P. Cappabianca

Application of neuroendoscopy to intraventricular lesions.

We present an overview of the history, development, technological advancements, current application, and future trends of cranial endoscopy. Neuroendoscopy provides a safe and effective management modality for the treatment of a variety of intracranial disorders, either tumoral or non-tumoral, congenital, developmental, and degenerative, and its knowledge, indications, and limits are fundamental for the armamentarium of the modern neurosurgeon.

Effect of surgery and radiotherapy on visual and endocrine function in nonfunctioning pituitary adenomas

The effect of surgery alone or followed by radiotherapy in recovering visual abnormalities, debulking tumor mass and restoring hormone impairments was evaluated in 84 patients with clinically nonfunctioning pituitary adenomas (NFPA) subjected to 1–10 yr follow-up. All patients underwent surgery via transsphenoidal (in 69) or transcranic-pterional approach (in 15). Radiotherapy was performed after surgery in 59 of 72 patients with incomplete tumor removal. The assessment of pituitary function was performed in all patients before and every 1–2 yr after surgery and/or radiotherapy. Radiological and ophthalmologic assessment was performed before and 3, 6 and 12 months after surgery, then yearly. At diagnosis, headache and visual disturbances occurred in 63 and 58 patients, respectively, while deficiency of GH, TSH, ACTH, FSH, LH and ADH was documented in 55, 7, 19, 47 and 6 patients, respectively. After surgery, gonadal function recovered in 12 women, visual disturbances improved in 43 patients (15 regained normal vision), pituitary function improved in 8 of 62 patients, worsened in 34 patients. At MRI, complete tumor removal was documented in 12 of 84 patients. After surgery alone, tumor regrowth was observed in 7 patients between 3–7 yr. After radiotherapy, vision improved in 9, remained unchanged in 49 and worsened in 1 of 59 patients. After radiotherapy, tumor regrowth was documented in 9 patients between 2–12 yr and the prevalence of hypopituitarism raised from 28.8% to 92% after 1 and 10 yr. In conclusion, surgery alone is effective only in a minority of patients (14.3%) and radiotherapy causes hypopituitarism in rather the totality of patients after 10 yr. The prevalence of tumor regrowth was similar in irradiated ones (15%) and non irradiated patients (28%; χ2, p=0.4). Therefore, a careful radiological follow-up is suggested after surgery so that radiotherapy can be performed promptly on the basis of clinical data, tumor regrowth and/or invasiveness documented at histology.

The role of the endoscopic transsphenoidal approach in pediatric neurosurgery

Abstract The endoscopic endonasal transsphenoidal approach to the sellar region for the removal of pituitary adenomas and of other neoplasms in the same area has proved its reliability and effectiveness for the very wide vision it offers, coupled with minimal surgical trauma. Indications and advantages of such a technique are reported, focused on the treatment of lesions of the sellar and parasellar environment in pediatric age-group patients, and based on a consecutive series of 100 patients, 3 of them adolescents, treated during the last 3 years.

Endoscopic Endonasal Transsphenoidal Approach to the Sellar Region

This chapter deals with the main aspects of the standard transsphenoidal approach to the sella by means of a “pure” endoscopic technique. With this term we mean a transsphenoidal procedure performed with an endoscope as the sole visualizing instrument during the whole operation. After almost a decade, this can be considered a regular way of surgical management of lesions of the sellar compartment, routinely employed in some centers. Special aspects, such as extended approaches to the skull base by means of variations of the standard procedure, will be treated in detail in next chapters of the book, and must be reserved to experienced surgeons.

Pseudoaneurysm of the intracavernous carotid artery following endoscopic endonasal transsphenoidal surgery, treated by endovascular approach.

Carotid artery injury following transsphenoidal microsurgery for sellar lesions [2, 5] or functional endoscopic sinus surgery (FESS) for paranasal sinus pathology [4] is a well known and fortunately uncommon complication of these procedures. It occurs more frequently during the course of re-operations and is associated with signi®cant morbidity and mortality. Endoscopicendonasaltranssphenoidalsurgeryhasbeen recently employed in the routine management of pituitary adenomas [3] and has been proposed as the treatment of choice for recurrences [1], but no similar complication has been reported to date.

Extended endoscopic endonasal transsphenoidal approaches to the suprasellar region, planum sphenoidale & clivus

The standard unilateral endoscopic transsphenoidal approach has permitted a very wide vision around the sella, with the possibility of lreating lesions not confined to its strict limits. This possibility does not concern only anatomical studies [1, 2, 3, 4, 6] but dinical cases too, that have undergone surgery both within the suprasellar, and in the dival compartments, besides the parasellar area, that has already been treated above. Relevant series on these extended approach es by means of the endoscopic technique have not yet been presented in the main literature, but sporadic reports are now coming in and we will introduce the main guidelines of the procedure along with some illustrative cases.

Pituitary macroadenoma and diaphragma sellae meningioma: differential diagnosis on MRI

Abstract Diaphragma sellae meningiomas are unusual tumours often not distinguished from pituitary macroadenomas. Preoperative differentiation is essential, because the trans-sphenoidal approach is used for surgical removal of adenomas, while meningiomas are approached via a craniotomy. We reviewed five patients in whom a diaphragma sellae meningioma was initially diagnosed as a nonsecreting pituitary macroadenoma. MRI criteria for differential diagnosis are discussed. The main findings considered are visibility of the pituitary gland, contrast enhancement, the centre of the lesion and sellar enlargement. These criteria, applied to a blind review, allow correct identification of the tumours.

Cabergoline-induced CSF rhinorrhea in patients with macroprolactinoma. Report of three cases

Three cases of cerebrospinal fluid (CSF) leak, in subjects with an invasive macroprolactinoma under treatment with cabergoline (CAB), are reported. The patients underwent surgical treatment by means of an endoscopic endonasal transsphenoidal approach, which allowed removal of the lesion and sealing of the fistula. Many cases of CSF rhinorrhea are described in literature after bromocriptine therapy in invasive prolactinomas, but only one report has been recently published of such condition after CAB treatment. The complication is likely due to the brisk cessation of the so-called “stopper effect”, i.e. the tumor mechanically blocking the CSF leak in spite of its previous erosion of the skull-base, when CAB induces the macroprolactinoma shrinkage. Endoscopic transsphenoidal surgery offers a safe, minimally invasive and efficient management of this complication, which allows to regularly perform the following steps of the therapeutical strategy against the prolactinoma.

Subarachnoid hemorrhage and "normal pressure hydrocephalus": fatal complication of percutaneous microcompression of the gasserian ganglion. Case report.

A 62-year-old man underwent percutaneous balloon catheter compression of the gasserian ganglion for typical trigeminal neuralgia. After this, a subarachnoid hemorrhage was discovered and normal pressure hydrocephalus developed, which required shunting. Although the neurological function recovered, the patient died 8 months later because of supervening hepatic insufficiency, probably caused by protracted antibiotic therapy. Such a fatal complication, the first one associated with the technique of percutaneous trigeminal compression, was perhaps predisposed by preexistent cerebral atrophy with enlargement of the subarachnoid spaces; the unforeseen piercing of the dilated trigeminal cistern probably permitted the intracranial subarachnoid diffusion of an otherwise trivial hemorrhage. The safety of the procedure may be greatly reduced in such instances.

Clinical comparison of remifentanil–sevoflurane vs. remifentanil–propofol for endoscopic endonasal transphenoidal surgery

Background: Endoscopic endonasal transphenoidal surgery has been recently proposed as a minimally invasive procedure for the treatment of pituitary adenomas. The main objective of the anaesthesiologist is to induce sufficient haemodynamic control together with rapid recovery at the end of surgery. The aim of this study was to examine recovery profile, surgical operative conditions and haemodynamic differences using remifentanil infusion with either propofol target controlled infusion system or sevoflurane. Method: Forty‐four adult patients were enrolled in a prospective, randomized, single‐blind, two‐group study: Group P received propofol target controlled infusion system and remifentanil; Group S received sevoflurane and remifentanil for maintenance of anaesthesia. Results: No statistically significant differences between the two groups with regards to the haemodynamic changes, operative conditions as assessed by a four‐step bleeding score (0–3), were obtained. Recovery times were considerably shorter after remifentanil–sevoflurane in comparison with remifentanil–propofol target controlled infusion system group (7.4 vs. 12.8 min, P < 0.01). Conclusion: This study demonstrates that sevoflurane–remifentanil gives a faster recovery and equivalent intraoperative status compared with propofol target controlled infusion system with remifentanil for the endoscopic endonasal transphenoidal approach.