Lina Raffaella Barzaghi

Prognostic factors of visual field improvement after trans-sphenoidal approach for pituitary macroadenomas: review of the literature and analysis by quantitative method

The objective of the study was to evaluate the preoperative visual field defect, the postoperative outcome and the possible prognostic factors in patients with pituitary macroadenoma, using a quantitative method (the mean deviation = MD), and to review the literature. A total of 73 patients, operated trough trans-sphenoidal approach, were selected, and data in single eyes were analysed by calculating the frequency and the degree of postoperative improvement (relative improvement). The visual field defect improved in 95.7% of eyes: The recovery was complete in 48.9% and partial in 46.8%. Multivariate logistic regression showed that factors, independently predictive for complete recovery, were as follows: low preoperative MD absolute value (p = 0.008), low cranio-caudal diameter of tumour (p = 0.02) and young age (p = 0.0001). The mean relative improvement in visual field defect (dMD%) was correlated with the preoperative visual acuity (p = 0.0001) and inversely related with the preoperative MD (p = 0.007) and the age (p = 0.017). The relative improvement was higher in tumours with a smaller cranio-caudal diameter (p = 0.0185). In conclusion, using a quantitative method, we can measure the degree of the postoperative visual field defect improvement. Predictive factors for a complete recovery were good preoperative visual function, young age and low cranio-caudal tumour.

Visual outcome after fronto-temporo-orbito-zygomatic approach combined with early extradural and intradural optic nerve decompression in tuberculum and diaphragma sellae meningiomas

OBJECT The surgical challenge of the treatment of tuberculum (TSMs) and diaphragma sellae meningiomas (DSMs) is to preserve or improve the visual function. Extradural and intradural optic nerve decompression should reduce surgical trauma of the nerve achieving a good visual result. METHODS We reported 37 consecutive TSMs and DSMs operated through fronto-temporo-orbito-zygomatic approach with extradural unroofing of the optical canal and early intradural incision of the dural sheath. Visual data were recorded measuring the visual impairment score (VIS), the visual acuity (VA), the visual field (VF) and the postoperative improvement. RESULTS A good visual outcome (VIS improved or unchanged) was obtained in 97.2% of patients (35/36). The evaluation of 72 eyes showed a good outcome (VA and VF unchanged or improved) in 98.6% (71/72 eyes). The degree of preoperative VA and VF impairment was the only factor correlating with the postoperative improvement of VA (P<.001 and P=.018) and VF defect (P<.001). Worsening of visual function occurred in 1/37 patient (2.7%). CONCLUSION Using this surgical technique we achieved a high improvement rate of visual defects and a low frequency of worsening.

Microsurgical therapy of pituitary adenomas

PurposeWe report the efficacy and safety of transsphenoidal microsurgery in a large and homogeneous cohort of patients with pituitary adenomas (PAs) treated at a single Institute by a single neurosurgeon.MethodsA total of 2145 consecutive patients undergoing first surgery for a PA were included: 795 (37.1%) had a nonfunctioning pituitary adenoma (NFPA), 595 (27.7%) acromegaly, 496 (23.1%) Cushing’s disease, 208 (9.7%) a PRL-secreting adenoma, and 51 patients (2.4%) a TSH-secreting adenoma. Remission was achieved when strict hormonal and radiological criteria were met.ResultsEarly surgical remission was achieved in 66% of acromegalic patients, 79.6% of patients with Cushing’s disease, 64.4% of prolactinomas, 74.5% of patients with a TSH-secreting adenoma, and 66.9% of NFPAs. The mean (±SE) follow-up was 60.1 ± 1.3 months. The recurrence-free survival at 10 years was 78.2% in acromegalic patients, 68.1% in prolactinomas, 74.3% in Cushing’s disease, 70.3% in TSH-secreting adenomas, and 75.3% in NFPAs. Preoperative hypoadrenalism recovered in 35.3%, hypogonadism in 43.3% and hypothyroidism in 37.4% of patients with impaired function before surgery. The mortality rate was 0.2% and major morbidity 2.1%. New onset hypoadrenalism occurred after surgery in 2.5% of patients at risk, hypogonadism in 4.1%, and hypothyroidism in 1.8%. Permanent diabetes insipidus (DI) occurred in 0.9% of patients.ConclusionsIn experienced hands, transsphenoidal microsurgery for PAs achieves remission in most patients with a low complication rate. Pituitary function is preserved in most cases and can recover in more than one-third of patients with preoperative hypopituitarism.

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.

The Trans-Frontal-Sinus Subcranial Approach for Removal of Large Olfactory Groove Meningiomas: Surgical Technique and Comparison to Other Approaches

BACKGROUND AND STUDY OBJECTIVE Several surgical approaches have been previously reported for the treatment of olfactory groove meningiomas (OGM).The trans-frontal-sinus subcranial approach (TFSSA) for the removal of large OGMs is described, comparing it with other reported approaches in terms of advantages and drawbacks. MATERIAL AND METHODS The TFSSA was performed on cadaveric specimens to illustrate the surgical technique. RESULTS The surgical steps of the TFSSA and the related anatomical pictures are reported. The approach was adopted in a clinical setting; a case illustration is reported to demonstrate the feasibility of the described approach and to provide intraoperative pictures. CONCLUSION The TFSSA represents a possible route to treat large OGMs. The subcranial approach provides early devascularization of the tumor, direct tumor access from the base without traction on the frontal lobes, good overview of dissection of the optic nerves and anterior cerebral arteries, and dural reconstruction with pedicled pericranial flap.

Transfrontal-Sinus-Subcranial Approach to Olfactory Groove Meningiomas: Surgical Results and Clinical and Functional Outcome in a Consecutive Series of 21 Patients

BACKGROUND The transfrontal-sinus-subcranial approach (TFSSA) allows for direct exposure and removal of olfactory groove meningiomas (OGMs), without any brain retraction. Compared with other skull base approaches (e.g., fronto-orbitobasal, transbasal, subcranial, fronto-orbitozygomatic, and one-and-half approach), it could offer the same advantages but is less invasive. OBJECTIVE We report the results in a series of 21 consecutive patients with OGMs and operated on through TFSSA, to propose a viable alternative approach. METHODS Mean maximum tumor diameter was 45.9 ± 3.4 mm (range, 25-70 mm). The aim of surgery was Simpson grade I removal. Surgical, clinical, and functional outcomes were reported. Mean follow-up was 87 ± 7 months (range, 36-176 months). RESULTS In all patients, magnetic resonance imaging after surgery confirmed complete tumor removal. The recurrence-free survival rate was 100% and 85.7% at 5 and 10 years, respectively. Surgery-related mortality and major morbidity were 0% and 4.8%, respectively. Risk of anosmia significantly correlates with meningioma size (P < 0.001) and smell sense was preserved only in patients with tumors less than 4 cm in maximum diameter (4/7; 57.1%). A significant improvement of Mini Mental Standard Examination score was recorded at follow-up (P < 0.001) and no patients worsened their cognitive profile. Visual function improved in 7/8 (87.5%). Karnofsky Performance Scale score after surgery significantly increased (P < 0.001). According to the Glasgow Outcome Score, good outcome was achieved in 20 patients (95.2%). CONCLUSIONS Based on reported results, TFSSA allows complete tumor removal with good outcome and low complication rate. It may be proposed as a safe and effective approach to treat large and giant OGMs.

Prosepective Study to Evaluate Rate and Frequency of Perturbations of Implanted Programmable Hakim Codman Valve After 1.5-Tesla Magnetic Resonance Imaging

BACKGROUND Exposure to magnetic fields may alter the settings of programmable ventriculoperitoneal shunt valves or even cause permanent damages to these devices. There is little information about this topic, none on live patients. OBJECTIVE To investigate the effects of 1.5-tesla magnetic resonance imaging (MRI) on Hakim-Codman (HC) pressure programmable valves implanted in our hospital. METHODS A single-center prospective study to assess the rate of perturbations of HC programmable valve implanted. One hundred consecutive patients implanted for different clinical reasons between 2008 and 2012 were examined. A conventional skull x-ray before and after a standard MRI on 1.5 tesla. We evaluated before and after results, analyzed modification rate, and verified eventual damages to the implanted devices. RESULTS Implanted HC valves are extremely handy and durable, even if they are likely to change often due to the exposure to magnetic fields. None of the patients complained of heating effects. Oscillations range from 10-30 mm H2O with a patient who reached 50 mm H2O and 1 who reached 60 mm H2O. Global alteration rate was 40%: 10 patients (10%) experienced a 10 mm H2O change; 14 patients (14%) had a 20 mm H2O change; 6 patients (6%) had a 30 mm H2O change; 8 patients (8%) had a 40 mm H2O change; 1 patient had a 50 mm H2O change; and 1 patient had a 60 mm H2O change. CONCLUSIONS HC valves presented a variable perturbation rate, with an alteration rate of 40% with 1.5-telsa MRI. We have not observed malfunctioning hardware as a result of magnetic influence. We claim ​ a cranial x-ray immediately after the MRI because of a high risk (40%) of decalibration, especially in patients with low ventricles compliance.

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.

Pediatric Pituitary Adenomas: Early and Long-Term Surgical Outcome in a Series of 85 Consecutive Patients

BACKGROUND Young age has been reported as a negative prognostic factor for pituitary adenomas (PAs). They are very uncommon in children and adolescents; therefore, surgical outcomes are poorly described. OBJECTIVE To report results of microsurgical transsphenoidal approach (MTSA) in pediatric PAs. METHODS The study retrospectively analyzed 3040 PAs treated in our institute, according to the adenoma subtype and then divided into pediatric (≤18 yr) and adult groups (>18 yr). The average follow-up after surgery was 58 mo (n = 2906). RESULTS In the pediatric group, the majority of adenomas were hormone-secreting (89.5%) with a female sex prevalence (78%) in prolactinomas and nonfunctioning pituitary adenomas (NFPAs); the maximum diameter of growth hormone (GH)-secreting adenomas was greater (28.1 ± 4.1 mm) than in adults (18 ± 0.3 mm, P = .002). Surgical remission rate at 6 mo was similar in both groups for all adenoma subtypes: 72.1% and 76% in pediatric and adult Cushings disease, 69.3% and 59.3% in prolactinomas, 55.6% and 61% in gigantism or acromegaly, 55.6% and 61.5% in NFPAs. Recurrences after remission occurred more frequently in pediatric GH-secreting adenomas compared to adults (40.0% vs 5.3%, P = .028) despite similar follow-up (38 ± 17 and 48.1 ± 2.2 mo, P = .7). Mortality was zero in the pediatric and 0.2% in the adult group (P = .7); major morbidity was 2.4% and 2.2%, respectively (P = .8). CONCLUSION MTSA was safe and effective in children and adolescents as in adults, with the only exception of higher recurrence rate in pediatric GH-secreting adenomas. No complications related to young age appeared.

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.