Role of Medical and Surgical Treatment in Management of the Patients With Prolactinoma; Single-Center Experience.

BACKGROUND: Current guidelines recommend dopamine agonists (DA) as the primary therapeutic approach for prolactinomas; however, emerging evidence suggests that surgical intervention can also yield favorable outcomes. OBJECTIVE: To comprehensively evaluate prolactinoma patients undergoing surgical and medical treatments at our pituitary center. METHODS: Retrospective review of medical records from prolactinoma patients treated between 2015 and 2022 was performed. The study focused on treatment outcomes and remission rates while investigating factors influencing the success of both treatment modalities in achieving remission. RESULTS: A total of 301 prolactinoma patients were included, of whom 199 were women. Among them, 235 were managed medically, while 66 underwent surgical intervention. The overall remission rates of patients treated with medical and surgery were similar at the final examination (Respectively 82.9% and 81.8%, p=0.114). Factors associated with remission in both treatment modalities included female sex, low initial prolactin levels, small adenoma size, and absence of cavernous invasion. Surgical treatment demonstrated a higher rate of drug-free remission compared to DA treatment for microadenomas, and macroadenomas without cavernous invasion. In cases with cavernous invasion, standalone surgical treatment yielded a low rate of drug-free remission (7.7%); however, when combined with DA therapy post-surgery, remission rates increased to 66.7%. CONCLUSION: Medical treatment with DAs remains the preferred option for macroadenomas with cavernous sinus invasion, and giant adenomas, with surgery reserved for selected cases to address complications. Conversely, surgery emerges as the most effective modality for achieving remission in patients with microadenomas, and macroadenomas confined to the sella. The recommendation of DAs as first-line therapy for all patients has been withdrawn in the current guidelines and individual treatment approaches based on tumor characteristics are emphasized. Our results support this approach.

The Relationship Between Inflammatory Processes and Apoptosis in Lumbar Disc Degeneration.

OBJECTIVE: Degenerative Disc Disease (DDD) is a common health problem in the population. There are recent studies focusing on relationship between DDD and immunological factors. However, there is still a lack of data on the role of apoptosis in DDD pathophysiology. Therefore, we aimed to investigate the relationship between Modic-type changes and the apoptosis in DDD. MATERIALS AND METHODS: Ninety adult male patients who presented with low back and/or radicular pain and were operated on due to lumbar disc herniation were included. Three groups were formed based on Modic type degeneration observed on magnetic resonance imaging. Specific parameters involved in the intrinsic and extrinsic pathways of apoptosis were assessed in excised disc materials using the enzyme-linked immunosorbent assay method. RESULTS: All three groups formed according to Modic degeneration types were homogenous in all variances. Cytochrome-C was significantly decreased only in the Modic type-3 group, whereas Tumor Necrosis Factor-Related Apoptosis-Inducing Ligand Receptor-1, B-Cell Lymphoma-2 (Bcl-2) Homologous Antagonist Killer-1, Direct Inhibitor of Apoptosis-Binding Protein with Low Pi, and Bcl-2 Associated X Apoptosis Regulator levels were significantly different in both Modic type-2 and -3 groups. However, BH3 interacting domain death agonist and Bcl-2 levels were similar across all groups. CONCLUSIONS: In conclusion, this study suggests that Direct Inhibitor of Apoptosis-Binding Protein with Low Pi, cytochrome - c, Bcl-2 Associated X Apoptosis Regulator, Bcl-2 Homologous Antagonist Killer-1, and Tumor Necrosis Factor-Related Apoptosis-Inducing Ligand Receptor-1proteins play important roles in the development and progression of DDD and are correlated with Modic types. Further studies are needed to explore the potential therapeutic role of inhibiting these apoptotic proteins in DDD.

Multilevel Cervical Epidural Hematoma After C5-6 Anterior Cervical Discectomy and Fusion: The Cry of a Neurosurgeon.

Anterior cervical discectomy and fusion (ACDF) is a safe and effective surgical treatment for cervical degenerative disk diseases. Almost every neurosurgeon is familiar with this approach. Anterior multilevel epidural hematoma (EDH) after a single ACDF is a very rare complication documented in the literature. There is no common consensus on the choice of optimal surgical treatment. Here, we report the case of a patient who showed multilevel EDH after ACDF at the C5-6 level to highlight that this complication should be kept in mind even after an uneventful surgery.

Role of the MyD88 Dependent Pathway in Degenerative Disc Disease.

AIM: To define the substantial role of the TLR4 signaling pathway in the MyD88-dependent pathway, and to evaluate the results of TLR4 activation in nucleus pulposus cells. Moreover, we aim to associate this pathway with intervertebral disc degeneration and magnetic resonance imaging (MRI) findings. Additionally, the clinical differences among patients and the effects of their drug use will be evaluated. MATERIAL AND METHODS: Eighty-eight adult male patients with lower back pain and sciatica underwent MRI studies, which showed degenerative changes. Disc materials were obtained intraoperatively from those who underwent surgery for lumbar disc herniation. These materials were kept in freezers at ?80°C without any delay. Then, the collected materials were examined using enzyme-linked immunosorbent assays. RESULTS: Modic type I degeneration had the highest values of all markers, whereas Modic type III degeneration had the lowest values. These results verified that this pathway plays an active role in MD. Moreover, contrary to the current knowledge on which Modic type inflammation is more dominant, we showed that it is the Modic type I phase. CONCLUSION: The most intense inflammatory process was observed in Modic type 1 degeneration, and the MyD88-dependent pathway was found to play a key role. While the most intense molecular increase was detected in Modic type 1 degeneration, the lowest levels were observed in Modic type III degeneration. It has been observed that the use of nonsteroidal anti-inflammatory drugs affects the inflammatory process through the MyD88 molecule.

The Combination of Dopamine Agonist Treatment and Surgery May Be the Best Option in Challenging Prolactinoma Cases: A Single-Centre Experience.

OBJECTIVE: To investigate the initial and long-term remission rates, factors related to remission, secondary treatments, and outcomes for patients with prolactinoma who underwent endoscopic transsphenoidal surgery (ETSS). METHODS: The medical files of the 45 prolactinoma patients who underwent ETSS between 2015 and 2022 were retrospectively reviewed. Relevant demographic and clinical data were obtained. RESULTS: Twenty-one (46.7%) patients were female. The median age of patients at ETSS was 35 (interquartile range, 22.5-50) years. The median clinical follow-up of patients was 28 (interquartile range 12-44) months. The initial surgical remission rate was 60%. Recurrence was detected in 7 patients (25.9%). Postoperative dopamine agonists were used in 25 patients, radiosurgery in 2, and second ETSS in 4 patients. After these secondary treatments, the long-term biochemical remission rate was 91.1%. The factors associated with failure in surgical remission are: male gender, older age, higher tumor size, advanced Knosp and Hardy stage, and elevated prolactin level at diagnosis. A prolactin level of <19 ng/mL in the first postoperative week predicted surgical remission with a sensitivity of 77.8% and a specificity of 70.6% in patients who received preoperative dopamine agonist treatment. CONCLUSIONS: In macro adenomas and/or giant adenomas with cavernous sinus invasion, and significant suprasellar extension, which constitutes the difficult part of prolactinoma treatment, neither surgery nor medical treatment alone may be effective enough. Both treatment modalities should be carried out together by a team of neurosurgery and endocrinology in the management of these patients.

Can TRIF/TICAM-1 Dependent Pathway be Target Pathway in Lumbar Intervertebral Disc Degeneration?

AIM: To elucidate the role of the TIR-domain-containing adaptor-inducing interferon-? (TRIF) dependent pathway in intervertebral disc degeneration (IVD). MATERIAL AND METHODS: A total of adult male patients with low back pain (LBP) (+/- radicular pain) were further evaluated by magnetic resonance imaging (MRI) with surgical indication for microscopic lumbar disc herniation (LDH). Preoperatively, patients were classified according to Modic Changes (MC), nonsteroidal anti-inflammatory drugs (NSAIDs) use, and the presence of radicular pain in addition to the LBP. RESULTS: The age of the 88 patients ranged from 19 to 75 years (mean: 47.3 ± 19.6 years). Twenty eight of the patients were evaluated as MC I (31.8%), 40 as MC II (45.4%), and 20 as MC III (22.7%). The majority of patients (81.8%) had radicular LBP, while 16 patients (18.1%) had only LBP. Predominantly, 55.6% of all patients were taking NSAIDs. Levels of all adaptor molecules were highest in the MC I group and lowest in the MC III group. The levels of IRF3, TICAM1, TICAM2, NF-kB p65, TRAF6, and TLR4 were significantly increased in the MC I group compared to the MC II and MC III groups. The variations of the individual adaptor molecules showed no statistically significant difference in the use of NSAIDs and radicular LBP. CONCLUSION: As a result of the impact assessment, the current study clearly demonstrated for the first time that the TRIFdependent signalling pathway plays a crucial role in the degeneration process in human lumbar intervertebral disc specimens.

Surgical Outcome of Young and Adult Patients with Temporal Lobe Epilepsy Related to Hippocampal Sclerosis in Modern Era.

AIM: To evaluate the preoperative, operative, and postoperative outcomes of young and adult patients who underwent surgery for temporal lobe epilepsy related to hippocampal sclerosis (TLE-HS). MATERIAL AND METHODS: This retrospective study assessed prospectively registered data collected from 2010 to 2020. Clinical, electrophysiological, pathological, and postoperative outcomes were evaluated and compared. Post-surgical seizure outcome was classified into continuous seizure freeness without aura and relapse. RESULTS: In total, 16 young and 48 adult patients with TLE-HS were included in the analysis. The clinical, electrophysiological, pathological, and postoperative outcomes were similar between the young and adult groups. However, the seizure outcome did not significantly differ between the two groups (p=0.38). A significant proportion of patients in both groups were satisfied with the surgical outcomes. CONCLUSION: Surgery is extremely effective against TLE-HS in young patients, as in adults. Furthermore, the clinical, radiological, and pathological outcomes are similar between young and adult patients with TLE-HS.

Clinical and radiological outcomes of arachnoid-preseving suboccipital decompression for adult chiari I malformation with and without syringomyelia.

OBJECTIVE: To share our experience related to clinic and radiologic outcomes of patients with Chiari I malformation. PATIENTS AND METHODS: This retrospective study evaluated surgical outcome of 48 patients who underwent posterior fossa decompression and duraplasty with arachnoid-preservation technique February 2010 and February 2019. Clinic and radiologic outcomes at long-term follow-up were provided. RESULTS: Surgery led to satisfactory outcomes in both clinic and radiologic measures. The majority of patients (66.7%) in the follow-up period informed us that their symptoms significantly improved. In 14 patients (29.2%), the symptoms were gone totally and no complaining was reported to us. Syringomyelia was encountered in 21 patients (43.7%) on pre-operative MRI. During long-term, significant improvement (syrinx segments were remarkably reduced in diameter) in syrinx size was noted in 16 of the 21 patients (76.1%). In 5 of the 21 patients (23.8), complete improvement, that is, syrinxes were totally collapsed, was seen. Surgery-related complications occurred in a total of 5 patients (10.4%). CONCLUSION: In our experience, we found decompressive craniectomy wide enough with duraplasty without arachnoid opening is safe and successful in patients with CIM. Complication rate is low and arachnoid preserving technique should be performed by experienced neurosurgeons.

Are low-grade gliomas of mesial temporal area alone?

BACKGROUND: Temporal neocortex which appears normal on magnetic resonance imaging (MRI) may have pathological tissues in low-grade gliomas (LGG) of pure mesial temporal area. Resection of the cortex may be required together with mesial temporal glioma for satisfactory seizure and oncological outcome. The aim of this study was to explore the presence of any pathological tissue on the temporal cortex that appeared normal on preoperative MRI in patients with pure mesial temporal LGGs. METHODS: This prospective study included 10 patients who underwent surgical resection of temporal lobe for LGG of mesial temporal area. The temporal neocortex with normal appearance on MRI and mesial temporal area were resected separately, and histopathological diagnosis was performed. RESULTS: LGGs of the mesial temporal area were diagnosed with glioneuronal tumors in 7 (70%) and low-grade astrocytoma in 2 (20%) patients. Regarding the temporal cortex, gliosis and focal cortical dysplasia were found in 7 (70%) and 2 (20%) patients. In one patient temporal cortex did not contain any pathological tissue. All were seizure-free and no tumor recurrence was noted at the last follow-up. CONCLUSION: Mesial temporal LGGs are not alone and a high proportion of temporal neocortex appeared normal on preoperative MRI, may contain dual pathology. Thus, anterior temporal resection should be performed to have satisfactory seizure and oncological outcomes.