Factors of influence upon the SF-36-based health related quality of life of patients following surgery for petroclival and lateral posterior surface of pyramid meningiomas.

OBJECTIVE: To describe the patient's self assessed health related quality of life (saHRQoL) based upon the medical outcome study 36-item short form health survey (SF-36) as well as the factors of influence upon the saHRQoL following surgery for petroclival (PCM) and lateral posterior surface of the pyramid (LPPM) meningiomas. PATIENTS AND METHODS: In a series of 78 patients operated consecutively for PCM (n = 46) or LPPM (n = 32) the preoperative, intraoperative and postoperative data were collected retrospectively. The saHRQoL was obtained by mailing the SF-36 questionnaire to the patients. The SF-36 data of the whole patients group was compared with a healthy population. The SF-36 data of the PCM- and LPPM were compared to each other. The influence of pre-, intra- and postoperative findings upon the SF-36 was assessed by uni- and multifactorial analysis. RESULTS: 58 (69%) out of the 78 patients answered the SF-36 questionnaire at a median postoperative follow-up of 59 months. The patients, who answered the SF-36 questionnaire, had a significant lower perioperative complication rate than those who did not (46% vs. 75%, p = 0.019). The saHRQoL of the LPPM and PCM was reduced on several sub-scales, when compared to the German reference population. The outcome of PCM is, assessed by saHRQoL as well as by conventional neurosurgical grading scales, inferior to that of LPPM. The saHRQoL of LPPM correlated in the uni- and multivariate analysis with the early postoperative KPI on the sub-scales SF1 (physical functioning) and SF5 (vitality). Accordingly, the sub-scale SF2 (role-physical) of PCM correlated with the change of the KPI from preoperative to the last follow up. CONCLUSIONS: The saHRQoL of the evaluable patients was lower than that of the normal population. The saHRQoL score of PCM-patients was lower than that of LPPM-patients. For the future the saHRQol should be assessed routinely; It reflects the patients' perspective upon postoperative outcome and enables the comparison with other treatment modalities of these difficult to treat tumors.

Differences in clinical presentation, intraoperative findings and outcome between petroclival and lateral posterior pyramid meningioma.

OBJECTIVE: The goal of this study was to determine the impact of the location of the most frequent skull base meningioma of the posterior fossa, i.e. petroclival (PCM) and lateral posterior pyramid meningioma (LPPM) on clinical presentation, surgical treatment and treatment results. PATIENTS AND METHODS: We retrospectively reviewed a consecutive series of patients operated on for PCM (n=46) and LPPM (n=32). Uni- and multivariate analyses were performed to identify differences in clinical presentation, surgical treatment and pre-, intra- and postoperative factors of influence upon the outcome parameters: Complications rate, mortality, tumour recurrence/progress, hospital stay, Karnofsky Performance Score (KPS). RESULTS: At Presentation, the rate of dizziness was higher in LPPM (56% vs. 7%, p<0,001) and trigeminal nerve impairment was more frequent in PCM (50% vs. 3%, p<0,001). Complete tumour resections were more often achieved (91% vs. 39%, p<0,001), and surgery lasted shorter (median: 247 min vs. 500 min, p<0,001) with less blood loss (median: 525 ml vs. 1000 ml, p<0,001) in LPPM compared to PCM. The overall complication rates (73% vs. 31%, p<0,001) as well the rate of irreversible complications (57% vs. 9%, p<0,004) were higher in PCM than in LPPM. The most frequent complications of PCM surgery were eye movement (46% vs. 6%, p<0,001), facial nerve (28% vs. 3%, p<0.02) and swallowing impairments (21% vs. 3%, p<0.02). The perioperative mortality was 11% in PCM and 0% in LPPM patients. In the multivariate analyses, KPS at discharge correlate positively with age (p=0.034) and preoperative KPS (p=0.0048) in LPPM and positively with staged resection (p=0.056) and negatively with the occurrence of surgical complications (p=0,0427) in PCM. Hospitalization time correlated with the blood loss (p<0,001) for PCM, negatively with the preoperative KPS (p=0.0002) for PCM and LPPM and positively with tumour diameter (p=0.0001) and non-surgical complications rate (p=0.0001) for LPPM. CONCLUSION: As compared to LPPM, surgical treatment of PCM is associated with higher morbidity and mortality. The outcome of LPPM was primarily influenced by preoperative factors: Patients age, tumour size, preoperative KPS. The outcome of PCM was primarily influenced by intraoperative factors like: blood loss, surgery duration, staged tumour resection and the surgical complications rate.

Metastasis to pituitary adenoma: case report and review of the literature.

We present a rare case of a metastasis to a pituitary adenoma and review 14 cases published in the literature to date. Metastases to pituitary adenomas most commonly present with rapidly progressing chiasm compression syndromes, headaches and oculomotor nerve palsies. The prognosis for this condition is poor. Metastases to pituitary adenomas have to be considered in the differential diagnosis of sellar tumors.

Peri-operative glucocorticoid replacement therapy in transsphenoidal pituitary adenoma surgery: a prospective controlled study.

BACKGROUND: We set out to prospectively study the peri-operative changes of the hypothalamic-pituitary-adrenal axis (HPA), and to test the hypothesis that the peri-operative corticoid replacement regimen used at the authors' institution in patients with impaired HPA undergoing transsphenoidal pituitary adenoma surgery is adequate. METHOD: Thirty seven patients (21 females, 16 males, mean age 50.6 years) underwent transsphenoidal pituitary adenoma surgery (mean tumour diameter 20.6 mm, 13 tumours hormone-secreting). The HPA functions of these patients were classified as impaired (group A, n = 15) or preserved (group B, n = 22) according to the results of a pre-operative corticotrophin releasing-hormone test (CRHT). Eleven patients (9 female, 2 male, mean age 53.6 years) without pituitary adenomas and with a preserved HPA (as assessed by medical history and morning serum cortisol (MSC) measurements), undergoing decompressive surgery for degenerative lumbar disc disease, were also studied (group C). On the day of surgery, the patients of group A received 100 mg hydrocortisone (HC) replacement therapy, which was thereafter gradually tapered off in a standardised fashion. The patients of groups B and C were not treated with corticoids. Pre-operative, intra-operative and post-operative variables of these three patient groups were compared. FINDINGS: The urinary free cortisol excretion (UFC) in group A declined from 6732 +/- 7683 microg/d on the day of surgery to 305 +/- 358 microg/d on the 10(th) post-operative day. In group B, the respective UFC values were 12,851 +/- 16,278 microg/d and 223 +/- 235 microg/d. In both of these groups, the mean UFC did not fall into the normal range during the first ten post-operative days. On none of the post-operative days, was there a significant difference between the UFC of groups A and B. The UFC values of group C dropped from 177 +/- 157 microg/d on the day of surgery to 87 +/- 61 microg/d on post-operative day six, reaching the normal range from the 2(nd) post-operative day onwards. All UFC values of group C were significantly lower than those of group A and B. None of the evaluated clinical, laboratory and MRI parameters, as disclosed by uni- and multivariate analysis, showed any significant influence on the peri-operative UFC values. CONCLUSIONS: The peri-operative UFC of pituitary adenoma patients with preserved HPA was very high, as compared to patients with degenerative lumbar disc disease. The present study showed for the first time, that the proposed regimen of peri-operative corticoid replacement therapy used in patients with pituitary adenomas and impaired HPA raised cortisol levels to match the physiological increase of UFC in patients with pituitary adenoma surgery and preserved HPA. However, although statistically not significant, the UFC of patients with pituitary adenomas and preserved HPA seemed considerably higher on the day of surgery than in patients with pituitary adenomas and HPA impairment. Although there is no evidence to make it mandatory, administration of 150 mg instead of 100 mg HC substitution on the day of pituitary adenoma surgery in patients with HPA impairment may be prudent.

Delayed postoperative hyponatremia followed by acute renal failure in a patient with an ACTH-secreting microadenoma of the pituitary.

The selective transsphenoidal adenomectomy of an ACTH-secreting microadenoma was followed by clinically symptomatic delayed hyponatremia in an otherwise healthy patient. During mild fluid restriction for the treatment of the hyponatremia, acute renal failure occurred. The renal failure was resolved by treatment with furosemide. Fluid restriction is considered a standard therapeutic approach for the treatment of this probably SIADH-induced hyponatremia. Until now, acute renal failure has not been reported under these circumstances. This unique case demonstrates the need of close monitoring of patients with delayed hyponatremia following pituitary surgery.

Non-functioning pituitary adenomas: endocrinological and clinical outcome after transsphenoidal and transcranial surgery.

AIM: To study improvement of anterior pituitary function after transsphenoidal and transcranial surgery of non-functioning (NF) pituitary macro- and microadenomas. METHODS: We retrospectively examined 155 patients with NF adenomas preoperatively and 3 months, 1 year and 2 years postoperatively. 130 patients harboured a macroadenoma, 109 underwent transsphenoidal (group one), 21 transcranial surgery (group two). 25 patients presented a microadenoma (transsphenoidal surgery, group three). Endocrine studies included basal serum levels and dynamic testing of anterior pituitary partial function. Clinical symptoms and hormone replacement therapy were documented. RESULTS: Preoperatively, in group one, two and three, somatotropic function was impaired in 85, 90 and 80 %, gonadotropic in 61, 57 and 24 %, corticotropic in 31, 38 and 28 %, thyreotropic in 32, 38 and 12 % and lactotropic in 22, 38 and 32 % cases, respectively. Pituitary functions did not improve significantly after transsphenoidal or transcranial surgery. Presurgically, 63, 62 and 0 % patients complained about visual impairments, 60, 48 and 40 % about headache, 53, 24 and 36 % about fatigue and 28, 33 and 20 % about disturbance of cycle or potency. After transsphenoidal surgery, impaired vision, headache and fatigue improved within 3 months; after transcranial surgery, only headache improved. Preoperatively, pituitary malfunctions were treated adequately. Postsurgically, more patients received adrenal and thyroid hormone substitution, less patients received sex hormones than examinations proved necessary. CONCLUSION: Anterior pituitary function of NF adenoma patients did not improve significantly after transsphenoidal or transcranial surgery. After transsphenoidal surgery, most clinical symptoms normalised within 3 months. In some of the patients, substitution was not optimally adjusted to hormonal impairments.

Endocrinological outcome following first time transsphenoidal surgery for GH-, ACTH-, and PRL-secreting pituitary adenomas.

BACKGROUND: To study remission rates and pituitary functions following transsphenoidal surgery of newly diagnosed GH-, ACTH-, and PRL-secreting pituitary adenomas. METHODS: Out of a series of 329 newly diagnosed pituitary adenomas, 131 (39.8%) were hormone (67 GH-, 27 ACTH-, 37 PRL-) secreting. PRL-secreting adenomas were subjected to surgery because they failed to respond to previous medical treatment therapy. The data on secreting adenomas, regarding the results of standardised endocrinological testing, MRI findings and water metabolism disturbances, were extracted retrospectively from the pituitary data-base of the hospital. The mean follow-up was 3.7 years. RESULTS: The overall remission rate for PRL-secreting adenomas (27%) was significantly lower than for GH- (71.6%) and ACTH-secreting (81.5%) ones. Remission rates correlated negatively with the magnitude of preoperative hormone excess (not in Cushing's disease), tumour size (not in prolactinoma) and invasiveness. Generally, the improvement of the adenopituitary functions was statistically significant during the first three postoperative months, and thereafter remained unchanged. Diabetes insipidus persisting for more than three months occurred with similar frequency in the three patient groups (in 9.4% of GH-, in 6.7% of ACTH-, and in 10% of PRL-secreting adenomas). Tumour regrowth occurred more often in PRL-(20%) than in ACTH- (9.1%) and GH- (0%) secreting tumours. CONCLUSIONS: In GH- and ACTH-secreting pituitary adenomas, remission rates were significantly higher and recurrence rates lower than in PRL-secreting adenomas, which had failed to respond to previous medical therapy. The overall postoperative adenopituitary function was improved in all patient groups. Diabetes insipidus occurred with similar frequency in all patient groups. When reporting on results of surgery for secreting pituitary adenomas, not only remission and recurrence rates, but also the results of the pituitary function should be included.

Lymphocytic hypophysitis: non-invasive diagnosis and treatment by high dose methylprednisolone pulse therapy?

Criteria for the non-invasive diagnosis of lymphocytic hypophysitis (LyHy) and the results of the first prospective trial of high dose methylprednisolone pulse therapy (HDMPT) in nine patients are presented. In three patients, the diagnosis was established histologically, and in the others by clinical and endocrinological assessment, MRI, CSF examination, and measurement of thyroglobulin autoantibody concentration. After HDMPT, adenopituitary function improved in four of the nine patients and diabetes insipidus ceased or improved in all four concerned patients. The MRI findings improved in seven patients. LyHy has to be considered in the differential diagnosis of sellar lesions. The presumptive non-invasive diagnosis of LyHy seems possible in a high proportion of patients. HDMPT may result in the improvement of clinical, endocrinological, and MRI findings.

Does octreotide treatment improve the surgical results of macro-adenomas in acromegaly? A randomized study.

It is not clear whether the pre-operative treatment of GH-secreting pituitary adenomas with Octreotide improves the surgical remission rates of acromegaly. In a prospective controlled study the results of transsphenoidal surgery in newly diagnosed GH-secreting macro-adenomas were compared in patients with (n = 11, group A) and without (n = 13, group B) preoperative Octreotide treatment. During the treatment with a daily dosage of 470 +/- 160 micrograms Octreotide for 16.5 +/- 10 weeks, the GH- and IGF-1-values of group A dropped significantly from 38.9 +/- 34.1 to 6.8 +/- 4.9 micrograms/l and from 2.7 +/- 1 to 1.7 +/- 0.7 arbitrary units respectively. The adenoma-shrinkage from 5.9 +/- 5.8 to 4.7 +/- 4.9 cm3 missed statistical significance by little. There was no statistically significant difference between the postoperative acromegaly remission rates of 55% in group A and 69% in group B. Of the adenomas that postoperatively were not in remission, 80% in group A and 75% in group B disclosed an infiltrative growth pattern not influenced by the Octreotide pretreatment. All other patients not cured presented with initial GH-values of > 50 micrograms/l. There was no statistically significant difference between the postoperative anterior pituitary function in the two patient groups. In this study Octreotide was not beneficial in improving the results of GH-secreting pituitary macro-adenoma surgery. However, larger prospective controlled studies are needed to address this issue.

Does additional discectomy and the degree of dural sac compression influence the outcome of decompressive surgery for lumbar spinal stenosis?

The discussion regarding factors that reliably predict the long-term surgical results in patients with lumbar spinal stenosis is still going on. This retrospective study analyses the relation between the dimensions of the dural sac and patients' clinical status before and after decompressive operations performed with or without additional discectomy. The type of surgery performed in 134 patients and the dural sac dimensions measured on postmyelograpic computed tomography in 100 of these patients were related to the Prolo scores before surgery and at follow-up (mean 46 months). The degree of dural sac compression correlated significantly with the patients' postoperative Prolo score and with the difference between the pre- and postoperative scores. The dural sac diameters predicted outcome after surgery more reliably than the preoperative Prolo scores. There was no statistically significant difference in the outcome when comparing patients with and without additional discectomy. The results presented suggest that the relief of symptoms after decompressive surgery for lumbar spinal stenosis correlates with the degree of the dural sac compression and that the simultaneous presence of disc herniation necessitating additional discectomy does not influence the postoperative outcome. However, these results have to be confirmed by prospective studies.

Treatment of accidental high dose intraventricular mezlocillin application by cerebrospinal fluid exchange.

An accidental high dose of intraventricular mezlocillin was given during antibiotic treatment for pneumonia in a patient admitted because of severe traumatic brain injury and occlusive hydrocephalus. Because of serial epileptic seizures not responsive to antiepileptic drug treatment, CSF exchange was performed. The CSF was drained through a ventricular catheter, while mock CSF was infused into the lumbar subarachnoid space. The patient soon recovered to her clinical status previous to intraventricular mezlocillin application. Side effects of CSF exchange were not seen. Under continued antiepileptic medication no more seizures occurred. It is concluded that high doses of intraventricular mezlocillin have proconvulsive effects. In this patient CSF exchange was a suitable means of preventing putatively permanent impairment of brain function caused by serial epileptic seizures due to intraventricular mezlocillin application.

Intravascular papillary endothelial hyperplasia of the sellar region. Report of three cases and review of the literature.

Intravascular papillary endothelial hyperplasia (IPEH) is considered a reactive proliferation of endothelium associated with thrombosis. The occurrence of IPEH in the cranial cavity is exceedingly rare. In this article, the authors report three cases of IPEH that originated from the cavernous sinus and extended into the sellar contents. The lesions were resected incompletely in two cases and completely in one case. The IPEH in one of the patients was incompletely resected and exhibited further growth on magnetic resonance imaging 3 months postoperatively; local radiation therapy was instituted. This led to shrinkage of the lesion over an additional follow-up period of 3.5 years. In a review of the literature, the authors located seven other cases of intracranial IPEH. The authors conclude that clinically symptomatic intracranial IPEH should be completely resected whenever possible, because it can cause considerable morbidity and mortality and because it is prone to progression or recurrence.

Pituitary apoplexy with spontaneous cure of acromegaly and its possible relation to Gd-DTPA-administration.

A case of pituitary apoplexy occurring after Gd-DTPA-administration for contrast enhanced MRI in a patient with an hGH-producing macro-adenoma is presented. Within days the initially increased hGH level fell to the normal range, the oral glucose tolerance test (OGTT) showed a normal suppression of hGH and complete anterior pituitary insufficiency developed. At this time repeated MRI suggested a haemorrhagic infarction of the macro-adenoma. Fourteen months later re-examination confirmed spontaneous cure of the acromegaly, improvement of adenopituitary function and shrinkage of the sellar content. The causal linkage between the pituitary adenoma apoplexy and Gd-DTPA-administration is unclear. It might be due to contrast induced blood pressure and endothelial permeability changes, possibly promoted by pre-existing diabetes mellitus associated vasculopathy.