Predictors for visual dysfunction in nonfunctioning pituitary adenomas - implications for neurosurgical management.

BACKGROUND: Despite ample experience with surgical treatment of nonfunctioning pituitary adenomas, objective data defining the risk for visual compromise depending on the suprasellar extension in pituitary adenomas are sparse. DESIGN AND PATIENTS: We measured the suprasellar extension of 98 newly diagnosed suprasellar nonfunctioning pituitary adenomas on sagittal and coronal magnetic resonance images using reference lines for the skull base level. In addition, the position of the optic chiasm in relation to the suprasellar adenoma was assessed. The findings were correlated with the degree of visual dysfunction and with the type of visual field defects (VFD). RESULTS: Seventy per cent of the patients suffered from VFD. The most frequent perimetric findings were bilateral (81·2%) or unilateral (10·1%) temporal hemifield defects. For the coronal view, a suprasellar extension of 12 mm was a practicable cut-off value for emergence of visual disturbances (87·0% sensitivity, 72·4% specificity). For the sagittal view, 8-mm suprasellar extension was a suitable cut-off for appearance of chiasma syndrome (87·0% sensitivity, 75·9% specificity). In five of seven cases without a chiasma syndrome despite a suprasellar extension >12 (coronal) and 8 mm (sagittal), the optic chiasm was found in an anterior position. No correlation was found between the position of the chiasm (i.e. anterior, superior or posterior) and the type of VFD (P = 0·647). A highly significant correlation was found between the decline of visual acuity and the suprasellar adenoma extension (P < 0·0001). CONCLUSION: Cut-off values possess a high sensitivity and specificity for imminent visual disturbances and are helpful for clinical decision-making. A delayed emergence of visual dysfunction may be observed with an anterior position of the optic chiasm.

Contemporary microsurgical concept for the treatment of Cushing's disease: endocrine outcome in 83 consecutive patients.

BACKGROUND: Evidence suggests that occult adenoma remnants are responsible for persistent Cushing's disease (CD) following transsphenoidal surgery (TSS). To optimize the outcome, we have adapted our microsurgical concept. The influence of our surgical strategy on remission rate and pituitary function is presented. DESIGN AND PATIENTS: 83 patients undergoing TSS for newly diagnosed CD. An enlarged resection was performed in 36 patients. A modified exploration technique with radial incisions was performed in 19 patients in whom an adenoma was not readily detectable. RESULTS: The overall remission rate of primary surgery was 84·3% (70/83). A remission rate of 87·5% (63/72) was achieved in microadenomas. Six patients with microadenomas were re-operated for persistence, and hypercortisolism was corrected in five of them. With re-operation included, the overall remission rate for microadenomas was 94·4%. No procedure-related complications occurred in primary surgery. Of the patients in remission, 72·5% had early postoperative random cortisol levels below 2 µg/dl, 17·4% had cortisol levels between 2 and 5 µg/dl, and 10·1% had cortisol levels >5 µg/dl. 15·2% of the patients with microadenomas developed postoperative partial hypopituitarism and 3% diabetes insipidus. No increased rate of hypopituitarism was found with enlarged adenomectomy compared to selective adenomectomy. Only a slightly higher rate of partial hypopituitarism (23·1%) was found if extensive exploration was required. CONCLUSION: With our microsurgical concept, a high initial cure rate is achievable with minimal surgical morbidity. Enlarged adenomectomy has no adverse effect on the rate of postoperative hypopituitarism. Early repeat surgery is a successful option if CD persists.

Postoperative intracranial seeding of craniopharyngiomas--report of three cases and review of the literature.

PURPOSE: Seeding of craniopharyngioma has been rarely reported. We present three cases that ectopically recurred with seeding along the surgical route and CSF spaces. METHODS: The first patient was a 13-year-old boy who had initially undergone radical excision of a suprasellar and retrosellar craniopharyngioma by a right pterional approach. Postoperative MRI showed no evidence of residual tumor. Two years later, MRI revealed a local recurrence and in addition a separated cystic tumor on the right side adjacent to the middle cerebral artery consistent with seeding along the surgical route. Both tumors were removed by re-operation. On histopathological examination, both, the local recurrent tumor and the distant deposit turned out to be adamantinomatous craniopharyngiomas. The second patient was a 27-year-old woman who was operated on for the first time via a right pterional and 1 year later for a recurrent craniopharyngioma via a transsphenoidal approach. Two years later, MRI revealed a right fronto-lateral intracranial metastasis at the site of the former craniotomy, which was removed by re-craniotomy. This deposit in the operative pathway was found to be an adamantinomatous craniopharyngioma, as was the initial tumor. The third patient was a 42-year-old man who was operated on 10 years ago for the first time via a right fronto-temporal approach. The recent control MRT revealed a right parietal intracranial tumor with peripheral contrast enhancement, which was located distant to the former craniotomy. The tumor was removed and histopathological examination revealed an adamantinomatous craniopharyngioma in accordance with the initial tumor. Postoperatively, the three patients were neurologically intact. CONCLUSION: Although craniopharyngiomas exhibit a benign histopathological pattern, cerebrospinal fluid seeding along the surgical route or along the CSF pathways has been observed. Ectopic recurrence of craniopharyngioma suggests that meticulous protection of the whole surgical field and careful handling of the tumor during the operation are required. It should be emphasized that long-term follow-up is mandatory, even in patients undergoing a total removal.