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1.
Artigo em Inglês | MEDLINE | ID: mdl-38717165

RESUMO

BACKGROUND AND OBJECTIVES: The widespread use of endoscope and increased surgical experiences in pituitary adenomas (PAs) has raised the expectations for higher resection and cure rates. The subject that will meet this expectation in all types of adenomas is the capsule and its dissection. The purpose of this study was to go beyond the commonly mentioned pseudocapsule definition for small-sized adenomas in previous studies and to describe the capsule structure in different morphologies present in pituitary adenomas of all sizes. This includes detailing the nuances of capsular dissection (CD) and presenting postoperative surgical outcomes through the experiences of a high-volume tertiary center. METHODS: In our center, 534 patients underwent endoscopic trans-sphenoidal surgery because of pituitary adenoma in 2022 by the same surgeon. The data of the patients were examined retrospectively. The surgical techniques applied were grouped as adenoma resection only, capsular resection after internal debulking, and direct extracapsular resection. RESULTS: CD was performed in 275 (51.5%) patients. The gross total resection (GTR) rate in nonsecretory adenomas with and without CD was 90.7% (97/107) and 90.7% (97/107), respectively. The remission rate in secretory adenomas with and without CD was 81.0% (136/168) and 44.0% (67/152), respectively. When the patients were examined in 2 groups as those who underwent CD and those who did not, the application of CD had a positive predictive value in terms of GTR/remission (P: .036). Capsule thickness was not found to be statistically significant depending on tumor subtype, size, and aggressiveness, but capsule thickness was statistically significant in terms of total capsular resection (P: .045). CONCLUSION: The morphology of the capsule, tumor size/subtype/consistency, and patient-specific factors are crucial for the selection of the surgical technique to be applied. It is possible to increase the GTR/remission rates in adenomas of all sizes by capsule dissection. Moreover, performing CD does not contribute significantly to the development of potential complications in such cases.

2.
World Neurosurg ; 184: e674-e681, 2024 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-38342165

RESUMO

OBJECTIVE: As surgical techniques become less invasive, the use of endoscopy in brain surgery supports this trend. Numerous endoscopic surgical approaches have been defined, especially for skull base diseases. The current study summarizes our experience of using the rarely reported endoscopic transnasal transdiaphragmatic approach through the existing hole in the diaphragma sella to access lesions extending into the suprasellar region. METHODS: Our surgical team performed 4876 endoscopic endonasal surgeries between August 1997 and December 2022 at the Department of Neurosurgery, Pituitary Research Center, Faculty of Medicine, Kocaeli University. The study retrospectively analyzed data from 11 patients who had undergone endoscopic transnasal transdiaphragmatic surgery since January 2020. Preoperative and postoperative magnetic resonance imaging, pituitary function examination, and clinical observation were carried out. RESULTS: The mean age of the patients was 31.1 ± 10.7 years and the female/male ratio was 6:5. Pathologic subtypes observed included breast cancer metastasis (n = 1), adrenocorticotropic hormone-secreting adenoma (n = 4), growth hormone-secreting adenoma (n = 3), craniopharyngioma (n = 2), and Rathke cleft cyst (n = 1). The mean postoperative hospital stay was 4.7 ± 1.1 days and none of the patients showed cerebrospinal fluid leakage during this period. CONCLUSIONS: The endoscopic transnasal transdiaphragmatic approach may be considered an alternative to the conventional extended endoscopic transnasal approach in patients with lesions extending into the suprasellar region. The main strength of this method is that it facilitates suprasellar region access through a small dural incision and bone defect in the base of the skull. As a result, it also reduces the risk of postoperative cerebrospinal fluid leakage and associated complications.


Assuntos
Adenoma , Neuroendoscopia , Neoplasias Hipofisárias , Humanos , Masculino , Feminino , Adulto Jovem , Adulto , Neuroendoscopia/métodos , Estudos Retrospectivos , Neoplasias Hipofisárias/diagnóstico por imagem , Neoplasias Hipofisárias/cirurgia , Neoplasias Hipofisárias/patologia , Endoscopia/métodos , Adenoma/diagnóstico por imagem , Adenoma/cirurgia , Vazamento de Líquido Cefalorraquidiano/cirurgia , Resultado do Tratamento
3.
J Neurosurg Pediatr ; 33(3): 223-235, 2024 Mar 01.
Artigo em Inglês | MEDLINE | ID: mdl-38157524

RESUMO

OBJECTIVE: Craniopharyngiomas are locally invasive neoplasms, and they cause potential lifelong morbidity because of their tendency for local recurrence. Despite advancements in endoscopic techniques, gross-total resection (GTR) of tumors with invasion or adhesion to important surrounding anatomical structures is extremely difficult. The authors present a single-center study that evaluated the impact of the endoscopic endonasal approach (EEA) on the surgical outcomes of pediatric craniopharyngiomas, the factors affecting the resection rate, and recurrence. METHODS: A total of 44 pediatric patients (age ≤ 18 years) who were treated via the EEA for craniopharyngioma from August 1997 to June 2022, as well as their 53 operations, were included in this study. The preoperative radiological configuration and surgical data of these cases were assessed. Also, preoperative and postoperative clinical (endocrinologic, neurological, and ophthalmological), hypothalamic, physical and social development, and neurocognitive assessment data were described. RESULTS: In total, 37 cases (69.8%) had no history of operation beforehand. The most common symptoms at presentation were endocrine disturbances (98.1%), headache without vomiting (84.3%), and visual disturbance (51%). Cases were classified as infrasellar (1.9%), sellar (32.1%), sellar-suprasellar (52.8%), and suprasellar (13.2%) localization. GTR was achieved in 34/53 cases (64.1%). The rate of GTR was higher in infrasellar and sellar tumors compared with sellar-suprasellar and suprasellar tumors (p = 0.003), and preoperative hypothalamic involvement was associated with lower likelihood of GTR (p = 0.024). Moreover, with experience, the rate of GTR increased (p = 0.037). Postoperative complications, other than endocrine impairment, occurred in 10/53 cases (18.9%). The mean duration of follow-up was 53.57 months. At follow-up, 21/53 (39.6%) cases presented with tumor recurrence. The 5-year progression-free survival (PFS) rate was 48.5%. There was a statistically significant difference between the GTR and other-than-GTR groups in terms of PFS (p < 0.001). According to univariate analysis, smaller tumor (p = 0.017), infrasellar and sellar localization (p = 0.031), and GTR (p < 0.001) were significantly associated with decreased rate of recurrence. Also, there was a statistically significant association between the recurrence rate and adhesion strength of the tumor (p < 0.001). CONCLUSIONS: This retrospective cohort study revealed surgical indications for EEA, as well as factors affecting the resection rate, recurrence, and quality of life during the follow-up period of the included cases. The authors believe that GTR should be the goal for craniopharyngioma treatment, but the authors' treatment approach was to provide a balance between radical surgery with maximum safety and adjuvant treatment for long-term disease control.


Assuntos
Craniofaringioma , Neoplasias Hipofisárias , Humanos , Criança , Adolescente , Craniofaringioma/diagnóstico por imagem , Craniofaringioma/cirurgia , Craniofaringioma/patologia , Seguimentos , Estudos Retrospectivos , Neoplasias Hipofisárias/diagnóstico por imagem , Neoplasias Hipofisárias/cirurgia , Neoplasias Hipofisárias/patologia , Qualidade de Vida , Recidiva Local de Neoplasia/cirurgia , Recidiva Local de Neoplasia/patologia , Intervalo Livre de Progressão
4.
Stereotact Funct Neurosurg ; 101(4): 244-253, 2023.
Artigo em Inglês | MEDLINE | ID: mdl-37429256

RESUMO

BACKGROUND: Spinal cord stimulation (SCS) has been investigated as a potential therapeutic option for managing refractory symptoms in patients with Parkinson's disease (PD). OBJECTIVE: This systematic review and meta-analysis aimed to evaluate the safety and efficacy of SCS in PD. METHOD: A comprehensive literature search was conducted on PubMed and Web of Science to identify SCS studies reporting Unified Parkinson Disease Rating Scale-III (UPDRS-III) or Visual Analogue Scale (VAS) score changes in PD cohorts with at least 3 patients and a follow-up period of at least 1 month. Treatment effect was measured as the mean change in outcome scores and analyzed using an inverse variance random-effects model. The risk of bias was assessed using the Newcastle-Ottawa Scale and funnel plots. RESULTS: A total of 11 studies comprising 76 patients were included. Nine studies involving 72 patients reported an estimated decrease of 4.43 points (95% confidence interval [CI]: 2.11; 6.75, p < 0.01) in UPDRS-III score, equivalent to a 14% reduction. The axial subscores in 48 patients decreased by 2.35 points (95% CI: 1.26; 3.45, p < 0.01, 20% reduction). The pooled effect size of five studies on back and leg pain VAS scores was calculated as 4.38 (95% CI: 2.67; 6.09, p < 0.001), equivalent to a 59% reduction. CONCLUSIONS: Our analysis suggests that SCS may provide significant motor and pain benefits for patients with PD, although the results should be interpreted with caution due to several potential limitations including study heterogeneity, open-label designs, small sample sizes, and the possibility of publication bias. Further research using larger sample sizes and placebo-/sham-controlled designs is needed to confirm effectiveness.


Assuntos
Doença de Parkinson , Estimulação da Medula Espinal , Humanos , Doença de Parkinson/terapia , Doença de Parkinson/tratamento farmacológico , Estimulação da Medula Espinal/métodos , Dor/etiologia
5.
World Neurosurg ; 176: e623-e633, 2023 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-37271260

RESUMO

OBJECTIVE: Pediatric pituitary adenomas are rare lesions and account for approximately 3% of all supratentorial tumors in children. There is a paucity of reports on endoscopic transsphenoidal surgery in children. The aim of this study was to assess the early/late outcomes of endoscopic pediatric pituitary adenoma surgery at a high-volume tertiary center, as well as to characterize the factors associated with aggressive growth, including the histopathological features. METHODS: Between August 1997 and June 2022, a total of 3256 patients underwent endoscopic transsphenoidal surgery for pituitary adenoma at the Department of Neurosurgery and Pituitary Research Center of the Kocaeli University School of Medicine. Of these, 70 (2.1%) pediatric patients (25 males, 45 females) (age ≤18 years) with a pathological diagnosis of pituitary adenoma were retrospectively reviewed. RESULTS: The mean age of patients was 15.5 ± 2.3 years. Among the hormone-secreting adenomas, 19 (34.5%) were adrenocorticotrophic hormone secreting, 13 (23.6%) were growth hormone secreting, 19 (34.5%) were prolactin secreting, and 4 (7.2%) were both growth hormone-prolactin secreting. Gross total resection was achieved in 93.3% of nonfunctional tumors. The early/late surgical remission rates for hormone-secreting adenomas were 61.5%/46.1% (mean follow-up: 63.7 ± 49.3 months) for acromegaly, 78.9%/68.4% (47.8 ± 51.0 months) for Cushing disease, 57.8%/31.5% (72.2 ± 59.5 months) for prolactinoma, and 25%/25% (35.2 ± 31.4 months) for growth hormone-prolactin-secreting adenomas. Five sparsely granulated corticotroph tumors, 5 sparsely granulated somatotroph tumors, and 11 densely granulated lactotroph tumors were classified as aggressive histopathological subtypes. CONCLUSIONS: The unique characteristics of the pediatric population and the aggressiveness of the disease in this population pose considerable therapeutic challenges. To increase treatment success, current adjuvant therapies that are appropriate for the morphological and biological characteristics of the tumor are required in addition to surgical treatment.


Assuntos
Adenoma , Neoplasias Hipofisárias , Masculino , Feminino , Humanos , Criança , Adolescente , Neoplasias Hipofisárias/cirurgia , Neoplasias Hipofisárias/patologia , Estudos Retrospectivos , Prolactina , Adenoma/cirurgia , Adenoma/patologia , Hormônio do Crescimento , Resultado do Tratamento
6.
World Neurosurg ; 170: e858-e867, 2023 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-36481446

RESUMO

OBJECTIVE: The classically recommended first-line therapy for microprolactinomas is medical therapy. In the presence of drug resistance and intolerance after the use of dopamine agonists or when the patients prefer surgery instead of medication, surgical treatment is considered as second-line treatment. The high hormonal remission and low complication rates after surgery for microprolactinomas suggest that the surgical outcome of endoscopic surgeries may be better than medical therapy in well-selected patients. This study reports a large series of patients with microprolactinoma treated by endoscopic transnasal approach and evaluates the efficiency of surgical treatment. METHODS: Our study is a retrospective cohort analysis of patients with microprolactinoma operated on by an endoscopic transnasal approach between August 1997 and February 2022 by an experienced pituitary surgeon in a single tertiary center. Inclusion criteria for microprolactinoma were based on increased prolactin levels, microadenoma (<10 mm in diameter) on pituitary magnetic resonance imaging, and histopathologically verified lactotroph adenoma. RESULTS: The mean follow-up was 74.90 months (range, 6-207). The postoperative day 1 remission rate was 85.7% and the long-term remission rate was 74.3%. The long-term remission rates of the patients in the preference group were significantly higher than those of the patients in the resistant or intolerance group (P = 0.002). Patients who used dopamine agonists for more than 3 years had a lower remission rate compared with patients who used dopamine agonists for a shorter period or who did not use it (P = 0.01). The surgical complication rate was 4.76%. CONCLUSIONS: According to our findings, endoscopic transnasal surgery performed by an experienced neurosurgeon in well-selected patients with microprolactinoma can be offered with cure rates superior to medical therapy and may be an alternative first-line treatment option to dopamine agonists.


Assuntos
Neoplasias Hipofisárias , Prolactinoma , Humanos , Prolactinoma/diagnóstico por imagem , Prolactinoma/tratamento farmacológico , Prolactinoma/cirurgia , Neoplasias Hipofisárias/diagnóstico por imagem , Neoplasias Hipofisárias/tratamento farmacológico , Neoplasias Hipofisárias/cirurgia , Agonistas de Dopamina/uso terapêutico , Estudos Retrospectivos , Resultado do Tratamento
7.
Clin Neurol Neurosurg ; 208: 106875, 2021 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-34388599

RESUMO

OBJECTIVE: Gross total resection (GTR) is the mainstay therapy for chordomas and chondrosarcomas to have the best prognosis. The aims of this study were to specify the limits of EEA, emphasize the need for additional combined approaches for tumors beyond these limitations for high resection rates, discuss the prognostic factors and operative nuances that affect GTR, and present the causes and characteristics of early and late recurrences. METHODS: We retrospectively analyzed the endoscopic endonasal surgeries in the Pituitary Research Center and Neurosurgery Department of the Kocaeli University Faculty of Medicine, Turkey between January 2004 and December 2019. We retrospectively reviewed the medical data, radiological images, and surgical videos of patients, and 72 patients with chordoma and chondrosarcoma were included in the study. RESULTS: Based on pathology reports, 72 patients (seven pediatric) were identified, to whom 91 endoscopic operations were performed. We determined the surgical limitations for each clival segment as superior, middle, and inferior. Then, we divided these into three subgroups according to whether the tumor shows dural invasion (extradural chordoma, large extradural - minimal intradural component, and minimal extradural - large intradural component). The tumors of 19 (26.4%), 25 (26.4%), and nine (12.5%) patients originated from the superior, middle, and inferior clivus, respectively. Nineteen (26.4%) patients had panclival involvement. GTR was performed in 47 (65.3%) the patients. The GTR rate in patients with panclival tumors was 47.3% (9/19). The experience, lateralization, dural involvement, and origin of the clivus affecting GTR were analyzed. Extradural - intradural extensions were verified as negative predictor factors for GTR, whereas tumors located in the superior (OR: 16.710, p=0.030) and middle (OR: 11.154, p=0.023) segments were positive predictive factors for GTR. CONCLUSION: An increasing experience in endoscopic surgery significantly increases the GTR rates by widening the surgical limitations. Due to dense bone infiltration and adhesion to critical neurovascular structures, recurrence rates are high despite performing GTR. Although surgery and adjuvant treatments improve the 5-year survival of patients, the mortality rates remain high. Therefore, surgery of these tumors should be performed by experienced centers. In addition to surgical and adjuvant therapies, targeted molecular and translational biological therapies are also needed for chordomas and chondrosarcomas in the future.


Assuntos
Condrossarcoma/cirurgia , Cordoma/cirurgia , Fossa Craniana Posterior/cirurgia , Neoplasias da Base do Crânio/cirurgia , Adolescente , Adulto , Idoso , Criança , Pré-Escolar , Condrossarcoma/diagnóstico por imagem , Condrossarcoma/patologia , Cordoma/diagnóstico por imagem , Cordoma/patologia , Fossa Craniana Posterior/diagnóstico por imagem , Fossa Craniana Posterior/patologia , Feminino , Humanos , Imageamento por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Neuroendoscopia , Estudos Retrospectivos , Neoplasias da Base do Crânio/diagnóstico por imagem , Neoplasias da Base do Crânio/patologia , Adulto Jovem
8.
Turk Neurosurg ; 29(2): 289-296, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-30843598

RESUMO

AIM: To better understand the indications and the impact of antidepressant drugs on the field of neurosurgery in terms of risks and benefits in Turkey. MATERIAL AND METHODS: A national survey was conducted among neurosurgeons in current practice in Turkey to report routine prescription trends of antidepressant drugs. Gender, neurosurgical subspecialty, city, type of practice, years of experience, antidepressant agent, indications and reasons not to prescribe were ascertained. A brief review of literature was done to show clinical and research evidence. RESULTS: A total of 336 neurosurgeons took the survey; 53% of them prescribe antidepressants routinely, whereas 47% of them do not. Of the 72% non-prescribers prefer to refer their patients to a psychiatrist and 22% of them believe that antidepressants have no role in neurosurgery. Vascular and pediatric neurosurgeons as well as neurosurgeons at research hospitals showed the lowest prescription proportion, while general and brain tumor neurosurgeons and ones in private practice showed the highest prescription proportion. Surgeons with more than 20 year-experience had the lowest prescription proportion (43%). Type of practice and years of experience showed a statistically significant association with the prescription of antidepressant drugs across (p=0.002 and p=0.025, respectively). CONCLUSION: Type of practice and years of experience showed a statistically significant association with the proportion of antidepressants' prescribers in Turkish neurosurgery practice at the time of this survey. Non-prescriber neurosurgeons need to recognize the indications, whereas prescribers have to understand the risks of using antidepressants.


Assuntos
Antidepressivos/uso terapêutico , Neurocirurgiões/estatística & dados numéricos , Padrões de Prática Médica/estatística & dados numéricos , Feminino , Humanos , Masculino , Neurocirurgia , Inquéritos e Questionários , Turquia
9.
Oper Neurosurg (Hagerstown) ; 14(4): E46-E50, 2018 04 01.
Artigo em Inglês | MEDLINE | ID: mdl-28962000

RESUMO

BACKGROUND AND IMPORTANCE: Stereotactic biopsies or needle aspirations of posterior fossa lesions are technically challenging. Here we report a novel technique for performing these procedures employing the Airo™ intraoperative computed tomographic (CT) scanner and the VarioGuide™ articulated arm (BrainLab, Munich, Germany). CLINICAL PRESENTATION: A 62-yr-old woman presented with an irregularly shaped, enhancing lesion of the left pons/middle cerebellar peduncle. Slowed diffusion on magnetic resonance imaging suggested an abscess, but no definitive infectious agent/source could be identified. When the patient deteriorated despite broad-spectrum antibiotic therapy, she was taken to the operating room for stereotactic drainage of the abscess employing the described technique. A specific infectious agent (Eikenella corrodens) was identified from the aspirate, allowing for tailored antibiotic therapy. The procedure was well tolerated and the patient made a full recovery with minimal neurological sequelae. CONCLUSION: The combination of the Airo™ intraoperative CT and the Varioguide™ articulated arm allows for safe, accurate, and efficient targeting of posterior fossa lesions.


Assuntos
Abscesso Encefálico/cirurgia , Tronco Encefálico/cirurgia , Drenagem/métodos , Eikenella corrodens , Infecções por Bactérias Gram-Negativas/cirurgia , Imageamento Tridimensional/métodos , Neuroimagem/métodos , Radiografia Intervencionista/métodos , Tomografia Computadorizada por Raios X/instrumentação , Antibacterianos/uso terapêutico , Abscesso Encefálico/diagnóstico por imagem , Abscesso Encefálico/tratamento farmacológico , Abscesso Encefálico/microbiologia , Tronco Encefálico/diagnóstico por imagem , Terapia Combinada , Drenagem/instrumentação , Eikenella corrodens/isolamento & purificação , Desenho de Equipamento , Feminino , Infecção Focal Dentária/complicações , Infecções por Bactérias Gram-Negativas/diagnóstico por imagem , Infecções por Bactérias Gram-Negativas/tratamento farmacológico , Humanos , Imageamento por Ressonância Magnética , Pessoa de Meia-Idade , Neuroimagem/instrumentação , Radiografia Intervencionista/instrumentação , Técnicas Estereotáxicas/instrumentação
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