Hipopituitarismo e síndrome amenorreia-galactorreia causados por trombose de aneurisma carotídeo e da artéria carótida no pescoço: relato de caso

Giant intra and parasellar aneurysm with a spontaneous thrombosis of internal carotid artery is rare. We report the case of a 34 years old woman presenting a unique giant sellar and parasellar aneurysm associated with hypopituitarism and amenorrhea-galactorrhea syndrome. Computed tomographic scans and magnetic resonance images were suggestive of a sellar tumor with a cystic component. Digital cerebral angiography showed spontaneous thrombosis of a intrasellar and parasellar carotid artery aneurysm and left internal carotid artery in the neck. A transseptal endoscopic biopsy was done and confirmed a thrombosed aneurysm. No other surgical treatment was required in this patient but permanent endocrinological treatment was necessary.Aneurismas selares e paraselares gigantes com trombose da artéria carótida cervical e intracraniana são raros. Apresentamos o caso de mulher de 34 anos apresentando hipopituitarismo e síndrome amenorréia-galactorréia. A tomografia computadorizada craniana e a ressonância magnética foram sugestivas de tumor selar com componente cístico. Angiografia digital cerebral mostrou aneurisma único gigante selar e parasselar e trombose completa da artéria carótida comum esquerda no pescoço. A biopsia transeptal endoscópica da lesão mostrou tratar-se de aneurisma carotídeo trombosado. Não foi realizado nenhum outro tratamento cirúrgico na paciente, mas apenas tratamento endocrinológico de reposição.Fortaleza General Hospital Department of NeuroendocrinologyUniversidade Federal de São Paulo (UNIFESP), Escola Paulista de Medicina (EPM)Federal University of Ceará Department of AnesthesiologyFortaleza General Hospital Department of Neck and Head SurgeryUNIFESP, EPMSciEL

Relação entre pressão intra-selar e volume de tumor de hipófise

OBJECTIVE: To determine if there was a relationship between intrassellar pressure (ISP) and pituitary tumor volume. METHOD: Between August 2002 and May 2004, 60 patients aged between 13 and 75 years old (39 males), having a pituitary adenoma were submitted to an endoscope transseptal approach. During the surgery and before tumor resection, 2 mm of the sella s floor were removed and a 1.5 mm dural opening made to place a transducer into the pituitary adenoma. The transducer was connected to a pressure monitor. RESULTS: The intrasellar pressure, ranged from 2-51 mmHg and was measured based on the classification of Hardy-Vezina. The most elevated was in the type II macro adenomas with 32.6 mmHg, sharply superior to the value of a normal intracranial pressure. CONCLUSION: These values showed that the macroadenomas confined to the sella, without destruction of the floor and integrity of the diaphragm, type II of Hardy-Vezina, presented a value of ISP much higher than intra-extrasellar macroadenoma s.OBJETIVO: Determinar se existia uma relação entre a pressão intraselar (ISP) e o volume de tumor de hipófise. MÉTODO: Entre agosto de 2002 e maio de 2004, 60 pacientes com idades variando entre 13 e 75 anos (39 homens), portadores de adenoma hipofisários foram operados por via transesfenoidal. Durante o ato cirúrgico e antes da resseção do tumor, uma osteotomia de 2 mm foi realizada no assoalho selar e uma abertura de 1,5 mm na duramater para a introdução de um transdutor dentro do tumor. O transdutor foi conectado a um monitor de pressão e esta foi medida por 2 minutos. RESULTADOS: A pressão intra-selar variou entre 2-51 mmHg e a correlação entre tamanho do tumor e ISP foi baseada na classificação de Hardy-Vezina. A média da ISP mais elevada foi encontrada nos macroadenomas tipo II com 32,6 mmHg, nitidamente superior a pressão intra selar normal. CONCLUSÃO: Estes valores mostram que os macroadenomas confinados a sela sem destruição do assoalho selar e com integridade do diafragma, classificados como tipo II de Hardy-Vezina, apresentam uma ISP muito superior aos outros adenomas.Hospital of Fortaleza Neurosurgery Department GeneralFederal University of São Paulo Neurosurgery ServiceFederal University of CearáUNIFESP, Neurosurgery ServiceSciEL

Abscessos cerebrais múltiplos após apendicectomia: relato de caso Multiple brain abscesses following appendicectomy: case report

Paciente masculino de 39 anos, com quadro de abdomen agudo de evolução de 72 horas, foi submetido a apendicectomia. Desenvolveu 14 dias após, quadro de cefaléia, vômitos, afasia, torpor, hemiplegia à direita e rigidez de nuca. A tomografia computadorizada craniana mostrou múltiplos abscessos cerebrais supra tentoriais bilateralmente. Após punção aspirativa do maior deles foi instituída antibióticoterapia resultando em cura do paciente.A 39 years old male patient with a 72 hours evolution of acute abdominal syndrome was submitted to appendicectomy. Fourteen days later he developed headache, vomiting, aphasia, torpor, nuchal stiffness and right hemiplegia. A CT-scan showed multiple brain abscesses on both hemispheres. After aspirative puncture of the largest one, antibiotic treatment was established with total recovery of the patient

Minimally invasive pituitary surgery in a hemorrhagic necrosis of adenoma during pregnancy

A 29-year-old woman with a prolactin microadenoma was under good control with bromocriptine (BCP) therapy until she became pregnant, when the treatment was stopped. During the third trimester of pregnancy the patient presented a unilateral visual loss and intermittent headaches. BCP was restarted and one week later she developed a complete ophthalmoplegia on the other side. The patient was submitted to an endoscopic transnasal transeptal resection of a hematoma and tumoral tissue in the pituitary region. One month after surgery, at 39 weeks of gestation, the patient spontaneously delivered a healthy girl weighing 3 kg, with an Apgar score of 9 and 10 at five minutes. This is the first case in the literature of a pregnant woman with second and third cranial nerve lesions, submitted to minimally invasive neuroendoscopic transnasal transsphenoidal approach in the third trimester of pregnancy.Gen Hosp, Dept Neurosurg, Fortaleza, Ceara, BrazilGen Hosp, Dept Otorhinolaryngol, Fortaleza, Ceara, BrazilFed Univ Ceara, Dept Anesthesiol, Fortaleza, Ceara, BrazilUniv Fed Sao Paulo, Dept Neurosurg, Sao Paulo, BrazilUniv Fed Sao Paulo, Dept Neurosurg, Sao Paulo, BrazilWeb of Scienc

Giant Pituitary Adenomas: Surgical Outcomes Of 50 Cases Operated On By The Endonasal Endoscopic Approach.

To present our experience with the surgical management of giant pituitary adenomas in a series of 50 cases operated on by an endoscopic endonasal approach. A retrospective data analysis of all patients who underwent transsphenoidal endonasal endoscopic surgery at the General Hospital of Fortaleza, Brazil, between January 1998 and November 2011 was performed. Patients who presented with pituitary adenomas larger than 4 cm were included in the study. Analysis of factors related to the choice of the operative approach, hormonal and visual status, extent of resection, tumor control rates, clinical outcome, and complications were evaluated. Fifty cases (10.41%) matched our inclusion criteria. Nonfunctioning tumors were present in 42 patients (84%); among functioning adenomas, five patients (10%) had growth hormone-secreting adenomas, and three patients (6%) had prolactinomas. Total removal of the tumor occurred in 19 cases (38%), near-total removal in 9 cases (18%), and partial removal in 22 cases (44%). Postoperative cerebrospinal fluid leaks occurred in four cases (8%). Postoperative diabetes insipidus was present in 10% and new anterior pituitary insufficiency affecting one axis or more than one axis was observed in 22% and 14%, respectively. The presence of Knosp score ≥3 was associated with subtotal resection. Patients harboring hormonally active adenomas were submitted to adjuvant medical therapy for long-term clinical control. Vision improved in 38 patients (76%), with only one case of visual deterioration reported. Transsphenoidal endoscopic endonasal surgery may provide effective treatment for patients with giant adenomas when performed by a surgical team that specializes in pituitary surgery. In cases in which total resection by the endoscopic approach may be associated with important complications, we advocate the use of partial resections followed by adjuvant drug therapy or radiotherapy. In cases of progressive enlargement of residual lesions, a second endoscopic debulking of the tumor may be considered for control of the disease.82e281-9

Endoscopic endonasal approach for pituitary adenoma: surgical complications in 301 patients

The authors investigate the complications of transnasal transsphenoidal endoscopic surgery in the treatment of 301 patients with pituitary adenomas. A retrospective analysis of complications in 301 patients submitted to transsphenoidal transnasal endoscopic surgery at the General Hospital of Fortaleza, Brazil between January 1998 and December 2009. The complications were divided in two groups: anatomical (oronasofacial, sphenoid sinus, intrasellar, suprasellar and parasellar) and endocrinological complications (anterior and posterior pituitary dysfunctions). We observed a total of 81 complications (26.9%) in our series. Anatomical complications occurred in 8.97% (27 cases): 8 CSF postoperative leaks (2.6%), 6 cases (1.9%) of delayed nasal bleeding, 5 cases (1.6%) of sphenoidal sinusitis, 3 cases (0.9%) of carotid artery lesion, 2 cases of meningitis (0.6%) and one case (0.3%) of each of the uncommon following complications: intrasella-suprasella hematoma, pontine hematoma and chiasmaplexy. Endocrinological complications occurred in 17.9% (54 cases): additional postoperative anterior lobe insufficiency in 35 cases (11.6%), and postoperative diabetes insipidus in 19 cases (6.3%). In our series, 3 cases of deaths (not directly related to the procedure) were also observed. Endoscopic transsphenoidal surgery represents an effective option for the treatment of patients with pituitary tumor. Complications still occur and must be reduced as much as possible. Successful endoscopic pituitary surgery requires extensive training in the use of an endoscope and careful planning of the surgery. Additional improvement can be expected with greater experience and new technical developments