Manifestation of a sellar hemangioblastoma due to pituitary apoplexy: a case report

Introduction Hemangioblastomas are rare, benign tumors occurring in any part of the nervous system. Most are found as sporadic tumors in the cerebellum or spinal cord. However, these neoplasms are also associated with von Hippel-Lindau disease. We report a rare case of a sporadic sellar hemangioblastoma that became symptomatic due to pituitary apoplexy. Case presentation An 80-year-old, otherwise healthy Caucasian woman presented to our facility with severe headache attacks, hypocortisolism and blurred vision. A magnetic resonance imaging scan showed an acute hemorrhage of a known, stable and asymptomatic sellar mass lesion with chiasmatic compression accounting for our patient's acute visual impairment. The tumor was resected by a transnasal, transsphenoidal approach and histological examination revealed a capillary hemangioblastoma (World Health Organization grade I). Our patient recovered well and substitutional therapy was started for panhypopituitarism. A follow-up magnetic resonance imaging scan performed 16 months postoperatively showed good chiasmatic decompression with no tumor recurrence. Conclusions A review of the literature confirmed supratentorial locations of hemangioblastomas to be very unusual, especially within the sellar region. However, intrasellar hemangioblastoma must be considered in the differential diagnosis of pituitary apoplexy

Pituitary surgery for small prolactinomas as an alternative to treatment with dopamine agonists

Despite the fact that consensus guidelines recommend long-term dopamine agonist (DA) therapy as a first-line approach to the treatment of small prolactinoma, some patients continue to prefer a primary surgical approach. Concerns over potential adverse effects of long-term medical therapy and/or the desire to become pregnant and avoid long-term medication are often mentioned as reasons to pursue surgical removal. In this retrospective study, 34 consecutive patients (30 female, 4 male) preferably underwent primary pituitary surgery without prior DA treatment for small prolactinomas (microprolactinoma 1–10 mm, macroprolactinoma 11–20 mm) at the Department of Neurosurgery, University of Bern, Switzerland. At the time of diagnosis, 31 of 34 patients (91%) presented with symptoms. Patients with microprolactinomas had significantly lower preoperative prolactin (PRL) levels compared to patients with macroprolactinomas (median 143 μg/l vs. 340 μg/l). Ninety percent of symptomatic patients experienced significant improvement of their signs and symptoms upon surgery. The postoperative PRL levels (median 3.45 μg/l) returned to normal in 94% of patients with small prolactinomas. There was no mortality and no major morbidities. One patient suffered from hypogonadotropic hypogonadism after surgery despite postoperative normal PRL levels. Long-term remission was achieved in 22 of 24 patients (91%) with microprolactinomas, and in 8 of 10 patients (80%) with macroprolactinomas after a median follow-up period of 33.5 months. Patients with small prolactinomas can safely consider pituitary surgery in a specialized centre with good chance of long-term remission as an alternative to long-term DA therapy

Decompressive craniotomy after middle cerebral artery infarction. Retrospective analysis of patients treated in three centres in Switzerland

QUESTIONS UNDER STUDY / PRINCIPLES Several studies have reported an improved outcome in patients presenting with complete middle cerebral artery (MCA) infarction treated by decompressive hemicraniectomy. Although this palliative treatment form has gained popularity in Switzerland since 2000, the results of these series have not been reported. The aim of this study is, firstly, to report factors influencing the outcome of our patients, in order to create awareness of the indications and decision-making processes in our departments, and, secondly, to analyse therapeutic strategies which are open to improvement and standardisation. METHODS This retrospective study included a total of 28 patients (age 51 +/- 12 years) who underwent decompressive craniectomy after MCA between January 2000 and May 2002 at the Departments of Neurosurgery of Aarau (n: 6), Bern (n: 10), and Zurich (n: 12). Demographic characteristics included preoperative clinical condition (NIHSS and GCS), timing of surgery, cause, location, and extension of infarction. Additionally, the time delay from the onset of symptoms to surgery and preoperative signs of herniation and their relation to final outcome was analysed. The final outcome was assessed in terms of mortality and scores such as modified Rankin scale and Barthel index. RESULTS The preoperative clinical condition according to NIHSS was 20.2 +/- 4.7 and GCS was 10.6 +/- 3.6. The mean time in hours to surgery after onset of symptoms was 35 +/- 24. Twelve patients (42.8%) underwent "early" surgery (within 24 hours) and 21 (75%) suffered non-dominant stroke. The follow-up period was 22 +/- 13 months and 17% of the patients died within this period. Outcome did not differ significantly between institutions. The overall mean Barthel index was 47 +/- 25 and modified Rankin scale was 4 +/- 1.3. CONCLUSIONS The outcome in patients undergoing decompressive craniectomy after MCA infarction in Switzerland is less favourable than in other series recently reported. Less favourable preoperative clinical condition, inclusion of dominant hemispheric infarction, poorly defined protocols and late involvement of neurosurgeons on these patients' admission may explain the results

Repeated laser-assisted high-flow bypass for recurrent giant intracranial aneurysm

The treatment of intracranial aneurysms is changing as endovascular obliteration possibilities and long-term results are being published in regard to outcome. However, not all aneurysms are amenable to direct endovascular or surgical treatment. In such situations, a high flow bypass for flow preservation can be considered as indirect treatment alternative, enabling a trapping of the aneurysm or occlusion of the feeding artery. We present the case history of a 57 year-old patient suffering of a recurrent giant intracranial carotid aneurysm. The aneurysm could be excluded using a new cerebral high-flow bypass technique for which no temporary occlusion of any intracranial vessels is required. This technique reduces the risks of perioperative neurological complications

Multiple spinal extradural meningeal cysts presenting as acute paraplegia. Case report and review of the literature

Multiple spinal extradural meningeal cysts are rare. To the authors' knowledge, there have been only four reported cases in the world literature. The authors report a case of multiple spinal extradural meningeal cysts in a 31-year-old woman presenting with acute paraplegia. Magnetic resonance imaging of the thoracolumbar spine revealed multiple extradural cystic lesions extending from T-7 to T-8 and from T-12 to L-3. Intraoperative findings demonstrated a white, fibrous, and tense cyst filled with cerebrospinal fluid-like colorless fluid. Excision of the posterior wall of the symptomatic cyst was followed by immediate neurological improvement. The examination of the pathological specimen showed a thick duralike layer of collagen and an inner membrane of arachnoid that is often not found in these lesions. The final diagnosis was based on combined imaging, intraoperative, and histopathological findings. The authors review the literature and discuss the etiological, diagnostic, and therapeutic aspects of this lesion