Surgeons' experience of venous risk with CPA surgery.

The study aims to systematize neurosurgeons' practical knowledge of venous sacrifice as applied to the posterior fossa region and to analyze the collected data to present and preserve relevant experience and expert knowledge for current and future practicing neurosurgeons. The venous structures assessed were the superior petrosal vein (SPV), sigmoid sinus (SS), and the tentorial veins (TV). The survey is constructed to obtain surgeons' idea of assessed risk when sacrificing specific venous structures during posterior fossa surgery. They were asked how they prep for surgery, number of operations conducted, and their basis of knowledge. Collected data were mainly qualitative and analyzed with a mixed-method approach. A mean absolute deviation was calculated measuring rate of disagreement for a given substructure. Consensus existed among the participating surgeons that sacrificing the SPV and the TV was considered safe. Although, the risk of death when occluding major structures like the main trunk of the SPV, one of the SS' and or a total occlusion of all TV yielded high risk of death. The risk of infarction was often too apparent to discredit even with low risk of death among an experienced class of surgeons. Our findings provide an overview of surgical risk associated with venous sacrifice. This will minimize cases where indispensable practical knowledge on safe handling veins in the cerebellopontine angle is either to be lost or taught among few when the neurosurgeons retire. This will lower the disagreement regarding risks and increase the quality of surgical decision-making.

Acute presentation of craniopharyngioma in children and adults in a Danish national cohort.

We aimed to study the occurrence of acute-onset symptoms at initial presentation in a national Danish cohort of patients with childhood- or adult-onset craniopharyngioma, and to investigate potential risk factors for acute presentation. Medical records of 189 consecutive patients (39 children, 150 adults) presenting with craniopharyngioma during the period 1985-2004 were reviewed, and data regarding initial symptoms, neuroimaging results, vision and pituitary function were systematically collected. Acute symptoms preceding hospital admission were noted. Subgroup analyses were based on age, gender and calendar year period. Potential risk factors for acute presentation were analysed through uni- and multivariate analyses. Acute symptoms were reported in 24 (13%) patients. Acute visual symptoms, headache, nausea or vomiting were most frequently reported, and acute symptoms were more frequent among children (28%) than among adults (9%) (P < 0.01). There were no differences according to sex or calendar year period. Hydrocephalus was present in half of childhood cases and one-fifth of adult patients (P < 0.001). Intra-tumour haemorrhage was seen in two cases. Acute symptoms were more frequent among patients with tumours occupying the third ventricle (P < 0.01), radiologic signs of calcification (P < 0.05) or hydrocephalus (P < 0.01). In multivariate analysis, however, only childhood onset (P < 0.05) and calcification (P < 0.05) were independent risk factors for acute presentation. Craniopharyngioma presented with acute symptoms in 13% of patients. Childhood onset and radiologic signs of calcification were independent risk factors for acute presentation. Intra-tumour haemorrhage was rare.

Incidence of craniopharyngioma in Denmark (n = 189) and estimated world incidence of craniopharyngioma in children and adults.

We studied the incidence of craniopharyngioma in Denmark during the period 1985-2004 and estimated worldwide incidence rates (IR) of craniopharyngioma based on a literature review. Craniopharyngioma patients diagnosed during the period 1985-2004 were identified from the Danish National Patient Registry, the Danish Cancer Registry and regional registries. Medical records were reviewed. Danish population data were obtained from Statistics Denmark. European and World population data were obtained from EU and WHO homepages. Prior studies providing data on craniopharyngioma IRs were identified via PubMed and, if appropriate, were included in a weighted analysis estimating overall and children's IRs of craniopharyngioma. IRs are given as new cases per million per year. We identified 189 patients with new verified (162) or probable craniopharyngioma. The overall WHO World-standardised incidence rate was 1.86 (1.60-2.14) for all ages and 2.14 (1.53-2.92) for children (age <15 years). Peak incidence rates were observed in age groups 5-9 and 40-44 years. Fifteen prior studies (including 1,232 craniopharyngioma cases) were identified. Seven and 11 studies, respectively, were eligible for weighted all-ages and childhood population IR analyses, yielding summary IRs of 1.34 (1.24-1.46) (all ages) and 1.44 (1.33-1.56) (children). We have provided a detailed survey of the incidence of craniopharyngioma in Denmark during a recent 20-year period. Overall IR of craniopharyngioma in Denmark was 1.86 (1.60-2.14) as compared to 2.14 (1.53-2.92) among children. Weighted estimates of craniopharyngioma world IRs were 1.34 (1.24-1.46) in all ages and 1.44 (1.33-1.56) among children.

Fractionated stereotactic radiotherapy in patients with acromegaly: an interim single-centre audit.

AIM: To evaluate the effect of fractionated stereotactic radiotherapy (FSRT) in acromegaly in a retrospective analysis. PATIENTS AND METHODS: Thirty-four patients (17 females, median 43 years (range 30-74)) with acromegaly were treated with FSRT (conformal dynamic arcing, dose 54 Gy, 27-30 fractions) between January 1998 and April 2007. Of the 34 patients, 32 had undergone transsphenoidal adenotomy, and 28 were on medical therapy before FSRT. Patients on medical therapy continued this during and after the irradiation. The treatment was gradually decreased/withdrawn after careful assessment. RESULTS: Magnetic resonance scanning of the pituitary gland 34 months (median, range 11-95) after irradiation showed stable or reduced volume of the remaining tumour tissue in 31 of 34 patients (91%). Seventeen patients (50%) were biochemically controlled (normalised nadir GH during oral glucose tolerance test and IGF1 <+2 S.D.) 30 months after FSRT (median, range 6-60), and ten of them had true biochemical remission (off medical therapy) 30 months after FSRT (median, range 12-69). Of 28 patients with one or more functioning pituitary axes before irradiation, 8 (29%) developed further deficit of one or two pituitary axes 48 months (median, range 6-102) after FSRT. Of 34 patients, 20 still required medical treatment for acromegaly at the end of this study, mainly those with a short follow-up period after irradiation. CONCLUSION: The FSRT seems promising in terms of treatment of acromegaly. Longer follow-up is, however, needed to assess the overall efficacy and safety of FSRT for acromegaly.

Prevalence and predictive factors of post-traumatic hypopituitarism.

OBJECTIVE: To estimate the prevalence and predictive factors of hypopituitarism following traumatic brain injury (TBI). DESIGN: A cross-sectional cohort study. PATIENTS: One hundred and four hospitalized TBI patients (26F/78M), median age 41 (range 18-64) years, body mass index (BMI) 25 (17-39) kg/m(2); severity: mild [Glasgow Coma Scale (GCS) score 13-15) n = 44, moderate (GCS 9-12) n = 20, severe (GCS < 9) n = 40]. MEASUREMENTS: Patients were evaluated 13 (10-27) months post-injury, with measurement of baseline (0800-1000 h) and post-stimulatory hormonal levels during an insulin tolerance test (ITT) (86%) or, if contraindicated, an arginine(arg)-GHRH test + Synacthen test (14%). Insufficiencies were confirmed by retesting. RESULTS: Hypopituitarism was found in 16 (15%) patients, affecting one axis in 10, two axes in four and more than two axes in two patients. The GH axis was most frequently affected (15%), followed by secondary hypoadrenalism (5%), hypogonadism (2%), hypothyroidism (2%) and diabetes insipidus (2%). The risk of pituitary insufficiency was increased in patients with severe TBI as opposed to mild TBI [odds ratio (OR) 10.1, 95% confidence interval (CI) 2.1-48.4, P = 0.004], and in those patients with increased intracerebral pressure [OR 6.5, 95% CI 1.0-42.2, P = 0.03]. Patients with only one affected axis were all GH deficient; 60% (n = 6) of these were overweight or obese. CONCLUSION: The prevalence of hypopituitarism was estimated at 16%. Although high, this value was lower than previously reported, and may still be overestimated because of well-known confounding factors, such as obesity. Indicators of increased TBI severity were predictive of hypopituitarism, with a high negative predictive value. Neuroendocrine evaluation should therefore be considered in patients with severe TBI, and in particular in those with increased intracerebral pressure (ICP).

Adrenocortical insufficiency after pituitary surgery: an audit of the reliability of the conventional short synacthen test.

BACKGROUND: Assessment of the hypothalamic-pituitary-adrenal (HPA) axis after pituitary surgery is important for appropriate decision making regarding replacement therapy. The synacthen test is often used but is questioned, as time has to elapse for adrenal atrophy to develop. OBJECTIVE: To audit the use of the 250 microg synacthen test after transsphenoidal adenomectomy. METHODS: A retrospective study of 110 patients submitted to first-time transsphenoidal adenomectomy. Anterior pituitary testing was performed preoperatively, 1 week and 1, 3, 6 and 12 months postoperatively. The adrenocortical function was tested by a synacthen test (250 microg synacthen i.v.). RESULTS: Thirty-two out of 71 patients with normal HPA function before surgery developed insufficiency postoperatively, seven patients presenting an insufficient test response after 1 week, 16 after 1 month and nine after 3 months, whereas none became insufficient during the remaining follow-up. Three patients presented symptomatic adrenal insufficiency during the first postoperative week despite a normal test. All of these developed an insufficient test 1 month postoperatively. A 1-week basal plasma cortisol > 400 nmol/l indicated HPA sufficiency, whereas a basal cortisol < or = 100 nmol/l indicated insufficiency when related to the diagnosis based on the 3-month synacthen test. CONCLUSION: This study confirms that the synacthen test is of limited use in the early postoperative phase, because out of 62 patients with normal 1-week postoperative synacthen responses, 23 patients developed a test that was indicative of adrenal insufficiency over 1-3 months. Our results indicate that a large proportion of patients should be considered for hydrocortisone replacement therapy up to 3 months postoperatively followed by reassessment of the HPA axis.

Ulnar neuropathy at the elbow: clinical and electrophysiological outcome of surgical and conservative treatment.

The objective was to evaluate and compare the clinical and electrophysiological outcome of treatment in patients with ulnar neuropathy at the elbow in 32 consecutive patients who were studied prospectively. Based on the electrophysiological findings 15 patients were treated by surgical decompression and 17 were treated conservatively. Sensory and motor nerve conduction studies across and below the elbow were done in all patients before treatment and again after one year. Postoperatively 10/15 patients (67%) improved clinically and 12 patients (80%) had improved nerve conduction results. There was clinical and electrophysiological agreement in eight patients in the surgically-treated group, all of whom improved both clinically and electrophysiologically. In the conservatively-treated group six patients (35%) showed clinical improvement, 10 patients had no improvement, and one patient was worse. The nerve conduction studies improved in six patients (35%), were unchanged in eight patients, and worse in three. There was clinical and electrophysiological agreement in 11 patients. We conclude that the electrophysiological examination was valuable in deciding which patients to operate on, and that most of the patients improved clinically or electrophysiologically postoperatively.

Vibrotactilometry as a diagnostic tool in ulnar nerve entrapment at the elbow.

Vibrotactilometry with testing of the thresholds of the vibration sense at seven frequencies between 8-500 Hz in different intensities has been correlated with nerve conduction studies of the ulnar nerve to evaluate its diagnostic power in neuropathies at the elbow. Thirty-nine patients with entrapment symptoms were studied. Vibrotactilometry was abnormal in 33 patients (85%) and nerve conduction studies were abnormal in 19 (49%). The sensitivity of vibrotactilometry in relation to nerve conduction studies was 89%, and in relation to the patients' symptoms was 85%. We conclude that vibrotactilometry is a sensitive test that correlates well with the patients' symptoms, while nerve conduction studies are less sensitive (49%) in relation to the patients' symptoms. Vibrotactilometry in the frequency area of 8-500 Hz is recommended in the screening of ulnar nerve entrapment. Nerve conduction studies are recommended in clinically doubtful cases to localise the entrapment to the elbow region.