Carmine A. Donofrio

Presentation and surgical results of incidentally discovered nonfunctioning pituitary adenomas: evidence for a better outcome independently of other patients' characteristics

OBJECTIVE Few data are available on the surgical results in patients with incidentally discovered nonfunctioning pituitary adenoma (NFPA). We investigated the efficacy and safety of surgery in patients with incidentally discovered NFPA. DESIGN Retrospective analysis of prospectively recorded outcomes. METHODS From 1990 to 2011, of 804 consecutive patients undergoing surgery for NFPA, 212 cases had an incidentally discovered tumor (26.4%). Among them, 117 patients were asymptomatic, while 95 had some visual and/or hormonal deficit. The main outcome of the study was to evaluate the frequency of radical resection as judged on the first postoperative neuroimaging study and detection of recurring disease during long-term follow-up. RESULTS Postoperative residual tumor was detected in 8.9% of patients with asymptomatic incidentalomas as compared with 31.2% of patients with symptomatic incidentalomas (P<0.001) and 41.2% of patients in the control group (P<0.001). Multivariate analysis confirmed that having an asymptomatic incidentaloma was independently associated with a better outcome. The 5-year recurrence-free survival in patients with incidentaloma was 86.8% (95% CI 80.2-92.4%) as compared with 77.9% (95% CI 73.6-82.2%; P<0.01) in the control group. This difference was almost completely due to a lower frequency of relapse in asymptomatic patients. Multivariate analysis confirmed the independent lower risk of tumor recurrence in asymptomatic NFPA. CONCLUSION Our study shows for the first time that surgically treated patients with asymptomatic NFPA have a better early and long-term outcome that is independent from all the other demographic, clinical, and morphologic characteristics of the patients.

The current role of Gamma Knife radiosurgery in the management of intracranial haemangiopericytoma

BackgroundHaemangiopericytomas (HPCs) are rare tumours characterised by aggressive behaviour with tendency to local recurrence and to metastasise. WHO grade II and grade III tumours show different progression-free survival and overall survival rates. Gross total tumour resection is still considered the treatment of choice. Adjuvant radiation therapies represent an option in the treatment strategy regardless the extent of resection. Based on this consideration, Gamma Knife radiosurgery has been introduced either as a primary treatment or as an adjuvant treatment for residual or recurrent tumours.MethodA systematic search was performed on PubMed, Web of Science and Google Scholar for clinical series reporting Gamma Knife radiosurgery, Cyberknife and Linear Accelerator (LINAC) for the management of intracranial HPCs.ResultsFourteen studies focusing on the effects of Gamma Knife radiosurgery for intracranial HPCs were included. Four studies reported data on Cyberknife radiosurgery and LINAC. A total of 208 patients harbouring 366 tumours have been reported. Patient’s features, radiosurgical treatment characteristics and follow-up data of the pertinent literature have been critically revised.ConclusionsGamma Knife radiosurgery and the other radiosurgical techniques represent a feasible and effective therapy in the management of HPCs. Tumour control and survival rate are comparable to those reported for radiotherapy. Further studies should be focused to define the exact role of Gamma Knife radiosurgery in the management of HPCs.

Safety of transsphenoidal microsurgical approach in patients with an ACTH-secreting pituitary adenoma

PurposePatients affected by Cushing’s disease often have important comorbidities directly linked to hypercortisolism that might enhance the operative risk. We report the safety of transsphenoidal surgery in patients affected by Cushing’s disease as compared with patients with nonfunctioning pituitary adenoma.MethodsWe have retrospectively analyzed 142 patients with Cushing’s disease and 299 patients with nonfunctioning pituitary adenoma who underwent transsphenoidal surgery performed by a single experienced neurosurgeon between September 2007 and December 2014. For all of them, an intraoperative computerized anesthetic record for the automatic storage of data was available.ResultsThe intraoperative vital parameters and the frequency of drugs administered during anesthesia were comparable between Cushing’s disease and nonfunctioning pituitary adenoma groups. The duration of surgery was similar between the two groups (41.2 ± 11.8 vs. 42.9 ± 15.6 min), while the duration of anesthesia was slightly shorter in Cushing’s disease patients (97.6 ± 18.1 min) than in nonfunctioning pituitary adenoma patients (101.6 ± 20.6 min, p = 0.04). The total perioperative mortality rate was 0.2% (0% in Cushing’s disease vs. 0.3% in nonfunctioning pituitary adenoma). Cushing’s disease patients had surgical and medical complication rates of 3.5% each, not different from those occurring in nonfunctioning pituitary adenoma. The postoperative incidence of diabetes insipidus (10.6%) and isolated hyponatremia (10.6%) in Cushing’s disease patients was significantly higher than in nonfunctioning pituitary adenoma patients (4.4 and 4.1%; p = 0.02 and p = 0.01, respectively).ConclusionsIn a large series of unselected and consecutive patients with Cushing’s disease, transsphenoidal surgery performed by one dedicated experienced neurosurgeon had a reasonably low risk of complications. In particular, despite the higher burden of comorbidities typically associated with hypercortisolism, medical complications are rare and no more frequent than in patients with nonfunctioning pituitary adenoma.

Bilateral Temporal Myofascial Flap for the Reconstruction of Frontal Sinus Defects

BACKGROUND A frontal sinus infection, following a transsinus skull base procedure, portends potentially life-threatening complications, making surgical revision mandatory in refractory infections. The authors describe the application of the bilateral temporal myofascial flap (BTMF) as a valuable option for frontal sinus reconstruction, when pericranial or galeal-frontalis myofascial flap (GFMF) is no longer available. METHODS A microanatomic laboratory cadaver investigation was conducted to obtain anthropometric measurements. Surgical technique is described, and intraoperative images are provided. RESULTS The surgical steps of this technique and the related intraoperative images are reported. One case illustration regarding frontal sinus reconstruction following a postoperative infection, as a complication after a transsinus procedure, is reported. CONCLUSION The BTMF should be considered as a valuable option for frontal sinus reconstruction after transsinus skull base procedures when GFMF is not available.

Endoscope-Assisted Trans-Maxillo-Sphenoidal Approach to Sellar and Parasellar Regions: Anatomic Study.

BACKGROUND Anterolateral skull base surgery in the sellar and parasellar regions has always represented a technical challenge for neurosurgeons. The microscopic endoscope-assisted transmaxillosphenoidal approach (MEMSA) affords a direct surgical corridor free from critical skull base structures. Here we describe and critically evaluate the use of MEMSA to access the sellar and parasellar areas, in terms of surgical exposure and operability. METHODS Six cadaveric heads were examined. A stepwise dissection using MEMSA was performed. Relevant anatomy and surgical technique were critically described and comparatively reviewed. The operability score was applied for quantitative analysis of surgical operability. RESULTS MEMSA provides wide bilateral surgical exposure and vascular control of the sellar, suprasellar, and parasellar regions, achieving the highest operability on the midline and in the parasellar region. The approach can be tailored to the lesion, with the surgical corridor easily widened toward the contralateral pterygopalatine fossa. Anatomic knowledge of maxillary sinus landmarks is key to the use of this approach. Favorable sphenoidal anatomy is the main limiting factor, making MEMSA a surgical alternative to endoscopic endonasal routes in situations where those routes are not feasible, and the approach of choice in selected cases of primarily sellar lesions widely extending contralaterally to the approached maxillary sinus. CONCLUSIONS MEMSA is a safe and effective technique that provides access to the sellar, suprasellar, and contralateral parasellar areas via a direct, minimally disruptive surgical corridor. The preservation of nasal anatomy ensures the availability of mucosal flaps for use in further reconstruction.

Endoscope-Assisted Transmaxillosphenoidal Approach to the Sellar and Parasellar Regions: An Anatomic Study

BACKGROUND Anterolateral skull base surgery in the sellar and parasellar regions has always represented a technical challenge for neurosurgeons. The microscopic endoscope-assisted transmaxillosphenoidal approach (MEMSA) affords a direct surgical corridor free from critical skull base structures. Here we describe and critically evaluate the use of MEMSA to access the sellar and parasellar areas, in terms of surgical exposure and operability. METHODS Six cadaveric heads were examined. A stepwise dissection using MEMSA was performed. Relevant anatomy and surgical technique were critically described and comparatively reviewed. The operability score was applied for quantitative analysis of surgical operability. RESULTS MEMSA provides wide bilateral surgical exposure and vascular control of the sellar, suprasellar, and parasellar regions, achieving the highest operability on the midline and in the parasellar region. The approach can be tailored to the lesion, with the surgical corridor easily widened toward the contralateral pterygopalatine fossa. Anatomic knowledge of maxillary sinus landmarks is key to the use of this approach. Favorable sphenoidal anatomy is the main limiting factor, making MEMSA a surgical alternative to endoscopic endonasal routes in situations where those routes are not feasible, and the approach of choice in selected cases of primarily sellar lesions widely extending contralaterally to the approached maxillary sinus. CONCLUSIONS MEMSA is a safe and effective technique that provides access to the sellar, suprasellar, and contralateral parasellar areas via a direct, minimally disruptive surgical corridor. The preservation of nasal anatomy ensures the availability of mucosal flaps for use in further reconstruction.

Sudden onset of Chiari malformation type 1 in a young child after trauma

IntroductionChiari 1 malformation is a rare craniovertebral junction malformation accounting up to 1 case in every 1000 newborns per year. It is characterized by herniation of cerebellar tonsils below the foramen magnum sometimes with syringomyelia. Usually, patients have a long history of slowly progressive neurological symptoms. Uncommonly, Chiari 1 malformation could present with a sudden onset, also after trauma. Few cases are reported about young children.MethodsThe authors report a case of a 6-month child with symptoms at onset after a mild trauma. The pertinent literature is reviewed.ConclusionsSymptoms of Chiari 1 malformation are usually slowly progressive. Few cases have been reported of the sudden onset of symptoms, some of these after trauma. In young children, the clinical setting could be insidious and potentially lethal. A sudden onset of Chiari 1 malformation must be considered as a consequence of trauma, usually after performing a brain MRI. Management of these cases is still controversial, and surgery may be indicated in managing symptoms; however, it seems to not affect clinical outcome.

Treatment of empty sella associated with visual impairment: a systematic review of chiasmapexy techniques

PurposeChiasmapexy is a poorly described surgical procedure adopted to correct the downward displacement of suprasellar visual system (SVS) into an empty sella (ES) causing visual worsening. The aim of our study is to define the indications for extradural and intradural chiasmapexy.MethodsA systematic literature review has been performed on MEDLINE database (US National Library of Medicine), including only articles that depicted cases of surgically treated patients affected by ES and progressive delayed visual worsening. Moreover, we have reported three cases of secondary ES syndrome (SESS) with visual worsening treated in our Department with transsphenoidal (TS) microsurgical intradural approach. Finally, we have compared the results of extradural and intradural chiasmapexy described in literature.ResultsThe etiology of visual impairment is different in primary and secondary ESS. In primary ESS (PESS) the only predisposing factor is a dehiscence of diaphragma sellae, and the anatomical distortion caused by displacement of optic chiasm or traction of pituitary stalk and infundibulum may determine a direct injury of neural fibers and ischemic damage of SVS. In PESS the mechanical elevation of SVS performed through extradural approach is sufficient to resolve the main pathologic mechanism. In SESS, arachnoidal adhesions play an important role in addition to downward herniation of SVS. Consequently, the surgical technique should provide elevation of SVS combined to intradural release of scar tissue and arachnoidal adhesions. In treatment of SESS, the intradural approaches result to be more effective, guaranteeing the best visual outcomes with the lowest complications rates.ConclusionsThe intradural chiasmapexy is indicated in treatment of SESS, instead the extradural approaches are suggested for surgical management of PESS.

Intraoperative Ultrasound Appearance of a Pancreatic Cerebral Metastasis: A Case Report

Abstract Background Brain metastases (BMs) derived from pancreatic adenocarcinoma (PAC) have an extremely low incidence (0.1‐0.4%) and are usually associated with a very poor prognosis. The treatment strategy is palliative and includes conventional radiotherapy, stereotactic radiosurgery, chemotherapy, and surgical resection. Case Description A 39‐year‐old man with a history of PAC developed a systemic tumor relapse with intracranial progression. Magnetic resonance imaging (MRI) documented a right rolandic, cortical, and cystic lesion with leptomeningeal intrasulcular extension. The intraoperative ultrasound (iUS) depicted a hyperechogenic area surrounding the anechogenic cystic lesion and allowed us to obtain gross total resection of the tumor. Conclusions To the best of our knowledge, we describe for the first time the iUS aspect of a pancreatic BM. In this case the use of iUS allowed us to increase the extent of resection and surgical safety, thus reducing the risk of new postoperative neurologic deficits.

Original ArticleEndoscope-Assisted Transmaxillosphenoidal Approach to the Sellar and Parasellar Regions: An Anatomic Study

BACKGROUND Anterolateral skull base surgery in the sellar and parasellar regions has always represented a technical challenge for neurosurgeons. The microscopic endoscope-assisted transmaxillosphenoidal approach (MEMSA) affords a direct surgical corridor free from critical skull base structures. Here we describe and critically evaluate the use of MEMSA to access the sellar and parasellar areas, in terms of surgical exposure and operability. METHODS Six cadaveric heads were examined. A stepwise dissection using MEMSA was performed. Relevant anatomy and surgical technique were critically described and comparatively reviewed. The operability score was applied for quantitative analysis of surgical operability. RESULTS MEMSA provides wide bilateral surgical exposure and vascular control of the sellar, suprasellar, and parasellar regions, achieving the highest operability on the midline and in the parasellar region. The approach can be tailored to the lesion, with the surgical corridor easily widened toward the contralateral pterygopalatine fossa. Anatomic knowledge of maxillary sinus landmarks is key to the use of this approach. Favorable sphenoidal anatomy is the main limiting factor, making MEMSA a surgical alternative to endoscopic endonasal routes in situations where those routes are not feasible, and the approach of choice in selected cases of primarily sellar lesions widely extending contralaterally to the approached maxillary sinus. CONCLUSIONS MEMSA is a safe and effective technique that provides access to the sellar, suprasellar, and contralateral parasellar areas via a direct, minimally disruptive surgical corridor. The preservation of nasal anatomy ensures the availability of mucosal flaps for use in further reconstruction.