ABSTRACT
The classification of neoplasms of adenohypophysial cells is misleading because of the simplistic distinction between adenoma and carcinoma, based solely on metastatic spread and the poor reproducibility and predictive value of the definition of atypical adenomas based on the detection of mitoses or expression of Ki-67 or p53. In addition, the current classification of neoplasms of the anterior pituitary does not accurately reflect the clinical spectrum of behavior. Invasion and regrowth of proliferative lesions and persistence of hormone hypersecretion cause significant morbidity and mortality. We propose a new terminology, pituitary neuroendocrine tumor (PitNET), which is consistent with that used for other neuroendocrine neoplasms and which recognizes the highly variable impact of these tumors on patients.
Subject(s)
Adenoma/classification , Neuroendocrine Tumors/classification , Pituitary Neoplasms/classification , HumansSubject(s)
Adenoma/drug therapy , Dacarbazine/analogs & derivatives , Pituitary Neoplasms/drug therapy , Pituitary Neoplasms/metabolism , Somatostatin/analogs & derivatives , Adenoma/metabolism , Adenoma/pathology , Clinical Trials as Topic/methods , Dacarbazine/therapeutic use , Humans , Pituitary ACTH Hypersecretion/drug therapy , Pituitary ACTH Hypersecretion/pathology , Pituitary Neoplasms/pathology , Somatostatin/metabolism , Somatostatin/therapeutic use , Temozolomide , Treatment OutcomeABSTRACT
The anaesthetic care of patients undergoing pituitary surgery involves an understanding of the varied presentations of pituitary disease and their implications for the patient's perioperative condition and management. The neuroanaesthetist must also have an appreciation of the issues relevant to the surgical approach (either transsphenoidal or, less commonly, transcranial) and be able to anticipate and manage them accordingly.
Subject(s)
Anesthesia , Neurosurgical Procedures/methods , Pituitary Gland/drug effects , Pituitary Gland/surgery , Humans , Operating Rooms/methods , Pituitary Diseases/surgerySubject(s)
Neural Tube Defects/complications , Skin Diseases/complications , Urinary Incontinence/complications , Female , Humans , Magnetic Resonance Imaging , Middle Aged , Neural Tube Defects/diagnosis , Neural Tube Defects/diagnostic imaging , Neurosurgical Procedures , Skin Diseases/diagnosis , Skin Diseases/diagnostic imaging , Spinal Cord/abnormalities , Spinal Cord/pathology , Tomography, X-Ray Computed , Urinary Incontinence/diagnosis , Urinary Incontinence/diagnostic imaging , Urodynamics/physiologyABSTRACT
Solid tumour brain metastases are a frequent clinical dilemma for oncologists and general physicians. The sound management of brain metastases requires a multidisciplinary approach. In this review we discuss the diagnosis and management of brain metastases including the role of surgery, radiotherapy, and chemotherapy. The standard approaches of surgical excision and primary radiotherapy have evolved from randomised studies. However, controversies remain regarding post-surgery irradiation in the setting of a solitary metastasis and the role of palliative chemotherapy.
Subject(s)
Brain Neoplasms/secondary , Brain Neoplasms/therapy , Antineoplastic Agents/therapeutic use , Brain Neoplasms/diagnosis , Chemotherapy, Adjuvant , Humans , Neurosurgical Procedures/methods , Palliative Care/methods , Postoperative Complications , Radiotherapy, Adjuvant , Randomized Controlled Trials as Topic , Treatment OutcomeSubject(s)
Aneurysm, Infected/etiology , Aneurysm, Ruptured/etiology , Endocarditis, Subacute Bacterial/complications , Adult , Aneurysm, Infected/microbiology , Aneurysm, Ruptured/microbiology , Aneurysm, Ruptured/pathology , Anti-Bacterial Agents/therapeutic use , Endocarditis, Subacute Bacterial/drug therapy , Endocarditis, Subacute Bacterial/pathology , Humans , Male , Tomography, X-Ray Computed/methodsABSTRACT
The incidence of haemorrhagic complications of intracranial pressure monitoring (ICPM) has previously been reported. However, in these studies, the techniques employed to access the inside of the cranium varied. While 3-mm essentially blind 'twistdrill' craniostomies have been used, their role has been limited for fear of haemorrhagic sequelae. This has also restricted their use in clinical applications other than ICPM. We conducted a prospective observational study looking at haemorrhagic complications of the twistdrill in order to determine its safety and whether it has a role in other clinical settings. Over the period January 1994-February 2001, 941 patients had 1032 twistdrill procedures. There were 550 (58.4%) male patients and 391 (41.6%) female. The age range was 3 months to 93 years (median age 35 years). Only four procedures (0.38%) caused clinically significant bleeds attributable to the twistdrill --all of which were managed conservatively without requiring surgical evacuation. We conclude that twistdrill craniostomies are safe and that their use could be extended to other neurosurgical procedures and potentially to ICPM in non-neurosurgical centres.
Subject(s)
Craniotomy/adverse effects , Surgical Instruments/adverse effects , Adolescent , Adult , Aged , Aged, 80 and over , Child , Child, Preschool , Craniotomy/instrumentation , Equipment Design , Female , Humans , Infant , Intracranial Hemorrhages/etiology , Male , Middle Aged , Postoperative Hemorrhage/etiologyABSTRACT
A case is reported describing a complication of an unsuccessful attempt to aspirate the reservoir of a ventriculoperitoneal shunt system with a suspected shunt infection. This arose due to a misunderstanding of the anatomy of the shunt and resulted in an intracerebral haematoma. The complications of cerebrospinal fluid shunting and the difficulty in the diagnosis thereof are outlined. We discuss the role and method of shunt tapping in diagnosing shunt problems before reviewing the literature describing the rationale. The variation in shunt design is emphasized. Guidelines are then proposed not to dissuade physicians from tapping shunts but to ensure that the procedure is performed safely and in collaboration with neurosurgical units.
Subject(s)
Cerebrospinal Fluid , Hydrocephalus/complications , Intracranial Hemorrhages/etiology , Seizures/etiology , Suction/adverse effects , Ventriculoperitoneal Shunt , Central Nervous System Infections/cerebrospinal fluid , Central Nervous System Infections/diagnosis , Diagnosis, Differential , Diagnostic Techniques, Surgical/adverse effects , Humans , Infant , Male , Medical Errors , Respiratory Tract Infections/blood , Respiratory Tract Infections/diagnosis , Suction/methods , Ventriculoperitoneal Shunt/adverse effects , Ventriculoperitoneal Shunt/instrumentationABSTRACT
There is growing evidence to support the use of motor cortex stimulation (MCS) in the management of patients with chronic neuropathic pain. A prospective audit of ten patients using a modified staged technique for motor cortex implantation provides further evidence for the analgesic effectiveness of this technique. Ten patients suffering from phantom limb pain (n=3), post stroke pain (n=5), post traumatic neuralgia secondary to gunshot injury to the brain stem (n=1) and brachyalgia secondary to neuro-fibromatosis (n=150% pain relief) and long-term benefit in 4/5 of patients who initially responded to intermittent cortical stimulation (longest follow up 31 months after implantation). Of those patients who benefited two had post stroke pain, two phantom limb pain and one post-traumatic neuralgia. We conclude that motor cortex stimulation is an effective analgesic intervention in some patients with chronic neuropathic pain, but it is difficult if not impossible to predict those patients who may respond to treatment prior to implantation. Randomised controlled trials are now urgently needed to test the effectiveness of motor cortex stimulation under double-blind conditions.
