Mirza Pojskić

First Report of Coexistence of Two Ectopic Pituitary Tumors: Rathke Cleft Cyst and Silent Adrenocorticotropic Hormone Adenoma

BACKGROUNDnRathke cleft cysts (RCCs) and pituitary adenomas (PAs) are thought to have a common embryonic ancestry; however, PAs with a concomitant RCC inside the sella turcica are rarely observed. Ectopic pituitary tumors are also rare.nnnCASE DESCRIPTIONnWe present the case of a 65-year-old woman with an ectopic RCC in the sphenoid sinus and outside the sella turcica concomitant with an adrenocorticotropic hormone (ACTH)-staining, clinically silent PA. The patient had headache but no endocrine or visual disturbances. Preoperative magnetic resonance imaging revealed infrasellar cystic lesion in the sphenoid sinus with erosion of the clivus and intact sellar floor. The patient underwent gross total microsurgical resection through the transnasal route with an uneventful postoperative course.nnnCONCLUSIONSnTo our knowledge, this is the first reported ectopic RCC located outside the sella turcica with a concomitant ACTH-staining PA. This also appears to be the first ACTH-staining adenoma concomitant with RCC reported in the literature, regardless of location, not presenting with Cushing disease. This case shows that we can now include pituitary adenoma with or without a concomitant RCC in the differential diagnosis of processes in the sphenoid sinus. As both PAs and RCCs are benign sellar lesions, surgical management of a concomitant occurrence of these tumors mainly depends on the size of the lesions and their clinical manifestations. For patients with PA and concomitant RCC, surgical resection should be considered, as there is an approximatrely 20% recurrence rate of the cyst after resection and the possibility of future clival erosion, if left untreated.

Microsurgical Resection of Tuberculum Sellae Meningioma through Left Cranio-orbital Approach

In this video clip, the authors present the resection of a tuberculum sellae meningioma with compression of the left optic nerve and a chiasm ( Fig. 1 ) through a standard cranial orbital (CO) skull base approach. 1 2 3 The key step in the tumor resection was microsurgical dissection of left and right A1 segments of the anterior cerebral artery and the anterior communicating artery and the separation of the tumor from these vascular structures. This was followed by careful separation of the meningioma from both optic nerves, the chiasm and the pituitary stalk. The final step was coagulation and resection of the tumor origin on the dura of the tuberculum sellae, devascularizing the tumor. Once this was achieved, the tumor was removed. Using this approach, an optimal surgical corridor to the sellar area was provided while minimizing the retraction of frontal and temporal lobes. The link to the video can be found at: https://youtu.be/O59Fj2dNXB0 .

Microsurgical Resection of Medulla Oblongata Hemangioblastoma: 2-Dimensional Operative Video

Abstract This video demonstrates the microsurgical resection of brainstem hemangioblastoma. The patient is a 32-yr-old woman with Von Hippel Lindau syndrome who presented with quadriparesis and inability to swallow. Magnetic resonance imaging (MRI) of the neuroaxis revealed a brainstem cystic lesion with contrast-enhancing tumor nodule right along the posterior aspect of the lower part of medulla oblongata. The surgery was performed in the prone position with suboccipital craniectomy and partial C1 posterior arch removal. The aim of the surgery was to remove the tumor nodule.1-12 The tumor was separated from the right dorsal nerve roots, and then progressively dissected with coagulation of arterial feeders and draining vein and division of the pia circumferentially. Postoperative MRI revealed complete resection. The patient completely recovered from her quadriparesis and difficulty swallowing.

Microsurgical Resection of Spinal Cord Hemangioblastoma: 2-Dimensional Operative Video

Abstract This video demonstrates microsurgical resection of spinal cord hemangioblastoma. Hemangioblastomas are rare, benign, highly vascularized tumors classified as grade I according to World Health Organization classification systems. About 3% of all intramedullary tumors are hemangioblastomas.1,2 Spinal cord hemangioblastomas are either sporadic3,4 or manifestations of von Hippel-Lindau (VHL) disease in 20% to 45% of patients.5,6 u2003A 30-year-old male presented with sudden onset urinary incontinence. Magnetic resonance imaging showed contrast enhancing intramedullary tumor with adjacent cyst in T11, and syringomyelia extending to C1. Surgical resection followed rules that apply to resection of arteriovascular malformations: coagulation of arterial feeders precedes the coagulation of the draining vein, which is preserved until the end of surgery.2,4,5,7,8 u2003First, posterior midline myelotomy was performed and the tumor cyst was drained in order to develop a dissection plane. Following this, we continuously separated dorsal nerve roots from the tumor nodule using microsurgical technique. The key step in tumor resection is devascularization of the tumor, achievable in 2 ways.2,7,9-13 The circumferential detachment of the normal pia from the tumor pia is crucial in developing a plane of dissection. The coagulation and division of arterial feeders while preserving the drainage vein further devascularizes the tumor. Once the tumor mural nodule was detached from the spinal cord, the drainage vein was coagulated last and the tumor was removed. The patient fully recovered from his incontinence and was neurologically intact. Screening for VHL disease was negative. u2003Written consent was obtained directly from the patient.

Retrospective single-surgeon study of 1123 consecutive cases of anterior cervical discectomy and fusion: a comparison of clinical outcome parameters, complication rates, and costs between outpatient and inpatient surgery groups, with a literature review

OBJECTIVE Outpatient anterior cervical discectomy and fusion (ACDF) is becoming more common and has been reported to offer advantages over inpatient procedures, including reducing nosocomial infections and costs, as well as improving patient satisfaction. The goal of this retrospective study was to evaluate and compare outcome parameters, complication rates, and costs between inpatient and outpatient ACDF cases performed by 1 surgeon at a single institution. METHODS In a retrospective study, the records of all patients who had undergone first-time ACDF performed by a single surgeon in the period from June 1, 2003, to January 31, 2016, were reviewed. Patients were categorized into 2 groups: those who had undergone ACDF as outpatients in a same-day surgical center and those who had undergone surgery in the hospital with a minimum 1-night stay. Outcomes for all patients were evaluated with respect to the following parameters: age, sex, length of stay, preoperative and postoperative pain (self-reported questionnaires), number of levels fused, fusion, and complications, as well as the presence of risk factors, such as an increased body mass index, smoking, and diabetes mellitus. RESULTS In total, 1123 patients were operated on, 485 (43%) men and 638 (57%) women, whose mean age was 50 years. The mean follow-up time was 25 months. Overall, 40.5% underwent 1-level surgery, 34.3% 2-level, 21.9% 3-level, and 3.2% 4-level. Only 5 patients had nonunion of vertebrae; thus, the fusion rate was 99.6%. Complications occurred in 40 patients (3.6%), with 9 having significant complications (0.8%). Five hundred sixty patients (49.9%) had same-day surgery, and 563 patients (50.1%) stayed overnight in the hospital. The inpatients were older, were more commonly male, and had a higher rate of diabetes. Smoking status did not influence the length of stay. Both groups had a statistically significant reduction in pain (expressed as a visual analog scale score) postoperatively with no significant difference between the groups. One- and 2-level surgeries were done significantly more often in the outpatient setting (p < 0.001). The complication rate was 4.1% in the outpatient group and 3.0% in the inpatient group; there was no statistically significant difference between the 2 groups (p = 0.339). Significantly more complications occurred with 3- and 4-level surgeries than with 1- and 2-level procedures (p < 0.001, chi-square test). The overall average inpatient cost for commercial insurance carriers was 26% higher than those for outpatient surgery. CONCLUSIONS Anterior cervical discectomy and fusion is safe for patients undergoing 1- or 2-level surgery, with a very significant rate of pain reduction and fusion and a low complication rate in both clinical settings. Outpatient and inpatient groups undergoing 3- or 4-level surgery had an increased risk of complications (compared with those undergoing 1- or 2-level surgery), with a negligible difference between the 2 groups. This finding suggests that these procedures can also be included as standard outpatient surgery. Comparable outcome parameters and the same complication rates between inpatient and outpatient groups support both operative environments.

Anterior Clinoid Metastasis Removed Extradurally: First Case Report

Background u2003We report a case of isolated metastasis on the anterior clinoid process (ACP) mimicking meningioma. Clinical Presentation u2003A 58-year-old male presented with headaches, right-sided visual disturbances, and blurred and double vision. The cause of double vision was partial weakness of the right III nerve, resulting from compression of the nerve by “hypertrophied” tumor-involved right anterior clinoid. Medical history revealed two primary malignant tumors—male breast cancer and prostate cancer (diagnosed 6 and 18 months prior, respectively). The patient was treated with chemotherapy and showed no signs of active disease, recurrence, or metastasis. Postcontrast head magnetic resonance imaging (MRI) showed extra-axial well-bordered enhancing mass measuring 1.6u2009×u20091.1u2009×u20091u2009×u20091 cm (anteroposterior, transverse, and craniocaudal dimensions) on the ACP, resembling a clinoidal meningioma. Extradural clinoidectomy with tumor resection was performed via right orbitozygomatic pretemporal skull base approach. Visual symptoms improved. Follow-up MRI showed no signs of tumor residual or recurrence. Conclusion u2003This is the first case report of a metastasis of any kind on ACP. Metastasis should be included as a part of the differential diagnosis of lesions of the anterior clinoid. Extradural clinoidectomy is a safe and effective method in the treatment of these tumors.

Standard navigation versus intraoperative computed tomography navigation in upper cervical spine trauma

AbstractPurposeIn surgery of C1–C2 fractures, standard navigation for screw placement based on preoperative image data was compared with intraoperative imaging guidance applying intraoperative computed tomography (iCT) with a special focus on accuracy of screw placement, workflow, and radiation exposure.nMethodsA single surgeon series of 16 consecutive patients with C1–C2 trauma was retrospectively analyzed. Seven patients were operated with standard navigation; preoperative image data were registered by a 20-point surface-matching process for each vertebra. Nine patients were operated with iCT guidance, allowing automatic navigation registration. Screw placement was examined and graded with either iCT or postoperative CT. Dose length product of CT and dose area products of fluoroscopy scans were assessed; effective radiation doses were estimated based on conversion factors. Radiation doses of intraoperative and postoperative X-ray and/or CT diagnostics for each group were summarized to compare the total effective doses.ResultsA total number of 72 screws were placed, 26 in the standard navigation group including 24 screws in C1 and C2, and 46 screws in the iCT group including 34 screws in C1 and C2. 15.38% (nu2009=u20094) of the C2 screws showed a grade 1 deviation and 3.8% (nu2009=u20091) a grade 2 deviation applying standard navigation. There was no misplacement of screws in the iCT group. Mean operating time in the standard navigation group was 186.57xa0min versus 157.11xa0min in the iCT group, while the mean summarized effective dose was 1.129xa0mSv in the standard navigation and 2.129xa0mSv in the iCT group.ConclusioniCT navigated surgery can lead to higher accuracy and shorter operating time compared to standard navigated operations. iCT is a safe and straightforward procedure allowing reduction in radiation exposure of the medical staff, while modified scan protocols resulted in a radiation exposure that is lower than in standard diagnostic neck CT.

Retrospective study of 229 surgically treated patients with brain metastases: Prognostic factors, outcome and comparison of recursive partitioning analysis and diagnosis-specific graded prognostic assessment

Background: Metastases are the most frequent tumors in the brain. Most often used scoring systems to predict the outcome are the RPA (Recursive Partitioning Analysis) classification and the DS-GPA (Diagnosis-Specific Graded Prognostic Assessment) score. The goal of our study was to determine prognostic factors which influence outcome in patients who undergo surgery for brain metastases and to compare different outcome scores. Methods: Two hundred and twenty-nine patients who underwent surgery for brain metastases in our institution between January 2005 and December 2014 were included in the study. Patient data were evaluated retrospectively. Results: The mean survival time was 19.2 months (median survival time, MST: 8 months), for patients with a single metastasis (n = 149) 17.6 months (MST: 8 months), and for patients with multiple metastases (n = 80) 17.9 months (MST: 6 months). Significant influence on MST had age <65 years (9 vs. 5 months, P = 0.002), female sex (10 vs. 6 months, P < 0.001), RPA Class I and II (11 vs. 4 months, P < 0.001), Karnofsky score >70% (11 vs. 4 months, P < 0.001), and postoperative radiotherapy (8 vs. 5 months, P < 0.002). To evaluate the diagnostic power of DS-GPA and RPA score in respect of survival, two Cox regressions were modeled, where the RPA classification showed a better predictive power. Conclusion: Favorable factors for prolonged survival were KPS >70%, RPA Class I and II, age <65 years, female sex, a DS-GPA Score of 2.5–3 and 3.5–4, and adjuvant radiotherapy. The RPA Classification was more accurate in predicting the outcome than the DS-GPA score.