Role of Anterior Nasal Packing in Endoscopic Skull Base Surgery: Italian Survey.

BACKGROUND: Nowadays, the endoscopic endonasal approach to sellar and parasellar region tumors is a common technique in neurosurgery, and surgical nuances, complications, and management strategies are shared in a multidisciplinary setting between neurosurgeons and ear, nose, and throat surgeons. Due to the heterogeneity of its variations, the role of the anterior nasal packing in endoscopic endonasal approach to the skull base surgery (EESBS) has not yet been unanimously accepted and no consensus or guidelines on its use exist. MATERIALS AND METHODS: A survey containing 10 questions about indications, management advantages, and pitfalls of the use of anterior nasal packing in EESBS was created by using an online open-source tool (SurveyMonkey). The questionnaire was sent to 39 Italian neurosurgical departments, which routinely adopt the endoscopic endonasal approach. RESULTS: Almost half of 39 selected centers (19; 48.7%) answered our survey. The main results can be summarized as 1) anterior nasal packing after EESBS is considered useful by 84% of participants, 2) prevention of epistaxis is the principal indication for anterior nasal packing, 3) the type of approach and skull base reconstruction influence the use of anterior nasal packing, and 4) nasal discomfort is considered the principal negative aspect of nasal packing. CONCLUSIONS: Our study identified that anterior nasal packing is commonly adopted in certain conditions, namely when extensive nasal dissection is performed. Furthermore, the choice to adopt or not the anterior nasal packing should be tailored taking in account specific conditions, such as acromegaly and Cushing disease. It represents an important factor in reducing postoperative sinonasal complications of EESB.

Clinical and Radiological Predictors of Biochemical Response to First-Line Treatment With Somatostatin Receptor Ligands in Acromegaly: A Real-Life Perspective.

Background: First-generation somatostatin receptor ligands (fg-SRLs) represent the first-line medical treatment for acromegaly, recommended in patients with persistent disease after neurosurgery, or when surgical approach is not feasible. Despite the lack of strong recommendations from guidelines and consensus statements, data from national Registries report an increasing use of medical therapy as first-line treatment in acromegaly. Objective: We retrospectively evaluated the potential role of a large number of clinical and radiological parameters in predicting the biochemical response to 6-month treatment with fg-SRLs, in a cohort of naïve acromegaly patients referred to a single tertiary center for pituitary diseases. Methods: Univariable and multivariable logistic regression and linear regression analyses were performed. Biochemical response was defined based on IGF-1 levels, represented as both categorical (tight control, control, >50% reduction) and continuous (linear % reduction) variables. Results: Fifty-one patients (33 females, median age 57 years) were included in the study. At univariable logistic regression analysis, we found that younger age (≤ 40 years; OR 0.04, p=0.045) and higher BMI (OR 0.866, p=0.034) were associated with a lower chance of achieving >50% IGF-1 reduction. On the contrary, higher IGF-1 xULN values at diagnosis (OR 2.304, p=0.007) and a T2-hypointense tumor (OR 18, p=0.017) were associated with a significantly higher likelihood of achieving >50% IGF-1 reduction after SRL therapy. Of note, dichotomized age, IGF1 xULN at diagnosis, and T2-hypointense signal of the tumor were retained as significant predictors by our multivariable logistic regression model. Furthermore, investigating the presence of predictors to the linear % IGF-1 reduction, we found a negative association with younger age (≤ 40 years; ß -0.533, p<0.0001), while a positive association was observed with both IGF-1 xULN levels at diagnosis (ß 0.330, p=0.018) and the presence of a T2-hypointense pituitary tumor (ß 0.466, p=0.019). All these variables were still significant predictors at multivariable analysis. Conclusions: Dichotomized age, IGF-1 levels at diagnosis, and tumor T2-weighted signal are reliable predictors of both >50% IGF-1 reduction and linear % IGF-1 reduction after 6 month fg-SRL treatment in naïve acromegaly patients. These parameters should be considered in the light of an individualized treatment for acromegaly patients.

The role of external ventricular drainage for the management of posterior cranial fossa tumours: a systematic review.

Posterior cranial fossa tumours frequently develop hydrocephalus as first presentation in up to 80% of paediatric patients and 21.4% of adults, although it resolves after tumour removal in 70-90% and 96%, respectively. New onset hydrocephalus is reported in about 2.1% of adult and 10-40% of paediatric patients after posterior fossa surgery. There is no consensus concerning prophylactic external ventricular drainage (EVD) placement that is frequently used before posterior fossa lesion removal, as well in those cases without clear evidence of hydrocephalus. The aim of the study was to define the most correct management for patients who undergo posterior fossa tumour surgery, thus identifying cohorts of patients who are at risk of persistent hydrocephalus prior to surgery. A systematic review of literature has been performed, following PRISMA guidelines. Most of the studies reported CSF shunt only in the presence of hydrocephalus, whereas only a few authors suggested its prophylactic use in the absence of signs of ventricular dilatation. Predictive factors for postoperative hydrocephalus has been identified, including young age (< 3 years), severe symptomatic hydrocephalus at presentation, EVD placement before surgery, FOHR index > 0.46 and Evans index > 0.4, pseudomeningocele, CSF leak and infection. The use of pre-resection CSF shunt in case of signs and symptoms of hydrocephalus is mandatory, although it resolves in the majority of cases. As reported by several studies included in the present review, we suggest CSF shunt also in case of asymptomatic hydrocephalus, whereas it is not indicated without evidence of ventricular dilatation.

Ipsilateral Nasoseptal Flap Pedicle for Transpterygoid Approach: Technical Note.

INTRODUCTION: Transpterygoid approach is an expanded endonasal approach (EEA) that allows surgical access to the medial infratemporal fossa, to the skull base area of petrous bone and to the Meckel's cave. During this approach, a sacrifice of sphenopalatine artery is often required, leading to the need of contralateral Hadad-Bassagasteguy flap (HBF) or alternative reconstructive techniques. MATERIALS AND METHODS: We report a case of spontaneous CSF leak due to a meningo-encephalocele in the left lateral recess of sphenoid sinus, in which an ispilateral nasoseptal flap was harvest and sphenopalatine artery was preserved. RESULTS: We described the surgical technique adopted to preserve the ipsilateral nasoseptal vascular pedicle during transpterygoid approach and we performed a review of the pertinent literature. CONCLUSION: Wide exposure of the pterygoid base through transpterygoid approach could be obtained preserving the sphenopalatine artery, allowing skull base reconstruction with ipsilateral nasoseptal flap.

Discordant GH and IGF-1 Results in Treated Acromegaly: Impact of GH Cutoffs and Mean Values Assessment.

CONTEXT: Discordant growth hormone (GH) and insulin-like growth factor-1 (IGF-1) values are frequent in acromegaly. OBJECTIVE: To evaluate the impact of different GH cutoffs on discordance rate. To investigate whether the mean of consecutive GH measurements impacts discordance rate when matched to the last available IGF-1 value. DESIGN: Retrospective study. SETTING: Referral center for pituitary diseases. PATIENTS: Ninety acromegaly patients with at least 3 consecutive evaluations for GH and IGF-1 using the same assay in the same laboratory (median follow-up 13 years). INTERVENTIONS: Multimodal treatment of acromegaly. MAIN OUTCOME MEASURES: Single fasting GH (GHf) and IGF-1 (IGF-1f). Mean of 3 GH measurements (GHm), collected during consecutive routine patients' evaluations. RESULTS: At last evaluation GHf values were 1.99 ± 2.79 µg/L and age-adjusted IGF-1f was 0.86 ± 0.44 × upper limit of normality (mean ± SD). The discordance rate using GHf was 52.2% (cutoff 1 µg/L) and 35.6% (cutoff 2.5 µg/L) (P = 0.025). "High GH" discordance was more common for GHf <1.0 µg/L, while "high IGF-1" was predominant for GHf <2.5 µg/L (P < 0.0001). Using GHm mitigated the impact of GH cutoffs on discordance (GHm <1.0 µg/L: 43.3%; GHm <2.5 µg/L: 38.9%; P = 0.265). At receiver-operator characteristic curve (ROC) analysis, both GHf and GHm were poor predictors of IGF-1f normalization (area under the curve [AUC] = 0.611 and AUC = 0.645, respectively). The prevalence of disease-related comorbidities did not significantly differ between controlled, discordant, and active disease patients. DISCUSSION: GH/IGF-1 discordance strongly depends on GH cutoffs. The use of GHm lessen the impact of GH cutoffs. Measurement of fasting GH levels (both GHf and GHm) is a poor predictor of IGF-1f normalization in our cohort.

Modified Endoscopic Diving Technique without the Traditional Irrigation System in Endoscopic Cranial Base Surgery: Technical Note.

BACKGROUND: We describe a modified endoscopic diving technique with an alternative irrigation system different than the one used by Locatelli et al. (CLEARVISION II, Karl Storz and Co., Tuttlingen, Germany). METHODS: From January 2016 to October 2018, our senior surgeon performed the modified endoscopic diving technique in 76 endoscopic surgical procedures. Diving surgery was performed in all procedures to check the completeness of tumor resection, thus allowing for the removal of any residual tumor tissue. RESULTS: In the modified endoscopic diving technique, the optic system and the irrigation source are separated into 2 independent tools, allowing surgeons to point the flow on a selected structure, whereas the endoscope can be pointed in the same direction or not. Moreover, the optic system and the irrigation source can be placed at different distances. Surgeons can control the infusion pressure and the entity of the flow. CONCLUSIONS: The use of the modified endoscopic diving technique allows surgeons to have more settings that could be controlled and also bypasses any compatibility issues between different endoscopic systems. In addition, the reproducibility of this technique, together with the low cost of the instrumentation, could allow an easier application of the diving technique.

Impact of pre-treatment with somatostatin analogs on surgical management of acromegalic patients referred to a single center.

First-line treatment of patients with growth hormone secreting adenomas is surgical resection. Disease control can be obtained by surgery (one or multiple steps), in case followed by medical treatment or adjuvant radiation therapy (radiosurgery or radiotherapy). The impact of pre-surgical treatment with somatostatin analogs (SSAs) on surgical outcome is still controversial. The aim of this study is to retrospectively evaluate the impact of SSA pre-treatment on biochemical outcome and post-surgical hypopituitarism in a consecutive surgical series from a single referral centre, with data covering 17 years' experience and to investigate the possible predictive value of early postoperative insulin-like factor 1 (IGF-I) on long-term biochemical control. Data from 68 acromegalic patients were revised. Endocrinological long-term follow-up (minimum 6 months) was available for 57 patients. Eighty-eight percent of patients received a single-step surgical treatment (single surgery, with or without adjuvant medical therapy). The remaining 12% underwent a multi-step strategy: redo-surgery (three macroadenomas) and/or radiation (four macro- and two microadenomas). Pre-surgical SSA treatment was performed in 77.9% and resulted in a significant lowering of basal IGF-I values (p = 0.0001). Early post-surgical IGF-I was significantly lower in patients biochemically controlled with single surgery alone (p = 0.016) and after overall treatment strategies (p = 0.005). Normalization of GH and IGF-I was obtained in 56.1%, and normalization of either one of them in 27.8% of patients. No major surgery-related complications occurred. Post-treatment hypopituitarism occurred in 11.9% and was lower in SSA pre-treated patients. Our results well compare with other recently published series. Very early post-surgical IGF-I improvement might be a useful predictor for biochemical disease control. Moreover, our results suggest that pre-surgical treatment with somatostatin analogs seems to prevent hypopituitarism.

Pituicytomas: radiological findings, clinical behavior and surgical management.

BACKGROUND: Pituicytomas are rare low-grade glial neoplasms originating in the neurohypophysis or infundibulum that appear as solid, noninfiltrative masses occupying the sella turcica, the suprasellar space or both. Due to their high tendency to bleed and the possible firmness and adhesion to surrounding structures, preoperative diagnosis of pituicytoma is a goal for the surgeon, but it is actually a challenge because of the absence of distinctive clinical or neuroradiological findings. METHODS: We report the new cases of three patients who underwent transsphenoidal surgery for suspected pituitary adenomas, which were determined to be pituicytomas at histological and immunohistochemical analysis. We also review previously reported cases of pituicytoma in the literature. RESULTS: To date, 51 cases of pituicytoma have been reported in addition to our own cases. The natural history and clinical characteristics of this rare tumor are outlined. CONCLUSIONS: Macroscopic aspects are variable, and final diagnosis is made from the typical histological and immunohistochemical pattern. The therapy of choice is gross total surgical resection since subtotal removal can lead to local regrowth, but the time to recurrence is unpredictable and highly variable. The role of adjuvant therapy is currently undefined.