Giorgio Frank

The endoscopic versus the traditional approach in pituitary surgery.

The transsphenoidal route is the most widely used technique for pituitary adenoma surgery due to its rapidity, good tolerance, effectiveness and low complication rate. These are the parameters we utilized in comparing endoscopic with microscopic transsphenoidal surgery. We reviewed the medical records of 418 patients affected by pituitary adenomas who underwent endoscopic transsphenoidal surgery between May 1998 and December 2004, and in this paper, we present the results of 381 patients who fulfilled the follow-up criteria after a minimum period of 15 months. Our experience confirms the previous data on the rapidity and satisfactory tolerance of the endoscopic procedure. We also confirm the low complication rate, specifying that complications characteristic of the approaching phase were certainly reduced; instead, complications characteristic of tumor removal still remained similar to those reported in the microsurgical literature. The results were comparable with those of the best microsurgical series regarding endosellar lesions, but tumor removal was notably superior when dealing with tumors having an extrasellar extension. The improvement may be explained by the excellent vision of the deep surgical fields due to the endoscope and by the extreme flexibility of the surgical trajectory, mainly due to the absence of the divaricator, giving access to the ramifications of the tumor, otherwise difficult to reach.

Ct scan and metrizamide CT cisternography in arachnoid cysts of the middle cranial fossa: Classification and pathophysiological aspects

Thirty-one cases of arachnoid cysts of the middle cranial fossa were investigated by CT scan, 7 of them undergoing additional metrizamide CT cisternography. In this paper we analyze and correlate the different findings from these two examinations and propose a classification of arachnoid cysts of the middle cranial fossa into three basic types. Pathophysiological and surgical implications are discussed.

The endoscopic extended transsphenoidal approach for craniopharyngiomas

OBJECTIVE: The endoscope has recently been applied to the supradiaphragmatic transsphenoidal approach, but only case reports dealing with different pathological features have been described. The authors present their experience with this technique in 10 patients with craniopharyngiomas. METHODS: A pure endoscopic endonasal technique was used. From November 1998 through May 2005, four males and six females with a craniopharyngioma, either purely supradiaphragmatic (six patients) or with a significant suprasellar component (four patients), were treated. The tumors had a mean diameter of 2.9 cm (range, 1–4 cm); four patients had a major prechiasmatic component and six had a retrochiasmatic one. RESULTS: Seven total, one subtotal, and two partial resections were obtained. Vision symptoms improved significantly in six out of eight patients. Endocrine function did not improve after surgery, and diabetes insipidus was the most frequent deficit, although it was transient in five out of eight patients. Cerebrospinal fluid leak was the most frequent complication and required reoperation in two patients. Postoperative obesity occurred in two patients. No recurrence has yet been documented in the total resection group. The mean follow-up period is 37 months (range, 3–75 mo). CONCLUSION: The endoscopic technique allows results comparable with the best microscopic series. We think that this technique increases the safety of the procedure because of improved vision. Further studies are required to better define the exact location of the tumor with respect to the arachnoidal plane, the extra-arachnoidal craniopharyngioma being the most suitable for a radical removal using a transsphenoidal supradiaphragmatic approach.

The Endoscopic Transnasal Transsphenoidal Approach for the Treatment of Cranial Base Chordomas and Chondrosarcomas

OBJECTIVE: We report our experience with endoscopic transsphenoidal or extended endoscopic transsphenoidal approaches for the treatment of cranial base lesions such as clival chordomas and chondrosarcomas. METHODS: Between May 1998 and April 2004, 11 patients (four were recurrences because they previously had been treated with surgery and/or radiotherapy) underwent transnasal transsphenoidal endoscopic surgery for cranial base chordomas and chondrosarcomas at the Neurosurgical Department of Bellaria Hospital in Bologna. The transsphenoidal endoscopic approach and the ethmoid-pterygo-sphenoidal endoscopic approach were used to accomplish resection of the lesions involving the clivus and extending up to the parasellar region and to the petrous apex, or within the cavernous sinus. RESULTS: Patient follow-up periods ranged from 15 to 69 months (mean, 27 mo). Three patients died of chordoma progression at 20, 14, and 10 months, respectively, after endoscopic treatment. One patient experienced two recurrences; the first was treated using a new endoscopic approach, whereas the second, 1 year later, was treated by means of a far lateral approach. Four patients underwent postoperative proton beam radiotherapy, whereas one underwent a conventional megavoltage x-radiation therapy. However, postoperative radiotherapy was not administered in the two patients treated for cranial base chondrosarcoma. CONCLUSION: The flexibility of this new technique with respect to the classical microscopic transsphenoidal approach permits us to widen the horizon of surgical management of aggressive cranial base tumors such as clival chordomas and chondrosarcomas.

Endoscopic Endonasal Cavernous Sinus Surgery, with Special Reference to Pituitary Adenomas

Cavernous sinus surgery has always been a surgical challenge because of the high functional importance of this region and the associated high morbidity. The augmented peripheral vision of the endoscope has led to the development of surgical approaches that allow adequate exposure of the cavernous sinus, with a reduction in surgical morbidity. Since 1998, 65 patients with pituitary adenomas and intraoperative evidence of cavernous sinus invasion were treated with a purely endoscopic approach. Follow-up was of at least 6 (mean 51.2) months. There was no perioperative mortality and extremely low morbidity. Radical tumor removal was obtained in 21/35 cases with nonfunctioning adenomas. Hormonal remission was obtained in 13/30 functioning adenomas. One patient with partial hypopituitarism and 1 patient with persistent diabetes insipidus were seen. Three patients with delayed CSF leaks required endoscopic repair. In 1 patient with hemorrhagic infarction in a residual tumor, reintervention with craniotomy was necessary. We advocate the central role of surgery in the treatment of cavernous sinus tumors, since it allows definition of true cavernous sinus involvement, histopathological diagnosis and, when cure is not feasible, tumor volume reduction, which might be an important factor in the response to adjuvant therapy.

The endoscopic endonasal approach for the management of craniopharyngiomas: a series of 103 patients

OBJECT Despite their benign histological appearance, craniopharyngiomas can be considered a challenge for the neurosurgeon and a possible source of poor prognosis for the patient. With the widespread use of the endoscope in endonasal surgery, this route has been proposed over the past decade as an alternative technique for the removal of craniopharyngiomas. METHODS The authors retrospectively analyzed data from a series of 103 patients who underwent the endoscopic endonasal approach at two institutions (Division of Neurosurgery of the Università degli Studi di Napoli Federico II, Naples, Italy, and Division of Neurosurgery of the Bellaria Hospital, Bologna, Italy), between January 1997 and December 2012, for the removal of infra- and/or supradiaphragmatic craniopharyngiomas. Twenty-nine patients (28.2%) had previously been surgically treated. RESULTS The authors achieved overall gross-total removal in 68.9% of the cases: 78.9% in purely infradiaphragmatic lesions and 66.3% in lesions involving the supradiaphragmatic space. Among lesions previously treated surgically, the gross-total removal rate was 62.1%. The overall improvement rate in visual disturbances was 74.7%, whereas worsening occurred in 2.5%. No new postoperative defect was noted. Worsening of the anterior pituitary function was reported in 46.2% of patients overall, and there were 38 new cases (48.1% of 79) of postoperative diabetes insipidus. The most common complication was postoperative CSF leakage; the overall rate was 14.6%, and it diminished to 4% in the last 25 procedures, thanks to improvement in reconstruction techniques. The mortality rate was 1.9%, with a mean follow-up duration of 48 months (range 3-246 months). CONCLUSIONS The endoscopic endonasal approach has become a valid surgical technique for the management of craniopharyngiomas. It provides an excellent corridor to infra- and supradiaphragmatic midline craniopharyngiomas, including the management of lesions extending into the third ventricle chamber. Even though indications for this approach are rigorously lesion based, the data in this study confirm its effectiveness in a large patient series.

Transsphenoidal endoscopic approach in the treatment of Rathke's cleft cyst.

OBJECTIVE:In this study, the usefulness of the transsphenoidal endoscopic approach in the treatment of a Rathke’s cleft cyst is reported. METHODS:Between June 1998 and December 2002, 22 patients affected by sellar-suprasellar Rathke’s cleft cysts were treated using a transsphenoidal endoscopic approach. Fourteen patients experienced pituitary dysfunction (64%), five experienced visual impairment (23%), and three reported headaches (14%). RESULTS:The patient follow-up ranged from 8 to 60 months (mean, 33 mo). Pituitary function was restored only in the four patients with hyperprolactinemia, whereas visual impairment and headache improved in all patients. However, when present before surgery, hypopituitarism was unaffected by surgery. Two patients experienced permanent diabetes insipidus (one of them before surgery). Only one recurrence was observed in a 13-year-old girl at 12 months after surgery, and it was treated using a new transsphenoidal endoscopic approach. CONCLUSION:The transsphenoidal endoscopic approach represents a straightforward and mini-invasive approach for the drainage and biopsy of a Rathke’s cleft cyst.

How many cases of true precocious puberty in girls are idiopathic

Fifteen girls with true precocious puberty were examined by computerized tomography. In seven hypothalamic hamartomas were suspected. A pneumoencephalogram was performed in six cases (one patient refused), with the following results. In five, the radiological features were highly suggestive of tuber cinereum hamartoma. All of our patients with pubertal signs appearing before the age of 2 years and 80% of the girls with early menstruation were in the group with suspected hamartoma. The luteinizing hormone and follicle-stimulating hormone levels of these five girls were significantly higher than those observed in the other girls with idiopathic precocious puberty. We conclude that there is a high frequency of small hypothalamic masses (suspected hamartoma) in girls with true precocious puberty (33% of the patients in our group), that it is important to confirm the presence of the mass with pneumoencephalography, and that surgery for diagnostic and therapeutic purposes should be carefully considered, given the absence of any neurologic symptoms for a long time after the appearance of the first pubertal signs.

Endoscopic endonasal approach for the treatment of benign schwannoma of the sinonasal tract and pterygopalatine fossa.

Schwannomas are tumors that rarely involve the sinonasal tract or the pterygopalatine fossa. Three cases of benign schwannomas originating in the nasal cavity, the nasal-ethmoid, and the pterygopalatine fossa are reported. Surgical treatment is considered the treatment of choice to achieve long-term success. In this study, the effectiveness of the endoscopic endonasal approach is outlined for the diagnosis and treatment of these benign tumors.

Endoscopic endonasal odontoidectomy in a patient affected by Down syndrome: technical case report.

OBJECTIVEAtlantoaxial instability and odontoid invagination may occur in Down syndrome. The treatment of this lesion may require an odontoidectomy. In similar circumstances, a transoral procedure may be hampered by a macroglossia which is part of Down syndrome. In a situation occurring in an 11-year-old child affected by atloaxial instability and os odontoideum, the persistence of ventral compression after a previous atloaxial fixation induced us to perform an endoscopic endonasal odontoidectomy. We feel that this is an elective indication for endoscopic endonasal odontoidectomy. CLINICAL PRESENTATIONAn 11-year-old child, affected by Down syndrome, presented with progressive tetraparesis with severe superior diplegia. He was wheelchair-bound. Recently, respiratory disturbances had appeared. INTERVENTIONThe patient underwent an endoscopic endonasal odontoidectomy. The postoperative course was uneventful, and the patient experienced improvement of the preoperative symptoms. CONCLUSIONAn endonasal technique is indicated for patients presenting with narrowness of the oral cavity, such as in the case reported, where the narrowness due to pediatric age and the macroglossia characteristic of Down syndrome hamper the transoral approach.