Josue Pereira

Thickening of the pituitary stalk: a finding suggestive of intrasellar tuberculoma? Case report.

We describe the case of a patient with an exclusively intrasellar mass, disclosed because of a left sixth nerve palsy and headaches. No other manifestation of disease, namely, endocrinological, was present. The lesion was approached transsphenoidally, and the pathological examination revealed a tuberculoma. Complete removal was achieved, and the patient started postoperative antituberculous therapy. In some circumstances, thickening of the infundibulum and the pituitary stalk could preoperatively suggest the diagnosis of hypophysial tuberculoma.

Thickening of the Pituitary Stalk

: We describe the case of a patient with an exclusively intrasellar mass, disclosed because of a left sixth nerve palsy and headaches. No other manifestation of disease, namely, endocrinological, was present. The lesion was approached transsphenoidally, and the pathological examination revealed a tuberculoma. Complete removal was achieved, and the patient started postoperative antituberculous therapy. In some circumstances, thickening of the infundibulum and the pituitary stalk could preoperatively suggest the diagnosis of hypophysial tuberculoma.

The infratentorial supracerebellar approach in surgery of lesions of the pineal region

Background: Surgery of pineal region lesions is considered a challenging task, due to the particular relationship of lesions in this location with neural and vascular structures. Few series with a significant experience of dealing with these patients have been reported. Methods: We review our experience using infratentorial supracerebellar approach in the surgery of pineal region, regarding the extension of the removal, postoperative morbidity, and discussing details of the surgical technique. In all cases, a supracerebellar infratentorial approach was used in the semi sitting position. Results: A total of 32 patients were operated in the past 20 years (3 germinomas, 3 teratoma, 3 pineocitoma, 2 pineal tumor of intermediate differentiation, 6 pineoblastomas, 6 low grade astrocytoma, 2 glioblastoma, 2 metastasis, 1 ependymoma, 1 epidermoid tumor, 1 cavernoma, and 2 arachnoid cyst). Total removal was achieved in 15 cases and subtotal extensive removal in 7 patients. In the remaining cases, only partial removal was possible, due to the involved pathological types. There was no surgical mortality and no cases of cerebellar venous infarction. Morbidity consisted of transient ocular movement disturbance in 14 patients, transient ataxia in 3 patients, and 1 case of local cerebrospinal fluid (CSF) fistula with meningitis that required surgical treatment. Conclusion: Supracerebellar infratentorial is a safe approach to lesions in the pineal region, and total or extensive subtotal removal is possible in most cases, with acceptable morbidity.

Endoscopic third ventriculostomy in the management of hydrocephalus: Outcome analysis of 168 consecutive procedures

BACKGROUND Endoscopic third ventriculostomy (ETV) is the treatment of choice for obstructive hydrocephalus, but the outcome is still controversial in terms of age and aetiology. METHODS Between 1998 and 2011, 168 consecutive procedures were performed in 164 patients, primarily children (56%<18 years of age and 35%<2 years of age). The causes of obstructive hydrocephalus included tumoural pathology, Chiari malformation, congenital obstruction of the aqueduct, post-infectious and post-haemorrhagic membranes, and ventriculo-peritoneal shunt (VPS) malfunctions. Successful ETV was defined by the resolution of symptoms and the avoidance of a shunt. RESULTS ETV was successful in 75.6% of patients, but 19% of the patients required VPS in the first month after ETV, and 5.4% required a VPS more than one month after ETV. Four patients were ultimately submitted for second ETVs. In this series, no major permanent morbidity or mortality was observed. CONCLUSIONS ETV is a safe procedure and an effective treatment for obstructive hydrocephalus even following the dysfunction of previous VPSs and in children younger than two years.

Trans-lamina terminalis approach for third ventricle and suprasellar tumours

BACKGROUND The trans-lamina terminalis (TLT) approach to the suprasellar region and third ventricle is complex, with risks of visual and hormonal deficits. However, the postoperative deficits might not be directly related to opening of the lamina terminalis but to the close relationship of tumours with vital neural and vascular structures. The analysis of results using this approach was the objective of this study. MATERIAL AND METHODS The TLT approach was used in 29 patients (18 craniopharyngiomas, 5 astrocytomas, 5 germinomas and 1 ganglioglioma). The extent of tumour removal, mortality and morbidity (especially visual or hormonal deficits) were studied. RESULTS Complete tumour removal was achieved in 15 patients, subtotal extensive removal (more than 90%) in 9 cases and partial removal in 5 cases. Panhypopituitarism developed in 22 patients. Total tumour removal was associated with the development of endocrinological disturbances. There was worsening or the onset of new visual field defects in 4 cases. Postoperative endocrine and visual deficits were in the range generally described regarding surgery for tumours in this region. CONCLUSION The TLT approach allows for extensive removal of third ventricle and suprasellar tumours, without increased risks of visual and hormonal deficits, compared to those described regarding surgery for lesions in this region.

Endoscopic re-opening of third ventriculostomy: Case series and review of literature.

OBJECTIVES Endoscopic third ventriculostomy (ETV) emerged as an effective alternative to shunting devices in patients with obstructive hydrocephalus. When ETV fails, neurosurgeons must choose between applying a shunting device or performing a repeat ETV (re-ETV) and attempt a shunt independent outcome. In this series, clinical, surgical and follow-up data from six patients who underwent a second ETV were reviewed. PATIENTS AND METHODS Between January 2005 and June 2015, six patients underwent re-ETV, with four being children. Causes of obstructive hydrocephalus included idiopathic aqueduct stenosis, congenital aqueduct stenosis, neonatal intraventricular haemorrage, hypothalamic glioma and post-meningitis aqueductal stenosis. Success of the procedure was defined by clinical improvement and shunt independence. RESULTS Overall success rate of this series was 83.3%, with re-ETV being effective in five of the six patients. The single case of re-ETV failure was observed in the pediatric population and was due to late stoma obstruction by tumoral growth, with a ventriculo-peritoneal shunt (VPS) being placed 6 months after re-ETV. In this series, no mortality and no major permanent morbidity were observed following re-ETV. CONCLUSION Repeat ETV is a safe and effective procedure and should be an option for treatment of recurrent obstructive hydrocephalus if stoma closure or obstruction is present. Younger age and the presence of a previous VPS should not discourage this procedure.

IL-4 and IL-6 levels and adipose tissue distribution in HIV-1 patients under antiretroviral therapy

PurposeCombined antiretroviral therapy (cART) for the treatment of HIV-1 infection has been associated with complications, including lipodystrophy. Several interleukins have been implicated in the pathology and physiology of lipodystrophy. The present study aimed to compare the levels of IL-4 and IL-6 in HIV-1 patients under cART with and without, clinically and fat mass ratio defined, lipodystrophy and in four different groups of fat distribution: (1) no lipodystrophy; (2) isolated central fat accumulation; (3) isolated lipoatrophy and (4) mixed forms of lipodystrophy.MethodsIn the present cross-sectional study we evaluated IL-4 and IL-6 levels, insulin resistance and insulin sensitivity indexes in 86 HIV-infected adults under cART.ResultsNo significant differences in IL-4 and IL-6 levels between the four groups of body composition were observed. Patients with HOMA-IR >4 presented higher levels of IL-6 and lower levels of IL-4, although without statistical significance. No correlation between IL-6, or IL-4, HOMA-IR and quantitative body fat mass distribution was found.ConclusionAlthough there was a tendency for patients with isolated lipoatrophy and isolated fat accumulation to present higher IL-6 levels, these differences were not statistically significant. No differences were found relating IL-4 levels.

Combined endonasal and neurosurgical resection of a congenital teratoma with pharyngeal, intracranial and orbital extension: Case report, surgical technique and review of the literature

OBJECTIVES This study reports a patient with a large teratoma involving the oropharynx, the nasopharynx and the left orbit, with intracranial extension. This case represents one of the first reported instances of such an association. A literature review reporting head and neck teratomas with intracranial involvement is also presented. CASE REPORT The authors describe a case of a neonate presenting with a huge teratoma causing respiratory distress due to upper airway obstruction. The child was operated on at 3 months of age with a combined neurosurgical and endonasal endoscopic-assisted approach. After more than 1-year follow-up, the child has no recurrence and no complications of surgery. DISCUSSION This type of teratoma is very rare and surgical morbidity is common. The diagnosis may be apparent before birth, which will facilitate the planning of respiratory management. The combined neurosurgical and otolaryngologic approach for a neonatal teratoma has not previously been described. Using an endoscopic-assisted approach for intranasal tumors removal in neonates and infants is a very rare surgical challenge. CONCLUSION Large nasopharyngeal teratomas of infancy with sinonasal and intracranial extension may be managed using a combined endoscopic-assisted endonasal and neurosurgical procedure.

A challenging coexistence of central diabetes insipidus and cerebral salt wasting syndrome: a case report

BackgroundCombined central diabetes insipidus and cerebral salt wasting syndrome is a rare clinical finding. However, when this happens, mortality is high due to delayed diagnosis and/or inadequate treatment.Case presentationA 42-year-old white man was referred to neurosurgery due to a non-functional pituitary macroadenoma. He underwent a partial resection of the tumor on July 2, 2015. On the day following surgery he presented polyuria with sodium 149 mEq/L, plasma osmolality 301 mOsm/kg, and urine osmolality 293 mOsm/kg. He started nasal desmopressin 0.05 mg/day with good response. He was already on dexamethasone 4 mg and levothyroxine 75 mcg due to hypopituitarism after surgery. On July 9 he became confused. Cerebral computed tomography was performed with no significant changes. His natremia dropped to 128 mEq/L with development of polyuria despite maintenance of desmopressin dose. His hemoglobin and hematocrit rose from 9.1 g/L to 11.6 g/L and 27.5 to 32.5, respectively. His thyroid function was normal and he was on hydrocortisone 30 mg/day. At 12 p.m. 150 mg/hydrocortisone infusion was initiated, but sodium did not increase. Plasma and urine osmolality were 264 mOsm/kg and 679 mOsm/kg, respectively. At 4 p.m. hydrocortisone was increased and hypertonic saline replacement started. Two hours later he was dehydrated with polyuria and vomiting, and natremia of 124 mEq/L. Hyponatremia was very resistant to treatment despite hypertonic saline replacement, hence desmopressin was suspended. The following day, urine spot analysis showed that natriuresis was 63 mEq/L with serum sodium 132 mEq/L. This was interpreted as a cerebral salt wasting syndrome and control was achieved with aggressive hypertonic saline replacements and fludrocortisone 0.1 mg/three times a day. ConclusionsWe present a rare case of a patient with diabetes insipidus and cerebral salt wasting syndrome, who was successfully treated. Hyponatremia in a patient with diabetes insipidus may erroneously be interpreted as inadequate diabetes insipidus control or as syndrome of inappropriate antidiuretic hormone secretion, leading to therapeutic errors. Thus, all clinical and analytical data should be evaluated together for early and correct diagnosis.

Prolactin-Producing Pituitary Carcinoma, Hypopituitarism, and Graves’ Disease—Report of a Challenging Case and Literature Review

Introduction The diagnosis of pituitary carcinoma is very rare, requires the evidence of metastatic disease, and has a poor overall survival. Malignant prolactinoma frequently requires dopamine agonist therapy, pituitary surgery, radiotherapy, and even chemotherapy. Case description A 19-year-old female presented with galactorrhea, primary amenorrhea, and left hemianopsia. Complementary study detected hyperprolactinemia and a pituitary macroadenoma with cavernous sinus invasion and suprasellar growth. She was treated with cabergoline and bromocriptine without clinical or analytical improvement. Resection of the pituitary lesion was programmed and a non-contiguous lesion of the nasal mucosa was detected during the approach. This metastasis led to the diagnosis of prolactin-producing pituitary carcinoma. After partial resection, the patient was submitted to radiotherapy for residual disease with persistent symptoms. She developed growth hormone deficiency, central hypothyroidism, hypogonadism, and permanent diabetes insipidus. Six years later she was admitted for the suspicion of secondary adrenal insufficiency and thyrotoxicosis. Physical findings, laboratory data, thyroid ultrasound, and scintigraphy achieved the diagnosis of Graves’ disease and hypocortisolism. She was treated with hydrocortisone and methimazole, but central hypothyroidism recurred after antithyroid drug withdrawal. Nine years after the diagnosis of a pituitary carcinoma, she maintains treatment with bromocriptine, has a locally stable disease, with no metastases. Conclusion This report highlights an unusual presentation of a prolactin-producing pituitary carcinoma in a young female. The patient had multiple hormone deficiencies due to a pituitary lesion and treatments. The posterior development of hyperthyroidism and adrenal insufficiency brought an additional difficulty to the approach.