Surgical outcomes in patients with acromegaly: Microscopic vs. endoscopic transsphenoidal surgery.

Transsphenoidal resection of growth hormone-secreting pituitary neuroendocrine tumors remains the first-line treatment for acromegaly. This can be performed through microsurgery or endoscopic surgery. For the past decades, endoscopic surgery has become the preferred technique in an increasing number of centers worldwide. However, whether it offers superior clinical outcomes has yet to be determined. In this paper, we performed a narrative review of the literature comparing both techniques in the treatment of acromegaly. We critically assessed available comparative studies from an objective perspective to determine their suitability for defining superiority of either technique. Available evidence displays substantial methodological variations and reports conflicting findings. Although endoscopic surgery provides a wider exposure and enhanced visibility of the surgical field, this does not consistently translate into better clinical outcomes, as most tumors are equally accessible through both techniques. Postoperative outcomes such as remission and complication rates are similar between both techniques. The management of acromegaly should be performed by experienced pituitary neurosurgeons, regardless of the approach. The involvement of a multidisciplinary team in a dedicated pituitary center is critical to ensure optimal outcomes.

Novel Hybrid Technique for Preservation of Frontal Branch of Facial Nerve: Subgaleal Preinterfascial Dissection.

OBJECTIVE: The pterional approach is the workhorse of skull-base neurosurgery, which allows virtual access to any intracranial lesion around the circle of Willis. Preserving the frontotemporal branch of the facial nerve and conserving the temporal muscle's symmetry are fundamental objectives besides the access that can be obtained through this versatile neurosurgical technique. This manuscript proposes a subgaleal preinterfascial dissection, a novel hybrid technique that provides advantages of previously described temporal muscle dissection techniques while preserving the integrity of facial nerve branches and the unobstructed broad pterional region. We describe the subgaleal preinterfascial dissection as a safe and simple to technique to achieve preservation of the facial nerve frontal branches during anterolateral approaches. METHODS: Two cadaveric heads were skillfully dissected and studied to perform a proper subgaleal preinterfascial dissection on both sides of each cadaver. Afterward, the same technique was employed in 108 patients during a pterional approach for different neurosurgical diseases, with a postoperative follow-up of 6 months. RESULTS: None of the 108 patients presented postoperative frontotemporal branch palsy during postoperative follow-up. Likewise, no complications related to the proposed technique were present. CONCLUSIONS: The subgaleal preinterfascial dissection is a reliable, safe technique that may be employed during a pterional approach with an unobstructed surgical view and excellent cosmetic and functional results, preserving the frontotemporal branch of the facial nerve.

Current and Future Perspectives of Microscopic and Endoscopic Transsphenoidal Surgery for Pituitary Adenomas: A Narrative Review.

Transsphenoidal resection remains the standard treatment for most pituitary adenomas. However, the ideal surgical approach to safely access these lesions, either microsurgical or endoscopic, continues to be debated. Since the introduction of endoscopic transsphenoidal surgery, centers around the world have increasingly adopted this technique, experiencing a shift away from the conventional microsurgical approach. Large series reporting the efficacy and safety of endoscopic surgery have fueled a growing interest in comparing clinical outcomes between both approaches. Still, proving superiority of either surgical approach remains an elusive task due to the inherent drawbacks of surgical observational studies, as we are still faced with a growing body of evidence reporting conflicting results. Thus, a comprehensive discussion regarding the reach and limitations of both techniques becomes necessary. In this narrative review, we perform a critical appraisal of the literature and provide an expert opinion on the state-of-the-art in transsphenoidal surgery for pituitary adenomas. The advantages and limitations of each approach are assessed and compared from a technical standpoint, and their reported outcomes evaluated in the framework of this transition phase. Available evidence should be interpreted in light of individual patient characteristics and within the context of each medical center, taking into consideration the known impact that surgical expertise and multidisciplinary management hold on clinical outcomes.

Assessing the Malignancy Risk of a Meningioma by Its Location.

BACKGROUND: Meningiomas represent 30% of primary intracranial tumors. The current incidence is up to 4.5 cases per 100,000 habitants worldwide. Although there is no prognostic difference among benign histopathological subtypes, atypical meningiomas and malignant meningiomas (WHO grade II and III respectively) may extend to the adjacent brain parenchyma, dura mater, and osseous tissue with a recurrence score (21-49%). This manuscript analyzes the malignancy risk according to neoplastic localization through a logistic retrospective analysis from a total sample of 452 patients with grade I, II, and III (WHO) meningiomas. METHODS: Detailed data collection through a three-year retrospective analysis (January 2008 to December 2011) was applied at Mexico's National Neurology and Neurosurgery Institute including patients with intracranial or spinal-cord meningioma, preoperative imaging study availability and post-surgical histopathological diagnosis. Formal written consent was not required with a waiver by the appropriate national research ethics committee in accordance with the provisions of the regulations of the general health law of Mexico. RESULTS: Convexity lesions displayed an increased risk of malignancy turning for non-benign meningiomas with an odds ratio of 3.1 (95% CI 1.6 to 5.7, p=0.0002) meanwhile skull-base meningiomas present an inverse risk with an odds ratio of 0.4 (95% CI 0.2 to 0.9, p=0.02), as well as spinal-cord meningiomas with an odds ratio of 0.3 (95% CI 0.1 to 0.9). CONCLUSION: Skull base and spinal cord meningiomas usually have benign behavior, meanwhile grade II or III meningiomas within this location are rare. The present work provides an additional criterion for decision making, according to the meningioma's location.

Characteristics and Long-Term Outcome of Cerebellar Strokes in a Single Health Care Facility in Mexico.

Objective The purpose of this study was to analyze and discuss the clinical characteristics, long-term outcome, and prognostic factors of cerebellar strokes treated in a single health care facility in Mexico. Methods We retrospectively reviewed the medical records of adult patients admitted to our hospital with diagnosis of cerebellar ischemic and hemorrhagic stroke between 2018 and 2020. Baseline data included sociodemographic and radiological variables, treatment (surgical versus conservative), and Glasgow Coma Scale on arrival (GCSOA). The final neurological outcome was evaluated with the Glasgow Outcome Scale (GOS) six months after hospital discharge. Results Ten patients (seven male and three female) with a mean age of 57.9 ± 9.3 years were included, six with cerebellar ischemic infarction and four with cerebellar hemorrhage. Out of the 10 patients, four underwent surgery (suboccipital decompressive craniectomy {SDC} ± ventriculostomy). The outcome was favorable in four cases (40%) and unfavorable in six (60%). Patients who underwent surgical treatment fared worse with all four cases associating poor outcome. The comparison between good and poor outcome groups showed significant differences in the presence of obstructive hydrocephalus (one versus six, p = 0.05) and poorer GCSOA (6.16 ± 1.72 versus 12.5 ± 3.6, p = 0.05), associating poorer outcome. Conclusion There is still controversy regarding the appropriate management of cerebellar strokes. The presence of obstructive hydrocephalus and poorer GCSOA are associated to worse outcomes.

Awake Surgery With Visual Pathway Mapping in Low Grade Glioma Surgery.

The visual pathway and its defects have been thoroughly studied in clinical correlation to temporal lobe lesions related to epilepsy and traumatic lesions. Nevertheless, its clinical correlation and other decision-making have not been addressed regarding neoplastic lesions. We present a case report of a 28-year-old man with a one-year history of generalized seizures and left superior homonymous quadrantanopia, with no other neurological disturbance on physical examination. According to diffusion tensor imaging tractography, MRI demonstrated a non-enhancing, right temporal lesion disrupting the visual pathway. An awake surgery with direct cortical electrostimulation of visual pathways was performed with subtotal resection of the tumor to preserve visual function, confirmed with postoperative MRI. Histopathological studies revealed a fibrillary astrocytoma. Surgical technique aided with intraoperative cortical and subcortical stimulation involving low-grade gliomas in eloquent areas is an exceptionally suitable procedure for complex cases where the visual pathway is compromised. Our objective is to describe how intraoperative mapping of visual function is performed in our institution and to comment on the relevant technical nuances, which can serve as a practical guideline for young neurosurgeons, as no previous cases have been reported in our country.

Endoport-assisted microsurgical treatment for a ruptured posterior cerebral artery aneurysm: A technical note.

Posterior Cerebral Artery aneurysms are scarce, yet its territory is frequently associated to large and giant aneurysms. Treatment is mostly a binary option between microsurgical clipping and endovascular coiling. Hybrid approaches are an option too, whereas innovation with less frequent techniques such as endoscope-controlled and endoscope-assisted procedure may provide a safer surgical approach with same successful results. Hereby we report a case of a 53 years old male examined at the ER after presenting generalized seizures and altered state of consciousness. Upon arrival, neurological evaluation revealed homonymous right hemianopia. Computed tomography (CT) scan revealed a subarachnoid hemorrhage and left parieto-occipital intraparenchymal hemorrhage with intraventricular extension; computed tomography angiogram (CTA) revealed an aneurysm at the left posterior cerebral artery (PCA) in its P4 segment. We performed a vascular exploration with drainage of the occipital and intraventricular hematoma through a single endoscopic port through transulcal approach guided by neuronavigation, in addition to clipping and aneurysmectomy. The combination of microsurgical clipping with previous Endoport-guided endoscopic procedure may be a surgical-operative option that not only may facilitate the approach to the desired lesion, but also provides a safer surgical scenario.

68Ga-DOTATOC-PET/CT-guided resection of a primary intraosseous meningioma: technical note.

Primary intraosseous meningiomas (PIMs) are rare tumors that present with a variable radiological appearance and a clinical behavior that is considerably different from that of intracranial meningiomas. Treatment of PIMs consists of complete resection, which may be difficult to achieve due to the lack of clear tumor margins on conventional imaging studies. PET/CT using 68Ga-DOTA-conjugated peptides has been used for the diagnosis and treatment planning of different types of meningiomas due to these tracers' affinity to somatostatin receptors, which are found in most meningiomas. However, this imaging modality's use as an intraoperative adjunct has not been reported for PIMs. In this technical note, the authors describe a [68Ga-DOTA0-Tyr3]octreotide (68Ga-DOTATOC)-PET/CT-guided resection of a PIM. In this case, the area of increased uptake in the 68Ga-DOTATOC-PET/CT study extended well beyond the tumor margins identified on MRI. The patient's pathology report confirmed the presence of tumor cells within peripheral bone, which macroscopically appeared normal. The authors propose 68Ga-DOTATOC-PET/CT as a valuable adjunct in the surgical management of PIMs and offer a reasonable justification for its use based on current evidence. Its use for intraoperative image guidance may aid neurosurgeons in achieving a complete resection, thus minimizing the risk of recurrence of this complex pathological entity.