Lucio Stella

Extended endoscopic transsphenoidal approach for tuberculum sellae meningiomas.

OBJECTIVE Tuberculum sellae meningiomas are classically removed through several different surgical transcranial approaches, including the pterional transsylvian route. Recently, the indications for the transsphenoidal technique, traditionally proposed only for the treatment of intrasellar lesions, have been extended to include lesions located in the supra- and parasellar areas and, among them, tuberculum sellae meningiomas. We describe the surgical technique for the purely endoscopic endonasal variant of the extended transsphenoidal “low route” to tuberculum sellae meningiomas. PATIENTS AND METHODS Over a 22-month period, six patients (three men and three women; mean age, 56.1 yr; age range, 44–70 yr) underwent an extended endoscopic transsphenoidal approach for the treatment of tuberculum sellae meningiomas. Two lesions were less than 2 cm and four were between 2 and 4 cm in size. The details of the surgical technique have been described. RESULTS Gross total removal of the lesion, without the need for brain retraction and with minimal neurovascular manipulation, was achieved in five patients (83.3%), whereas in one patient, only subtotal removal was possible (>90%) because the mass extended into the right optic canal. Four patients with preoperative visual function defects had complete recovery, whereas two patients experienced a temporary worsening of vision. Both of these patients fully recovered within a few days. One patient had a postoperative cerebrospinal fluid leak that required three operations for cranial base defect repair. This patient showed rapid and unexpected worsening with respect to level of consciousness and anisocoria. An intraventricular hemorrhage was discovered, and the patient died 6 days later. Another patient developed new permanent diabetes insipidus that required hormonal replacement therapy. CONCLUSION In experienced hands and in carefully selected patients, the extended endoscopic transsphenoidal approach may constitute a viable alternative to transcranial approaches for tuberculum sellae meningioma. At present, the major limits of the approach include the lack of a reliable technique for the reconstruction of a cranial base defect and inadequate follow-up.

Cerebral gliosarcomas: correlation of computed tomographic findings, surgical aspect, pathological features, and prognosis.

The cases of 5 patients with cerebral gliosarcomas examined by computed tomography are reported and the correlations among the computed tomographic (CT) findings, the surgical and histological aspects, and the prognosis are discussed. In some patients, these tumors appear on CT scan as intracerebral lesions, with large necrotic areas and peripheral contrast enhancement; this CT aspect, similar to that of glioblastomas, corresponds to a diffusely infiltrating growth of the tumor and the prevalence of a gliomatous component. In other patients, the tumor appears on the CT scan as a hyperdense mass with well-defined margins and homogenous contrast enhancement; this CT finding, which may mimic that of a meningioma, corresponds to a rather well-demarcated surgical aspect and the prevalence of sarcomatous component. In our series, we have also noticed a more prolonged survival in a patient with a CT aspect that suggested a meningioma and prevalence of the sarcomatous component.

Dysphagia and dyspnea due to an anterior cervical osteophyte

Abstract. Hypertrophic anterior cervical osteophytes have been reported as a cause of dysphagia, with about 100 cases described in the literature; on the other hand, chronic or acute dyspnea due to edema of the laryngeal inlet or bilateral vocal cord adduction-fixation is rare. We report a 57-year-old patient with a 2-year history of dysphagia and episodic dyspnea, who suffered sudden, severe respiratory distress necessitating emergency tracheotomy. A voluminous anterior cervical osteophyte at the C5 level was diagnosed by computed tomography (CT) and barium swallow test and removed by an anterior approach to the cervical spine, with clinical remission. The incidence, pathogenetic mechanisms, radiological diagnosis, and surgical indications of anterior cervical osteophytes associated with dysphagia and dyspnea are discussed. We advise examining cervical spine patients with dysphagia and/or dyspnea by radiography and CT when other investigations are not conclusive for a digestive or respiratory pathology.

Benign intrasellar cysts

Four cases of benign intrasellar cysts are reported. Three of these were treated surgically. Their origin and typical clinical features are discussed, in particular the altered pituitary function and visual disturbances. Computerized tomography has many advantages over traditional neuroradiological tools in reaching a diagnosis. The indication for active treatment and the surgical techniques and the methods used in the prevention of complications are outlined.

The empty sella

The data from 55 patients with empty sellae seen during the past five years are examined. The clinical and radiological features most helpful in defining and classifying each case are identified. The most frequent and most serious complications and the warning signs useful in diagnosis are discussed. The indications for and the results of surgical treatment are reviewed.

Empty Sella and Benign Intrasellar Cysts

The term “empty sella” defines an anatomical condition in which the sella is largely occupied by an arachnoid diverticulum containing cerebrospinal fluid (CSF), whilst the abnormally small hypophysis appears flattened against the infero-posterior wall of the sella (Fig. 1). An inherent feature is the absence, or extreme incompetence of the diaphragma sellae.

Phlebography of the cavernous and intercavernous sinuses

The study of pituitary diseases is described, with visualization of the cavernous and intercavernous sinuses accomplished through percutaneous, transfemoral catheterization, using special methods to ensure its reliability. The most characteristic normal and pathological findings are described. The value of this method and the indications for its use in diagnosis are discussed. The possibility of combining morphological investigations with regional functional studies of pituitary hormones by selective blood sampling is suggested. This technical development opens new prospects for the future and further broadens the indications for use of this procedure.

Chondroma of the petrous apex.

The clinicopathological features of a chondroma of petrous apex area examined with magnetic resonance (MRI) are presented. The extreme rarity of the location, the MRI aspect, and the surgical strategy based upon MRI studies make this case noteworthy.

Giant sacral perineurial cyst: a case report

A rare case of giant sacral perineurial cyst, causing sciatic pain, explored by myelography and computerized tomography, is reported. The cyst, associated with large erosion of the sacrum, was poorly visualized on the myelography, because of its large size, whereas it was better defined on CT scan. Sacral perineurial cysts are usually small and asymptomatic and rarely cause radicular symptoms. The radiological diagnosis and the treatment of these nerve root cysts are briefly discussed.