Extended transsphenoidal microsurgical approach for diaphragma sellae and tuberculum meningiomas.

Diaphragma sellae meningiomas represent a difficult challenge for neurosurgeons; they are generally operated on by a transcranial approach. Some authors reported transsphenoidal surgery in selected cases, but without accurately focusing the surgical technique that should be necessary for removing the typical hard fibrous tissue of the meningioma, that is not aspirable, by this approach. We present the surgical technique and the useful instrumentarium for removing a diaphragma sellae meningioma through an extended microsurgical transsphenoidal approach.

Unilateral reduction of head pain and facial vasodilatation after gasserian ganglion lesion.

The features of histamine-induced headache and its associated vascular responses were studied in 52 patients with different surgical lesions of the gasserian ganglion and in 12 control subjects. Certain features of headache (eg, intensity, type, and duration) were similar in patients and control subjects. However, the pain was absent on the side of the trigeminal lesion in 26 (50%) of the patients. This unilateral absence of pain was not related to the hypoesthesia that was caused by the operation, and it was associated with a decrease in vascular responses (histamine-induced facial flushing and increase in temperature) on the side operated on. These abnormalities were more prevalent in patients who had undergone thermocoagulation and presented with more severe damage of the trigeminal ganglion than in those who were subjected to trigeminal compression or glycerolization. The trigemino-vascular system seems to control headache of a vascular type and associated craniofacial vasodilatation in human subjects.

Neurophysiologic assessment of trigeminal function after surgery for trigeminal neuralgia.

To assess the function of the three trigeminal divisions, we studied corneal reflex, early and late blink reflexes, early and late masseter silent periods, and jaw jerk in normal subjects and in 35 patients submitted to surgery for trigeminal neuralgia. The corneal reflex was most sensitive to thermocoagulation and the jaw jerk to microcompression; the other reflexes showed an intermediate behavior, depending on afferent fiber size. Trigeminal function was less impaired after microcompression and recovered earlier than after thermocoagulation.

Cellular receptors for sex steroids in human pituitary adenomas.

Cellular receptors for sex steroids (SSRs) were studied in an unselected series of 55 human pituitary tumors. Cytosolic receptors for estrogen (ERcs) and progesterone (PgRcs) were determined in all cases and cytosolic androgen receptors (ARcs) in 47 cases. Nuclear receptors (ERns, PgRns, ARns) were also studied in 33 cases. ERs and PgRs were determined by an ELISA and ARs by [3H]methyltrienolone binding. Where both cytosolic and nuclear receptors were studied (n = 33), ERs, PgRs and ARs were found in at least one subcellular fraction in 66.7, 60.6 and 81.8% of cases respectively, ERs and ARs being mainly recovered from the cytosol and PgRs from the nucleus. No linear correlation was found between pre-operative plasma steroid hormones and their specific cellular receptors. Nonetheless, the differential expression of SSRs according to sex and gonadal status at the time of surgery strongly supports their regulation by the steroid environment in vivo: PgRcs were more frequent in tumors found in women (41.4 vs 15.4%, P < 0.05), whereas a high expression of ERcs and ARcs (> 15 fmol/mg protein) was more common in tumors found in men (34.5 vs 10.3%, P < 0.05 and 54.5 vs 24.0% respectively). PgRs were positively correlated with ERns, indicating the possibility of estrogen priming of their expression, and negatively correlated with ARs in nuclear fractions. SSRs appeared to be widely distributed among pituitary tumors, although, compared with other hormone-secreting groups, prolactinomas displayed a higher ERc expression (34.8 +/- 11.3 vs 4.8 +/- 5.1 fmol/mg protein, P = 0.007) and gonadotroph cell adenomas lower ARc values (1.3 +/- 0.8 vs 38.2 +/- 10.6 fmol/mg protein, P = 0.048). Microadenomas were characterized by a higher PgR expression than macroadenomas, whereas hemorrhagic (macro)adenomas were characterized by a high ER expression (> 90%). The present results indicate that most pituitary tumors are targets for sex steroids, SSR expression being partially triggered by the steroid environment itself. Possible physiopathological and therapeutic implications of these findings are discussed.

Chemical meningitis: unusual presentation of a cerebellar astrocytoma: case report and review of the literature.

Chemical meningitis resulting from the spillage of the contents of a cystic tumor rarely constitutes the sole manifestation of a cranial or spinal tumor. The case of a man who initially had signs and symptoms of meningitis that on computed tomographic scan was shown to be a space-occupying cerebellar lesion is reported. Thirty-five cases of cranial and spinal tumors in which the presenting symptom was chemical meningitis are also reviewed.

Intrasellar tuberculoma: case report.

We report a unique case of exclusively intrasellar tuberculoma. The patient was operated on by the transsphenoidal approach, which allowed total removal of the lesion and prevented cerebrospinal fluid contamination. After histological diagnosis, the patient was treated with isoniazid, 300 mg daily for 3 months, as prophylaxis against tuberculous meningitis.

Hemorrhagic pituitary adenomas: clinicopathological features and surgical treatment.

Forty-five (9.9%) of 453 pituitary adenomas operated on between January 1973 and November 1988 demonstrated hemorrhagic changes at surgery: 24 had a blood collection, 12 had a blood collection associated with hemorrhagic necrosis, and 9 had hemorrhagic necrosis. Thirteen patients (28.9%) experienced the acute symptoms of pituitary apoplexy, whereas another 32 had an "asymptomatic" hemorrhage, that is, the clinical course was comparable to an uncomplicated adenoma. Nineteen tumors (42.2%) showed marked suprasellar extension, 8 (17.8%) showed moderate extension, and 11 (24.5%) showed slight extension; another 2 (4.4%) were laterosellar and 5 (11.1%) were intrasellar. Invasive behavior was present in 32 cases (71.1%) and this may suggest another hypothesis to explain the pathogenesis of tumoral hemorrhage. The incidence of hemorrhagic complications in invasive adenomas with marked suprasellar extension was particularly impressive; therefore, we do not suggest preoperative bromocriptine treatment in this type of tumor. Two of 14 patients operated on by the transcranial route died after surgery, whereas there was no operative mortality in the 31 patients operated on by the transsphenoidal route. It proved advantageous to operate as early as possible, even during the acute phase of pituitary apoplexy. The transsphenoidal approach gave the best results, but to achieve satisfactory late results multidisciplinary treatment was necessary, namely, postoperative radiotherapy in 23 patients, bromocriptine in 12, and endocrine replacement therapy in almost all. In an average follow-up period of 6.2 years, 5 (11.1%) symptomatic recurrences were observed.

Microsurgical treatment of glossopharyngeal neuralgia: case reports.

Three patients with excruciating glossopharyngeal neuralgia underwent microsurgical operations in the posterior cranial fossa. In each patient, neurovascular compression was found involving the posteroinferior cerebellar artery and involving the 9th and 10th cranial nerves. In two of the patients, the compression was caused by arachnoiditis and in the other by an arterial loop. In each patient, neuralgia was successfully eliminated by microvascular decompression and by section of the upper rootlets of the vagus nerve. In one patient, partial section of the 9th cranial nerve was also performed. Because of the frequent involvement of the vagus nerve in the pathogenesis of this condition, open surgery should be preferable to percutaneous thermorhizotomy, which is unable to act selectively on the 10th cranial nerve.

Treatment of trigeminal neuralgia by thermocoagulation, glycerolization, and percutaneous compression of the gasserian ganglion and/or retrogasserian rootlets: long-term results and therapeutic protocol.

From 1976 to 1986, 681 patients with drug-refractory trigeminal neuralgia (TN)--typical in 641, symptomatic of multiple sclerosis in 23 and of tumor in 10, atypical in 5, and postherpetic in 2--were treated with various percutaneous procedures. Controlled differential thermocoagulation of the gasserian ganglion and/or retrogasserian rootlets was performed in 533 patients; glycerolization of the trigeminal cistern in 32; and compression of the gasserian ganglion by balloon catheter in 159. Results and complications of each procedure are assessed at a mean follow-up of 6.5 years for thermocoagulation, 5 years for glycerolization, and 3.5 years for compression. The following therapeutic protocol is proposed: 1) in TN patients at first operation: a) gasserian compression (or glycerolization, if experience warrants it) is indicated in all cases of typical TN, unless the 3rd division alone is affected; b) in the latter case and in symptomatic TN, we suggest thermocoagulation; 2) in recurrences: a) after glycerolization or gasserian compression, gasserian compression (or glycerolization) is indicated; b) after thermocoagulation or open surgery, thermocoagulation is suggested.

The contribution of Davide Giordano (1864-1954) to pituitary surgery: the transglabellar-nasal approach.

This report describes the fundamental contribution made by Davide Giordano, proposing the transglabellar surgical approach in a period in which transfacial and transbasal operative approaches to the pituitary gland were considered inadvisable because of their risk. His idea was to gain access through bilateral paranasal and frontal skin incisions, allowing removal of the ethmoid bone and the anterior wall of the sphenoidal cube. With the anterior and inferior aspects of the sella turcica thus exposed, bone is removed and the gland is exposed by incision of the dura mater. The technique proposed by Giordano is undoubtedly a forerunner of the transsphenoidal route to the pituitary gland. The importance of his contribution was confirmed by Cushing, who reported his first use of the approach of Giordano in 1909 in a patient with a pituitary adenoma. The efforts of Giordano clearly inspired surgeons of his era to perform this operation clinically, giving impetus to the further development of neurosurgery.

Glossopharyngeal neuralgia with cardiac syncope.

Glossopharyngeal Neuralgia is an uncommon craniofacial pain syndrome that is occasionally associated with cardiac syncope. Involvement of the glossopharyngeal nerve may be painless or may be marked by true episodic neuralgia, and this justifies the term neuralgia reported here. We present 5 cases of this uncommon syndrome, of a total of 15 observed cases of glossopharyngeal neuralgia, successfully treated by section of the rootlets of Cranial Nerves IX and X or by microvascular decompression in the posterior cranial fossa. We also analyze the relevant literature and discuss the pathogenesis and treatment of the syndrome.

Posterior partial rootlet section in the treatment of spasticity.

Twenty-six patients were operated on using a techinal modification of Förster's method of treating spasticity, which consists of a partial section of the roolets constituting the posterior roots. Many patients had mild cerebral spastic quadriplegia or spastic diplegia: several of them were nearly independent when standing or walking, and two of them completely independent. The spastic disorders that were not made worse by voluntary movements were reduced or abolished in all but one patient, in whom rootlet section was insufficient. The spastic disorders that were made worse by voluntary movements were only partially reduced; after operation they were scarcely evident or absent in a static position, but evident during voluntary movements. No improvement was observed in one patient who suffered from spastic disorders that were evident only during voluntary movements, or in one patient suffering from dystonia. The procedure caused no sensory disorders. The operation was especially useful in patients who were acquiring or had already acquired independence when standing or walking.

Pituitary adenomas with onset during puberty. Features and treatment.

From a series of 207 patients with pituitary adenoma operated on by microsurgical technique from 1973 to February, 1982, the cases of nine young people whose symptoms had appeared between the ages of 11 and 15 years are presented. The most important data are that all the children were pubertal and that in seven the tumor was, or later became, invasive. By contrast, the tumor was enclosed in eight of nine other patients whose symptoms manifested between the ages of 16 and 20 years, and in 152 of the remaining 189 patients whose symptoms appeared after the age of 20 years. Considering the gravity of the disease treated, the results in this series may be termed encouraging. The treatment was multidisciplinary: starting with surgery, followed by radiotherapy, endocrine replacement therapy, and, in adenomas secreting prolactin and/or growth hormone, medical therapy with bromocriptine. The divergence between authors on the subject of childhood adenomas, especially as to whether they are more often invasive or enclosed, could be overcome, at least in part, if the term "pediatric age" were unequivocally defined and if there were an agreed distinction between puberty and childhood on the one hand and puberty and adolescence on the other.

Transmaxillosphenoidal approach to tumors invading the medial compartment of the cavernous sinus.

A transmaxillosphenoidal approach was used to remove sellar tumors invading the cavernous sinus. This procedure, a widening of the standard transsphenoidal approach to the sella turcica, uses the sublabial or transnasal route in which the medial wall of the maxillary sinus is laterally dislocated. This method provides good exposure of the prominences of bone above the carotid artery which lies on the posterolateral wall of the sphenoid sinus. This bone area is the key to opening the cavernous sinus inferomedially and removing lesions within its medial compartment. The inferomedial approach takes an entirely extracerebral route so that tumors invading the cavernous sinus through its medial wall are approached inferomedially following the direction of tumor growth. It also allows direct visualization of the intracavernous carotid artery during tumor removal, thus sparing the cranial nerves, which run on the opposite side. Adequate surgical exposure of a pituitary adenoma is achieved with a custom-made sphenoidal retractor with asymmetric blades, the shorter blade holding aside the thin medial wall of the maxillary sinus. Between October, 1989, and July, 1993, 11 patients with tumors invading the cavernous sinus underwent surgery via this approach; 10 had pituitary adenomas and one had a craniopharyngioma. Eight tumors were treated by primary operation: four tumors were totally and four subtotally (> 80%) removed; one tumor already operated on elsewhere was totally removed; and of two tumors already operated on and irradiated, one was subtotally removed and the other only partially (approximately 40%) removed owing to marked postirradiation scarring. None of the patients suffered permanent cranial nerve deficit and all but one showed marked clinical improvement.

Chronic paleocerebellar stimulation in dystonia and athetosis. Report of two cases.

Two patients suffering from dystonia and athetosis have been treated by means of chronic electrical stimulation of the paleocerebellum and were followed for over two and a half years. One of the patients showed signs of slight improvement, while no improvement at all was observed in the other patient. Some observations and problems are discussed.

Trigeminal schwannoma with infratemporal extension. Case report.

The case of a 55-year-old woman with a rare trigeminal schwannoma extending into the infratemporal fossa is described. The presentation and treatment of this type of intra and extracranial tumor are discussed.

Paraganglioma of the cauda equina. Case report with 33-month recurrence free follow-up and review of the literature.

Paraganglioma of the cauda equina is an unusual tumor and do not have the secretory properties of the same tumors arising outside the nervous system. In none of the few cases reported in literature a preoperative diagnosis was possible, and the surgical findings raised questions in the differential diagnosis with ependymomas. A rare case of paraganglioma of the cauda equina studied both pre- and postoperatively by MRI, and treated with subtotal excision combined with radiotherapy is described. Results and recurrence rates of the cases reported in literature are reviewed. Though MRI imaging has proven to be more sensitive than other radiological procedures, we stress the difficulties of preoperative diagnosis of paragangliomas in this site. The correct diagnosis of the paraganglioma of the cauda equina still relies on immunochemistry and electron microscopy. Total excision is often very difficult owing the tendency of these neoplasms to infiltrate cauda's roots. A 33-month recurrence free follow-up of our patient confirms that successful treatment is achieved by subtotal resection combined with radiotherapy.

Intracranial arterial aneurysms in early childhood.

Cerebral saccular aneurysms are rare in early childhood. Seventy-one cases in children under 5 years of age found in the literature, plus one case of our own, are analyzed. In early childhood these aneurysms seem to have features that distinguish them from the same variety in adults. In children a congenital pathogenesis appears more convincing because of the higher frequency in the first 2 years of life, the often peripheral site (41.6%), the high frequency of large (50%) or giant (26.8%) aneurysms, and the association with other cerebral and vascular congenital abnormalities. Onset was nonhemorrhagic in 18.1% of cases compared with 2.5% in adults. The surgical outcome seems better in children than in adult patients in terms of both morbidity and mortality.

Computed tomography-guided transsphenoidal closure of postsurgical cerebrospinal fluid fistula: a transmucosal needle technique.

BACKGROUND: Cerebrospinal fluid (CSF) fistula represents a fearful complication of transsphenoidal surgery and, despite careful intraoperative repair and prolonged postoperative lumbar CSF drainage, need for a new surgical intrasphenoidal plasty is not uncommon. METHODS: These cases prompted us to develop a simple, minimally invasive, harmless repeatable technique consisting of a computed tomography (CT)-guided intrasphenoidal injection of fibrin glue through a 12-gauge spinal needle. RESULTS: Five patients presenting with rhinoliquorrhea following a transsphenoidal approach for the excision of pituitary adenomas (three cases) and craniopharyngiomas (two cases) were treated successfully with the presented technique. In two cases the first attempt attained only partial success and therefore the procedure was repeated. In the last two cases, the injection of fibrin glue was preceded by 2 cc of fresh autologous blood, with the aim of enhancing the mechanisms of healing, possibly inducing adhesions and fibrosis. CONCLUSIONS: The proposed method of treatment for CSF leakage following transsphenoidal surgery may represent a valid alternative to the surgical option.

The surgical treatment of pituitary adenomas in the eighth decade.

BACKGROUND: The surgical treatment of pituitary adenomas in elderly patients (i.e., over 70 years of age) is a special problem because of the increased rate of perioperative complications and the reduced tolerance of postoperative fluid and electrolyte imbalance. Therefore, the unquestionable progress in the pharmacological and radiotherapy may not allow these patients the option of radical surgical treatment. We report our experience with the transsphenoidal procedure for pituitary adenomas in aged patients in an attempt to contribute to a better definition of the actual role of surgery. METHODS: Transsphenoidal surgery was performed in 11 patients over 70 years of age affected by various histological types of pituitary micro- and macroadenomas, ranging from Hardy Grade I through IIIc. Special care was dedicated to the postoperative treatment, in particular to water and electrolyte balances, and to the immediate treatment of any pathological variation of these parameters. RESULTS: We had no mortality and no postoperative adjunctive morbidity. All the patients recovered well from the operation with an average hospital stay of 20 days. The tumor removal was complete in six cases and partial in the remaining five. With an average follow-up of 2 years, we did observe only one case of symptomatic recurrence of the disease. CONCLUSIONS: Transsphenoidal surgery in the elderly is feasible and quite safe in the hands of an experienced team, if special care is devoted to the preoperative selection of patients and to the postoperative treatment of fluid and electrolyte imbalance.