Quantitative and functional visual field outcomes after endoscopic trans-sphenoidal pituitary adenectomy.

OBJECTIVE: Quantitative data on visual outcomes after trans-sphenoidal surgery is lacking in the literature. This study aims to address this by quantitatively assessing visual field outcomes after endoscopic trans-sphenoidal pituitary adenectomy using the capabilities of modern semi-automated kinetic perimetry. METHODS: Visual field area (deg2) calculated on perimetry performed before and after surgery was statistically analysed. Functional improvement was assessed against UK driving standards. RESULTS: Sixty-four patients (128 eyes) were analysed (May 2016-Nov 2019). I4e and I3e isopter area significantly increased after surgery (p < 0.0001). Of eyes with pre-operative deficits: 80.7% improved and 7.9% worsened; the median amount of improvement was 60% (IQR 6-246%). Median increase in I4e isopter was 2213deg2 (IQR 595-4271deg2) and in I3e isopter 1034 deg2 (IQR 180-2001 deg2). Thirteen out of fifteen (87%) patients with III4e data regained driving eligibility after surgery. Age and extent of resection (EOR) did not correlate with visual improvement. Better pre-operative visual field area correlated with a better post-operative area (p < 0.0001). However, the rate of improvement in the visual field area increased with poorer pre-operative vision (p < 0.0001). CONCLUSIONS: A median visual field improvement of 60% may be expected in over 80% of patients. Functionally, a significant proportion of patients can expect to regain driving eligibility. EOR did not impact on visual recovery. When the primary goal of surgery is alleviating visual impairment, optic apparatus decompression without the aim for gross total resection appears a valid strategy. Patients with the worst pre-operative visual field often experience the greatest improvement, and therefore, poor pre-operative vision alone should not preclude surgical intervention.

Utility of Arterial Spin Labeling Magnetic Resonance Imaging in Differentiating Sellar Region Meningiomas from Pituitary Adenomas.

BACKGROUND: Differentiating sellar region meningiomas from pituitary adenomas on standard magnetic resonance imaging (MRI) sequences can be difficult. Arterial spin labeling (ASL) is a noninvasive technique of magnetic resonance perfusion imaging. The range of applications of ASL in neurosurgery has increased, and the information provided can be unique and complementary to other MRI sequences. Here we investigate the utility of ASL MRI in differentiating between sellar region meningiomas and pituitary adenomas. METHODS: This was a retrospective comparison of quantitative assessments on absolute and normalized tumor blood flow in histologically proven meningiomas versus pituitary adenomas. RESULTS: A total of 15 patients with sellar region lesions were identified, including 9 meningiomas and 6 pituitary adenomas. Mean absolute tumor blood flow and normalized tumor blood flow were significantly higher in meningiomas (131 mL/100 g/min and 2.22) than adenomas (47 mL/100 g/min and 0.92; P < 0.05). CONCLUSIONS: ASL MRI is a useful adjunct sequence in differentiating sellar region meningiomas, which exhibit high perfusion, from pituitary adenomas, which exhibit relatively low perfusion.

Spontaneous Spinal Epidural Haematoma Secondary to Autoimmune Acquired Haemophilia.

Spontaneous spinal epidural haematoma is a rare entity associated with high morbidity. Although there are previous reports of spinal haematoma secondary to X-linked genetic haemophilia, there are no such cases secondary to acquired autoimmune haemophilia. We report the case of a 71-year-old patient who presented with sudden quadriplegia secondary to cervical (C2 to T1) epidural haematoma as a result of undiagnosed autoimmune acquired haemophilia A. She underwent emergency cervical laminectomy and evacuation of spinal haematoma with significant recovery in upper limb function. This case highlights the importance of haematological investigations in patients with spontaneous spinal haematoma.

Gas Embolic Stroke Secondary to Bowel Infarction.

A 69-year-old gentleman with metastatic esophageal adenocarcinoma presented with acute abdominal pain to the emergency medicine department and subsequently developed an acute left hemiplegia while in the resuscitation unit. An unenhanced computed tomography (CT) scan of the head showed right frontal cerebral gas emboli while an unenhanced CT scan of the abdomen and pelvis showed extensive portal venous gas and pneumatosis intestinalis, presumed secondary to bowel infarction.

A rare case of symmetrical four limb gangrene following emergency neurosurgery.

INTRODUCTION: The authors report a case of symmetrical peripheral gangrene (SPG) following emergency neurosurgery. PRESENTATION OF CASE: A 35-year-old female presented to hospital in Thailand with nausea, headache, and subsequent seizures. She was found to have a large intracranial space-occupying lesion with mass effect. Following emergency surgical debulking and decompression, she suffered from severe sepsis with multiple organ failure, treated with high dose intravenous vasopressors and developed secondary gangrene in all four limbs. She was repatriated to the UK with a baseline GCS of 8 and multiple postoperative medical complications. With initial conservative management, the patient made a prolonged but satisfactory progression to recovery prior to semi-elective debridement and selected digit amputation of the gangrene. DISCUSSION: This is the first reported case of four limb symmetrical peripheral gangrene following an emergency craniotomy. CONCLUSION: Although rare, SPG is a substantial complication with high mortality and morbidity and therefore should be especially taken into account for emergency intracranial pathologies in neurosurgical patients, particularly if they require emergency surgery.

Influence of light and time on bilirubin degradation in CSF spectrophotometry for subarachnoid haemorrhage.

AIM: Investigation of the influence of light on bilirubin degradation over time in cerebrospinal fluid (CSF) specimens from patients with computed tomography (CT) positive subarachnoid haemorrhage (SAH). METHODS: Twenty-nine CSF samples were analysed from 23 patients with CT-positive SAH. Samples were divided into two cohorts - one half being stored in the dark, the other in normal room light conditions. Samples were assayed by spectrophotometry 0, 1, 2, 6, 19, 24 and 48 h post-storage. Net bilirubin absorbance (NBA) was measured in absorbance units (AU) by determining the optical density at 476 nm. RESULTS: In 27 of 28 (96%) samples stored in light conditions and 21 of 29 (72%) samples stored in dark, a decline in the amount of bilirubin detected in CSF over time was observed. The rate of bilirubin degradation over 24 h for CSF samples stored in the light ranged from 0.0001 to 0.0048 AU/h (mean 0.0020 AU/h), and was significantly greater (p < 0.01) than the rate of degradation in the dark, which ranged from 0 to 0.0024 AU/h (mean 0.0005 AU/h). CONCLUSION: CSF bilirubin samples are susceptible to the same photodegradation as shown in serum bilirubin samples. The rate of degradation is not predictable or consistent. This photodegradation may potentially produce false-negative results in the diagnosis of SAH. If spectrophotometry cannot be carried out immediately, all such CSF samples should at least be centrifuged immediately, the supernatant protected from light as soon as possible and the collection and analysis times provided in the report.