Stem Cell Markers in Neoplasms and their Relationship with Progression-free and Overall Survival in Patients with Recurrence.

BACKGROUND: Gliomas account for 30% of primary brain tumors in adults, and despite the scientific progress in the field, recurrence is prevalent. Glioma Stem Cells (GSCs) can generate tumor cells in vivo and in vitro and they are associated with treatment resistance, tumor progression, and recurrence. Furthermore, the expression of SOX transcription factors (SOX1, SOX2, SOX9) in these cells is responsible for maintaining an oncogenic genotype and is associated with an aggressive tumor phenotype. The relationship between SOX transcription factors and their prognostic role in recurrent gliomas has not been described in detail. Therefore, we set out to describe the relationship between SOX expression and Progression-free Survival (PFS) and Overall Survival (OS) in patients with recurrent gliomas. METHODS: In this observational study, we have retrospectively analyzed 69 patients, of which 20 met the inclusion criteria. The clinical, radiological, and histopathological findings have been described, and survival analysis has been performed according to SOX expression for PFS and OS. RESULTS: We found SOX1, SOX2, and SOX9 to show a non-statistically significant trend with increasing histopathological grade, co-expressed with Ki67, a cell proliferation factor. CONCLUSION: There has been found an inversely proportional correlation between the degree of immunopositivity of SOX1 and OS. A higher SOX1 immunopositivity could predict a worse clinical prognosis. There has also been found an interaction between a pluripotent genotype (GSC) and cell proliferation.

Surgical treatment of pituitary neuroendocrine tumors with coexisting intracranial lesions: A case series and review of the literature.

Background: Pituitary neuroendocrine tumors (PitNETs) are a diverse group of benign neoplasms that account for a significant proportion of intracranial tumors (13%). The coexistence of PitNET with other intracranial lesions, such as meningiomas and intracranial aneurysms, has been constantly reported in the literature; yet, the pathophysiological mechanisms remain unknown, and the appropriate management is controversial. This study aims to describe the clinical characteristics, surgical treatment, and outcomes of patients with PitNET with coexisting intracranial lesions in a single healthcare center. Methods: A retrospective analysis was conducted on 12 patients who underwent surgical treatment for PitNET and another intracranial lesion at our single tertiary referral center over 15 years from January 2008 to May 2023. Results: Among these coexisting lesions, aneurysms were the most commonly found (41.67%), followed by meningiomas (33.33%). Surgical intervention for both lesions was performed in a single-stage procedure for most cases (75%), employing transcranial, endoscopic endonasal, and combined approaches. We found low preoperative Karnofsky Performance Scale scores in three patients, with significant differences in functional outcomes. Conclusion: These findings contribute to the limited knowledge about PitNET coexisting with other intracranial lesions and emphasize the importance of patient-tailored, multidisciplinary management in these unusual scenarios.

Unilateral caudate infarct following pituitary adenoma resection.

Cerebral ischemic complications after pituitary surgery are not frequently reported. Multiple mechanisms have been proposed, including vasospasm, and delayed cerebral ischemia resulting from postoperative subarachnoid bleeding. Given the unknown etiology of vasospasm following these situations, little is known about its prevention. Through a case report and bibliographic review, the authors warn about the importance of recognizing key signs postoperatively that could indicate increased risk for cerebral vasospasm and must be recognized in a timely manner, with appropriate treatment strategies implemented once these symptoms present.

Poorly differentiated sinonasal neuroendocrine carcinoma with skull base invasion: A case report.

Background: Sinonasal neuroendocrine carcinoma is a rare head and neck tumor that represents only 5% of sinonasal neoplasms. This lesion has a high risk of invasion to adjacent structures such as the orbit, skull base, and soft tissues, with symptoms usually being nonspecific. Most cases are diagnosed in late stages, decreasing overall survival without treatment. To date, there is no consensus on management given its low prevalence; however, it has been shown that multimodal therapy, with the correct surgical approach as the mainstay, offers a better disease-free prognosis. Case Description: A 46-year-old woman presented with a 1 year history of nasal symptoms, characterized by obstruction and epistaxis. Imaging studies showed an extra-axial mass causing skull base erosion and displacement of the right fronto-orbital region, without invasion of brain parenchyma or meninges. A biopsy was performed and an unresectable poorly differentiated sinonasal neuroendocrine carcinoma was diagnosed. Treatment with radio and chemotherapy was initiated and, as the tumoral volume decreased, she was referred for neurosurgical intervention; an endonasal endoscopic approach was performed. Gross total resection was achieved and the patient was discharged without postoperative complications and no residual lesion on imaging. Conclusion: We describe the evolution of a rare advanced-stage neoplasm. It highlights that despite receiving an initial diagnosis of an unresectable mass, multimodal therapy, and an adequate surgical approach deemed the entire lesion to be resected. Despite the favorable clinical evolution, the follow-up of neuroendocrine carcinoma is prioritized as a neoplasm with a high rate of recurrence and metastasis.

A rare case of a right infratentorial meningioma and a left giant posterior communicating thrombosed aneurysm.

Background: Giant intracranial aneurysms cause symptoms due to mass effect and can mimic other lesions in imaging studies. The coexistence of tumors and aneurysms is relatively rare, with meningiomas being the predominant tumors found in such cases. The relationship between these two entities is complex and represent a neurosurgical challenge. Case Description: A 61-year-old woman presented with intermittent headache, vertigo, right peripheral facial palsy, hearing loss, and left hemiparesis. Magnetic resonance imaging revealed two lesions: a supratentorial paraclinoid lesion in the left frontotemporal region and a right infratentorial extra-axial mass, suggestive of a meningioma. The patient underwent a two-staged surgical intervention to address both lesions. Conclusion: In this particular case, the lesions were located on different sides and in different cranial compartments, making it even rarer.

Unilateral approach for bilateral clipping of posterior communicating artery aneurysms in a hybrid operating room: A technical note.

Bilateral posterior communicating (pComm) artery aneurysms represent only 2% of mirror intracranial aneurysms. Usually, these are surgically approached through bilateral craniotomies for clipping. We present the case of a 50-year-old female presenting with headache and horizontal diplopia. Neurological examination revealed a left oculomotor palsy, with no other neurological deficits. Imaging studies revealed bilateral aneurysmatic lesions in both internal carotid arteries (ICA). A conventional left pterional approach was planned in order to treat the symptomatic aneurysm, and, if deemed feasible, a contralateral clipping through the same approach. The procedure was performed in a hybrid operating room (HOR), performing an intraoperative digital subtraction angiography (DSA) and roadmapping assistance during dissection and clipping. Transoperatively, a post-fixed optic chiasm was identified, with a wide interoptic space, which allowed us to perform the contralateral clipping through a unilateral approach. This technique for clipping bilateral pComm aneurysms can be performed when the proper anatomical features are met.

Prognostic Factors in the Surgery of Clinoidal Meningiomas.

INTRODUCTION: Clinoidal meningiomas are currently among the intracranial meningiomas with the greatest neurosurgical complexity, morbidity, and mortality associated with their resection. The worldwide literature has described tumor size (>4 cm3), patient age (>60 years), and invasion of the cavernous sinus as factors associated with a worse clinical outcome following surgery. METHODS: We describe the series of cases of patients with clinoidal meningiomas who underwent microsurgical resection at our institution between January 2014 and March 2019. The intention was to analyze the multiple preoperative variables, such as the patient's demographic, tumor, and surgical characteristics, such as the Al-Mefty Classification to find a relationship with the patient's clinical outcome during their postoperative follow-up.  Results: Death occurred in 4.8% of the cases. Postoperative morbidity was documented in 42.9%, the most frequent being ophthalmoparesis, followed by worsening of visual acuity, and new onset motor deficits. Radiological characteristics were assessed based on preoperative MRI. The maximum diameter, midline shift, invasion of the cavernous sinus, arterial encasement, and peritumoral edema were evaluated. Average intraoperative bleeding was 1.3 L. The most frequent histological grade was World Health Organization (WHO) grade 1 in 85.6% of the cases. Complete resection was obtained in 52.4% of the cases; 42.8% received fractionated stereotactic radiotherapy after surgery for disease control, and one received radiosurgery. Recurrence occurred in 33.3%. The average follow-up in months was 23.8.  Conclusions: Demographic factors and tumor characteristics in clinoidal meningioma surgery are related to the subtype of meningioma according to the Al-Mefty Classification and impact directly the degree of resection, progression of the disease, and degree of postoperative complications. To achieve maximal resection while minimizing morbidity and mortality, these factors must be considered to decide on an appropriate approach and specific plan for each case.

Photo-Stacking Technique for Neuroanatomical High-Definition Photography and 3-Dimensional Modeling.

BACKGROUND: Three-dimensional (3D) neuroanatomical knowledge is vital in neurosurgery. Technological advances improved 3D anatomical perception, but they are usually expensive and not widely available. The aim of the present study was to provide a detailed description of the photo-stacking technique for high-resolution neuroanatomical photography and 3D modeling. METHODS: The photo-stacking technique was described in a step-by-step approach. The time for image acquisition, file conversion, processing, and final production was measured using 2 processing methods. The total number and file size of images are presented. Measures of central tendency and dispersion report the measured values. RESULTS: Ten models were used in both methods achieving 20 models with high-definition images. The mean number of acquired images was 40.6 (14-67), image acquisition time 51.50 ± 18.8 s, file conversion time 250 ± 134.6 s, processing time 50.46 ± 21.46 s and 41.97 ± 20.84 s, and 3D reconstruction time was 4.29 ± 0.74 s and 3.89 ± 0.60 s for methods B and C, respectively. The mean file size of RAW files is 1010 ± 452 megabyte (MB) and 101.06 ± 38.09 MB for Joint Photographic Experts Group files after conversion. The mean size of the final image means size is 71.9 ± 0.126 MB, and the mean file size of the 3D model means is 37.4 ± 0.516 MB for both methods. The total equipment used was less expensive than other reported systems. CONCLUSIONS: The photo-stacking technique is a simple and inexpensive method to create 3D models and high-definition images that could prove valuable in neuroanatomy training.

Roadmapping technique in the hybrid operating room for the microsurgical treatment of complex intracranial aneurysms.

OBJECTIVE: To describe the roadmapping technique and our three-year experience in the management of intracranial aneurysms in the hybrid operating room. METHODS: We analyzed all patients who underwent surgical clipping for cerebral aneurysms with the roadmapping technique from January 2017 to September 2019. We report demographic, clinical, and morphological variables, as well as clinical and radiological outcomes. We further describe three illustrative cases of the technique. RESULTS: A total of 13 patients were included, 9 of which (69.2%) presented with subarachnoid hemorrhage, with a total of 23 treated aneurysms. All patients were female, with a mean age of 47.7 years (range 31-63). All cases were anterior circulation aneurysms, the most frequent location being the ophthalmic segment of the internal carotid artery (ICA) in 11 cases (48%), followed by posterior communicating in 8 (36%), and ICA bifurcation in 2 (8%). Intraoperative clip repositioning was required in 9 aneurysms (36%) as a result of the roadmapping technique in the hybrid operating room. There were no residual aneurysms in our series, nor reported mortality. CONCLUSIONS: The roadmapping technique in the hybrid operating room offers a complementary tool for the adequate occlusion of complex intracranial aneurysms, as it provides a real time fluoroscopic-guided clipping technique, and clip repositioning is possible in a single surgical stage, whenever a residual portion of the aneurysm is identified. This technique also provides some advantages, such as immediate vasospasm identification and treatment with intra-arterial vasodilators, balloon proximal control for certain paraclinoid aneurysms, and simultaneous endovascular treatment in selected cases during a single stage.

Intra-aneurysmatic thrombectomy in a distal anterior cerebral artery aneurysm.

Thrombectomy procedures following intra-aneurysmatic lesions are extremely rare, and few cases have been reported. This article describes a microsurgical intra-aneurysmatic thrombectomy (MIaT) for a distal anterior cerebral artery (DACA) aneurysm. We present the case of a 48-year-old female that was admitted to the emergency room, showing neurologic deterioration with focal deficits. A computed tomography angiography (CTA) scan revealed an aneurysm located in the distal segment of the left anterior cerebral artery. During the surgical procedure, after clipping, a wellformed clot was visualized through the aneurysm's wall obstructing the left DACA flow. We proceeded to open the aneurysm's dome to remove the thrombus and clip the aneurysm neck, re-establishing the flow of the left DACA. Intra-aneurysmatic thrombosis can occur as a complication during clipping, obstructing the distal flow of vital arteries and causing fatal results in the patient's postoperative status. MIaT is a good technique for restoring the flow of the affected vessel and allows a secure aneurysm clipping after thrombus removal.

Clinical, Therapeutic, and Prognostic Experience in Patients With Glioblastoma.

BACKGROUND: Glioblastoma (GB) represents the most aggressive type of glioma with a poor prognosis despite the therapies used. As of today, data availability for therapeutic and prognosis experiences is limited. The cornerstone for this study is to create a framework overview of Mexico´s experience throughout 17 years of research. METHODS: Retrospective analysis from 2000 to 2017 including patients with a histological diagnosis of GB was performed. Data were collected from the ABC Medical Center and the Neurology and Neurosurgery National Institute. RESULTS: One hundred and thirty-seven patients were included with a mean age of 54 years. Histological diagnosis was made in all patients, of which 58.1% had a total resection, 31.6% had a partial resection, and 10.3% of them underwent biopsy. In all cases, patients received treatment under the following conditions: 10 patients were treated exclusively with stereotactic radiotherapy (RT). In 55 patients, a combination of RT and TMZ was used, the other 40 patients received RT plus CBP. Eighteen patients RT added to nitrosourea medication and lastly, 14 patients received a combination of RT/TMZ and Bevacizumab, a monoclonal antibody that inhibits the formation of blood vessels (BVZ). The progression-free survival (PFS) and overall survival (OS) were higher in the RT/TMZ/BVZ group (16.5 to 22.9 months) and the RT/TMZ group (11 to 17 months), the prognostic parameters included: Isocitrate dehydrogenase 1 mutation (IDH1), usage of BVZ and TMZ in the PLS and OS, considering as well, age range (<70 years) as a favorable prognostic factor. CONCLUSIONS: GB represents the most frequent intracranial neoplasia. Combined fractionated stereotactic RT added to Temozolomide and Bevacizumab received in our population reports favorable and superior results compared to the ones described in the literature. Further studies are necessary to know the biological behavior of our population.

Macro Pituitary Adenoma and Frontal Calcified Cavernous Malformation: A Coincidence or a True Partnership?

Collision tumors are rare neoplasms composed of two different types of histological tissues in the same organ. The most frequent association with cerebral cavernous malformations (CCMs) are meningiomas, gliomas, and gangliogliomas, while the most frequent sellar collision is between pituitary adenoma (PA) and craniopharyngiomas, and still very few cases have been reported. We present the case of a 43-year-old woman who started two months ago with a fall from her height followed by severe headache and bilateral hemianopsia. An isointense, enhancing sellar tumor, and a right frontal lesion compatible with CCM were observed on MRI. Surgery was performed through anterior interhemispheric and endoscopic transnasal approaches for the cavernoma and the sellar tumor, respectively, removing both lesions and sending them to pathology. The sellar tumor corresponded to a PA showing positive immunohistochemistry for prolactin and follicle-stimulating hormone (FSH). In the post-op period, the patient developed a seizure and diabetes insipidus, for which she received appropriate treatment. Our findings were conclusive with a collision tumor, since both lesions presented two different histological tissues. Different densities were observed in both lesions using imaging studies, which were later confirmed with histopathology and immunohistochemistry.

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.

Clinical Significance of Delirium With Catatonic Signs in Patients With Neurological Disorders.

OBJECTIVE: According to DSM-5, catatonia and delirium are mutually exclusive clinical syndromes. The investigators explored the co-occurrence of delirium and catatonia (i.e., catatonic delirium) and the clinical significance of this syndrome with a sample of neurological patients. METHODS: This prospective study with consecutive sampling included patients diagnosed with delirium at the National Institute of Neurology and Neurosurgery of Mexico. DSM-5 criteria for delirium, the Confusion Assessment Method, and the Delirium Rating Scale-Revised-98 were used to select and characterize patients. Catatonia was assessed using the Bush-Francis Catatonia Rating Scale and DSM-5 diagnostic criteria. Logistic regression analysis was performed to identify etiological factors associated with catatonic delirium. RESULTS: A total of 264 patients with delirium were included, 61 (23%) of whom fulfilled the criteria for catatonia and delirium simultaneously. Brain tumors, subarachnoid hemorrhage, acute hydrocephalus, and ischemic stroke were associated with delirium without catatonic signs. Catatonic delirium was observed among patients with encephalitis, epilepsy, brain neoplasms, and brain tuberculosis. After multivariate analysis, the association between catatonic delirium and encephalitis (both viral and anti-N-methyl-d-aspartate receptor [NMDAR]) was confirmed. CONCLUSIONS: Delirium is a common complication of neurological diseases, and it can coexist with catatonia. The recognition of catatonic delirium has clinical significance in terms of etiology, as it was significantly associated with viral and anti-NMDAR encephalitis.

De-novo formation of neighboring intracranial aneurysm after spontaneous thrombosis of a ruptured distal anterior cerebral artery aneurysm: A case report and review of the literature.

Intracranial aneurysms arise in 1-2% of the population and usually present as hemorrhagic strokes. Spontaneous thrombosis of a ruptured intracranial aneurysm occurs in 1-3% and most commonly in giant aneurysms, with complete thrombosis in just 13-20% of the cases. Thrombosis of smaller aneurysms is rare. Here we present a case of a patient who presented with a ruptured intracranial aneurysm that subsequently thrombosed, discovering a neighboring de-novo aneurysm during follow-up. We hypothesized that after thrombosis, the hemodynamic characteristics that contributed to the formation of the first aneurysm were replicated.

Middle Transclival Endoscopic Endonasal Resection of a Ventral Pontine Cavernous Malformation.

The surgical management of lesions within or around the brainstem is usually associated with significant morbidity. Even though several safe entry zones have been described for brainstem lesions, especially cavernous malformations (CMs), their resection remains a challenge due to the convergence of highly functional nerve tracts and nuclei in this rather small structure. Moreover, the ventral location of some of these lesions usually calls for complex surgical approaches involving extensive bone drilling and significant manipulation of neurovascular structures. The expanded endoscopic endonasal approach has been subject to considerable advancements, widening the range of lesions accessible through this route. In this operative video, we describe the surgical nuances of an endoscopic endonasal transclival resection of a ventral pontine CM (Figures 1 and 2). A pedicled nasoseptal flap was harvested for reconstruction, gaining access to the sphenoid rostrum, which was resected. The sellar floor was removed to expose the middle third of the clivus, which was drilled out until posterior fossa dura mater was identified. A centered dural incision was performed to expose the ventral pons and basilar artery. Using image guidance, a limited pial incision over the most superficial aspect of the lesion allowed a prompt drainage of the hematoma and resection of the CM. The surgical cavity was directly inspected through the endoscope, confirming a complete resection. Reconstruction was carried out in a multilayered fashion. The patient presented a postoperative cerebrospinal fluid leak, which resolved with a lumbar drain. Neurologic status remained unchanged after surgery, with the patient displaying a favorable clinical outcome (Video 1).

Moderate Delayed Middle Cerebral Artery Vasospasm With Clinical Repercussions After the Resection of a Giant Pituitary Adenoma Using an Endonasal Endoscopic Approach: A Case Report.

Endoscopic endonasal approach (EEA) techniques have evolved significantly in recent years, with better techniques guaranteeing better surgical results in the treatment of sellar and parasellar region pathologies. Although the complications associated with the EEA have been widely described, with cerebrospinal fluid fistulas being the most commonly reported, some rare complications, such as vasospasm after surgery in extended approaches, turn out to be poorly understood. Here, we describe a case of middle cerebral artery delayed vasospasm associated with the resection of a non-functional pituitary adenoma via an EEA.

Endoscopic endonasal lateral transellar approach for growth hormone-secreting adenomas with cavernous sinus invasion: Technical note and surgical results / Abordaje transelar lateral endonasal endoscópico para adenomas hipofisiarios productores de hormona del crecimiento con invasión al seno cavernoso: nota técnica y resultados quirúrgicos

Background Cavernous sinus (CS) invasion is found in 15–20% of pituitary adenomas; it represents a poor prognosis factor and a surgical challenge even in experienced pituitary centers. We present our experience and technical note description for surgical management of pituitary adenomas with CS invasion in acromegaly by the transsellar lateral approach with an endoscopic endonasal transsphenoidal route. Method prospective case series of patients who underwent endoscopic endonasal surgery for Growing Hormone (GH) producing adenomas with CS invasion treated at the Neurosurgery departments of National Institute of Neurology and Neurosurgery in Mexico City, and of Toluca Medical Center of Social Security Institute of the State of Mexico and Provinces between January 2014 and March 2019. Results Thirty-two of 94 patients with diagnosis of pituitary adenoma treated at our institutions (34%) had acromegaly; thirteen of patients with acromegaly diagnosis met the inclusion criteria for CS invasion. Postoperative images reported gross total resection in 10 patients (76.9%). Mean follow-up time was 28.3 months. Remission criteria were achieved in nine patients (69.2%), with one of these patients (11.1%) having recurrence during follow up. All patients with no biochemical remission had improvement in GH and IGF profiles. Three patients without remission underwent radiosurgery (14Gy), and one patient had remission after the procedure. Conclusions We consider this to be a safe and efficient approach for tumors invading CS, when surgical team have good experience in endoscopy of the skull base and reconstruction techniques, appropriate instruments are available, and tumor has soft consistency (AU)

Antecedentes Se encuentra invasión al seno cavernoso en el 15-20% de los adenomas hipofisiarios, y representa un factor de mal pronóstico, así como un reto quirúrgico en algunas series. En el presente trabajo describimos y evaluamos nuestra experiencia con una técnica quirúrgica para el manejo de adenomas hipofisiarios con invasión al seno cavernoso en pacientes con acromegalia a través de un abordaje transelar lateral por la vía endonasal endoscópica. Métodos Serie de casos prospectiva de pacientes tratados con cirugía endonasal endoscópica para pacientes con diagnóstico de acromegalia y adenomas hipofisiarios con invasión al seno cavernoso tratados en los Departamentos de Neurocirugía del Instituto Nacional de Neurología y Neurocirugía en la Ciudad de México y en el Centro Médico Toluca del Instituto de Seguridad Social del Estado de México y Municipios entre enero del 2014 y marzo del 2019. Resultados Treinta y dos pacientes de 94 con diagnóstico de adenoma hipofisiario fueron tratados en nuestras instituciones, cumplieron con criterios clínicos y bioquímicos para el diagnóstico de acromegalia (34%); de estos, 13 pacientes cumplieron con criterios por imagen y quirúrgicos de invasión al seno cavernoso (40,6%). Las imágenes postoperatorias mostraron resección completa en 10 pacientes (76,9%). El tiempo medio de seguimiento fue de 28,3 meses. Se alcanzó un índice de remisión bioquímica en el 69,2% de los casos, con un paciente presentando recurrencia durante el seguimiento. Tres de los pacientes sin remisión bioquímica fueron sometidos a radiocirugía, con respuesta terapéutica en uno de ellos (AU)

Endonasal Endoscopic and Hybrid Surgery Techniques for Blunt Trauma Fractures of the Skull Base With Cerebrospinal Fluid Leaks.

ABSTRACT: Cerebrospinal fluid (CSF) leakage caused by skull base fracture represents high risks of bacterial meningitis, and a rate of mortality of 8.9%. Endoscopic endonasal repair of CSF leaks is quite safe and effective procedure with high rates of success. The aim of this study is to describe our technique for management of skull base CSF leaks secondary to craniofacial trauma based on the anatomic location of the leak. This is a retrospective case series of 17 patients with diagnosis of craniofacial trauma, surgically treated with sole endonasal endoscopic and combined endonasal/transcranial approaches with diagnosis of CSF leak secondary to skull base fractures. Seventeen patients met inclusion criteria for this study. Mean age was 46 years old. Most common etiology was motor vehicle. Early surgery was performed in 8 patients, and late surgery in 9 patients. The most common site of CSF leak was at ethmoid cells or at the fronto-ethmoid junction in 9 patients. Thirteen patients (76.4%) were treated only with endonasal endoscopic technique, and 4 (23.5%) with hybrid surgery, combining endonasal endoscopic and cranial bicoronal approaches with nasal and pericranial vascularized flaps, and nasal mucosal free flaps. Mean hospital stay was 23.7 days.The mean follow-up time was 25.6 months. When surgical reconstruction is indicated for CSF leaks secondary to skull base fractures, endonasal endoscopic techniques should be part of the surgical management either as a sole procedure, or in combination with classical transcranial approaches with high rates of success and low morbidity.

Endoscopic endonasal lateral transellar approach for growth hormone-secreting adenomas with cavernous sinus invasion: Technical note and surgical results.

BACKGROUND: Cavernous sinus (CS) invasion is found in 15-20% of pituitary adenomas; it represents a poor prognosis factor and a surgical challenge even in experienced pituitary centers. We present our experience and technical note description for surgical management of pituitary adenomas with CS invasion in acromegaly by the transsellar lateral approach with an endoscopic endonasal transsphenoidal route. METHOD: prospective case series of patients who underwent endoscopic endonasal surgery for Growing Hormone (GH) producing adenomas with CS invasion treated at the Neurosurgery departments of National Institute of Neurology and Neurosurgery in Mexico City, and of Toluca Medical Center of Social Security Institute of the State of Mexico and Provinces between January 2014 and March 2019. RESULTS: Thirty-two of 94 patients with diagnosis of pituitary adenoma treated at our institutions (34%) had acromegaly; thirteen of patients with acromegaly diagnosis met the inclusion criteria for CS invasion. Postoperative images reported gross total resection in 10 patients (76.9%). Mean follow-up time was 28.3 months. Remission criteria were achieved in nine patients (69.2%), with one of these patients (11.1%) having recurrence during follow up. All patients with no biochemical remission had improvement in GH and IGF profiles. Three patients without remission underwent radiosurgery (14Gy), and one patient had remission after the procedure. CONCLUSIONS: We consider this to be a safe and efficient approach for tumors invading CS, when surgical team have good experience in endoscopy of the skull base and reconstruction techniques, appropriate instruments are available, and tumor has soft consistency.