Craig H. Rabb

Variations on the standard transsphenoidal approach to the sellar region, with emphasis on the extended approaches and parasellar approaches: surgical experience in 105 cases.

OBJECTIVE:The traditional boundaries of the transsphenoidal approach may be expanded to include the region from the cribriform plate of the anterior cranial base to the inferior clivus in the anteroposterior plane, and laterally to expose the cavernous cranial nerves and the optic canal. We review our combined experience with these variations on the transsphenoidal approach to various lesions of the sellar and parasellar region. METHODS:From 1982 to 2003, we used the extended and parasellar transsphenoidal approaches in 105 patients presenting with a variety of lesions of the parasellar region. This study specifically reviews the breadth of pathological lesions operated and the complications associated with the approaches. RESULTS:Variations of the standard transsphenoidal approach have been used in the following series: 30 cases of pituitary adenomas extending laterally to involve the cavernous sinus, 27 craniopharyngiomas, 11 tuberculum/diaphragma sellae meningiomas, 10 sphenoid sinus mucoceles, 18 clivus chordomas, 4 cases of carcinoma of the sphenoid sinus, 2 cases of breast carcinoma metastatic to the sella, and 3 cases of monostotic fibrous dysplasia involving the clivus. There was no mortality in the series. Permanent neurological complications included one case of monocular blindness, one case of permanent diabetes insipidus, and two permanent cavernous cranial neuropathies. There were four cases of internal carotid artery hemorrhage, one of which required ligation of the cervical internal carotid artery and resulted in hemiparesis. The incidence of postoperative cerebrospinal fluid fistulae was 6% (6 of 105 cases). CONCLUSION:These modifications of the standard transsphenoidal approach are useful for lesions within the boundaries noted above, they offer excellent alternatives to transcranial approaches for these lesions, and they avoid prolonged exposure time and brain retraction. Technical details are discussed and illustrative cases presented.

A statistical analysis of factors related to symptomatic cerebral vasospasm.

SummaryA retrospective review of patients presenting to our institution with aneurysmal subarachnoid hemorrhage between 1980–1990 was accomplished. Eleven variables were examined as to their relationship to clinical vasospasm: age, sex, clinical grade, amount of subarachnoid blood on CT, aneurysm location, incidence of vasospasm, incidence of complications, use of calcium channel blockers, time to surgery, length of stay, and outcome. Data were analyzed with univariate and multivariate logistical regression methodology.By univariate analysis, age under 20, amount of subarachnoid hemorrhage, and clinical grade were associated with a higher risk of vasospasm. Using multivariate logistic regression, these factors, along with age under 35, were correlated as being predictive of clinical vasospasm. When all patients are grouped into either good or bad outcome, and a similar analysis is performed, only in the poor outcome group is the amount of subarachnoid hemorrhage and clinical grade correlated with vasospasm. This suggests that there is a group of patients with a predisposition to vasospasm that is independent of subarachnoid hemorrhage and clinical grade, and that these patients may have a more favorable outcome.

Isolated cerebral mucormycosis : case report and therapeutic considerations

Cerebral mucormycosis (without associated involvement of and invasion from the nasal sinuses and turbinates) is an extremely rare opportunistic infection of the central nervous system. We report the case of an intravenous drug abuser (who was negative for the human immunodeficiency virus) who presented with hemiparesis on the right side, slurred speech, altered mental status, and an unsteady gait. Imaging studies revealed a large left-side basal ganglia lesion. A stereotactic biopsy obtained a tissue sample that revealed wide, nonseptated hyphal fragments with granulomatous inflammation. The patient was treated with 3 gm of amphotericin B during a 5-month period. The patient had no residual neurological dysfunction after treatment. Open surgical resection was not employed. This case suggests that stereotactic biopsy followed by long-term amphotericin B therapy, in lieu of open surgical resection, represents a viable treatment option for this rare disorder.

Hemangiopericytoma of the temporal Bone Presenting as a Retroauricular Mass

An unusual case of a hemangiopericytoma arising from the temporal bone is presented. The patient was noted to have a postauricular mass and was neurologically asymptomatic. A preoperative magnetic resonance image and an angiogram revealed the tumor to be highly vascular. Preoperative embolization facilitated the surgical removal of the tumor by rendering it avascular. Current therapy consists of radical resection of the tumor with postoperative radiation therapy. Patients must be monitored carefully for local recurrence and systemic metastasis.

Minimally invasive treatment of multilevel spinal epidural abscess

The use of minimally invasive tubular retractor microsurgery for treatment of multilevel spinal epidural abscess is described. This technique was used in 3 cases, and excellent results were achieved. The authors conclude that multilevel spinal epidural abscesses can be safely and effectively managed using microsurgery via a minimally invasive tubular retractor system.

Enlarging Subependymal Cyst

ABSTRACTA 1-MONTH-OLD INFANT with a Dandy-Walker malformation underwent the placement of a ventriculoperitoneal shunt to treat progressive hydrocephalus. On the initial computed tomographic scan, a subependymal cystic lesion larger than 1 cm in diameter was noted in the head of the right caudate nuc

Enlarging subependymal cyst: case report.

A 1-month-old infant with a Dandy-Walker malformation underwent the placement of a ventriculoperitoneal shunt to treat progressive hydrocephalus. On the initial computed tomographic scan, a subependymal cystic lesion larger than 1 cm in diameter was noted in the head of the right caudate nucleus, which enlarged to 3 cm in diameter on follow-up imaging studies over the course of a year. Biopsies taken at the time of fenestration failed to show the presence of neoplasia. This appears to be the first reported case of a cyst of this nature to show progressive enlargement.

The Use of Dobutamine to Enhance Cardiac Performance and Improve Outcome in Patients Refractory to Hypervolemic Therapy for Cerebral Vasospasm: a Preliminary Study

We have previously concluded that CVP was an unreliable index of cardiac performance during hypervolemic therapy and that in previously healthy individuals a PAWP of 14 mm Hg was associated with maximal cardiac performance1. We describe the use of the Beta-agonist, Dobutamine, in combination with hypervolemic preload enhancement on cardiac performance in a preliminary report of 10 patients who failed to respond to traditional preload enhancement following aneurysmal subarachnoid hemorrhage. All patients had the placement of a flow directed balloon-tipped catheter and measurement of pulmonary artery wedge pressure (PAWP), central venous pressure (CVP), cardiac index (CI), stroke volume index (SVI), total peripheral resistance (TPR), and left ventricular stroke work index (LVSWI) during hyperdynamic therapy. Dobutamine was administered at a rate of 5 to 10 ug/kg/h for a period of up to ten days.