Pituitary apoplexy with intraventricular hemorrhage: Clinical presentation, treatment and outcome, case report

Background: Pituitary tumor apoplexy is a clinical syndrome characterized by abrupt onset of a severe headache, nausea, vertigo, meningismus, and/or decreased level of consciousness.Case report: we report a case of a 56-year old man presented to medical attention with sudden severe headache, nausea, vomiting, dizziness, diplopia and blurring of vision. Computer tomography and contrast-enhanced magnetic resonance imaging of the head proved a large sellar tumor with extension to the sphenoid sinus, suprasellar region and both cavernous sinuses, predominantly on the right side with intratumoral hemorrhagic zones and the hemorrhagic accumulation in the posterior horns of the lateral ventricles.The treatment of choice was transsphenoidal approach and the patient was discharged in a good condition, completely oriented, without other neurological signs.Conclusions: Pituitary apoplexy remains a potentially life-threatening disease. Its presentation may vary from relatively benign symptoms to major neurological deficits and even death. Its early recognition and treatment are vital

Update on the natural history of infratentorial cavernous malformations

Infratentorial cavernous malformations are still a source of serious controversies in neurosurgery and their natural history and treatment are intensely debated in literature. Recent studies suggest that symptomatic infratentorial cavernous malformations have a more aggressive clinical outcome than the supratentorial ones (the risk of hemorrhage is approximately 30 times that of the supratentorial cavernomas) The optimal therapeutic approach of infratentorial cavernomas need a good understanding of the natural history and also the characteristics that may influence the associated neurological risk, like the patient status at admission, the localization and the genetics of the malformation. Many studies have been published in the last decades to enlight the clinical aspects and the natural history of these vascular malformations. The purpose of this analysis is to make a literature review of the morbidity risk associated to cavernous malformations and their influence on the treatment plan

Endoscopic Endonasal Transsphenoidal Approach in the Management of Sellar and Parasellar Lesions: and Standard Surgical Technique (Part I)

Transsphenoidal approaches have been used for a century for the resection of pituitary and other sellar tumors. In the past decade, however, the endoscopic endonasal transsphenoidal approach has been proposed as a minimally invasive procedure for the treatment of pathologies of the sellar region. This procedure introduces various advantages compared with the transsphenoidal microsurgical approach, such as an improved vision of the surgical field, less traumatism of the nasal structures and reduced complications. Patients’ quick recovery, short hospital stays and minimal postoperative discomfort have been observed. More recently, the standard endoscopic endonasal technique has been extended to provide access to parasellar lesions. This expansion carries significant potential for the resection of skull base lesions. In this article, the authors review the indications of the endoscopic endonasal transsphenoidal approach and define the main phases of the standard surgical technique. Preoperative evaluation, equipment, preoperative and postoperative care are presented. Endoscopic endonasal technique is a safe and effective method for removal of most sellar and some parasellar masses, providing more complete lesion excision and reducing complications

Endoscopic endonasal transsphenoidal approach in the management of sellar and parasellar lesions: Alternative surgical techniques, results, complications (Part II)

The endoscopic endonasal transsphenoidal approach is a minimally invasive surgical technique for the removal of sellar and parasellar lesions. It allows panoramic vision of the surgical target and surrounding structures, with minimal trauma and a low complication rate. The procedure has been gaining in popularity in recent years. There are now surgical instruments intentionally conceived to respond to the specific characteristics of the neuroendoscopy. The widespread use of the endoscope in transsphenoidal surgery has recently contributed to the extension of the approach superior, inferior or lateral. This expansion carries significant potential for the resection of skull base lesions. For selected patients, the various techniques of the endoscopic endonasal transsphenoidal approach are valid alternatives to transcranial approaches. Macroadenomas, suprasellar or even intraventricular craniopharyngiomas, tuberculum sellae or even planum sphenoidale meningiomas and clival tumors become accessible for removal via an endoscopic approach. The authors review the main alternative surgical techniques of the endoscopic endonasal transsphenoidal approach. They also present the results and the complications of the endoscopic transsphenoidal surgery. Due to an improvement and refinement of the surgical procedures, the endoscopic endonasal transsphenoidal approach can be considered a good choice for the excision of the sellar and parasellar lesions

Deontological issues - possible misdiagnosis of cerebral metastases

Authors analyses a number of 4588 (52, 24% over 50 years old) patients operated for cerebral tumors in the Clinic Emergency Hospital “Bagdasar-Arseni” from Bucharest, between 2000-2010, with peculiar attention to the concordance between the preoperative and postoperative diagnosis, related to the actual policy to evaluate a neurosurgical patient before surgery. 903 cases were cerebral metastases and 69,5% aged over 50 years old. In 9,7% of cases we recorded a preoperative misdiagnosis of a metastasis due to few main reasons: unavailable information about a present primitive cancer, treacherous MRI image with a single confusing appearance of a cerebral lesion, age less than 50 years old, clinical presentation and biological evaluation inconsistent with malignancy. Authors point that these situations can have serious consequences related to professional competence, deterioration of the patient-doctor relationship, increasing costs for completion of diagnosis and treatment, and inadequate information about patient’s prognosis

Neuroprotection against surgically induced brain injury

Neurosurgical procedures are carried out routinely in hospitals across the world. Every neurosurgical procedure, regardless the purpose, involves a certain degree of brain injury that results from the procedure itself because of the unique nature of the nervous system. Brain tissue is at risk of injury by various means, including incisions and direct trauma, electrocautery, hemorrhage, and retractor stretch. Fortunately there are various substances with neuroprotective effect on human brain, with different molecular pathways, which can be used, together with surgical protective measures, as therapeutically drugs preventing brain damage during surgery. Among them steroids, some anesthetic agents intraoperative hypothermia are suggested to provide cerebral neuroprotection, but also new established therapeutic agents, such as erythropoietin and statins, Src tyrosine kinase inhibitor, used clinically in patients for different nonneurological disorders, which have also shown promise as neuroprotectants in experimental studies. Any form of pretreatment that proved effective when used before brain injury may have a significant impact on patient recovery and outcome of procedures. This review is intended to raise the question about neuroprotection methods and agents against surgically induced brain injury available today in neuroscience scientific community and stimulate discussions about future approaches and therapies