Extended endoscopic transplanum-transtuberculum approach for pituitary adenomas.

Few pituitary adenomas require removal through a transcranial route. This may be associated with more significant morbidity and mortality, compared to the transsphenoidal approach. An endoscopic, extended, transplanum-transtuberculum approach (ETTA) in selected pituitary adenomas may offer an alternative to the transcranial route. We describe our technique and experience of ETTA in pituitary adenomas over 10 years. Between 2000 and 2010, we performed 700 endoscopic endonasal procedures for pituitary adenomas. Nineteen patients (13 men; mean age, 48 years; range, 22-76 years) underwent 22 ETTAs. Thirteen patients had non-functioning adenomas. Three tumor groups were identified: (1) tumors developing in or around the pituitary stalk; (2) tumours with sub- frontal extension and (3) tumours with a major extrasellar component. Mean follow-up was 37 months (range 6-72 months). Gross total resection was achieved in 11 procedures (no recurrences), with partial tumour resection in 11 procedures. Of the 12 patients with visual symptoms, ten improved. Of eight patients with hormonal hypersecretion four were cured. Complications included CSF leak (14%), haemorrhage (9%), hemiplegia (5%). There were no mortalities. Experience using the ETTA for pituitary adenomas is limited because it is indicated in highly selected cases (3.1% of our series). An absolute indication is represented by ectopic secreting pituitary stalk/peri-stalk adenomas. ETTA is a useful option in midline frontal adenomas and adenomas with a major extrasellar component, but has a higher morbidity than that seen in the standard transsphenoidal approach. A study comparing ETTA versus transcranial resection is highly desirable.

Awake craniotomy using stealth frameless stereotaxy without rigid skull fixation.

The authors describe a technique using the Medtronic Stealth spinal reference array allowing awake craniotomy to be performed without cranial fixation in the Mayfield pin head rest. A Medtronic spinal reference array (four-point H-shaped LED array) is fitted to a Yasargil footplate via a three-jointed swingarm. The Yasargil footplate is directly attached to the cranium after craniotomy and following stereotactic registration the patient is awakened. The patient is free to move his head during the procedure as the reference array does not move in relation to the cranial contents and the fiducials, preserving accuracy.

Delayed postoperative intracerebral abscess caused by Proprionibacterium acnes: case report and review of the literature.

A case of delayed intracerebral abscess due to Proprionibacterium acnes (P. acnes), 18 months after an uneventful excision of a parasagittal haemangiopericytoma in a 61-year-old female is reported. This is highly unusual as cerebral abscess by P. acnes is rare and it occurred so late postoperatively in the absence of known risk factors. We propose the inclusion of cerebral abscess by P. acnes in the differential diagnosis of lesions that mimic tumour recurrences, after clean craniotomies.

High and low pressure states associated with posterior sacral meningocele.

We describe the rare cases of a 44-year-old woman and a 28-year-old woman each presenting with a large posterior sacrococcygeal mass and alternating symptoms of high and low intracranial pressure. The first patient underwent excision of her large sacral meningocele and simple ligation of the neck, resulting in resolution of all her associated symptoms. The second patient suffered traumatic rupture of the meningocele; she underwent excision of the redundant sac and repair of the dural defect using a musculofascial flap, also resulting in resolution of her symptoms.