RESUMEN
BACKGROUND: Transsphenoidal surgery (TSS) is the main method to remove pituitary neuroendocrine tumor (PitNET), but large or multi-lobulated one is still challenging. OBJECTIVE: The less invasive simultaneous combined keyhole mini-transcranial approach and standard transsphenoidal approach was used to remove multi-lobulated or hourglass-shaped non-functioning PitNET to avoid the specific complications related to extended TSS. METHODS: Twenty-one patients of large multi-lobulated or hourglass-shaped PitNET (6 patients were recurrent cases after TSS or transcranial approach) were treated by this simultaneous combined approach. The supraorbital or midline keyhole approach was performed under the operating microscope so that the fine arteries feeding optic apparatus were dissected from the tumor capsule safely and securely and the suprasellar part of the tumor was removed in the extra-capsular fashion in combination with transsphenoidal approach. RESULTS: Visual function improved after the surgery in 14 (74â¯%) of 19 patients with preoperative disturbance of the visual fields. Four patients (19â¯%) developed postoperative deterioration of pituitary endocrine functions requiring permanent hormonal replacement. One patient (4.2â¯%) suffered cortical laminar necrosis without permanent disorders and another patient (4.2â¯%) suffered cerebrospinal fluid rhinorrhea but neither was permanent. Postoperative computed tomography detected no subarachnoid hemorrhage in any patient. Gross total removal was achieved in 15 patients (71â¯%). Five patients (24â¯%) with subtotal removal and one patient (4.2â¯%) with partial removal had lateral tumor extension with Knosp classification 3 or 4. CONCLUSION: The combined method is an effective treatment option to remove complex PitNET safely and securely with dissecting fine arteries on the tumor capsule.
Asunto(s)
Tumores Neuroendocrinos , Neoplasias Hipofisarias , Humanos , Neoplasias Hipofisarias/cirugía , Neoplasias Hipofisarias/diagnóstico por imagen , Femenino , Masculino , Persona de Mediana Edad , Adulto , Tumores Neuroendocrinos/cirugía , Tumores Neuroendocrinos/patología , Anciano , Procedimientos Neuroquirúrgicos/métodos , Resultado del Tratamiento , Craneotomía/métodos , Neuroendoscopía/métodos , Adulto Joven , Complicaciones Posoperatorias , Hueso Esfenoides/cirugíaRESUMEN
BACKGROUND: The sphenoid wing dural arteriovenous fistula (AVF) is rare, and can manifest with severe symptoms, particularly in cases classified as greater sphenoid wing type. Endovascular therapy is generally employed, however, open surgical intervention could be warranted in cases with complex fistula. METHOD: We present a case with ruptured greater sphenoid wing dural AVF (Cognard type IV), in which endovascular embolization using liquid material was performed, followed by open surgery to concurrently disconnect the fistula and evacuate the hematoma. CONCLUSION: The sphenoid wing dural AVFs may be effectively cured by open surgery for fistula disconnection in conjunction with endovascular embolization.
Asunto(s)
Malformaciones Vasculares del Sistema Nervioso Central , Embolización Terapéutica , Humanos , Malformaciones Vasculares del Sistema Nervioso Central/cirugía , Malformaciones Vasculares del Sistema Nervioso Central/diagnóstico por imagen , Malformaciones Vasculares del Sistema Nervioso Central/terapia , Embolización Terapéutica/métodos , Masculino , Procedimientos Endovasculares/métodos , Hueso Esfenoides/cirugía , Hueso Esfenoides/diagnóstico por imagen , Resultado del Tratamiento , Persona de Mediana Edad , Femenino , Angiografía CerebralRESUMEN
BACKGROUND AND IMPORTANCE: Spheno-orbital meningiomas (SOMs) pose a challenge to the skull base neurosurgeon because of their variable presentation and involvement of critical structures within the orbit. There is no consensus on optimal management of these patients and how to achieve maximal safe resection. The authors share an illustrative case with an accompanying video to demonstrate their aggressive approach to resect SOMs and their intraorbital components. CLINICAL PRESENTATION: A 75-year-old-woman presented with progressive vision loss and proptosis. Magnetic resonance imaging was consistent with a large, left-sided sphenoid wing meningioma with extension to the orbital wall and compression of the optic nerve medially. The patient elected to undergo surgical excision and optic nerve decompression. She did well postoperatively with resolution of proptosis and good resection margins on follow-up imaging. CONCLUSION: Aggressive resection of SOMs is possible with an understanding of the underlying anatomy. Familiarity with the orbit can facilitate a maximal safe resection with optic nerve decompression.
Asunto(s)
Neoplasias Meníngeas , Meningioma , Procedimientos Neuroquirúrgicos , Neoplasias Orbitales , Humanos , Meningioma/cirugía , Meningioma/diagnóstico por imagen , Femenino , Anciano , Neoplasias Meníngeas/cirugía , Neoplasias Meníngeas/diagnóstico por imagen , Procedimientos Neuroquirúrgicos/métodos , Neoplasias Orbitales/cirugía , Neoplasias Orbitales/diagnóstico por imagen , Hueso Esfenoides/cirugía , Hueso Esfenoides/diagnóstico por imagen , Descompresión Quirúrgica/métodos , Órbita/cirugía , Órbita/diagnóstico por imagen , Imagen por Resonancia MagnéticaRESUMEN
BACKGROUND: Rhinorrhea is a common complication after endoscopic endonasal transsphenoidal pituitary surgery (EETPS). This study evaluates the effectiveness of our sellar reconstruction technique in preventing rhinorrhea. METHODS: From June 2020 to March 2024, a surgical team performed 490 EETPS procedures on 458 pituitary adenoma patients. Demographic data, surgery status, and radiological and histopathological classifications were retrospectively analyzed. 4 grades for sellar reconstruction were defined based on intraoperative cerebrospinal fluid (CSF) leakage and diaphragm sella defect size. Grade 0: no CSF leakage; cavity filled with absorbable material. Grade 1: small defect; covered with fat and fascia lata grafts. Grade 2: large defect; added lumbar drainage. Grade 3: extended approach; added nasoseptal flap. RESULTS: Of the 490 operations, 433 were primary and 57 recurrent. Patients were 50.2% male, mean age 49.01 years. Follow-up averaged 20.5 months. Postoperative rhinorrhea occurred in 8 cases (1.6%). In 404 surgeries (82.5%) without intraoperative CSF leakage, 3 cases (0.7%) developed postoperative rhinorrhea. CSF leakage was detected in 86 cases (17.5%), with postoperative rhinorrhea in 5 cases (5.8%). The risk of rhinorrhea was 8.3 times higher with intraoperative CSF leakage (P = 0.005). Rhinorrhea rates: 0.7% in Grade 0, 3% in Grade 1, 8.7% in Grade 2, and 0% in Grade 3 (P = 0.017). Meningitis occurred in 8 patients (1.7%) and pneumocephalus in 4 (0.9%), with one death (0.2%). The average hospital stay was 17.4 days with rhinorrhea and 5.2 without (P = 0.024). CONCLUSIONS: Intraoperative CSF leakage is highly correlated with rhinorrhea. Multilayered and graded closure strategies significantly reduce postoperative rhinorrhea rates in EETPS.
Asunto(s)
Rinorrea de Líquido Cefalorraquídeo , Neoplasias Hipofisarias , Procedimientos de Cirugía Plástica , Complicaciones Posoperatorias , Silla Turca , Humanos , Masculino , Femenino , Persona de Mediana Edad , Adulto , Neoplasias Hipofisarias/cirugía , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/etiología , Complicaciones Posoperatorias/prevención & control , Estudios Retrospectivos , Rinorrea de Líquido Cefalorraquídeo/etiología , Rinorrea de Líquido Cefalorraquídeo/prevención & control , Rinorrea de Líquido Cefalorraquídeo/epidemiología , Anciano , Silla Turca/cirugía , Procedimientos de Cirugía Plástica/métodos , Algoritmos , Adulto Joven , Adenoma/cirugía , Adolescente , Pérdida de Líquido Cefalorraquídeo/etiología , Pérdida de Líquido Cefalorraquídeo/epidemiología , Pérdida de Líquido Cefalorraquídeo/prevención & control , Resultado del Tratamiento , Procedimientos Neuroquirúrgicos/métodos , Procedimientos Neuroquirúrgicos/efectos adversos , Hueso Esfenoides/cirugía , Neuroendoscopía/métodos , Neuroendoscopía/efectos adversosAsunto(s)
Neoplasias Meníngeas , Meningioma , Procedimientos Neuroquirúrgicos , Humanos , Meningioma/cirugía , Meningioma/diagnóstico por imagen , Neoplasias Meníngeas/cirugía , Neoplasias Meníngeas/diagnóstico por imagen , Procedimientos Neuroquirúrgicos/métodos , Procedimientos Neuroquirúrgicos/educación , Neoplasias Orbitales/cirugía , Neoplasias Orbitales/diagnóstico por imagen , Órbita/cirugía , Órbita/diagnóstico por imagen , Hueso Esfenoides/cirugía , Hueso Esfenoides/diagnóstico por imagen , Hueso Temporal/cirugía , Hueso Temporal/diagnóstico por imagenAsunto(s)
Neoplasias Meníngeas , Meningioma , Procedimientos Neuroquirúrgicos , Humanos , Meningioma/cirugía , Meningioma/diagnóstico por imagen , Neoplasias Meníngeas/cirugía , Neoplasias Meníngeas/diagnóstico por imagen , Procedimientos Neuroquirúrgicos/métodos , Procedimientos Neuroquirúrgicos/educación , Neoplasias Orbitales/cirugía , Neoplasias Orbitales/diagnóstico por imagen , Órbita/cirugía , Órbita/diagnóstico por imagen , Hueso Esfenoides/cirugía , Hueso Esfenoides/diagnóstico por imagen , Hueso Temporal/cirugía , Hueso Temporal/diagnóstico por imagenAsunto(s)
Neoplasias Meníngeas , Meningioma , Procedimientos Neuroquirúrgicos , Humanos , Meningioma/cirugía , Meningioma/diagnóstico por imagen , Neoplasias Meníngeas/cirugía , Neoplasias Meníngeas/diagnóstico por imagen , Procedimientos Neuroquirúrgicos/métodos , Procedimientos Neuroquirúrgicos/educación , Neoplasias Orbitales/cirugía , Neoplasias Orbitales/diagnóstico por imagen , Órbita/cirugía , Órbita/diagnóstico por imagen , Hueso Esfenoides/cirugía , Hueso Esfenoides/diagnóstico por imagen , Hueso Temporal/cirugía , Hueso Temporal/diagnóstico por imagenAsunto(s)
Fístula del Seno Cavernoso de la Carótida , Complicaciones Posoperatorias , Humanos , Fístula del Seno Cavernoso de la Carótida/cirugía , Fístula del Seno Cavernoso de la Carótida/diagnóstico por imagen , Fístula del Seno Cavernoso de la Carótida/etiología , Complicaciones Posoperatorias/etiología , Complicaciones Posoperatorias/diagnóstico por imagen , Hueso Esfenoides/cirugía , Procedimientos Neuroquirúrgicos/efectos adversosAsunto(s)
Neoplasias Meníngeas , Meningioma , Procedimientos Neuroquirúrgicos , Humanos , Meningioma/cirugía , Meningioma/diagnóstico por imagen , Neoplasias Meníngeas/cirugía , Neoplasias Meníngeas/diagnóstico por imagen , Procedimientos Neuroquirúrgicos/métodos , Procedimientos Neuroquirúrgicos/educación , Neoplasias Orbitales/cirugía , Neoplasias Orbitales/diagnóstico por imagen , Órbita/cirugía , Órbita/diagnóstico por imagen , Hueso Esfenoides/cirugía , Hueso Esfenoides/diagnóstico por imagen , Hueso Temporal/cirugía , Hueso Temporal/diagnóstico por imagenRESUMEN
BACKGROUND: An ACTH-secreting pituitary adenoma is the most common cause of excessive endogenous glucocorticoid production resulting in Cushing's Syndrome. A multidisciplinary approach is paramount. Selective adenomectomy is the treatment of choice. METHOD: Endoscopic transnasal transsphenoidal approach to the tumour, along with techniques for resection, are demonstrated. CONCLUSION: Endoscopic transsphenoidal approaches with its magnified view of the pituitary gland allows precise microsurgical dissection during selective adenomectomy. This technique increases the possibility of proving a gross total resection, leading to clinical and biochemical cure in these patients.
Asunto(s)
Adenoma , Hipersecreción de la Hormona Adrenocorticotrópica Pituitaria (HACT) , Humanos , Adenoma/cirugía , Adenoma/diagnóstico por imagen , Hipersecreción de la Hormona Adrenocorticotrópica Pituitaria (HACT)/cirugía , Endoscopía/métodos , Adenoma Hipofisario Secretor de ACTH/cirugía , Neoplasias Hipofisarias/cirugía , Neoplasias Hipofisarias/diagnóstico por imagen , Neuroendoscopía/métodos , Resultado del Tratamiento , Procedimientos Neuroquirúrgicos/métodos , Femenino , Hueso Esfenoides/cirugíaRESUMEN
BACKGROUND: At times, a regulation internal carotid artery-posterior communicating artery junction (ICA-P-Comm) aneurysm becomes a surgical hurdle owing to its close proximity to the anterior clinoid process, an immovable ICA and a concealed dominant P-Comm artery arising from the aneurysm neck. METHOD: A 70 year old patient with a low lying ICA-P-Comm aneurysm underwent a "tailored" intradural clinoidectomy for aneurysm clipping. CONCLUSION: A tailored anterior clinoidectomy to expose "just enough" allows a proximal ICA control in a suitable area, mobility of an atherosclerotic ICA and exposes the P-Comm artery origin which are essential in safe clipping of these aneurysms.
Asunto(s)
Arteria Carótida Interna , Aneurisma Intracraneal , Anciano , Humanos , Enfermedades de las Arterias Carótidas/cirugía , Arteria Carótida Interna/cirugía , Arteria Carótida Interna/diagnóstico por imagen , Aneurisma Intracraneal/cirugía , Aneurisma Intracraneal/diagnóstico por imagen , Procedimientos Neuroquirúrgicos/métodos , Hueso Esfenoides/cirugía , Hueso Esfenoides/diagnóstico por imagen , Resultado del TratamientoAsunto(s)
Neoplasias Meníngeas , Meningioma , Humanos , Meningioma/diagnóstico por imagen , Meningioma/patología , Meningioma/cirugía , Neoplasias Meníngeas/diagnóstico por imagen , Neoplasias Meníngeas/patología , Pronóstico , Neoplasias Orbitales/diagnóstico por imagen , Neoplasias Orbitales/cirugía , Neoplasias Orbitales/patología , Hueso Esfenoides/diagnóstico por imagen , Hueso Esfenoides/cirugíaAsunto(s)
Neoplasias Meníngeas , Meningioma , Humanos , Meningioma/diagnóstico por imagen , Meningioma/patología , Meningioma/cirugía , Neoplasias Meníngeas/diagnóstico por imagen , Neoplasias Meníngeas/patología , Neoplasias Meníngeas/cirugía , Pronóstico , Neoplasias Orbitales/diagnóstico por imagen , Neoplasias Orbitales/cirugía , Neoplasias Orbitales/patología , Hueso Esfenoides/diagnóstico por imagen , Hueso Esfenoides/cirugíaRESUMEN
PURPOSE: Langerhans cell histiocytosis (LCH) is a rare condition arising from the monoclonal expansion of myeloid precursor cells, which results in granulomatous lesions that characteristically express CD1a/CD207. We report a case of LCH in a 3-year-old male involving the sphenoid bone with extension into the sellar/suprasellar region. CASE REPORT: A 3-year-old male presented with progressively worsening headaches and associated night sweats, neck stiffness, and fatigue over the previous 4 weeks. Magnetic resonance imaging (MRI) revealed a 2.4-cm lytic lesion within the basisphenoid, exerting mass effect upon the pituitary gland. A biopsy was performed to determine the etiology of the lesion. Postoperatively, the patient developed an intralesional hematoma with visual complications requiring emergent surgical resection via endoscopic endonasal approach. Final pathology confirmed LCH. The patient had improvement in his vision long term. CONCLUSIONS: LCH extending into the sella is a rare but important diagnosis to consider in pediatric patients presenting with lesions in this region. We presented a case of a pediatric patient presenting with LCH of the sphenoid bone extending into the sella, with subsequent apoplexy and vision loss. Review of the literature showed varying treatment options for these patients, including purely surgical and non-surgical treatments. Early intervention may be necessary to avoid potentially devastating neurologic sequelae.
Asunto(s)
Histiocitosis de Células de Langerhans , Imagen por Resonancia Magnética , Humanos , Histiocitosis de Células de Langerhans/complicaciones , Histiocitosis de Células de Langerhans/cirugía , Histiocitosis de Células de Langerhans/diagnóstico por imagen , Histiocitosis de Células de Langerhans/patología , Masculino , Preescolar , Silla Turca/diagnóstico por imagen , Silla Turca/patología , Silla Turca/cirugía , Hueso Esfenoides/cirugía , Hueso Esfenoides/diagnóstico por imagen , Hueso Esfenoides/patologíaRESUMEN
OBJECTIVE: Bilateral spheno-orbital meningiomas (bSOMs) are a rare entity among meningiomas. These tumors are benign and predominantly affect women. They represent 4% of spheno-orbital meningiomas (SOMs) and are poorly described in the literature. This study aimed to describe the characteristics, risk factors, evolution, and management of bSOMs. METHODS: Twenty patients with bSOMs were enrolled in a multicentric descriptive study including 15 neurosurgical departments. RESULTS: In this study, the authors found that bSOMs affected exclusively women, with a mean age of 50 years. Approximately 65% of patients were on progestin therapy. The mean follow-up in this series was 55 months. Clinically, visual symptoms were predominant: proptosis was present in 17 of 20 patients (85%; 7 unilateral, 10 bilateral), and a decrease in visual acuity was observed in 11 of 20 patients (55%; 6/10 to 9/10 in 6 patients, 3/10 to 5/10 in 1 patient, and < 3/10 in 4 patients). Contrary to unilateral SOMs, the authors identified that intracranial hypertension was a common presentation (25%) of bSOMs. Surgical management with gross-total resection was the gold standard treatment. Recurrences only occurred following subtotal resection in 36% to 60% of patients, with a median time of 50 to 54 months after surgery. Visual improvement or stability was observed in 75% of cases postoperatively. Progesterone receptor expression levels were 70% to 100% in 10 of 11 (91%) cases. CONCLUSIONS: Bilateral SOMs are usually found in female patients and are strongly associated with hormone replacement therapy. Early surgical management with gross-total resection is the most effective treatment in terms of recurrence and improves visual acuity. Given the slow progressive nature of bSOMs and their time to recurrence, which can be up to 10 years, long-term follow-up of patients is essential.
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Progresión de la Enfermedad , Neoplasias Meníngeas , Meningioma , Recurrencia Local de Neoplasia , Neoplasias Orbitales , Hueso Esfenoides , Humanos , Femenino , Meningioma/cirugía , Persona de Mediana Edad , Masculino , Recurrencia Local de Neoplasia/cirugía , Anciano , Adulto , Neoplasias Meníngeas/cirugía , Hueso Esfenoides/cirugía , Neoplasias Orbitales/cirugía , Estudios de Seguimiento , Procedimientos Neuroquirúrgicos/métodos , Resultado del TratamientoAsunto(s)
Neoplasias Meníngeas , Meningioma , Neoplasias Orbitales , Humanos , Meningioma/cirugía , Meningioma/diagnóstico por imagen , Meningioma/patología , Neoplasias Meníngeas/diagnóstico por imagen , Neoplasias Meníngeas/cirugía , Neoplasias Meníngeas/patología , Neoplasias Orbitales/diagnóstico por imagen , Neoplasias Orbitales/cirugía , Neoplasias Orbitales/patología , Hueso Esfenoides/diagnóstico por imagen , Hueso Esfenoides/cirugíaRESUMEN
Transsphenoid surgery is a common procedure for removing pituitary and other sellar tumors. The quality and density of the sphenoid bone, which serves as the access route to the sellar region, can affect the surgical outcomes and complications. However, there is no standardized method to assess sphenoid bone quality. I propose a sphenoid bone quality score, based on criteria and parameters derived from preoperative imaging techniques. This score could provide information on the bone characteristics and challenges of each case, and help to select the optimal surgical approach, instruments, grafts, and measures. This score could also enable a consistent evaluation of the surgery and the outcomes, and facilitate the communication and collaboration among different medical disciplines.
Asunto(s)
Procedimientos Neuroquirúrgicos , Neoplasias Hipofisarias , Hueso Esfenoides , Humanos , Procedimientos Neuroquirúrgicos/métodos , Neoplasias Hipofisarias/cirugía , Hueso Esfenoides/cirugíaRESUMEN
OBJECTIVE: The endoscopic superior eyelid transorbital approach has garnered significant consideration and gained popularity in recent years. Detailed anatomical knowledge along with clinical experience has allowed refinement of the technique as well as expansion of its indications. Using bone as a consistent reference, the authors identified five main bone pillars that offer access to the different intracranial targeted areas for different pathologies of the skull base, with the aim of enhancing the understanding of the intracranial areas accessible through this corridor. METHODS: The authors present a bone-oriented review of the anatomy of the transorbital approach in which they conducted a 3D analysis using Brainlab software and performed dry skull and subsequent cadaveric dissections. RESULTS: Five bone pillars of the transorbital approach were identified: the lesser sphenoid wing, the sagittal crest (medial aspect of the greater sphenoid wing), the anterior clinoid, the middle cranial fossa, and the petrous apex. The associations of these bone targets with their respective intracranial areas are reported in detail. CONCLUSIONS: Identification of consistent bone references after the skin incision has been made and the working space is determined allows a comprehensive understanding of the anatomy of the approach in order to safely and effectively perform transorbital endoscopic surgery in the skull base.