Endoscopic endonasal management of recurrent petrous apex cholesterol granuloma.

Petrous apex cholesterol granulomas (PACG) are uncommon lesions. Recurrence following transcranial or endonasal approaches to aerate the cyst occurs in up to 60% of cases. We describe the technical nuances pertinent to the endonasal endoscopic management of a recurrent symptomatic PACG and review the literature. A 19-year-old woman presented with a recurrent right abducens nerve paresis. Four months prior, she underwent an endonasal transsphenoidal surgery (TSS) for drainage of a symptomatic PACG. Current imaging documented recurrence of the right PACG. Transsphenoidal and infrapetrous approaches were performed to obtain a wider bony opening along the petrous apex and drain the cyst. A Doyle splint was inserted into the cyst's cavity and extended out into the sphenoid, maintaining patency during the healing process. Three months after surgery, the splint was removed endoscopically, allowing visualization of a patent cylindrical communication between both aerated cavities. The patient remains symptom- and recurrence-free. Endoscopic endonasal surgery must be adapted to manage recurrent PACG. A TSS may not be sufficient. An infrapetrous approach with wider bony opening, extensive removal of the cyst's anterior wall, and use of a stent are indicated for the treatment of recurrent PACG and to prevent recurrences

Extended endoscopic endonasal transsphenoidal approach to the suprasellar area: Anatomic considerations - Part I

INTRODUCTION: Interest in using the extended endonasal transsphenoidal approach for management of suprasellar lesions, with either a microscopic or endoscopic technique, has increased in recent years. The most relevant benefit is that this median approach permits the exposure and removal of suprasellar lesions without the need for brain retraction. MATERIALS AND METHODS: Fifteen human cadaver heads were dissected to evaluate the surgical key steps and the advantages and limitations of the extended endoscopic endonasal transplanum sphenoidale approach. We compared this with the transcranial microsurgical view of the suprasellar area as explored using the bilateral subfrontal microsurgical approach, and with the anatomy of the same region as obtained through the endoscopic endonasal route. RESULTS: Some anatomic conditions can prevent or hinder use of the extended endonasal approach. These include a low level of sphenoid sinus pneumatization, a small sella size with small distance between the internal carotid arteries, a wide intercavernous sinus, and a thick tuberculum sellae. Compared with the subfrontal transcranial approach, the endoscopic endonasal approach offers advantages to visualizing the subchiasmatic, retrosellar, and third ventricle areas. CONCLUSION: The endoscopic endonasal transplanum sphenoidale technique is a straight, median approach to the midline areas around the sella that provides a multiangled, close-up view of all relevant neurovascular structures. Although a lack of adequate instrumentation makes it impossible to manage all structures that are visible with the endoscope, in selected cases, the extended endoscopic endonasal approach can be considered part of the armamentarium for surgical treatment of the suprasellar area

Advances in the Management of Pituitary Tumors

A new development in the management of pituitary tumors is the transsphenoidal technique. It will be my purpose to show that it provides an elegant way of handling the great majority of pituitary problems, at least the ones that I have encountered, although it has its shortcomings as well as its advantages

Intraoperative magnetic resonance imaging-assisted transsphenoidal pituitary surgery in patients with acromegaly

In this largest study to date of GH-producing pituitary adenomas in which iMR imaging-guided transsphenoidal surgery was analyzed, the results suggest that this method is a highly effective and safe treatment modality, even compared with previously published surgical series in which high-field iMR imaging was used. Limitations of iMR imaging are the detection of small residual tumor in the cavernous sinus and persisting disease that could not be observed, even on diagnostic high-field follow-up MR images. This points to a general limitation regarding remission rates that can be achieved using iMR imaging. Nevertheless, iMR imaging led to an increase of the remission rate in this study

Temporal lobe (TL) damage following surgery and high-dose photon and proton irradiation in 96 patients affected by chordomas and chondrosarcomas of the base of the skull

Purpose: To determine the temporal lobe (TL) damage rate in 96 patients treated with high-dose proton and photon irradiation for chordomas and chondrosarcomas of the base of the skull. Methods and Materials: The records of 96 consecutive patients treated at Massachusetts General Hospital (MGH) and Harvard Cyclotron Laboratory (HCL) between June 1984 and 1993, for chordomas and chondrosarcomas of the base of the skull were reviewed. All the patients had undergone some degree of resection of the tumor prior to radiation therapy. Seventy-five patients were classified as 'primary tumors' and 21 as recurrent or regrowing tumors after one or more surgical procedures. All the patients were randomized to receive 66.6 or 72 cobalt Gray equivalent (CGE) on a prospective dose-searching study by proton and photon irradiation (Radiation Therapy Oncology Group No.85-26) with conventional fractionation (1.8 CGE/day, 5 fractions/week). All treatments were planned using the three-dimensional (3D) planning system developed at the Massachusetts General Hospital, and the dose was delivered using opposed lateral fields for the photon component and a noncoplanar isocentric technique for the proton component. Clinical symptoms of TL damage were classified into 4 grades. Computerized tomography (CT) and magnetic resonance imaging (MRI) scans were evaluated for white matter changes. Abnormalities associated with persistent or recurrent tumor were distinguished from radiation-induced changes. TLs were delineated on the original scans of the 10 patients with damage and those of a group of 33 patients with no clinical or MRI evidence of injury. Dose distributions were calculated and dose- volume histograms were obtained for these patients. Results: Of the patients, 10 developed TL damage, with bilateral injury in 2 and unilateral injury in 8. The cumulative TL damage incidence at 2 and 5 years was 7.6 and 13.2%, respectively. The MRI areas suggestive of TL damage were always separated from the tumor bed. Symptoms were severe to moderate in 8 patients. Several baseline factors, tumor- or host-related, were analyzed to evaluate their predictivity for TL damage: age, gender, tumor site, histology, type of presentation, type and number of surgical procedures, primary tumor volume, prescribed dose, normal tissue involvement, and volume of TL receiving doses ranging between 10 and 50 CGE or more. Only gender, in a univariate analysis (log rank) was a significant predictor of damage (0.0155), with male patients being at significantly higher risk of TL injury. In a stepwise Cox regression that included gender as a variable, no other baseline variable improved the prediction of damage. Conclusions: The 2- and 5-year cumulative TL damage rates were 7.6 and 13.2%, respectively. Despite the different TL damage rates related to age, tumor volume, number of surgical procedures prior to radiation therapy, and prescribed doses to the tumor, only gender was a significant predictor of damage (p = 0.0155) using a univariate (log rank) test. Chordomas and chondrosarcomas of the base of the skull may represent an interesting model to evaluate the TL damage rates because of their extradural origin, displacing the white matter instead of infiltrating it as gliomas do, because of their longer local recurrence-free survival other than gliomas and other brain tumors and because of the high doses of irradiation delivered to the target volume to obtain local control

Pathological study of the pituitary tumours: especially as regards their types, incidence & course

From the study of 200 cases serially sectioned, the following histological findings have been ascertained.1. The cells of the pars distalis of the pituitary are so arranged that the eosinophil cells appear in the centre of the gland and the basophil and chromophobe cells are seen at the border line between these two zones. This arrangement is fairly constant.2. Foetal or undifferentiated epithelial cells have been recognised in all the glands at all ages. Their amount is variable; but their site is constant. They lie in the peripheral zone of the anterior lobe especially at its lower and posterior part near the cleft. The cells are arranged radially around connective tissue cores and blood vessels in a papilliferous manner. The solid masses described are nothing but compressed :papillae forming a sort of a trabecular arrangement.3. Colloid substance is present in 72% of the cases examined. The substance lies amongst all types of cells in the pars distalis and not amongst chromophobe cells as was once suggested.4. Basophilic infiltration of the pars nervosa is present in 118 cases (of the 200). It was so marked in 10 cases that the infiltration reached the posterior pole of the gland. This basophilia of the pars nervosa was only associated with hypertension in one case. The condition was also encountered in cases with healthy blood vessels.5. Rathke' s cleft cysts are seen in 13% of the cases. The presence of ciliated epithelium in their walls was ascertained. This distension was not accompanied by any activity on the part of pars intermedia, on the contrary the latter was atrophied in such cases.Again, although a high percentage of these cases with distended Rathke's cleft are associated with increased intracranial tension, yet there is a certain number of them in which the brain was atrophic. Moreover, not all the cases of increased intracranial tension are accompanied by distended Rathke' s cleft.6. The presence of tubular extensions of the cleft into the pars nervosa was detected in 6 cases. (i.e. 3%).7. The incidence of epithelial rests in pars tuberalis was found to be 41.5%. The relics of epithelium either lie superficial to the pars tuberalis or intermingled with its cell structures. The rests are often seen above the diaphragma sellae, along the infundibulum. The root of the pars tuberalis is the next site in frequency. Rarely, the rests are seen under the capsule of the pars distalis or deep down in its connective tissue core.Coinciding with other observers, no relics of epithelium were found in subjects less than twenty years of age.Again, these epithelial nests are more common in females than in males.8. Lipochrome pigment is detected in the pars nervosa. it is common in old subjects and in young subjects with cachetic debilitating diseases

Incidence of subjective anosmia after interhemispheric approach to anterior skull pathology

Oral Poster Paper IIINTRODUCTION: Interhemispheric approach to anterior skull base pathology may cause damage to the olfactory nerve by traction with subsequent anosmia. This deficit may affect patient’s daily activities and work. We aim to find out the incidence of subjective anosmia after interhemispheric approach and possible influence to patient. METHOD: Patients with interhemispheric approach since 1999 were selected. Those who had impaired conscious status and had impaired olfactory function before operation were excluded. Subjective evaluation of anosmia and effect on daily living were assessed by telephone interview. RESULT: In progresspostprin