Ivan Ciric

Short-term outcome of endoscopic versus microscopic pituitary adenoma surgery: a systematic review and meta-analysis

Endoscopic transsphenoidal pituitary surgery has become increasingly more popular for the removal of pituitary adenomas. It is also widely recognised that transsphenoidal microscopic removal of pituitary adenomas is a well-established procedure with good outcomes. Our objective was to meta-analyse the short-term results of endoscopic and microscopic pituitary adenoma surgery. We undertook a systematic review of the English literature on results of transsphenoidal surgery, both microscopic and endoscopic from 1990 to 2011. Series with less than 10 patients were excluded. Pooled data were analysed using meta-analysis techniques to obtain estimate of death, complication rates and extent of tumour removal. Complications evaluated included cerebrospinal fluid leak, meningitis, vascular complications, visual complications, diabetes insipidus, hypopituitarism and cranial nerve injury. Data were also analysed for tumour size and sex. 38 studies met the inclusion criteria yielding 24 endoscopic and 22 microscopic datasets (eight studies included both endoscopic and microscopic series). Meta-analysis of the available literature showed that the endoscopic transsphenoidal technique was associated with a higher incidence of vascular complications (p<0.0001). No difference was found between the two techniques in all other variables examined. Meta-analysis of the available literature reveals that endoscopic removal of pituitary adenoma, in the short term, does not seem to confer any advantages over the microscopic technique and the incidence of reported vascular complications was higher with endoscopic than with microscopic removal of pituitary adenomas. While we recognise the limitations of meta-analysis, our study suggests that a multicentre, randomised, comparative effectiveness study of the microscopic and endoscopic transsphenoidal techniques may be a reasonable approach towards establishing a true valuation of these techniques.

Operative findings and outcomes of microvascular decompression for trigeminal neuralgia in 35 patients affected by multiple sclerosis

OBJECTIVE:The concept of vascular compression of the trigeminal root as the main etiological factor in idiopathic trigeminal neuralgia has achieved widespread acceptance, and microvascular decompression (MVD) is a well-established surgical procedure for its treatment. Multiple sclerosis (MS) has long been considered to be an absolute contraindication to MVD because of the supposed exclusive causative role of a demyelinating lesion affecting the trigeminal root entry zone. Magnetic resonance imaging preoperative identification of suspicious vessels along the cisternal course of the trigeminal nerve in MS patients raises the question of a possible causative role of vascular compression in MS patients. METHODS:We describe magnetic resonance imaging findings, surgical findings, and outcomes in 35 MS patients who underwent MVD for medically intractable trigeminal neuralgia. Results were assessed by clinical follow-up and periodic phone surveys. The mean follow-up was 44 months (range, 6–108 mo). RESULTS:Magnetic resonance imaging revealed the presence of demyelinating lesions affecting the brainstem trigeminal pathways of the painful side in 26 (74%) of 35 patients. During surgery, severe neurovascular compression at the trigeminal root entry zone was found in 16 (46%) of 35 patients. The long-term outcome was excellent in 39%, good in 14%, fair in 8%, and poor in 39% of patients. No statistically significant prognostic factor predicting good outcome could be found. There was no mortality, with a 2.5% long-term morbidity rate (facial nerve palsy in one patient). CONCLUSION:Results of MVD in trigeminal neuralgia MS patients are much less satisfactory than in the idiopathic group, indicating that central mechanisms play a major role in pain genesis.

MR imaging of pituitary tumors before and after surgical and/or medical treatment

Four hundred fifteen cases of suspected pituitary tumors were examined by CT and magnetic resonance (MR). Forty-one microadenomas and 26 large sellar-suprasellar pituitary tumors were diagnosed and surgically removed (61 cases) or treated with bromocriptine (six cases). The present study demonstrated that (a) in cases of microadenomas, MR was more accurate than CT in three cases, as accurate as CT in 33 cases, but missed six cases diagnosed on CT, when MR images were suboptimal (thicker than 5 mm); (b) when the sellar-suprasellar mass was markedly constricted at the diaphragma sellae on MR sagittal slices (16 cases), transsphenoidal surgical approach was not only insufficient for total removal but could be dangerous, as the remaining suprasellar portion may rapidly increase in size following surgery from postoperative hemorrhage and/or acute edema with severe obstructive hydrocephalus (three cases) and/or acute blindness (two cases); (c) hemorrhage in pituitary tumors was easily seen on MR and missed on CT; (d) coronal MR slices visualized the carotid siphon obviating the need for angiography to rule out intrasellar aneurysm, which can mimic pituitary tumor on contrast CT; (e) postoperative MR was needed before considering radiotherapy to visualize accurately the relation of the optic chiasm to the residual tumor and to follow up its gradual change in size; (f) finally, in cases treated with bromocriptine, MR was more accurate than CT in following the gradual decrease of pituitary tumor.

MR Diagnosis of Acoustic Neuromas

Two hundred forty-three patients with clinically suspected acoustic neuroma were evaluated radiologically by CT, and in selected cases CT cisternography and/or magnetic resonance imaging. Fifty-one acoustic neuromas were diagnosed and surgically removed; 36 were large tumors with extracanalicular extension and 15 were strictly intracanalicular small tumors. With routine CT (without and with contrast medium) large and enhancing lesions (36 of 51) were visualized, but small intracanalicular tumors (15 lesions) were missed. The latter were visualized by CT cisternography (seven cases) or MR (eight cases). Magnetic resonance, when used with spin-echo technique using both short as well as long sequences for axial and coronal thin slices (5 mm or smaller), demonstrated all the surgically verified lesions.

Current concepts in neuroradiological diagnosis of acoustic neuromas

Two hundred twenty‐one cases with clinical suspicion of a cerebellopontine angle (CPA) and/or internal auditory canal (IAC) lesions were evaluated in our hospital in the last 2 1/2 years by various radiological modalities. Fifty‐two tumors were diagnosed and surgically removed; 48 were acoustic neuromas (33 large tumors and 15 intracanalicular small tumors) and 4 meningiomas.

U.S. health care: a conundrum and a challenge.

BACKGROUND This report was conceived as a contribution to the national debate regarding U.S. health care (HC) and as a means of explaining the challenges facing U.S. HC to the international readers of WORLD NEUROSURGERY. METHODS The basic economic concepts pertinent to health care, including fundamentals of economic theories, gross domestic product (GDP), U.S. revenues and expenditures and the U.S. federal deficit and national debt, are discussed at the outset of this study. This is followed by a review of the U.S. health insurance paradigms and a detailed analysis of the escalating cost of U.S. health care. Finally, the efforts designed to reverse the paradigm of escalating health care costs will be discussed. RESULTS This study reveals that should the U.S. HC cost continue to escalate at the same rate, HC would consume the entire gross domestic product by 2070. The root causes for this trend are overutilization of HC, inappropriate allocation of HC costs at the end of life, defensive medicine, high-end technology and prescription drugs, failure of competitive market forces, and administrative costs, inefficiency, and waste. The proposed means of reversing this paradigm, including the Patient Protection and Affordable Care Act, are discussed in light of their economic and social impact. CONCLUSIONS The reversal of the current paradigm of escalating cost of U.S. HC will require extraordinary leadership across the entire spectrum of HC delivery. It is concluded that neither the Affordable Care Act nor the Path to Prosperity will succeed unless the escalating cost of U.S. HC is reversed. It is hoped that this report contributes to that end.

Kirschner Wire Migration through the Jugular Foramen

Kirschner wires commonly are used to provide interosseous fixation. Although they usually retain their intended position, migration of these sharply pointed metal pins has been reported.

Vascular malformations of the thalamus with normal angiograms

We describe two patients with fatal vascular malformations of the thalamus whom we thought had gliomas. They had progressive neurological impairment with subacute onset as adults. Computed tomography showed lesions of increased density with slight post-contrast enhancement; cerebral angiography was normal. Without biopsy, they received radiation therapy without benefit. Two other patients with similar radiological studies have done well with conservative treatment. We believe that these lesions have a distinctive appearance on CT, that vascular malformations can be diagnosed, even with normal cerebral angiograms, and distinguished with reasonable certainty from gliomas.

Pituitary hemorrhagic necrotic syndrome.

n the report titled “Pituitary Apoplexy: Large Surgical Series with Grading System.” Jho et al. present a new classificaI tion, largely influenced by the advent of magnetic resonance imaging, of patients who present with a pituitary hemorrhagicnecrotic syndrome. Specifically, the authors include not only patients with an acute hemorrhage, necrosis, or both in a pituitary tumor causing visual loss and requiring urgent surgical care that is traditionally codified under the banner of a pituitary apoplexy, but also patients who may have an asymptomatic hemorrhage into a nonthreatening Rathke cyst at the lower end of their classification, or conversely, at the higher tier of the proposed grading, patients who may have a significant comorbidity, as, for example, an acute head trauma in conjunction with a marked decrease in the Glasgow Coma Scale and whose imaging shows an incidental hemorrhage into an otherwise-innocuous sellar abnormality. Clearly, such broadened inclusivity of a variety of hemorrhagic pituitary occurrences into the previously crisp and neatly enclosed nosologic entity of a pituitary apoplexy was an invitation to question the appropriateness of such a classification. The debate could have been avoided if the authors had adopted the nomenclature as suggested in the title of this Perspective.

The Creator Invented Spinal Fluid to Annoy Neurosurgeons

W e read with great interest the report titled “The History of Autologous Fat Graft Use for Prevention of Cerebrospinal Fluid Rhinorrhea After Transsphenoidal Approaches” authored by Drs. Mateo Ziu and David F. Jimenez, from the University of Texas at San Antonio. This comprehensive report encompasses the whole spectrum of nonand iatrogenic cerebrospinal fluid (CSF) leaks both historically and substantively. From a historical perspective, we are delighted that the authors paid due tribute to greats such as Cushing, Hirsch, Halstead, Dott, Guiot, Hardy, Laws, Montgomery, and many others on whose shoulders stands the present generation of pituitary surgeons. They have surely experienced the neurosurgeon’s sleepless anguish when dealing with, and have undoubtedly witnessed the miserable agony of patients suffering from intractable CSF leaks. Reading the manuscript, and notwithstanding the conclusions, we get the distinct impression that the authors, after a careful review of the literature and based on their experience, favor the use of a fat allograft over other tissues in sealing a CSF fistula and the use of a vascularized mucosa-perichondrial flap when dealing with refractory CSF leaks.