16y 7m, ranging from 11 to 25 years) were selected after a subjective analysis of 1630 cases. Sample was grouped as follows: Group 1 - class I facial pattern; group 2 - class II facial pattern; and Group 3 - class III facial pattern. Two angular measurements, SNGoGn and SNGn, were taken in order to determine skeletal vertical facial pattern. A logistic regression with errors distributed according to a binomial distribution was used to test the influence of the sagittal relationship (Class I, II, III facial patterns) on vertical diagnostic measurement congruence (SNGoGn and SNGn). RESULTS: RESULTS show that the probability of congruence between the patterns SNGn and SNGoGn was relatively high (70%) for group 1, but for groups II (46%) and III (37%) this congruence was relatively low. CONCLUSION: The use of SNGn appears to be inappropriate to determine the vertical facial skeletal pattern of patients, due to Gn point shifting throughout sagittal discrepancies. Clinical Significance: Facial pattern determined by SNGn must be considered carefully, especially when severe sagittal discrepancies are present.

Assessment of 2D:4D in subjects with anteroposterior mandibular dysplasia.

OBJECTIVES: To compare 2D:4D ratio which is determined by testosterone levels with patients having orthognathic, retrognathic and prognathic mandibles. MATERIALS AND METHODS: The study was performed at Chennai, on 320 subjects of which, 60 subjects (32 males and 28 females) had retrognathic mandible; 55 subjects (25 males and 30 females) had prognathic mandible and 205 subjects (98 males and 107 females) had normal mandible. All the subjects had a normal maxilla and were in the age group of 18 to 25 years. 2D:4D ratio was determined using the photocopies of the ventral surface of right hand made with vernier calipers of 0.01 mm accuracy. Statistical analysis was undertaken using Student's t- test, ANOVA test and TukeyHSD test. RESULTS: (i) Low 2D:4D is seen in subjects with mandibular prognathism, (ii) Among females, low 2D:4D is seen only in prognathic mandible. CONCLUSION: These findings highlight the fact that testosterone plays an important role in mandibular growth. Thus 2D:4D, a least invasive and reproducible procedure can be used as an early marker for mandibular progathism, and as a diagnostic tool in correlating the mandibular growth with causal relations between hormones and craniofacial development.

Assessment of skeletal stability of intraoral vertical ramus osteotomy with one-day maxillary-mandibular fixation followed by early jaw exercise.

PURPOSE: Intraoral vertical ramus osteotomy (IVRO) is an effective surgical technique for cases of mandibular setback, is simpler and has a lower incidence of mental paraesthesia when compared to sagittal split ramus osteotomy (SSRO). However, IVRO has a disadvantage in the prolonged duration of postoperative maxillary-mandibular fixation (MMF) required due to the absence of rigid bone fixation. To avoid an extended MMF period, we developed a postoperative management protocol for our IVRO patients, using jaw exercises with elastic bands starting on the second day after surgery. METHODS: We evaluated the cephalometric skeletal and dental stabilities of 16 IVRO patients as they followed our protocol. RESULTS: The stabilities were confirmed and were similar to those of previous reports. CONCLUSION: One-day MMF and early initiation of jaw exercise after IVRO did not affect the jaw position stability. Moreover, our findings suggest that starting jaw exercise earlier after IVRO surgery is beneficial, as it allows patients to avoid a long period of rigid MMF so that they can resume their normal daily activities sooner.

An assessment of skeletal craniofacial asymmetry in South Indian population.

The present study was undertaken to assess the skeletal craniofacial asymmetry in South Indian population by a posteroanterior cephalometric radiographic method. The skeletal craniofacial structures on one side of the face were compared with that of the other, by drawing various triangles representing different craniofacial regions. The sample consisted of 60 subjects (30 males and 30 females) aged between 18 to 25 years, who were mainly dental college students from South India. Overall 52 X-rays were obtained, with four errors each in the male and the female groups. The results revealed that the total facial structures in the South Indian population were larger on the left side (statistically insignificant). The cranial base area exhibited a greater degree of asymmetry than any other component area of the face, which might be due to the inaccuracy at the condylar point.

Are T2-weighted images more useful than T1-weighted contrast-enhanced images in assessment of postoperative sella and parasellar region?

BACKGROUND: The proper diagnosis and management of patients after surgery for pituitary tumors are of great importance in clinical practice. The purpose of this study was to investigate the magnetic resonance features of the postoperative sella with fast spin echo T2-weighted imaging and to evaluate the benefits of this sequence compared to the classically performed contrast-enhanced T1-weighted imaging at 1.5T unit. MATERIAL/METHODS: The study group consisted of 101 patients who underwent resection of pituitary tumors. There were 58 women (57.4%), aged 22 to 75 (mean age, 52.67 years) and 43 men (42.6%), aged 21 to 79 (mean age, 49 years). In all patients preoperative and multiple postoperative MR studies were performed. Post-contrast T1 and pre-contrast T2 images were interpreted by 2 independent readers (neuroradiologists). RESULTS: Contrast-enhanced T1-weighted imaging was significantly superior to T2-weighted imaging in assessment of infundibulum (p<0.05). There was no statistically significant difference for each of readers between T1- and T2-weighted images regarding to the following features: visualization of residual pituitary gland (p = 0.062 and p = 0.368), contours of pituitary (p = 0.959 and p = 0.265), optic chiasm (p = 0.294 and p = 0.843), and visualization of presence of residual tumor (p = 0.204 and p = 0.169). T2-weighted images were significantly superior to contrast-enhanced T1-weighted imaging with regard to visualization of contours of residual tumors (p<0.05). CONCLUSIONS: T2-weighted images may help to discriminate tumorous from non-tumorous involvement of the postoperative sella and the sphenoid sinus. T2-weighted images are also very useful for a long time after the resection in the postoperative evaluation of the implanted muscle with fascia.

Intraoperative conversion from endoscopic to microscopic approach for the management of sellar pathology: incidence and rationale in a contemporary series.

BACKGROUND: The endoscopic transsphenoidal approach has become widely used for pituitary and extended skull base operations. Intraoperative conversion to a microscopic approach may be an important option in selected cases. We aim to characterize the operative situations in which such conversion occurred and facilitated the procedure. METHODS: From April 2008 through August 2009, 148 planned endoscopic transsphenoidal approaches were performed. All cases were retrospectively reviewed to identify those patients converted to a microscopic approach. Clinical and operative characteristics, reasons for conversion, and patient outcomes were reviewed. RESULTS: Of the 148 endoscopic cases, conversion was undertaken in 27 (18%). Ten patients (37%) had undergone previous transsphenoidal surgery. Reasons for conversion in nonreoperation cases were atypical nasal anatomy (6 patients), acromegaly with distorted anatomy (5 patients), desire for binocular vision (3 patients), complex sphenoid sinus anatomy and difficulty visualizing sella/midline (2 patients), and obstructive mucosal bleeding (1 patient). Of the 10 reoperation procedures, conversions occurred in 3 patients with Cushing's disease and 2 with acromegaly. The primary reasons for conversion in reoperations were scarring with loss of anatomic landmarks (4 patients), mucosal bleeding (2 patients), acromegaly with distorted anatomy (2 patients), technical problem with visualization (1 patient), and desire for binocular surgery (1 patient). CONCLUSIONS: Although endoscopic transsphenoidal surgery provides superior visualization in most patients, conversion to a microscopic or endoscopic-assisted approach may provide essential visualization in selected patients. This may be especially true in patients undergoing reoperation and patients with acromegaly or Cushing's disease. Trainees learning the endoscopic transsphenoidal approach should become familiar with the benefits and limitations of the various transsphenoidal approaches.

Orthodontists' and laypersons' aesthetic assessment of Class III subjects referred for orthognathic surgery.

This study was undertaken to compare laypersons' and professionals' perception of soft tissue profiles of Class III adults, and to evaluate which cephalometric variables are likely to influence the profile assessment score (PAS). Lateral headfilms and coloured profile photographs of 18 skeletal Class III Caucasian adult patients (10 males, 8 females with a mean age of 24.5 years) prior to surgery, and nine adult Caucasian patients (four males, five females with a mean age of 27.4 years) with a dental Class I occlusion and no major skeletal discrepancy were included in the study. The headfilms were hand traced and digitized. Various cephalometric variables were calculated by computer software. Each printed profile photograph was evaluated aesthetically by 18 laypersons and 18 orthodontists using a 10-graded visual analogue scale (VAS) and a standard profile for calibration. Intra-observer reliability was tested and no significant error was found. Paired and unpaired t-tests were used to compare the scores. The association between various cephalometric variables and the PAS was tested. In general, compared with orthodontists, laypersons were less critical in their evaluation of the Class III profiles (+0.3 grade on the VAS) as well as the reference profiles (+0.7). The reference profiles were found to be more attractive than the Class III profiles by both laypersons and orthodontists (+2.3 grades). The degree of facial concavity had a negatively predictive value for the orthodontists' and laypersons' evaluations. The degree of facial concavity together with the steepness of the mandibular plane were negatively predictive factors for the PAS given by the orthodontists.

Outcome of surgical intrasellar growth hormone tumor performed by a pituitary specialist surgeon in a developing country.

BACKGROUND: Acromegaly is an excessive GH secretion, which in most cases, is caused by a pituitary GH-secreting adenoma. Traditional treatment of acromegaly consists of surgery, drug therapy, and eventually radiotherapy. The aim of this retrospective study is to evaluate the results of transsphenoidal endoscopic surgery in a group of patients with intrasellar GH adenoma who were operated by a pituitary specialist surgeon. We shall then argue about the economical advantages, for the NHS of a developing country, between surgical and medical treatment. METHODS: We have analyzed data from 33 patients with intrasellar GH tumor who had been referred to the neuroendocrine department of the HGF, Brazil. The patients underwent a transsphenoidal endoscopic adenomectomy for acromegaly between 2000 and 2005. Their ages were between 20 and 67 years (mean, 44 years) at the moment of surgery. No cavernous sinus invasion was present. Follow-up was a median of 2 years (range, 12 months-6 years). RESULTS: All 33 patients had intrasellar adenoma, 84.84% of patients achieved remission by surgery. One patient was operated twice and reached hormonal normalization. Five patients still had the disease and refused a second surgery. A treatment with octreotide was started for these 5 patients and resulted in an adequate control of GH and IGF-1 levels. No patients had radiotherapy. CONCLUSION: Our patients, with intrasellar GH tumor, operated by a pituitary specialist neurosurgeon had remission rates approaching those obtained by most specialized neurosurgical centers worldwide. For equal results, our study shows that the surgical treatment is the best issue for the patient and for the NHS.

Quantitative and qualitative assessment of morphology in sagittal synostosis: mid-sagittal vector analysis.

Consensus remains lacking regarding the optimal surgical treatment modality for sagittal synostosis. There is, however, wide agreement that objective analytical methods are required to demonstrate the characteristic morphology of the condition and to substantiate the benefits of specified surgical techniques. Simple calculated anthropomorphic indices, such as the cranial index, are commonly used but fail to provide satisfactory representation of morphology, which is far more complex than can be represented by its simple length-width ratio. Techniques to provide more comprehensive, yet practical, assessment of morphology are needed for analytic purposes. Herein, we introduce vector analysis as an objective, computed tomography (CT)-based morphometric technique for assessment of cranial morphology; this work represents the first application of the technique mid-sagittal vector analysis (MSVA). MSVA is a single plane application that was devised to address dysmorphology in sagittal synostosis. It was our hypothesis that MSVA would quantitatively and qualitatively depict preoperative morphology and postoperative correction in specific regions. Sixteen patients undergoing cranial reshaping surgery for sagittal synostosis were included in the study. All patients underwent routine preoperative and 1 year postoperative CT scans, from which the MSVA was derived. MSVA is a radial vector analysis in which distances to the cranial surface are measured from a single reference point origin in the sagittal plane. Preoperative morphology, characterized by respective vectors, was analyzed in three regions: the frontal, vertex, and occipital regions. Comparison with postoperative paired data was conducted for each patient. The analysis of postoperative change demonstrated (1) decrease in prominence in the frontal and occipital regions, (2) increase in height and forward translation of the vertex, and (3) ability to distinguish and qualify frontal versus occipital bossing and correction thereof. We conclude that the longitudinal differences associated with scaphocephaly are well characterized and differentiated by MSVA. Quantitative and qualitative assessment identifies three relevant regions affected by the condition and its treatment: the frontal, vertex, and occipital regions. The transverse dimension is not addressed in this single plane analysis; a more comprehensive application will require additional planes of analysis and the development of a normative database.

Assessment of skeletal and dental pattern of Class II division 1 malocclusion with relevance to clinical practice.

Class II division 1 malocclusion represents the most common skeletal discrepancy which orthodontists see in daily practice. The understanding of the morphology is a key element in planning dentofacial orthopedic treatment for this type of malocclusion. The purpose of the present study was to examine prepubertal children with Class II division 1 malocclusion and to evaluate maxillary and mandibular skeletal positions in comparison with normal growth standards by means of cephalometric measurements used by clinical practitioners. For the study casts and cephalograms of 86 consecutive patients with Class II division 1 malocclusion were used. The Class II division 1 malocclusion demonstrates broad variation in its skeletal and dental morphology. The retrognathic mandible (60%), maxillary prognathism (55.8%) and reduce vertical skeletal jaw relationship is the most common characteristic of Class II division 1 malocclusion. The optimal correction of the anteroposterior and vertical dental and skeletal discrepancies could be designed on the base of individual diagnosis for every Class II division 1 patient.

Metastatic prolactinoma: case report with immunohistochemical assessment for p53 and Ki-67 antigens.

Pituitary carcinomas are rare neoplasms characterized by craniospinal and/or systemic metastases originated from the pituitary. Their histopathology is frequently indistinguishable from that of benign adenomas. The development of markers that better reflect their behavior is desirable. We present the case of a 47 year-old man with a prolactin-secreting macroadenoma who was submitted to surgeries, cranial radiation therapy, and bromocriptine treatment, but evolved to a fatal outcome after the disclosure of intracranial metastases. Tumor samples underwent p53 and Ki-67 immunohistochemical assessment. p53 was absent in all samples, a rare finding among pituitary carcinomas. Ki-67 proliferative index was 2.80% in the original tumor, 4.40% in the relapse, and 4.45% in the metastasis. The figure in the relapse is higher than the expected for a noninvasive adenoma. In conclusion, p53 staining is not positive in all pituitary carcinomas. A high Ki-67 proliferative index in a pituitary adenoma might indicate a more aggressive behavior.

Metastatic prolactinoma: case report with immunohistochemical assessment for p53 and Ki-67 antigens

Pituitary carcinomas are rare neoplasms characterized by craniospinal and/or systemic metastases originated from the pituitary. Their histopathology is frequently indistinguishable from that of benign adenomas. The development of markers that better reflect their behavior is desirable. We present the case of a 47 year-old man with a prolactin-secreting macroadenoma who was submitted to surgeries, cranial radiation therapy, and bromocriptine treatment, but evolved to a fatal outcome after the disclosure of intracranial metastases. Tumor samples underwent p53 and Ki-67 immunohistochemical assessment. p53 was absent in all samples, a rare finding among pituitary carcinomas. Ki-67 proliferative index was 2.80% in the original tumor, 4.40% in the relapse, and 4.45% in the metastasis. The figure in the relapse is higher than the expected for a noninvasive adenoma. In conclusion, p53 staining is not positive in all pituitary carcinomas. A high Ki-67 proliferative index in a pituitary adenoma might indicate a more aggressive behavior.

Carcinomas pituitários são neoplasias raras caracterizadas pela presença de metástases cranio-espinhais e/ou sistêmicas originadas da hipófise. Sua histopatologia é freqüentemente indistinguível daquela dos adenomas benignos. O desenvolvimento de marcadores que melhor reflitam o seu comportamento é desejável. Apresentamos o caso de um homem de 47 anos com um macroadenoma secretor de prolactina que foi submetido a procedimentos cirúrgicos, radioterapia e tratamento com bromocriptina, mas que evoluiu para o óbito após o descobrimento de metástases intracranianas. Amostras do tumor foram submetidas à análise imuno-histoquímica para os antígenos p53 e Ki-67. A coloração para p53 foi negativa em todas as amostras, um achado raro entre os carcinomas pituitários. O índice proliferativo Ki-67 foi 2,80% no tumor original, 4,40% na recidiva e 4,45% na metástase. O valor obtido na recidiva é maior que o esperado para um adenoma não-invasor. Concluindo, a coloração para p53 não é positiva em todos os carcinomas pituitários. Um índice proliferativo Ki-67 alto em um adenoma pituitário poderia indicar um comportamento mais agressivo.

The value of high-field MRI (3T) in the assessment of sellar lesions.

The aim of this study was the evaluation of the normal sellar anatomy in vitro and in vivo with high-field MRI and its application in the diagnosis of sellar pathologies in comparison to standard MRI. All high-field MR images were obtained using a 3T Bruker Medspec 30/80 Scanner with a head birdcage transmit/receive coil and an actively shielded gradient system with a maximum gradient strength of 45 mT/m. Firstly an in vitro study of the sella turcica was performed to depict normal pituitary and sellar anatomy at high field. After a pilot-study this sequence-protocol was established: A RARE sequence (TR/TE = 7790/19 ms; matrix size, 512 x 512; RARE factor = 8, FOV, 200 mm) was used for T2-weighted coronal, axial and sagittal images. A 3D gradient echo sequence with magnetization-preparation (MP-RAGE, TR/TE/TI = 33.5/7.6/800 ms, matrix size, 512 x 512; FOV, 200 mm, effective slice thickness, 1.88 mm; 3 averages) was used for acquisition of T1-weighted pre- and post-contrast images. Between January 2002 and March 200458 patients were enrolled in this study. Seven patients were examined for suspected microadenoma and in 51 patients 3T MRI was used to obtain additional information about the sellar lesion already known to be present from standard MRI. In 21 cases the accuracy of the imaging findings was assessed afterwards by comparison with intraoperative findings. The infiltration of the medial cavernous sinus wall was suspected on standard MRI on 15 sides (47%), on high-field MRI on 9 sides (28%) and could be verified by intraoperative findings on 6 sides (19%). Accordingly, sensitivity to infiltration was 83% for 3T and 67% for standard MRI. Specificity was 84% for 3T and 58% for standard MRI. Moreover, high-field MRI revealed microadenomas in 7 patients with a median diameter of 4mm (range 2-9 mm). The segments of the cranial nerves were seen as mean 4 hypointense spots (range 2-5 spots) on high-field MRI in contrast to 3 spots (range 0-4 spots) on standard MRI. This difference was considerably significant (P < 0.001, Wilcoxon rank sum test). The histopathological results revealed pituitary adenoma in 16 patients and non-adenomatous sellar pathologies such as Rathke's cleft cyst, sarcoidosis, meningeoma and metastasis in 5 patients. High-field MRI is superior to standard MRI for the prediction of invasion of adjacent structures in patients with pituitary adenomas and improves surgical planning of sellar lesion.

Assessment of the nasopharyngeal area by cephalometry in cases of cleft lip and palate.

The nasopharyngeal area in 149 patients with cleft lip and palate and 157 normal individuals was evaluated by cephalometric radiography. The patients were male and female Caucasians, ranging in age from 12 to 16 years. Linear cephalometric parameters: (Ptm'-Sl; Ptm'-IPPF; IPPF-I, I-Ptm'), ANS angle and nasopharyngeal area were utilized. From comparative analysis of nasopharyngeal area in the cleft and the control groups, the following conclusions were made: 1) The nasopharyngeal area was smaller in the cleft group. 2) There was no correlation between ANS angle and nasopharyngeal area in either group.

A comparison of CT and MRI in the assessment of the pituitary and parasellar region.

We have carried out a prospective study to compare high resolution thin slice, contrast-enhanced, axial computed tomography (CT) with unenhanced magnetic resonance imaging (MRI) at 1.5T in the assessment of the pituitary and parasellar region. Forty patients with suspected pituitary disease presenting to an endocrine unit were studied. MRI was superior to CT for the identification of the posterior pituitary and pituitary stalk and was better at showing the cystic nature of tumours. Visualization of the optic chiasm and assessment of displacement of the optic chiasm and the carotid arteries were also better with MRI. CT was equally good at showing cavernous sinus displacement or invasion, sphenoid sinus invasion and erosion of the floor of the sella turcica and was the only technique able to show calcification of the gland. More focal abnormalities were seen in the pituitary gland with CT than with unenhanced MRI, but there was a higher false positive rate for microadenoma detection with CT. All the scans were interpreted separately by three observers, two radiologists and one clinician. The percentage agreement between the observers for the identification of pituitary and parasellar structures was better for MRI than for CT and the clinician in particular found interpretation of the MR images easier. MRI thus not only gives more information overall than CT but it is a more reliable technique between different observers for the assessment of the pituitary and parasellar region.