Abstract: Post-operative care of major neurosurgical procedures is aimed at the prevention, detection and treatment of secondary brain injury. This consists of a series of pathological events (i.e. brain edema and intracranial hypertension, cerebral hypoxia/ischemia, brain energy dysfunction, non-convulsive seizures) that occur early after the initial insult and surgical intervention and may add further burden to primary brain injury and thus impact functional recovery. Management of secondary brain injury requires specialized neuroscience intensive care units (ICU) and continuous advanced monitoring of brain physiology. Monitoring of intracranial pressure (ICP) is a mainstay of care and is recommended by international guidelines. However, ICP monitoring alone may be insufficient to detect all episodes of secondary brain insults. Additional invasive (i.e. brain tissue PO2, cerebral microdialysis, regional cerebral blood flow) and non-invasive (i.e. transcranial doppler, near-infrared spectroscopy, EEG) brain monitoring devices might complement ICP monitoring and help clinicians to target therapeutic interventions (e.g. management of cerebral perfusion pressure, blood transfusion, glucose control) to patient-specific pathophysiology. Several independent studies demonstrate such multimodal approach may optimize patient care after major neurosurgical procedures. The aim of this review is to evaluate some of the available monitoring systems and summarize recent important data showing the clinical utility of multimodal neuromonitoring for the management of main acute neurosurgical conditions, including traumatic brain injury, subarachnoid hemorrhage and stroke.
Abstract: Spinal epidural hematoma (SEH) is a rare neurosurgical emergency. SEH is characterized by an archetypal clinical presentation including abrupt spinal pain followed more or less rapidly by various degrees of neurological deficit. The diagnosis of SEH, often based on a clinical presumption, represents a clinical challenge. Several reports have outlined missed or delayed diagnosis due to unusual and confusing onsets or unawareness of this diagnosis by physicians. Therefore, physicians should keep in mind the possibility of SEH in their differential diagnosis when confronted with patients complaining of sudden onset of acute spinal pain with or without neurological sign, because the impact of a delayed diagnosis can be disabling catastrophic neurological sequelae. We suggest that SEH is a dynamic disease, which occurs in patients with an abnormal vasculature structural degenerative change. The bleeding is probably of multifactorial origin incriminating veins as well as arteries. Therefore, we proposed a classification of SEH, according to the most probable etiology whatever the associated factors, in six groups: spontaneous, secondary, iatrogenic, traumatic, recurrent, and idiopathic SEH.
Abstract: Traumatic brain injury (TBI) is recognized as a cause of hypopituitarism even after mild TBI. Although over the past decade, a growing body of research has detailed neuroendocrine changes induced by TBI, the mechanisms and risk factors responsible for this pituitary dysfunction are still unclear. Around the world, sports-especially combative sports-are very popular. However, sports are not generally considered as a cause of TBI in most epidemiological studies, and the link between sports-related head trauma and hypopituitarism has not been investigated until recently. Thus, there is a paucity of data regarding this important concern. Because of the large number of young sports participants with near-normal life expectancy, the implications of undiagnosed or untreated postconcussion pituitary dysfunction can be dramatic. Understanding the pathophysiological mechanisms and risk factors of hypopituitarism caused by sports injuries is thus an important issue that concerns both medical staff and sponsors of sports. The aim of this paper was to summarize the best evidence for understanding the pathophysiological mechanisms and to discuss the current data and recommendations on sports-related head trauma as a cause of hypopituitarism.
Abstract: Object The cavernous sinus and surrounding regions-specifically the Meckel cave, posterior sector of the cavernous sinus itself, and the upper part of the petroclival region-are the location of a large variety of lesions that require individual consideration regarding treatment strategy. These regions may be reached for biopsy by a percutaneous needle inserted through the foramen ovale. The aim of this retrospective study was to evaluate the diagnostic accuracy of percutaneous biopsy in a consecutive series of 50 patients referred for surgery between 1991 and 2010. Methods Seven biopsies (14%) were unproductive and 43 (86%) were productive, among which 28 lesions subsequently underwent histopathological examination during a second (open) surgery. To evaluate the diagnostic accuracy of the procedure, results from surgery were compared with those from the biopsy. Results Sensitivity of the percutaneous biopsy was 0.83 (95% CI 0.52-0.98), specificity was 1 (95% CI 0.79-1), and κ coefficient was 0.81. Conclusions Because of its valuable diagnostic accuracy, percutaneous biopsy of the cavernous sinus and surrounding regions should be performed in patients with parasellar masses when neuroimaging does not provide sufficient information of a histopathological nature. This procedure would enable patients to obtain the most appropriate therapy, such as resective surgery, corticosteroids, chemotherapy, radiotherapy, or radiosurgery.
Abstract: Pituitary surgery is a recent development in neurosurgery and most of the surgical techniques concerned have been described within the last century. We provide a historical perspective by reviewing the major steps in the development of this neurosurgical subspecialty through the ages. We concentrate on the most important figures whose advances in the study of the physiology and anatomy of the pituitary are most significant. This journey into the past will demonstrate that our current knowledge is the summation of a long road of investigation.
Abstract: During the last two decades, endoscopic endonasal approach has completed the minimally invasive skull base surgery armamentarium. Endoscopic endonasal skull base surgery (EESBS) was initially developed in the field of pituitary adenomas, and gained an increasing place for the treatment of a wide variety of skull base pathologies, extending on the midline from crista galli process to the occipitocervical junction and laterally to the parasellar areas and petroclival apex. Until now, most studies are retrospective and lack sufficient methodological quality to confirm whether the endoscopic endonasal pituitary surgery has better results than the microsurgical trans-sphenoidal classical approach. The impressions of the expert teams show a trend toward better results for some pituitary adenomas with the endoscopic endonasal route, in terms of gross total resection rate and probably more comfortable postoperative course for the patient. Excepting intra- and suprasellar pituitary adenomas, EESBS seems useful for selected lesions extending onto the cavernous sinus and Meckel's cave but also for clival pathologies. Nevertheless, this infatuation toward endoscopic endonasal approaches has to be balanced with the critical issue of cerebrospinal fluid leaks, which constitutes actually the main limit of this approach. Through their experience and a review of the literature, the authors aim to present the state of the art of this approach as well as its limits.
Abstract: PURPOSE: To evaluate the diagnostic accuracy of ultrasonography of optic nerve sheath diameter (ONSD) for assessment of intracranial hypertension. METHODS: Systematic review without language restriction based on electronic databases, with manual review of literature and conference proceedings until July 2010. Studies were eligible if they compared ultrasonography of ONSD with intracranial pressure (ICP) monitoring. Data were extracted independently by three authors. Random-effects meta-analysis and meta-regression were performed. RESULTS: Six studies including 231 patients were reviewed. No significant heterogeneity was detected for sensitivity, specificity, positive and negative likelihood ratios or diagnostic odds ratio. For detection of raised intracranial pressure, pooled sensitivity was 0.90 [95% confidence interval (CI) 0.80-0.95; p for heterogeneity, p (het)Â =Â 0.09], pooled specificity was 0.85 (95% CI 0.73-0.93, p (het)Â =Â 0.13), and the pooled diagnostic odds ratio was 51 (95% CI 22-121). The area under the summary receiver-operating characteristic (SROC) curve was 0.94 (95% CI 0.91-0.96). CONCLUSIONS: Ultrasonography of ONSD shows a good level of diagnostic accuracy for detecting intracranial hypertension. In clinical decision-making, this technique may help physicians decide to transfer patients to specialized centers or to place an invasive device when specific recommendations for this placement do not exist.
Abstract: Object Because of their size and lateral extension, total removal of nonfunctioning pituitary adenomas (NFPAs) remains a challenge and postoperative tumor remnants are frequent. Endoscopy has improved the surgeon's view; however, its superiority in terms of surgical outcome remains undetermined. The authors' aim in this study was to compare the clinical results and morbidity between microscopic and endoscopic techniques in 164 patients with NFPAs. Methods Tumoral (3D MR imaging), endocrinological, and ophthalmological results and morbidity were compared between 2 groups of 82 patients with newly diagnosed NFPAs surgically treated via either a sublabial microscopic approach (Group B) or a fully endonasal endoscopic technique (Group A). Results The groups showed no difference in terms of clinical features, tumor size, or cavernous sinus invasion (p > 0.05). One year postoperatively, the quality of resection was significantly improved in Group A (gross-total removal [GTR]: 74% vs 50% in Group B, p = 0.002) with greater control of lateral extension (Knosp Grade 2: GTR 88.2% vs 47.8% in Group B, p = 0.02; Knosp Grade 3: 67.9% vs 16.7% in Group B, p < 0.001) and suprasellar extension (tumor height 20-30 mm: GTR 76% vs 53% in Group B, p = 0.01). Endocrinological outcome in patients with a partial deficiency in anterior pituitary function preoperatively was significantly better in Group A (improvement 56% vs 25% in Group B, stabilization 22% vs 46%, and aggravation 22% vs 29%; p = 0.01). Among the ophthalmologically symptomatic patients, 100% from Group A improved compared with 93% in Group B (p = 0.35). Lastly, no significant difference was found regarding morbidity. These data were supported by the literature in which the GTR rate is consistently higher for endoscopy compared with microscopy. Conclusions In this large series of patients with NFPAs, endoscopy improved the quality of resection and endocrinological outcome. Larger studies focusing on the impact of these promising results on the long-term recurrence of NFPAs are warranted.
Abstract: Nontraumatic intracerebral hemorrhage constitutes a major public health problem worldwide. Intracerebral hemorrhage leads to a high rate of morbidity and mortality. To date, no medical or surgical trials have clearly attested to the benefit of a particular therapy. The aim of this review was to summarize the best evidence for management decision-making in intracerebral hemorrhage.
Abstract: Adams-Oliver syndrome is a rare congenital anomaly characterized by aplasia cutis congenita (ACC) and variable degrees of terminal transverse limb defects. We report on a neonatal case with the sporadic form of the disease with minimal expression, illustrating the wide spectrum of clinical expression in Adams-Oliver syndrome. We also review the literature and highlight the different pathogenetic hypotheses of this syndrome.
Abstract: Although hearing loss in newborns and infants is predominantly due to malformations and infections, there are other situations which may compromise hearing quality in later stages, including posterior-fossa arachnoid cysts (ACs). We report the case of an 8-year-old girl who presented with hearing loss linked to a pontocerebellar-angle AC which had been diagnosed and treated when she was 14 months old. The pathophysiology of this late AC complication is discussed. This case reminds us that a close follow-up with audiologic monitoring and/or brain stem auditory evoked response is necessary in children with posterior-fossa AC because modern neuroradiological imaging methods do not inform about cerebral and nerve functions, although they provide excellent morphological details of ACs and have improved the ease and accuracy of their early diagnosis. Therefore, surgery should be performed before complete hearing loss occurs; however, in hearing-impaired patients, it remains unclear which surgical treatment is most appropriate.
Abstract: Background: Astrocytomas are the most common brain tumours, accounting for 28 – 50% of all primary CNS tumours. Diagnosis of CNS tumours remains difficult because the varied and nonspecific presentations of CNS tumours in childhood. Objectives/method: The clinical presentations of CNS astrocytomas vary with their sites of location; therefore, a period of uncertainty often precedes diagnosis, and approximately 42% of patients with an intracranial process make several visits to various physicians between the onset and diagnosis. However, on clinical suspicion of a brain tumour, a wide range of neuroimaging techniques may be used to assess the diagnosis of paediatric brain lesions. In this review the authors, for ease of presentation, describe the clinical presentations of supratentorial, infratentorial and spinal cord astrocytomas as well as their radiological and pathological features, and discuss their differential diagnoses. Results/conclusions: Understanding and mastering the numerous imaging features of several subtypes of primary brain tumours affecting children, in addition to radiological features of non-tumoural disorders, remains a significant challenge and demands increased awareness of the paediatric brain diseases.
Abstract: Ventriculoperitoneal (VP) shunt surgery is the most used technique for the treatment of hydrocephalus. This procedure is associated with a large amount of complications. Bowel perforation caused by a peritoneal shunt catheter is one of these complications, sometimes fatal, and is usually difficult to recognize, except when protrusion of the peritoneal catheter through a natural orifice occurs. This report presents the case of a 2-year-old boy who had undergone a VP shunt and later presented with protrusion of the peritoneal catheter through his mouth. The shunt device was removed and an external shunt procedure was achieved, using the original ventricular catheter kept in place. The diagnosis of bacterial meningitis was retained and an antibiotic therapy was started. The evolution was fatal in 15 days secondary to a bacterial ventriculitis. Through the reported cases of bowel perforation, many risk factors were individualized, such as age, congenital etiology of the hydrocephalus, silicon allergy or the length of the peritoneal catheter. Bowel perforation is a serious complication of VP shunt surgery, leading sometimes to a fatal outcome.
Abstract: Metastatic spreading is a rare complication of meningioma. We report a subcutaneous metastasis from an atypical meningioma of the tentorium. A 69-year-old man presented with a meningioma of the tentorium. The tumor was totally resected. The histological diagnosis was atypical meningioma. The tumor recurred two years later and was irradiated. Despite irradiation, the tumor progressed and was resected three years later. Five months following the second surgery, an isolated subcutaneous mass developed at the skin incision and was resected. The histological examination of the subcutaneous tumor showed histological features of atypical meningioma. Surgery of atypical meningioma carries the risk of iatrogenic metastasis, despite previous irradiation.
Abstract: Knowledge of the pathological diagnosis before deciding the best strategy fortreating parasellar lesions is of prime importance, due to the relative high morbidity and side-effects of open direct approaches to this region, knownto be rich in important vasculo-nervous structures. When imaging is not evocative enough to ascertain an accurate pathological diagnosis, a percutaneous biopsy through the transjugal-transoval route (of Hartel) may be performed to guide the therapeutic decision. The chapter is based on the authors’ experience in 50 patients who underwent the procedure over the ten past years. There was no mortality and only little (mostly transient) morbidity. Pathological diagnosis accuracy of the method revealed good, with a sensitivity of 0.83 and a specificity of 1. In the chapter the authors first recall the surgical anatomy background from personal laboratory dissections. They then describe the technical procedure, as well as the tissue harvesting method. Finally they define indications together with the decision-making process. Due to the constraint trajectory of the biopsy needle inserted through the Foramen Ovale, accessible lesions are only those located in the Meckel trigeminal
Cave, the posterior sector of the cavernous sinus compartment, and the upper part of the petroclival region.
The authors advise to perform this percutaneous biopsy method when imaging does not provide sufficient evidence of the pathological nature of the lesion, for therapeutic decision. Goal is to avoid unnecessary open surgery or radiosurgery, also inappropriate chemo-=radio-therapy.
Abstract: Rationale: Endoscopic endonasal routes represent actually an awesome complement to skull base surgeons, gaining incremental fields of applications for anterior, middle and posterior skull base diseases. In the specific field of anterior and middle skull base tumors, extended endonasal endoscopic approaches have raised the issues of skull base reconstruction and postoperative cerebrospinal fluid leakage as well as quite constant postoperative rhinological morbidity. Moreover, the tumoral margins especially for meningioma cannot be clearly exposed leading to a higher risk of recurrence. Therefore, we propose as an alternative the purely endoscopic supraorbital approach to anterior and middle skull base tumors, either through an eyebrow or an eyelid incision.
Methods: These approaches have been used in 15 patients: 80% meningiomas (one cribriform plate, one planum sphenoidale, 10 tuberculum and diaphragma sellae) and 20 % suprasellar pituitary adenomas. Eyelid incision was preferred in case a small eyebrow, large frontal sinus or anteriorly based tumor that required a more lateral entry point.
Results: Complete resection has been performed in all cases. All patients improved or normalized their ophthalmologic exams and cosmetic results were excellent. Morbidity includes 2 cases of eyelid hematoma treated medically with no mortality. There were no CSF leaks.
Conclusion: These approaches provide an enhanced visualization of neurovascular structures provided by high definition endoscopes compared to microscope while reducing dramatically the risk of CSF leak and eliminating the rhinological discomfort that may be observed after endonasal procedures. The purely endoscopic supraorbital approach represents a valuable mini-invasive technique for small or medium-sized tumors involving the anterior and middle skull base.
Abstract: Background and aims: Endoscopy, improving the lateral vision, may allow a better resection of the lateral part of pituitary adenomas (PA). The aim of this study was to evaluate the quality of resection of PA, suspected of invading the cavernous sinus, operated on by PEETS.
Methods: Tumoral (3D MRI), endocrinological, ophthalmological results and morbidity were retrospectively analyzed in a series of 112 patients bearing PA invading the cavernous sinus (grade II, III or IV of the Knosp's classification) and operated on between 2007 and 2010. For all, authors tried to remove as much as feasible the lateral extension of tumors remaining nevertheless medial with regard to the internal carotid. The quality of resection to the Knosp's grading was judged on MRI for Non Functioning Pituitary Adenomas (NFPA) and on endocrinological criteria of cure for Functioning Pituitary Adenomas (FPA).
Results: They were 76 NFPA (grade II:25;III:42;IV:9) and 36 FPA including 26 somatotropic adenomas (II:14;III:11;IV:1), 6 prolactinomas (II:4;III:2) and 4 corticotropic adenomas (II:1;III:2;IV:1). Gross total removal (GTR) or cure was achieved in 69.7% of NFPA (II:88%;III:73.8%;IV:0%;p< 0.001), 57.7% of somatotropic adenomas (II:78.6%;III:36.4%;IV:0%;p=0.04), 33.3% of prolactinomas (II:50%;III:0%;p>0.05) and 50% of corticotropic adenomas (II:100%;III/IV:0%;p>0;05). No difference was observed regarding ophthalmological and endocrinological results as well as regarding morbidity according to the grade.
Conclusions: Due to a better visualization, the removal of the cavernous sinus extension can be attempt with endoscopy without additional morbidity. This allows a GTR or cure in 73.8% and 36.4% of grade III NFPA and somatotrophic adenomas respectively.
Abstract: Background and aims: Total removal of nonfunctioning pituitary adenoma (NFPAs) remains a challenge for neurosurgeons. Endoscopy has improved the surgeon's view. However, its superiority in terms of quality of resection remains unclear. The aim of this study was to compare the clinical results and morbidity between microscopic and endoscopic techniques in 164 patients with NFPAs operated on by the same author.
Methods: Tumoral (3D MR imaging), endocrinological, and ophthalmological results and morbidity were compared between 2 groups of 82 patients with newly diagnosed NFPAs surgically treated via either a sublabial microscopic approach (Group B) or a fully endonasal endoscopic technique (Group A). The results were judged at 12 months.
Results: Endoscopy significantly improved the quality of resection in group A with greater control of lateral extension (Knosp Grade 2: Gross total removal (GTR) 88% vs 47.8% in group B,p = 0.02;Knosp grade 3: 67.9% vs 16.7% in group B,p < 0.001) and suprasellar extension (tumor height 20-30mm : GTR 76% vs 53% in group B, p=0.01). Endocrinological outcome in patients with a partial deficiency in anterior pituitary function preoperatively was significantly better in Group A (improvement 56% vs 25% in Group B, stabilization 22% vs 46%, and aggravation 22% vs 29%;p = 0.01). No significant difference was found regarding morbidity.
Conclusions: In this series of 164 NFPAs, endoscopy significantly improved the quality of resection and endocrinological outcome, especially regarding tumors with lateral and suprasellar extension. We recommend that endoscopy should be considered as the choice technique for NFPAs removal.
Abstract: Non Functioning Pituitary Macroadenomas still challenge neurosurgeons with frequent postoperative tumor remnants. Due to the panoramic view provided by endoscopy, one can expect tumor removal to improve. We therefore compared the results obtained with the microscope to those obtained with an endoscopic procedure in a consecutive series of 65 macroadenomas operated by a single surgeon.
Thirty six patients with Non Functioning Pituitary Adenomas were operated with a pure endoscopic endonasal approach (17 males, 19 females; mean age: 55 years). The patients were explored pre-operatively and post-operatively by static and dynamic tests for pituitary functions, ophthalmologic exams and by 3D-contrast MRI. Endocrinological and ophthalmologic results, the percentage of tumor remnant and morbidity were compared to a cohort of 29 patients (19 males, 10 females; Mean age: 54 years) explored with the same protocol and treated the year before with the microscope.
Preoperatively, in the endoscopic group, 68.5 and 61.1% of the patients demonstrated visual and endocrinological abnormalities. The mean tumor diameter and height were 22 and 25.3 mm with invasion of the cavernous sinus in 19.4%. In the microsurgical group, 75.8 and 79.3% of the patients demonstrated visual and endocrinological abnormalities. The mean tumor diameter and height were 25 and 28.9 mm with invasion of the cavernous sinus in 20.6%. With the exception of the mean tumor volume diameter, none of the differences were significant. Postoperatively, in both groups, none of the patients with preoperative normal ophthalmologic exams worsened. In the endoscopic group, 100% of the symptomatic patients improved whereas 90.9% improved, 4.5% remained stable and 4.5% worsened in the microsurgical group. Regarding anterior pituitary functions in the whole population, 42.8% of the patients improved, 45.7% remained
unchanged and 11.4% worsened in the endoscopic group compared to respectively 26.9, 44.8 and 24.1% in the microsurgical group. Definitive insipid diabetes occurred in two patients in the endoscopic group and in one in the microsurgical group. Complete removal was achieved in 86.1% with endoscopy and in 65.5% with microsurgery without compressive tumor remnant in the first group as opposed to 2 in the latter. Six postoperative LCS fistulas occurred (one meningitis) in the endoscopic group versus 4 LCS fistulas (2 meningitis) for the microsurgical
group.
Even though it wasn't a randomized study, endoscopy seems to be more efficient in treating non Functioning Pituitary Adenomas and may be recommended as the treatment of choice to treat such pituitary tumors.
