Endoscopic transsphenoidal treatment in recurrent and residual pituitary adenomas--first experience.

AIM OF THE STUDY: The aim of the study has been the assessment of the endoscopic method in the surgical management of recurrent and residual pituitary adenomas, as concerns treatment efficiency, substantial complications, and its possible advantages for the operating surgeon and patient. MATERIAL AND METHODS: In Department of Neurosurgery, Silesian University School of Medicine in Katowice, between October 2001 and June 2004, 125 patients underwent endoscopic surgery due to pituitary adenoma. The analysis comprised 20 patients, who were operated on due to recurrent adenomas or residual tumour not completely removed during the first surgical procedure. The group of patients was composed of 9 women and 11 men. The youngest patient was 32 years of age, the oldest 79. The average age was 53.9 years. The analysed group had 14 non-functioning adenomas, 4 GH-secreting adenomas, 1 PRL-secreting adenoma and 1 ACTH-secreting adenoma. 19 of them were macroadenomas while 1 was a microadenoma. 11 of the 20 adenomas infiltrated the cavernous sinuses. The surgical procedures were performed by a stable team, composed of 2 neurosurgeons, a laryngologist and an anaesthesiologist. The surgery method was based upon the technique developed by Jho and Carrau, with own modifications of the operators. A rigid neuroendoscope having the diameter of 4 mm with 0 degrees and 30 degrees optics by Storz was used. The follow-up period after surgery was between 12 and 42 months, 24.2 months on average. RESULTS: Of the 20 cases, complete recovery was achieved in 40% of patients undergoing secondary surgical procedures. In the group of 11 patients with adenomas not infiltrating the cavernous sinuses, recovery was reported for 8 of them, that is 73%. No fatalities occurred. 7 cases of liquorrhoea occurred during operation, requiring reconstruction and sealing of the sella by means of tissue glue and artificial dura or freeze-dried human dura. In 1 case, despite the application of post-operative lumbar drainage, rhinorrhoea occurred one month after the procedure, which required endoscopic reconstructive treatment. In the same patient, a pneumoencephalocele was observed. The average time of the repeat surgical procedure using endoscopic techniques was shorter by 18 minutes than the repeat procedure using microscopic techniques. CONCLUSIONS: The endoscopic method is a safe, hardly invasive and efficient surgical technique in the treatment of recurrent and residual pituitary adenomas. Advantages which add to its attractiveness are also reduction of the procedure duration, very good visualisation of the operative field, absence of serious complications, less pain experienced after the surgery.

Endoscopic transsphenoidal treatment of empty sella turcica syndrome using a silastic coil.

An empty sella turcica is due to the presence of an arachnoid diverticulum with its fluid content in the sella turcica, exerting pressure on the pituitary gland. In most cases this condition has an asymptomatic course, and is discovered by accident. Some patients, however, develop empty sella turcica syndrome with headaches, mild dishormonose, dysopsia and, rarely, spontaneous rhinorrhoea. Surgical treatment of empty sella turcica consists of filling the sella, through the transsphenoid route, with tissues collected from the patient or with artificial material. The aim of this report is to present our own experience of endoscopic extradural sella elevation using a silicone spiral, in 4 patients with primary empty sella turcica syndrome. The main indication for surgery was progressing dysopsia. The microinvasive endoscopic transsphenoidal method has been used, based upon the Jho technique with our own modifications. For the elevation of the sella, we used a coiled section of a Pudenz valve intraventricular silicone drain, adjusting its size to the dimensions of the operated sella. Both the implantation of the helix, and the postoperative course were uncomplicated for all surgically treated patients. The follow-up of several months confirmed improvement of the dysopsia in all surgically treated patients. MR examinations confirmed the correct location of the silicone spiral placed in the sella. It seems that the good results achieved are due to a correct indication for surgical treatment. The follow-up period ranges from 12 to 30 months and, so far, the clinical improvement is stable and satisfying both for the patients who underwent treatment and for the neurosurgeons.

Endoscopic transnasal transsphenoidal treatment of pathology of the sellar region.

From October 2001 to the end of November 2002 in Department of Neurosurgery, Silesian University School of Medicine in Katowice 70 explorations of the sella turcica were executed using the endoscopic method. In 63 cases the operation was done because of pituitary gland adenomas. In one case the diagnosis was craniopharyngioma, in 1 chordoma of the clivus, in one glioma of the optic nerve, in 1 the reason for an operation was an empty sella syndrome and in 3 cases the pathological diagnosis was an amorphous masses. Patients were operated using the 4-mm diameter endoscope with 0- and 30-degree angled lenses, using the method according to Jho and Carrau with our own modifications. In all cases of adenomas the total removal of the tumour was obtained in 71.4 %. Permanent diabetes insipidus occurred in 4.3 % of all operated patients. In our series of patients we did not observe any postoperative CSF leak or rhinological complications. One patient died, corresponding to 1.4 % of all cases. We the recommend transsphenoidal transnasal endoscopic approach for use in the cases of sellar region pathology because of the advantages of the method for surgeon and for comfort of the patient.

[Monitoring of neurophysiologic modalities during surgery for cerebellopontine angle tumors. Personal experiments]. / Monitorowanie neurofizjologicznych modalnosci w trakcie zabiegów operacyjnych guzów kata mostowo-mózdzkowego. Doswiadczenia wlasne.

The purpose of intraoperative monitoring of many modalities is to save some structures of the nervous system being at risk of damaging during surgical procedures. In cerebellopontine angle (cpa) tumour cases these nervous system structures can include cranial nerves (trigeminal, facial, cochlear, accessory), motor and sensory tracts localised within brainstem, and other. Continuous registration of somatosensory and auditory evoked potentials as well as electromyography of masseter muscle, orbicular muscle of eye and trapezius muscle during procedure is the method of brainstem, cochlear tract and cranial nerves status evaluation. Direct stimulation of cranial nerves within posterior fossa using bipolar electrode is the method of facial, trigeminal and accessory nerves localisation, especially in patients with large tumours. In Department of Neurosurgery Silesian University School of Medicine for intraoperative monitoring of many modalities in cpa lesion cases Nocolet Viking IV D unit with special IOM software is employed. Authors presented own experience in such method and effect in treatment of group of 15 patients operated with electrophysiological intraoperative monitoring.

Cerebral aneurysms in childhood.

OBJECTS: The aim of this work was to ascertain any clinical and anatomical factors allowing differentiation between aneurysms of childhood and those occurring in adults by comparing both groups. METHODS: Results obtained in a total of 17 children and adolescents aged up to 18 who had been operated on for cerebral aneurysm in our department from 1989 to 1997 (3% of all patients treated for subarachnoid haemorrhage resulting from ruptured cerebral aneurysm in this period) were compared with those in the adult group operated on in our department. In contrast to the situation in adults, there was a male predominance in our population. In children we found only 1 case of middle cerebral aneurysm and 1 case of multiple aneurysms. We also found a high rate of rebleeding in the paediatric group. CONCLUSIONS: We suggest that the very good outcome (100% very good results in patients operated on early) obtained and the high risk of rebleeding in children with cerebral aneurysm allow the recommendation of early surgery in children with ruptured cerebral aneurysms.

[Neurovascular compression within posterior cranial cavity]. / Konflikt naczyniowo-nerwowy w obrebie tylnej jamy czaszki.

30 years ago Janetta proposed neurovascular compression as an etiology factor of trigeminal neuralgia. Neuroanatomical, neurophysiological studies and observations during neurosurgical operations seems to confirm Janetta's suggestions. The conception of neurovascular compression was accepted also as an etiology factor in hemifacial spasm. There are more diseases of unknown etiology described in literature in which neurovascular compression as an etiological factor is suspected. The results of initial treatment of these diseases performed by neurovascular decompression were presented. We are described the methods of contemporary diagnostics of neurovascular compression syndrome. The difficulties with correct diagnostics were underlined. MRI and neurophysiological examinations were pointed out as the most useful in an evaluation of neurovascular compression syndromes.

How should we manage children after mild head injury?

There are many controversies concerning the management of children after mild head injury. Most of these patients achieve a full recovery without medical or surgical intervention. A small percentage of them deteriorate owing to intracranial complications. The goal of this study was to identify significant factors that might allow the identification of patients at risk of subsequent deterioration. Its secondary goal was to establish a clinical protocol for the management of mild head injuries in children. We retrospectively reviewed the records of 166 children and adolescents with head trauma who had Glasgow Coma Scale (GCS) or Children Coma Scale (CCS) scores of 13-15 at the time of admission. The patients were divided into five age categories: babies younger than 1 year, children 1-3, 4-6, and 7-14 years old, and adolescents 15-17 years of age. The largest age group consisted of children 7-14 years old (83 cases). There was a male predominance (2:1). The main causes of injury were traffic accidents (55 cases) and falls (53 patients). Neurosurgical procedures were required in 93 of the 166 patients (56%). The most common intracranial lesion was subdural and epidural hematoma (60 cases). In 26 children (15.6%) diffuse brain swelling was the only lesion. A skull fracture was found in 103 cases and was accompanied by epidural hematoma (HED) in 19 cases (18%) and by subdural hematoma (HSD) in 12 cases (12%). However, the 63 children without a fracture also included 18 (29%) who had HSD and 11 (17%) who had HED. In our population 165 (99%) of the patients obtained a very good or good result. None was left severely disabled or in a vegetative state. One patient with GCS 13 died of an infection. We concluded that skull X-ray examination is not sufficient to rule out intracranial hematoma. We recommend CT scanning and admission to hospital for 24-h observation for all children with minor head injury, because of the risk of delayed hematoma.

[Neurovascular compression as a reason for neurogenic hypertension]. / Konflikt naczyniowo-nerwowy jako przyczyna powstania nadcisnienia neurogennego.

30 years ago Janetta proposed neurovascular compression as an etiological factor of trigeminal neuralgia. Neuroanatomical, neurophysiological studies and observations during neurosurgical operations seem to confirm Janetta's suggestion. The conception of neurovascular compression is accepted also as an etiological factor in hemifacial spasm. In literature a neurovascular compression is suspected as an etiological factor in many diseases of unknown etiology. The results of neurovascular decompression performed as initial treatment of these diseases were presented. The methods of contemporary diagnostics of neurovascular compression syndromes and difficulties with correct diagnosis were described. MRI and neurophysiological examinations were pointed out as the most useful in the evaluation of neurovascular compression syndromes.

[Anorexia as a symptom of cerebral aneurysm in a 14-year-old boy]. / Jadlowstret jako glówny objaw tetniaka mózgu u 14-letniego chlopca.

The authors present a very rare case of a child with anterior communicating artery aneurysm and symptoms of anorexia nervosa. Because of coexistence of subarachnoid haemorrhage and head trauma false diagnosis of temporal and frontal lobe contusion was initially established. Headaches, anorexia and cachexia occurred with aneurysm enlargement. Computed tomography and cerebral angiography allowed to indicate operation. After successful surgery all symptoms disappeared.

Surgery or conservative treatment in children with traumatic intracerebral haematoma.

In contrast to the case of extracerebral haematomas, the criteria for operative treatment of traumatic intracerebral haematoma (TIH) are not clear. The purpose of this study was to find factors that would be helpful in reaching a decision for surgical or conservative treatment of TIH. We performed a retrospective analysis of 31 consecutive cases of TIH treated in our department. The following factors were estimated: age, mechanism of injury, initial GCS or CCS score, neurological deficits, coexistence of arterial hypotension and respiratory disturbances, and localisation and size of the haematoma. The outcome was evaluated according to a modified GOS. Treatment was surgical for 20 patients and conservative for 11. Patients with GCS or CCS scores of 3-8 were treated surgically significantly more often than those with higher scores. The other factors did not correlate with type of treatment. It seems, then, that the clinical status of the patient, especially the level of consciousness according to the GCS or CCS score, is the most important predictor of the need for surgery in children with TIH.

[Pineal cyst in MRI: clinical symptoms and analysis]. / Analiza i symptomatologia torbieli szyszynki w badaniach rezonansu magnetycznego.

Application of magnetic resonance imaging (MRI) in radiology allows to estimate and analyse pineal gland and pineal region pathology more precisely. We report 47 MRI brain studies of patients in whom pineal cyst was recognized as the only pathologic finding. MRI of the brain was performed because of clinical symptoms as headaches (32%), vertigo (26%) and altered behaviour (13%). Because of the common occurrence of pineal cyst in MRI brain imaging it seems to be important to decide whether these patients need neurosurgical intervention, especially if together with morphologic abnormality definite clinical symptoms exist.

[Own experience with the treatment of intracranial aneurysms using "Perneczky" - Zeppelin clips]. / Wlasne doswiadczenia w leczeniu tetniaków mózgu przy zastosowaniu zacisków naczyniowych typu "Perneczky" Zeppelin.

The basic design and the mechanism of clip application have not changed for many years. However in cases of aneurysms located deeply inside brain structure, in narrow spaces, multiple aneurysms or those which require applying of several clips the surgeon may have problems with visual control of the position of the clamping arms on the neck of aneurysm, nearby blood vessels and nerve structures. The above mentioned problems motivated prof. Axel Perneczky to construct a new model of clip with an applying and a removing holder whose mechanism is based on the principle of inverted--spring. Between February and August 1998 in the Neurosurgical Clinic in Katowice, 12 Perneczky's clips were applied in 9 patients. Intraoperative complications were not observed in any of the cases. In two cases of aneurysms located on the bifurcation of the basilar artery, application of two clips enabled precise intraoperative control of clip position.

[Petronasal fistula caused by the epidermal cyst of the cerebellopontine angle region]. / Przetoka skalisto-nosowa spowodowana torbiela naskórkowa okolicy kata mostowo-mózdzkowego.

The authors report a rare case of the occurrence of the paradoxical CFN rhinerrhea in a three months after epidermal cyst of the cerebellopontine region removal. The good result of the surgical fistula obliteration was reached by using muscle graft and tissue glue.

[Epidermoid cysts in the area of the pontocerebellar angle]. / Torbiele naskórkowe okolicy kata mostowo-mózdzkowego.

Five cases of epidermoid tumours in the vicinity of the pontocerebellar angle were treated surgically. The mean age of the patients was 31 years. Four were women, one man. Good and very good result was achieved in 80%. The surgical technique and difficulties in cases of epidermoids in this situation are described. The own experience of the authors is compared with the reports of other authors and the need for radical removal of the lesion is stressed since malignant transformation is possible, even long after operation.

[Growth of intracranial meningiomas after trauma. A case report]. / Wzrost oponiaków sródczaszkowych po urazach. Opis przypadku.

A case is described of intracranial meningioma development in a woman aged 69 who had craniotomy 28 years earlier. The meningioma grew at the site of previous craniotomy. Documented cases from the literature are quoted in which craniocerebral trauma was unequivocally related to meningioma development, although the coincidence of trauma with meningioma is still controversial.

[A case of arachnoid cyst in vertebral canal]. / Przypadek torbieli pajeczynówki kanalu kregowego.

A rare case of intradural subarachnoid cyst in the vertebral canal was observed in a female aged 52 years. Operation was followed by marked improvement of the neurological condition. The large defect of the dura required grafting of lyophilized dura. The role of MRI in the diagnosis of this case is stressed.

[Two cases of intracranial lipomas]. / Tluszczaki wewnatrzczaszkowe. Opis dwóch przypadków.

The authors report two rare cases of intracranial lipomas recognized in CT of the head. The tumours were situated in the corpus callosum in one case, and in the posterior fossa in the other case. Both cases were thought unsuitable for surgical intervention, and one of the patients was given only anticonvulsant treatment.

[A case of large myelomeningocele complicated with liquorrhoea in a 32-year old man]. / Przypadek powiklanej plynotokiem duzej przepukliny oponowo-rdzeniowej u 32-letniego mezczyzny.

A case is presented of a 32-year-old man with giant myelomeningocele situated in the lumbosacral segment of the spine. The patient was admitted to the department with manifestations of active liquorrhoea from the dorsal surface of the hernial sac. An X-ray examination was performed which demonstrated an extensive spina bifida from L3 to S2. The patient was operated on preparing the myelomeningocele gate. In the described case the attention is paid to the lack of other developmental anomalies of the nervous, urinary, and osteoarticular system.

[A case of bilateral acoustic neuroma in a 19-year-old girl]. / Przypadek obustronnego nerwiaka nerwu sluchowego u 19-letniej dziewczyny.

A rare case of bilateral neurinoma of the acoustic nerve is described. The patient was a girl aged 19 years without external evidence of von Recklingshausen disease.