Morphometric analysis of transsphenoidal surgery in Peruvian population.

Background: Transsphenoidal surgery has become a key element in the approach to skull base pathologies. The objective of the study was to explore the morphometry of the sphenoidal region in the Peruvian population, with an emphasis on understanding its specific anatomical characteristics and providing quantitative data for the planning of transsphenoidal surgery. Methods: A cross-sectional study included a random sample of 81 cases of healthy individuals who presented to the Radiology Department of a Private Hospital Center in Peru over 1 year. Skull computed tomography scans without contrast were performed, and a detailed morphometric analysis was conducted by an expert neurosurgeon, including measurements of four parameters to evaluate the anatomy of the craniofacial region. Results: Most participants exhibited complete sellar pneumatization, followed by incomplete sellar pneumatization, while conchal pneumatization was rare. Significant differences were found between men and women in the distance from the nasal opening to the dorsum of the sella turcica. No significant gender differences were observed in other anatomical measurements or significant changes with age in anatomical measurements. Conclusion: Morphometric analysis provides crucial data for the precise customization of surgical interventions in the Peruvian population, especially in transsphenoidal surgery. The results highlight the importance of considering individual anatomical differences and gender variability during surgical planning. Morphometry emerges as a valuable tool to enhance the quality and safety of transsphenoidal surgery by adapting surgical strategies to the specific anatomical dimensions of each patient.

Improvement of metabolic syndrome and its components in patients who underwent transsphenoidal resection for pituitary adenoma.

BACKGROUND: Pituitary adenomas (PA) are neoplasms of pituitary adenohypophyseal cell lineage, which are the third most common cause of brain tumors among adults. Due to hormone secretion, PAs are closely related to metabolic syndrome (MetS). However, the relationship between these two entities has been scarcely studied to date. PURPOSE: This paper aims to evaluate changes in the metabolic status of patients with PA before and after surgical treatment and to look for differences in metabolic outcomes among patients according to the adenoma type and the surgery success rate. METHODS: We assessed patients with PA who went through transsphenoidal surgery for its treatment, documenting metabolic parameters before and after surgery, analyzed whole sample changes, and then stratified them according to adenoma type (nonfunctioning, somatotroph, lactotroph, and corticotroph), and surgery success (total resection, near-total resection, partial resection, subtotal resection). RESULTS: A total of 214 patients were enrolled for this study. The prevalence of MetS with AACE criteria went from 51.52% before surgery to 28.99% after surgery (P < 0.001). Hyperglycemia (HG) was the most beneficial component; it went from 56% pre-surgery to 40.51% post-surgery (P = 0.03). The total resection group had the best improvement, with a significant decrease of prevalence in MetS from 83 to 16% (P < 0.001), and every component, except hypoalphalipoproteinemia (HA): obesity went from 96 to 67% (P < 0.001), arterial hypertension (AH) 59 to 24% (P < 0.001), HG 74 to 23% (P < 0.001), and hypertriglyceridemia (HTG) from 81 to 54% (P < 0.001). According to MetS prevalence, there was no difference in the improvement according to PA type. CONCLUSION: Surgical treatment in patients with PA is associated with MetS improvement.

Real World Data on the Epidemiology, Diagnosis, and Treatment of Acromegaly: A Registries-based Approach.

INTRODUCTION: Despite the inherent heterogeneity of the information derived from national registries, they are a useful tool to investigate the epidemiological, clinical, biochemical and treatment outcome characteristics of low prevalence conditions such as acromegaly. Although the information provided by single-center experiences is more homogeneous, these studies usually comprise a limited number of patients and thus, frequently lack statistical power. AREAS COVERED: Registry-based Information regarding the epidemiology, clinical presentation, biochemical and imaging diagnosis, as well as therapeutic outcome and mortality in acromegaly is critically analyzed. EXPERT OPINION: By gathering data from multiple centers in a specific Country, these registries generate important insights into the real-life behavior of this condition, that should be considered, both, in international consensus meetings and in the design of local, Country-specific diagnostic and therapeutic strategies.

Endoscopic endonasal approach for acromegaly: surgical outcomes using 2018 consensus criteria for remission.

Objective: The primary aim is to analyze the endoscopic endonasal surgical results in short-term and two-year follow-ups according to the 11th Acromegaly Consensus statement (2018). Indeed, prognostic factors and complications were analyzed. Subjects and methods: 40 patients who underwent endoscopic endonasal surgery by acromegaly between 2013 to 2020 was analyzed. Patients were considered in remission if an upper limit of normal (ULN) IGF-1 was less than 1.0 at the six-month and two-year follow-ups. Moreover, we assessed the Knosp grade, tumor volumetry, ULN, T2 signal in MRI, reoperation, and complications. Results: The mean age of admission was 46.7 years. Thirty-two patients were in remission after six months of surgery (80%), decreasing to 76.32% at the two-year follow-up. All microadenomas presented remission (n = 6). Regarding the complications, three patients had permanent panhypopituitarism (7.5%); postoperative cerebrospinal fluid (CSF) leaks did not occur in this series. The hyperintense signal on the T2 MRI and a higher tumor volumetry were the single predictor's factors of non-emission in a multivariate regression logistic analysis (p < 0.05). Preoperative hormone levels (GH and IGF-1) were not a prognostic factor for remission. The re-operated patients who presented hypersignal already had a high predictor of clinical-operative failure. Conclusion: The endoscopic endonasal surgery promotes high short-term and two-year remission rates in acromegaly; the tumor's volumetry and the T2 hypersignal were statistically significant prognostic factors in non-remission - the complications presented at similar rates in comparison to the literature. In invasive GH-secreting tumors, we should offer these patients a multi-disciplinary approach to improve acromegalic patients' remission rates.

Neurosurgical aspects and clinical outcomes on the treatment of Cushing disease in pediatric patients: Case series and literature review.

Background: Cushing disease (CD) is a state of hypercortisolism caused by an adrenocorticotropic hormone-(ACTH) producing pituitary adenoma which rarely occurs in pediatric patients. The outstanding features are weight gain and growth retardation. However, the insidious onset and rarity of the disease in children and adolescents often result in delayed diagnosis. Case Description: We present five patients <14 years of age who underwent neurosurgical treatment for CD at the Department of Neurosurgery of a public referral hospital in Lima, Peru. Age at diagnosis ranged from 5.5 to 12.5 years with a history of disease from 9 months to 3.5 years of moderate to severe stunting and obesity, among other features of Cushing syndrome (CS). Although biochemical tests and cerebral imaging were crucial for the diagnosis, confirmation was made by bilateral petrosal sinuous sampling. Regarding treatment, three patients underwent transcranial surgery, one patient underwent endoscopic transsphenoidal surgery, and one patient underwent microscopic transsphenoidal surgery. None of the patients underwent radiotherapy or pharmacological treatment. Only one patient had a recurrence and achieved remission until an endoscopic transsphenoidal approach was performed. Short- and long-term endocrinologic follow-up is also described in detail. Conclusion: CD is a heterogeneous disorder that requires multidisciplinary diagnosis and management. Transsphenoidal selective adenomectomy is the optimal treatment because of its higher remission rates. However, technical and anatomic aspects should be considered in pediatric patients.

Endoscopic endonasal approach for acromegaly: surgical outcomes using 2018 consensus criteria for remission

ABSTRACT Objective: The primary aim is to analyze the endoscopic endonasal surgical results in short-term and two-year follow-ups according to the 11th Acromegaly Consensus statement (2018). Indeed, prognostic factors and complications were analyzed. Subjects and methods: 40 patients who underwent endoscopic endonasal surgery by acromegaly between 2013 to 2020 was analyzed. Patients were considered in remission if an upper limit of normal (ULN) IGF-1 was less than 1.0 at the six-month and two-year follow-ups. Moreover, we assessed the Knosp grade, tumor volumetry, ULN, T2 signal in MRI, reoperation, and complications. Results: The mean age of admission was 46.7 years. Thirty-two patients were in remission after six months of surgery (80%), decreasing to 76.32% at the two-year follow-up. All microadenomas presented remission (n = 6). Regarding the complications, three patients had permanent panhypopituitarism (7.5%); postoperative cerebrospinal fluid (CSF) leaks did not occur in this series. The hyperintense signal on the T2 MRI and a higher tumor volumetry were the single predictor's factors of non-emission in a multivariate regression logistic analysis (p < 0.05). Preoperative hormone levels (GH and IGF-1) were not a prognostic factor for remission. The re-operated patients who presented hypersignal already had a high predictor of clinical-operative failure. Conclusion: The endoscopic endonasal surgery promotes high short-term and two-year remission rates in acromegaly; the tumor's volumetry and the T2 hypersignal were statistically significant prognostic factors in non-remission - the complications presented at similar rates in comparison to the literature. In invasive GH-secreting tumors, we should offer these patients a multi-disciplinary approach to improve acromegalic patients' remission rates.

Analyzing giant pituitary adenomas: An 8-year review (2012-2020) at a reference center in Brazil.

PURPOSE: This study aimed to review the cases of giant adenomas that were operated on from 2012 to 2020 and to analyze the epidemiological profile, complications, and resection rates using the transseptal/transnasal endoscopy technique. We also compared the results with data from revised literature. METHODS: This is an observational, retrospective study includes a review of the medical records of 26 patients diagnosed with giant adenomas (diameter > 4 cm or volume >10 cm3) who underwent 28 surgical procedures. RESULTS: Of the 57 patients operated for pituitary adenoma, 26 (50.8%) had giant adenomas. The mean volume was 17.28 cm3 (95% confidence interval [CI], 8.3359-26.2241). Moreover, 64.28% of the patients were graded Knosp 3 (p < 0.0001). Most cases were of nonsecretory adenomas (88.46%). Visual impairment was present in 89.2% of the patients and hormonal deficit and headache affected 53.5% of them. The visual impairment improved in 60% of the patients. The most common surgical complication was cerebrospinal fluid fistula (10.71%). Tumor resection > 90% was achieved in 53.56% of the cases, and the mean resection rate was 78.36% (95% CI, 71.316-87.956). CONCLUSIONS: The endoscopic endonasal technique is a good treatment option for giant adenomas, showing satisfactory optic apparatus decompression rates and a low incidence of complications when performed by surgeons with expertise in this approach.

Surgical and Pharmacological Outcomes in Acromegaly: Real-Life Data From the Mexican Acromegaly Registry.

CONTEXT: Acromegaly registries constitute a valuable source of therapeutic outcome information in real-life. OBJECTIVE: The objective of this work is to analyze surgical and pharmacological outcomes in the Mexican Acromegaly Registry (MAR). DESIGN AND METHODS: Data were extracted from the MAR informatic platform. Surgical remission was defined by a postoperative postglucose (GH) of less than 1 ng/mL and an insulin-like growth factor 1 (IGF-1) of less than 1.2 × upper limit of normal (ULN). Pharmacological remission was defined by a basal GH of less than 1 ng/mL and an IGF-1 of less than 1.2 × ULN. RESULTS: A total of 650 surgical outcomes were analyzed (94.6% transsphenoidal). Surgical remission was achieved in 40.15%, whereas 44.15% remained biochemically active. Persistently active disease after surgery was significantly associated with harboring an invasive macroadenoma, a basal GH of greater than 10 ng/mL, and/or an IGF-1 of greater than 2 × ULN at diagnosis on bivariate and multivariate analysis. The outcome of monotherapy with first-generation somatostatin analogs (SSAs) was evaluated in 267 patients (adjunctive in 65%), of whom 28.4% achieved remission. Persistently active disease was significantly associated with harboring an invasive macroadenoma as well as with pretreatment basal GH and IGF-1 levels of greater than 10 ng/mL and greater than 2 × ULN, respectively, on bivariate and multivariate analysis. Combined therapy with SSA and cabergoline was analyzed in 100 patients, of whom 19% achieved remission and 44% remained active; in this subset of patients, only a pretreatment IGF-1 of greater than 2 × ULN was significantly associated with persistent disease activity. CONCLUSION: Surgical and pharmacological outcomes in acromegaly are highly dependent on tumor size/invasiveness as well as on the degree of hypersomatotropinemia.

Microsurgical and Endoscopic Anatomy of the Cavernous Sinus

Objective To describe the endoscopic and microsurgical anatomy of the cavernous sinus (CS) with focus on the surgical landmarks in microsurgical anatomy. Materials and methods Ten formalin-fixed central skull base specimens (20 CSs) with silicone-injected carotid arteries were examined through an extended endoscopic transsphenoidal approach. Fifteen formalin-fixed heads were dissected to simulate the surgical position in CS approaches. Results Endoscopic access enables identification of the anterior and posterior surgical corridors. Structures within the CS and on its lateral wall could be visualized and studied, but none of the triangular areas relevant to the transcranial microsurgical anatomy were fully visible through the endoscopic approach. Conclusion The endoscopic approach to the CS is an important surgical technique for the treatment of pathological conditions that affect this region. Correlating endoscopic findings with the conventional (transcranial)microsurgical anatomy is a useful way of applying the established knowledge into a more recent operative technique. Endoscope can provide access to the CS and to the structures it harbors.

Predicting prolonged length of stay after endoscopic transsphenoidal surgery for pituitary adenoma.

BACKGROUND: Endoscopic transsphenoidal surgery (ETS) for the resection of pituitary adenoma has become more common throughout the past decade. Although most patients have a short postoperative hospitalization, others require a more prolonged stay. We aimed to identify predictors for prolonged hospitalization in the setting of ETS for pituitary adenomas. METHODS: A retrospective chart review as performed on 658 patients undergoing ETS for pituitary adenoma at a single tertiary care academic center from 2005 to 2019. Length of stay (LoS) was defined as date of surgery to date of discharge. Patients with LoS in the top 10th percentile (prolonged LoS [PLS] >4 days, N = 72) were compared with the remainder (standard LoS [SLS], N = 586). RESULTS: The average age was 54 years and 52.5% were male. The mean LoS was 2.1 days vs 7.5 days (SLS vs PLS). On univariate analysis, atrial fibrillation (p = 0.002), hypertension (p = 0.033), partial tumor resection (p < 0.001), apoplexy (p = 0.020), intraoperative cerebrospinal fluid (ioCSF) leak (p = 0.001), nasoseptal flap (p = 0.049), postoperative diabetes insipidus (DI) (p = 0.010), and readmission within 30 days (p = 0.025) were significantly associated with PLS. Preoperative continuous positive airway pressure (CPAP) (odds ratio, 15.144; 95% confidence interval, 2.596-88.346; p = 0.003) and presence of an ioCSF leak (OR, 10.362; 95% CI, 2.143-50.104; p = 0.004) remained significant on multivariable analysis. CONCLUSION: For patients undergoing ETS for pituitary adenomas, an ioCSF leak or preoperative use of CPAP predicted PLS. Additional common reasons for PLS included postoperative CSF leak (10 of 72), management of DI or hypopituitarism (15 of 72), or reoperation due to surgical or medical complications (14 of 72).

Correlation analysis between short-term insulin-like growth factor-I and glucose intolerance status after transsphenoidal adenomectomy in acromegalic patients: a large retrospective study from a single center in China

ABSTRACT Objectives: Our study aimed to investigate the associations of glucose tolerance status with insulin-like growth factor-I (IGF-I) and other clinical laboratory parameters of acromegalic patients before and after the patients underwent transsphenoidal adenomectomy (TSA) by conducting a single-center, retrospective study. Subjects and methods: A total of 218 patients with acromegaly who had undergone TSA as the first treatment were retrospectively analyzed. Serum IGF-I, growth hormone (GH) and glucose levels were measured before and after surgery. Results: The follow-up levels for random GH, GH nadir, and the percentage of the upper limit of normal IGF-I (%ULN IGF-I) were decreased significantly. The percentages of normal (39.0%), early carbohydrate metabolism disorders (33.0%) and diabetes mellitus (28.0%) changed to 70.2%, 16.5% and 13.3%, respectively, after TSA. %ULN IGF-I at baseline was higher in the diabetes mellitus (DM) group than in the normal glucose tolerance group and impaired glucose tolerance (IGT) /impaired fasting glucose (IFG) groups before TSA, and the DM group exhibited a greater reduction in %ULN IGF-I value after surgery. The follow-up %ULN IGF-I value after surgery was significantly lower in the improved group, and Pearson's correlation analysis revealed that the reductions in %ULN IGF-I corresponded with the reductions in glucose level. Conclusion: This study examined the largest reported sample with complete preoperative and follow-up data. The results suggest that the age- and sex-adjusted IGF-I level, which reflects altered glucose metabolism, and the change of it are associated with improved glucose tolerance in acromegalic patients both before and after TSA.

Surgical-pharmacological interactions in the treatment of acromegaly.

INTRODUCTION: Acromegaly requires a multimodal treatment approach that includes surgery by an expert pituitary neurosurgeon, pharmacological treatment with one or more of the available drugs and radiation therapy. These treatment alternatives are not mutually exclusive but rather complement each other when properly indicated in the individual patient. In this review, we summarize and analyze the available data concerning the choice of the surgical approach (microscopy vs. endoscopy) and the interactions between medical treatment with somatostatin analogs and pituitary surgery. AREAS COVERED: Technical aspects, complications and outcome of transsphenoidal surgery (TSS); Advantages and disadvantages of the microscopic and endoscopic approaches; Safety and efficacy of somatostatin analogs (SSA); Primary pharmacological therapy versus primary TSS; Benefits of the preoperative treatment with SSA; and the effect of surgical tumor debulking in the therapeutic response to SSA. EXPERT COMMENTARY: Continuing efforts at improving surgical techniques and at generating more efficacious pharmacological therapies for acromegaly are likely to improve the outcome of these patients. However, an integral approach of the patient aimed not only at achieving biochemical criteria of cure but also at treating the individual comorbidities is mandatory to improve the quality of life of these patients and to reduce their mortality rate.

Endoscopic and Microsurgical Approaches to the Cavernous Sinus ­ Anatomical Review

Cavernous sinus surgery has always represented a surgical challenge due to the great importance of the surrounding anatomical structures and to the high morbidity associated to it. Although the anatomy of this region has been extensively described, controversy remains related to the best treatment and approaches for different kinds of lesions. In this article, a literature review was performed on the surgical anatomy and approaches to the cavernous sinus.

A cirurgia da região do seio cavernoso sempre representou um desafio devido à grande importância das estruturas anatômicas e às altas taxas de morbidade associadas. Embora a anatomia da região tenha sido extensivamente descrita, permanece controverso o melhor tratamento e o acesso para diferentes tipos de lesão que acometem a região. Neste artigo foi realizada uma revisão de literatura focando a anatomia cirúrgica e os acessos à região do seio cavernoso.

Intrasphenoid septations inserted into the internal carotid arteries: a frequent and risky relationship in transsphenoidal surgeries / Septações intraesfenoidais inseridas nas artérias carotídeas internas: uma relação frequente e arriscada nas cirurgias transesfenoidais

Abstract Introduction: When an expanded endonasal transsphenoidal surgical approach is performed, intrasphenoid septations must be completely resected. If these structures are close to the internal carotid artery (ICA), then their manipulation might cause vascular injury. Objective: The objective of this study is to describe the frequency of intrasphenoid septations in the internal carotid artery protuberance (ICAp). Methods: Computed tomography (CT) scans of 421 patients were analysed. Intrasphenoid septations (classified as intersphenoid or accessory) and their relationship to the ICAp were described. Additionally, a sphenoid sinus classification was performed based on their degree of pneumatisation to determine whether a difference exists in the frequency of intrasphenoid septations inserted into ICAp with regard to sinus type. Results: The patient mean age was 39 ± 21.4 years. Overall, 219 patients (52%) had septations in the ICAp; 359 patients (85.3%) had intersphenoid septations; of the latter, 135 (37.6%) had septations in the ICAp. This frequency was higher among patients with sphenoid sinus type 4 or 5 (44.7% and 43.5%, respectively). Accessory septations were found in 255 patients (60.6%); 140 of these septations (54.9%) were in the ICAp. Among 351 patients with types 3, 4 or 5 sphenoid sinuses (i.e., only well-pneumatised sphenoid sinuses), 219 (62.4%) had septations in the ICAp. These frequencies are higher than those reported in most previous studies. Conclusion: The frequency of intrasphenoid septations in the ICAp found is considerable. It is higher among patients with more pneumatised sinuses. This finding justifies an appropriate pre-operative study, and careful attention must be paid during transsphenoidal surgery.

Resumo Introdução: Quando uma abordagem cirúrgica transesfenoidal endonasal ampliada é feita, septações intraesfenoidais devem ser completamente ressecadas. Se essas estruturas estiverem próximas à artéria carótida interna (ACI), a manipulação pode causar lesão vascular. Objetivo: O objetivo deste estudo foi descrever a frequência de septações intraesfenoidais na protuberância da artéria carótida interna (pACI). Método: Exames de tomografia computadorizada (TC) de 421 pacientes foram analisados. As septações intraesfenoidais (classificadas como interesfenoidais ou acessórias) e sua relação com a pACI foram descritas. Além disso, uma classificação do seio esfenoidal foi feita com base no seu grau de pneumatização para determinar se existe uma diferença na frequência de septações intraesfenoidais inseridas em pACI em relação ao tipo de seio. Resultados: Pacientes com idade média de 39 ± 21,4 anos foram incluídos. No geral, 219 pacientes (52%) apresentavam septações na pACI; 359 (85,3%) septações interesfenoidais; 135 (37,6%) septações na pACI. Essa frequência foi maior entre os pacientes com seio esfenoidal tipo 4 ou 5 (44,7 e 43,5%, respectivamente). As septações acessórias foram encontradas em 255 doentes (60,6%); 140 dessas septações (54,9%) estavam na pACI. Entre 351 pacientes com seios esfenoidais tipos 3, 4 ou 5 (isto é, apenas seios esfenoidais bem pneumatizados), 219 (62,4%) tinham septações na pACI. Essas frequências são superiores às relatadas na maioria dos estudos. Conclusão: A frequência de septações intraesfenoidais na pACI encontrada é considerável, é maior entre pacientes com seios mais pneumatizados. Esse achado justifica um estudo pré-operatório adequado e uma atenção especial deve ser dada durante a cirurgia transesfenoidal.

Intrasphenoid septations inserted into the internal carotid arteries: a frequent and risky relationship in transsphenoidal surgeries.

INTRODUCTION: When an expanded endonasal transsphenoidal surgical approach is performed, intrasphenoid septations must be completely resected. If these structures are close to the internal carotid artery (ICA), then their manipulation might cause vascular injury. OBJECTIVE: The objective of this study is to describe the frequency of intrasphenoid septations in the internal carotid artery protuberance (ICAp). METHODS: Computed tomography (CT) scans of 421 patients were analysed. Intrasphenoid septations (classified as intersphenoid or accessory) and their relationship to the ICAp were described. Additionally, a sphenoid sinus classification was performed based on their degree of pneumatisation to determine whether a difference exists in the frequency of intrasphenoid septations inserted into ICAp with regard to sinus type. RESULTS: The patient mean age was 39±21.4 years. Overall, 219 patients (52%) had septations in the ICAp; 359 patients (85.3%) had intersphenoid septations; of the latter, 135 (37.6%) had septations in the ICAp. This frequency was higher among patients with sphenoid sinus type 4 or 5 (44.7% and 43.5%, respectively). Accessory septations were found in 255 patients (60.6%); 140 of these septations (54.9%) were in the ICAp. Among 351 patients with types 3, 4 or 5 sphenoid sinuses (i.e., only well-pneumatised sphenoid sinuses), 219 (62.4%) had septations in the ICAp. These frequencies are higher than those reported in most previous studies. CONCLUSION: The frequency of intrasphenoid septations in the ICAp found is considerable. It is higher among patients with more pneumatised sinuses. This finding justifies an appropriate pre-operative study, and careful attention must be paid during transsphenoidal surgery.

A review on the diagnosis and treatment of patients with clinically nonfunctioning pituitary adenoma by the Neuroendocrinology Department of the Brazilian Society of Endocrinology and Metabolism

ABSTRACT Clinically nonfunctioning pituitary adenomas (NFPA) are the most common pituitary tumors after prolactinomas. The absence of clinical symptoms of hormonal hypersecretion can contribute to the late diagnosis of the disease. Thus, the majority of patients seek medical attention for signs and symptoms resulting from mass effect, such as neuro-ophthalmologic symptoms and hypopituitarism. Other presentations include pituitary apoplexy or an incidental finding on imaging studies. Mass effect and hypopituitarism impose high morbidity and mortality. However, early diagnosis and effective treatment minimizes morbidity and mortality. In this publication, the goal of the Neuroendocrinology Department of the Brazilian Society of Endocrinology and Metabolism is to provide a review of the diagnosis and treatment of patients with NFPA, emphasizing that the treatment should be performed in reference centers. This review is based on data published in the literature and the authors’ experience. Arch Endocrinol Metab. 2016;60(4):374-90.

Morphometric analysis of the medial opticocarotid recess and its anatomical relations relevant to the transsphenoidal endoscopic endonasal approaches.

BACKGROUND: The medial opticocarotid recess (MOCR) is located in the posterior wall of the sphenoid sinus, medial to the junction of the optic canal (OC) and the carotid prominence (CP). There is controversy in the literature in relation to the presence of the MOCR and its constancy, which is relevant when approaching the skull base through an endoscopic route. METHODS: The morphometric relations of the MOCR with the surrounding structures were studied in 18 cadaveric specimens after endoscopic endonasal approach (EEA). RESULTS: The distance between both MOCR was 11.06 ± 1.14 mm; the distance between the MOCR and the lateral opticocarotid (LOCR) recess was 5.56 ± 0.85 mm; the distance between the MOCR and the suprasellar recess was 3.72 ± 0.49 mm; the angle between the MOCR plane and the OC 13.32 ± 2.30°; the angle between the MOCR plane and the CP 13.50 ± 2.68° and; the angle between the OC and the CP 26.81 ± 4.26°. All measurements showed low variability, with low standard deviation and interquartile range. No relations were found between any of the measurements. CONCLUSIONS: The MOCR may be used as a reference point for precise location of structures during EEA. Objective measurements may be especially useful in cases with distorted sphenoid bone anatomy.

Manejo quirúrgico del síndrome de silla turca vacía primaria con compromiso visual campimétrico y sin evidencia de herniación del sistema visual / Surgical treatment of primary empty sella syndrome with visual compromise and no evidence of visual system herniation

Presentamos el caso de una mujer de 36 años con síndrome de silla turca vacía primaria (STVP) caracterizado por cefalea, estrechamiento concéntrico periférico progresivo de la visión y oligomenorrea, quien fue sometida a remodelamiento selar con colocación de un autoinjerto intraselar. La evolución postoperatoria fue con mejoría importante del defecto campimétrico, en ambos ojos.

We report the case of a 36 year old woman with primary empty sella syndrome (PESS) and symptoms consisting in headache, progressive concentric peripheral narrowing of vision and oligomenorrhea, who underwent sellar remodeling with placement of an intrasellar autograft. Post operative course showed bilateral improvement in campimetric defect.

Apoplejía postoperatoria de un macroadenoma hipofisiario residual e infarto de la arteria cerebral media / Post-operative apoplexy of a residual pituitary macro-adenoma and middle cerebral artery infarction

La apoplejía postoperatoria de los adenomas hipofisiarios es una complicación rara vez reportada. La presión ejercida por el tumor residular edematoso puede comprometer estructuras nerviosas y vasculares adyacentes a la región selar. Describios el caso de un hombre de 69 años de edad con un tumor selar gigante a quien le fue realizada una resección incompleta a través de un acceso pterional. La cirugía fue detenida por inestabilidad hemodinámica. Cuarenta y ocho horas más tarde, desarrolla oftalmparesias y disminución bilateral de la agudeza visual, deterioro del estado de consciencia, poliuria y hemiparesia izquierda. Una tomografía cerebral simple de emergencia demostró incremento del volumen tumoral con hemorragia y un infarto en el territorio de la arteria cerebral media derecha. El paciente falleció siete días más tarde. Este caso ejemplifica esta rara y catastrófica complicación con alta morbilidad y mortalidad. En la revisión de la literatura, solo fueron encontrados dos casos de ictus isquémico debido a la compresión de arterias intracraneales mayores por apoplejía postoperatoria de macroadenomas residuales.

Postoperative apoplexy of residual pituitary adenomas is a rarely reported complication. Pressure from edematous residual tumor may affect vascular and nervous structures adjacent to sellar region. We described a 69 years old man with a giant sellar tumor who underwent to incomplete resection through pterional approach. Surgery was stopped by hemodynamic instability. Forty-eight hours later, he developed bilateral decreased of visual acuity, bilateral ophthalmoparesis, drowsiness, polyuria and left hemiparesis. An emergency computed tomography scan showed increase in tumor volume with hemorrhage and an infarct of right middle cerebral artery. The patient died seven days later. This case exemplifies this rare and catastrophic complication with high morbidity and mortality. On literature review, only two cases of ischemic strokes due to compression major intracranial arteries by postoperative tumor apoplexy were found.