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Sample records for endonasal transsphenoidal approach

  1. [Transsphenoidal endoscopic endonasal approach for the surgery of pituitary abscess].

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    Yu, Huanxin; Liu, Gang

    2014-01-01

    To evaluate the effectiveness of transsphenoidal endoscopic endonasal approach for the surgery of pituitary abscess. Eighteen pathologically diagnosed pituitary abscess were resected through transsphenoidal endoscopic endonasal approach at Tianjing Huanhu hospital between January 2000 and December 2011.Retrospective analysis was done upon clinical presentations and imaging features. There were 6 males and 12 females. The average age was 48.5 years old and the average disease course was 5.8 years. The typical clinical manifestations included headache (13 cases), pituitary dysfunction (10 cases), Diabetes Insipidus (4 cases) visual interference (8 cases) and fever (4 cases). All cases were resected by transsphenoidal endoscopic endonasal approach with general anesthesia. The postoperative symptoms and follow-up results were recorded. All patients were followed up from 6 months to 6 years. Postoperatively, headache was recovered in 13 cases, visual was improved in 6 cases, hypopituitarism was relieved in 8 cases and polyuria was disappeared in 3 cases. One case was recurrent and cured by transsphenoidal endoscopic endonasal approach. Transsphenoidal endoscopic endonasal approach for the surgery of pituitary abscess is effective.

  2. Variations of endonasal anatomy: relevance for the endoscopic endonasal transsphenoidal approach.

    NARCIS (Netherlands)

    Lindert, E.J. van; Ingels, K.J.A.O.; Mylanus, E.A.M.; Grotenhuis, J.A.

    2010-01-01

    BACKGROUND: The endoscopic endonasal transsphenoidal approach (EETA) to the pituitary is performed by ear, nose, and throat (ENT) surgeons in collaboration with neurosurgeons but also by neurosurgeons alone even though neurosurgeons have not been trained in rhinological surgery. PURPOSE: To register

  3. [The extended endoscopic endonasal transsphenoidal approach in surgery for epidermoid cysts of the chiasmatic region].

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    Fomichev, D V; Kalinin, P L; Kutin, M A; Sharipov, O I; Chernov, I V

    Surgical treatment for epidermoid cysts of the chiasmatic region is a challenge because of the tendency to a massive spread of epidermoid masses through the cerebrospinal fluid pathways and a significant lesion deviation from the midline. To analyze capabilities of the extended endoscopic endonasal transsphenoidal approach in surgery for epidermoid cysts. The study included 6 patients with epidermoid cysts of the chiasmatic region who were operated on using the extended anterior endoscopic endonasal transsphenoidal approach at the Burdenko Neurosurgical Institute in the past 5 years. Epidermoid masses were completely removed in 5 patients; in none of the cases, complete removal of the epidermoid cyst capsule was achieved. There were no cases of vision deterioration and the development of new focal neurological symptoms. One female patient developed hypopituitary disorders in the postoperative period. There was no recurrence of epidermoid cysts during follow-up. Removal of epidermoid cysts of the chiasmatic region using the extended anterior endoscopic transsphenoidal approach may be an alternative to transcranial microsurgery.

  4. Three-Hand Endoscopic Endonasal Transsphenoidal Surgery: Experience With an Anatomy-Preserving Mononostril Approach Technique.

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    Eseonu, Chikezie I; ReFaey, Karim; Pamias-Portalatin, Eva; Asensio, Javier; Garcia, Oscar; Boahene, Kofi D; Quiñones-Hinojosa, Alfredo

    2018-02-01

    Variations on the endoscopic transsphenoidal approach present unique surgical techniques that have unique effects on surgical outcomes, extent of resection (EOR), and anatomical complications. To analyze the learning curve and perioperative outcomes of the 3-hand endoscopic endonasal mononostril transsphenoidal technique. Prospective case series and retrospective data analysis of patients who were treated with the 3-hand transsphenoidal technique between January 2007 and May 2015 by a single neurosurgeon. Patient characteristics, preoperative presentation, tumor characteristics, operative times, learning curve, and postoperative outcomes were analyzed. Volumetric EOR was evaluated, and a logistic regression analysis was used to assess predictors of EOR. Two hundred seventy-five patients underwent an endoscopic transsphenoidal surgery using the 3-hand technique. One hundred eighteen patients in the early group had surgery between 2007 and 2010, while 157 patients in the late group had surgery between 2011 and 2015. Operative time was significantly shorter in the late group (161.6 min) compared to the early group (211.3 min, P = .001). Both cohorts had similar EOR (early group 84.6% vs late group 85.5%, P = .846) and postoperative outcomes. The learning curve showed that it took 54 cases to achieve operative proficiency with the 3-handed technique. Multivariate modeling suggested that prior resections and preoperative tumor size are important predictors for EOR. We describe a 3-hand, mononostril endoscopic transsphenoidal technique performed by a single neurosurgeon that has minimal anatomic distortion and postoperative complications. During the learning curve of this technique, operative time can significantly decrease, while EOR, postoperative outcomes, and complications are not jeopardized. Copyright © 2017 by the Congress of Neurological Surgeons

  5. Transsphenoidal Approach in Endoscopic Endonasal Surgery for Skull Base Lesions: What Radiologists and Surgeons Need to Know.

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    García-Garrigós, Elena; Arenas-Jiménez, Juan José; Monjas-Cánovas, Irene; Abarca-Olivas, Javier; Cortés-Vela, Jesús Julián; De La Hoz-Rosa, Javier; Guirau-Rubio, Maria Dolores

    2015-01-01

    In the last 2 decades, endoscopic endonasal transsphenoidal surgery has become the most popular choice of neurosurgeons and otolaryngologists to treat lesions of the skull base, with minimal invasiveness, lower incidence of complications, and lower morbidity and mortality rates compared with traditional approaches. The transsphenoidal route is the surgical approach of choice for most sellar tumors because of the relationship of the sphenoid bone to the nasal cavity below and the pituitary gland above. More recently, extended approaches have expanded the indications for transsphenoidal surgery by using different corridors leading to specific target areas, from the crista galli to the spinomedullary junction. Computer-assisted surgery is an evolving technology that allows real-time anatomic navigation during endoscopic surgery by linking preoperative triplanar radiologic images and intraoperative endoscopic views, thus helping the surgeon avoid damage to vital structures. Preoperative computed tomography is the preferred modality to show bone landmarks and vascular structures. Radiologists play an important role in surgical planning by reporting extension of sphenoid pneumatization, recesses and septations of the sinus, and other relevant anatomic variants. Radiologists should understand the relationships of the sphenoid bone and skull base structures, anatomic variants, and image-guided neuronavigation techniques to prevent surgical complications and allow effective treatment of skull base lesions with the endoscopic endonasal transsphenoidal approach. ©RSNA, 2015.

  6. Endoscopic Endonasal Transsphenoidal Approach for Apoplectic Pituitary Tumor: Surgical Outcomes and Complications in 45 Patients.

    Science.gov (United States)

    Zhan, Rucai; Li, Xueen; Li, Xingang

    2016-02-01

    Objective To assess the safety and effectiveness of the endoscopic endonasal transsphenoidal approach (EETA) for apoplectic pituitary adenoma. Design A retrospective study. Setting Qilu Hospital of Shandong University; Brain Science Research Institute, Shandong University. Participants Patients admitted to Qilu Hospital of Shandong University who were diagnosed with an apoplectic pituitary tumor and underwent EETA for resection of the tumor. Main Outcome Measures In total 45 patients were included in a retrospective chart review. Data regarding patient age, sex, presentation, lesion size, surgical procedure, extent of resection, clinical outcome, and surgical complications were obtained from the chart review. Results In total, 38 (92.7%) of 41 patients with loss of vision obtained visual remission postoperatively. In addition, 16 patients reported a secreting adenoma, and postsurgical hormonal levels were normal or decreased in 14 patients. All other symptoms, such as headache and alteration of mental status, recovered rapidly after surgery. Two patients (4.4%) incurred cerebrospinal fluid leakage. Six patients (13.3%) experienced transient diabetes insipidus (DI) postoperatively, but none of these patients developed permanent DI. Five patients (11.1%) developed hypopituitarism and were treated with replacement of hormonal medicine. No cases of meningitis, carotid artery injury, or death related to surgery were reported. Conclusion EETA offers a safe and effective surgical option for apoplectic pituitary tumors and is associated with low morbidity and mortality.

  7. COMPLICATIONS OF ENDONASAL ENDOSCOPIC TRANSSPHENOIDAL APPROACH FOR PITUITARY ADENOMAS: OUR EXPERIENCE IN 50 PATIENTS TREATED AT OUR TERTIARY CENTRE

    Directory of Open Access Journals (Sweden)

    Mani Ram

    2015-12-01

    Full Text Available INTRODUCTION Between September 2013 and October 2014, we conducted a retrospective analysis to assess the complications related to endoscopic pituitary surgery in a series of 50 patients. We analysed the complications in preoperative, postoperative and endocrinological categories. We had a follow up of 1-2 years. Endonasal endoscopic transsphenoidal surgery (ETSS is an effective option for pituitary tumors. Complications do occur, but they can be reduced with experience & expertise and there is a steep learning curve. It demands a multidisciplinary approach.

  8. Surgical outcomes of the endoscopic endonasal transsphenoidal approach for large and giant pituitary adenomas: institutional experience with special attention to approach-related complications

    Directory of Open Access Journals (Sweden)

    Edson Rocha Constantino

    2016-05-01

    Full Text Available ABSTRACT Objective In this study, we investigate our institutional experience of patients who underwent endoscopic endonasal transsphenoidal approach for treatment of large and giant pituitary adenomas emphasizing the surgical results and approach-related complications. Method The authors reviewed 28 consecutive patients who underwent surgery between March, 2010 and March, 2014. Results The mean preoperative tumor diameter was 4.6 cm. Gross-total resection was achieved in 14.3%, near-total in 10.7%, subtotal in 39.3%, and partial in 35.7%. Nine patients experienced improvement in visual acuity, while one patient worsened. The most common complications were transient diabetes insipidus (53%, new pituitary deficit (35.7%, endonasal adhesions (21.4%, and cerebrospinal fluid leak (17.8%. Surgical mortality was 7.1%. Conclusions Endoscopic endonasal transsphenoidal surgery is a valuable treatment option for large or giant pituitary adenomas, which results in high rates of surgical decompression of cerebrovascular structures.

  9. A checklist for endonasal transsphenoidal anterior skull base surgery.

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    Laws, Edward R; Wong, Judith M; Smith, Timothy R; de Los Reyes, Kenneth; Aglio, Linda S; Thorne, Alison J; Cote, David J; Esposito, Felice; Cappabianca, Paolo; Gawande, Atul

    2016-06-01

    OBJECT Approximately 250 million surgical procedures are performed annually worldwide, and data suggest that major complications occur in 3%-17% of them. Many of these complications can be classified as avoidable, and previous studies have demonstrated that preoperative checklists improve operating room teamwork and decrease complication rates. Although the authors' institution has instituted a general preoperative "time-out" designed to streamline communication, flatten vertical authority gradients, and decrease procedural errors, there is no specific checklist for transnasal transsphenoidal anterior skull base surgery, with or without endoscopy. Such minimally invasive cranial surgery uses a completely different conceptual approach, set-up, instrumentation, and operative procedure. Therefore, it can be associated with different types of complications as compared with open cranial surgery. The authors hypothesized that a detailed, procedure-specific, preoperative checklist would be useful to reduce errors, improve outcomes, decrease delays, and maximize both teambuilding and operational efficiency. Thus, the object of this study was to develop such a checklist for endonasal transsphenoidal anterior skull base surgery. METHODS An expert panel was convened that consisted of all members of the typical surgical team for transsphenoidal endoscopic cases: neurosurgeons, anesthesiologists, circulating nurses, scrub technicians, surgical operations managers, and technical assistants. Beginning with a general checklist, procedure-specific items were added and categorized into 4 pauses: Anesthesia Pause, Surgical Pause, Equipment Pause, and Closure Pause. RESULTS The final endonasal transsphenoidal anterior skull base surgery checklist is composed of the following 4 pauses. The Anesthesia Pause consists of patient identification, diagnosis, pertinent laboratory studies, medications, surgical preparation, patient positioning, intravenous/arterial access, fluid management

  10. Urgent Optic Nerve Decompression via an Endoscopic Endonasal Transsphenoidal Approach for Craniopharyngioma in a 12-Month-Old Infant: A Case Report.

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    Shibata, Teishiki; Tanikawa, Motoki; Sakata, Tomohiro; Mase, Mitsuhito

    2018-01-01

    Craniopharyngiomas are benign tumors and account for approximately 5.6-13% of all intracranial tumors in children. Diagnosis of pediatric craniopharyngioma is often delayed until the tumor becomes relatively large and manifests severe visual and/or endocrine disturbance. Endoscopic endonasal approaches have recently been introduced to surgery for craniopharyngioma. These techniques, however, have rarely been utilized in patients affected with craniopharyngioma as young as 1 year old. This report documents a 12-month-old male infant with sellar craniopharyngioma who presented with acute total vision loss. To increase the chances of visual recovery, an endoscopic endonasal optic nerve decompression was performed as an urgent procedure. After decompression, which resulted in improvement of his visual disturbance, gross total resection of the tumor was undertaken through an anterior interhemispheric approach at a later date. Tumor mass reduction through an endoscopic endonasal transsphenoidal approach followed by secondary radical total resection under craniotomy was considered to be useful in cases such as this when urgent optic nerve decompression is required. © 2018 S. Karger AG, Basel.

  11. Is endoscopic endonasal transsphenoidal surgery increases the susceptibility to rhinosinusitis.

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    Topuz, Muhammet Fatih; Sarı, Murat; Binnetoglu, Adem; Dogrul, Ramazan; Bugdaycı, Onur; Şeker, Aşkın

    2017-08-01

    The aim of the study was to analyze whether the measurement of changes in the anatomical position and volume of middle concha, the volume changes in the area between the middle concha and lamina papyracea, the evaluation of opacification in major paranasal sinuses, and osteomeatal complex occlusion in cases with middle concha by out-fracture technique during endoscopic endonasal transsphenoidal approach is a minimally invasive surgery, and also to find out whether these changes lead to the development of tendency to rhinosinusitis. It was a retrospective clinical study. Forty-five cases, between 2013 and 2015, planned for endoscopic endonasal transsphenoidal surgery due to hypophyseal pathology at the Neurosurgery Departments of Marmara University Hospital were evaluated retrospectively. The patients were evaluated for the changes in the anatomy of the middle concha and the effects of these changes to paranasal sinuses by paranasal computed tomographies were studied at the preoperative second week and postoperative 12 month. The Lund-Mackay scoring system was used for the evaluation of opacification in the five major paranasal sinuses and occlusion of the osteomeatal complex in the pre- and postoperative period. The Lund-Mackay scoring system was used to analyze the paranasal computed tomography of the patients at the preoperative 2 weeks and postoperative first year. According to the Lund-Mackay scoring system, no significant difference was detected between the preoperative and postoperative opacification of paranasal sinuses (p > 0.05). Besides, there was also no significant difference between the preoperative and postoperative osteomeatal complex occlusion (p > 0.05). Considering the distance between middle concha and lamina papyracea following the out-fracture of the middle concha, a significant lateralization of 0.5 mm between the preoperative and postoperative period was observed (p transsphenoidal surgery causes some variations in the structures of

  12. Extended Transsphenoidal Endoscopic Endonasal Surgery of Suprasellar Craniopharyngiomas.

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    Fomichev, Dmitry; Kalinin, Pavel; Kutin, Maxim; Sharipov, Oleg

    2016-10-01

    The endoscopic extended transsphenoidal approach for suprasellar craniopharyngiomas may be a really alternative to the transcranial approach in many cases. The authors present their experience with this technique in 136 patients with craniopharyngiomas. From the past 7 years 204 patients with different purely supradiaphragmatic tumors underwent removal by extended endoscopic transsphenoidal transtuberculum transplanum approach. Most of the patients (136) had craniopharyngiomas (suprasellar, intra-extraventricular). The patients were analyzed according to age, sex, tumor size, growth and tumor structure, and clinical symptoms. Twenty-five patients had undergone a previous surgery. The mean follow-up was 42 months (range, 4-120 months). The operation is always performed with the bilateral endoscopic endonasal anterior extended transsphenoidal approach. A gross-total removal was completed in 72%. Improvement of vision or absence of visual deterioration after operation was observed in 89% of patients; 11% had worsening vision after surgery. Endocrine dysfunction did not improve after surgery, new hypotalamopituitary dysfunction (anterior pituitary dysfunction or diabetes insipidus) or worsening of it was observed in 42.6%. Other main complications included transient new mental disorder in 11%, temporary neurological postoperative deficits in 3.7%, bacterial meningitis in 16%, cerebrospinal fluid leaks in 8.8%. The recurrence rate was 20% and the lethality was 5.8%. Resection of suprasellar craniopharyngiomas using the extended endoscopic approach is a more effective and less traumatic technology, able to provide resection of the tumor along with high quality of life after surgery, and relatively rare postoperative complications and mortality. Copyright © 2016 Elsevier Inc. All rights reserved.

  13. A prospective qualitative study on patients' perceptions of endoscopic endonasal transsphenoidal surgery.

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    Edem, Idara J; Banton, Beverly; Bernstein, Mark; Lwu, Shelly; Vescan, Allan; Gentilli, Fred; Zadeh, Gelareh

    2013-02-01

    Endoscopic transsphenoidal surgery has been shown to be a safe and effective treatment option for patients with pituitary tumours, but no study has explored patients' perceptions before and after this surgery. The authors in this study aim to explore patients' perceptions on endoscopic transsphenoidal surgery. Using qualitative research methodology, two semi-structured interviews were conducted with 30 participants who were adults aged > 18 undergoing endoscopic transsphenoidal surgery for the resection of a pituitary tumour between December 2008 and June 2011. The interviews were audiotaped and transcribed. The resulting data was analyzed using a modified thematic analysis. Seven overarching themes were identified: (1) Patients had a positive surgical experience; (2) patients were satisfied with the results of the procedure; (3) patients were initially surprised that neurosurgery could be performed endonasally; (4) patients expected a cure and to feel better after the surgery; (5) many patients feared that something might go wrong during the surgery; (6) patients were psychologically prepared for the surgery; (7) most patients reported receiving adequate pre-op and post-op information. This is the first qualitative study reporting on patients' perceptions before and after an endoscopic endonasal transsphenoidal pituitary surgery, which is increasingly used as a standard surgical approach for patients with pituitary tumours. Patients report a positive perception and general satisfaction with the endoscopic transsphenoidal surgical experience. However, there is still room for improvement in post-surgical care. Overall, patients' perceptions can help improve the delivery of comprehensive care to future patients undergoing pituitary tumour surgery.

  14. Clinical Pearls in Anaesthesia for Endoscopic Endonasal Transsphenoid Pituitary Macroadenoma Surgery

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    Shah Shagun B

    2015-11-01

    Full Text Available Endoscopic Endonasal Trans-sphenoid Surgery (EETS aided by avant-garde neuro-navigation techniques, ultrasonic aspirators and bone curettes has come of age. Endoscopic surgery supersedes conventional microscopic approach due to better visualization, avoidance of craniotomy, brain retraction and undue neurovascular manipulation with less morbidity, blood loss and improved safety. Anaesthetic techniques must be tailored to cater for such advances in surgery.

  15. Utility and safety of the flexible-fiber CO2 laser in endoscopic endonasal transsphenoidal surgery.

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    Jayarao, Mayur; Devaiah, Anand K; Chin, Lawrence S

    2011-01-01

    This study sought to report on the utility and safety of the flexible-fiber CO2 laser in endoscopic endonasal transsphenoidal surgery. A retrospective chart review identified 16 patients who underwent laser-assisted transsphenoidal surgery. All tumor pathology types were considered. Results were assessed based on hormone status, tumor size, pathology, complications, and resection rates. Sixteen pituitary lesions (pituitary adenomas, 12; Rathke cleft cyst, 2; pituitary cyst and craniopharyngioma, 1 each) with an average size of 22.7 mm were identified by radiographic and pathologic criteria. All patients underwent flexible-fiber CO2 laser-assisted endoscopic endonasal transsphenoidal surgery. Of the adenomas, 8 were nonsecreting and 4 were secreting (3 prolactinomas and 1 ACTH secreting). Gross total resection was achieved in 7 of 16 patients (43.75%) with hormone remission in all patients (100%) after a mean follow-up of 19.3 months. Postoperative complications occurred in 3 patients (18.75%): 2 patients developed transient diabetes insipidus (DI) and 1 developed a CSF leak requiring surgical repair. Five patients (31.25%) underwent postoperative radiation to the residual lesions. We found that CO2-laser-assisted endoscopic endonasal transsphenoidal surgery for sellar tumors is a minimally invasive approach using a tool that is quick and effective at cutting and coagulation. The surgery has a low rate of complication, and no laser-related complications were encountered. The laser fiber allows the surgeon to safely cut and coagulate without the line-of-sight problems encountered with conventional CO2 lasers. Further studies are recommended to further define its role in endoscopic endonasal sellar surgery. Copyright © 2011 Elsevier Inc. All rights reserved.

  16. Olfactory function and quality of life following microscopic endonasal transsphenoidal pituitary surgery.

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    Wang, Shousen; Chen, Yehuang; Li, Jianzhong; Wei, Liangfeng; Wang, Rumi

    2015-01-01

    Olfactory outcomes as well as oronasal postoperative complications of transsphenoidal pituitary surgery have not been well studied. The objective of this study was to investigate nasal symptoms including olfactory function as well as quality of life following transsphenoidal pituitary surgery. The study is designed as a prospective cohort study set in a single tertiary hospital. A total of 53 patients with pituitary adenomas were included. All patients underwent pituitary surgery with the right-sided endonasal transsphenoidal approach. Outcomes were assessed with the Chinese version of the Medical Outcomes Study Short Form-36 (SF-36) to survey patient health, the Chinese version of the 22-item Sinonasal Outcome Test (SNOT-22), and a Toyota and Takagi (T&T) olfactometer. Assessments were carried out before surgery and at 1 week, and 1 and 4 months after surgery. The overall SF-36 scores were significantly lower, but the SNOT-22 scores were higher at 1 week and 1 month postoperatively compared with baseline (all P surgery were independent risk factors for a higher SNOT-22 score at 1 week after surgery. The findings show that microscopic endonasal transsphenoidal pituitary surgery impairs olfactory function in most patients for at least 4 months after surgery.

  17. Endoscopic endonasal trans-sphenoid surgery of pituitary adenoma

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    Y R Yadav

    2012-01-01

    Full Text Available Endoscopic endonasal trans-sphenoid surgery (EETS is increasingly used for pituitary lesions. Pre-operative CT and MRI scans and peroperative endoscopic visualization can provide useful anatomical information. EETS is indicated in sellar, suprasellar, intraventricular, retro-infundibular, and invasive tumors. Recurrent and residual lesions, pituitary apoplexy and empty sella syndrome can be managed by EETS. Modern neuronavigation techniques, ultrasonic aspirators, ultrasonic bone curette can add to the safety. The binostril approach provides a wider working area. High definition camera is much superior to three-chip camera. Most of the recent reports favor EETS in terms of safety, quality of life and tumor resection, hospital stay, better endocrinological, and visual outcome as compared to the microscopic technique. Nasal symptoms, blood loss, operating time are less in EETS. Various naso-septal flaps and other techniques of CSF leak repair could help reduce complications. Complications can be further reduced after achieving the learning curve, good understanding of limitations with proper patient selection. Use of neuronavigation, proper post-operative care of endocrine function, establishing pituitary center of excellence and more focused residency and endoscopic fellowship training could improve results. The faster and safe transition from microscopic to EETS can be done by the team concept of neurosurgeon/otolaryngologist, attending hands on cadaveric dissection, practice on models, and observation of live surgeries. Conversion to a microscopic or endoscopic-assisted approach may be required in selected patients. Multi-modality treatment could be required in giant and invasive tumors. EETS appears to be a better surgical option in most pituitary adenoma.

  18. Endoscopic endonasal transsphenoidal approach for pituitary adenomas: technical aspects and report of casuistic Abordagem endoscópica endonasal para adenomas de hipófise: aspectos técnicos e relato de casuística

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    Américo Rubens Leite dos Santos

    2010-08-01

    Full Text Available OBJECTIVE: Analyse technical aspects, effectiveness and morbidity of the endoscopic endonasal transphenoidal approach for pituitary adenomas. METHOD: From January 2005 to September 2008, 30 consecutive patients underwent endoscopic endonasal resection of pituitary adenomas with a follow up from 3 to 36 months. Their medical charts were retrospectively analysed. RESULTS: There were 18 women and 12 men, mean age 44 years (range 17-65 yr. Among the 30 patients, 23 had macroadenomas and 7 microadenomas. Twelve patients had non-functioning tumors, 9 had ACTH-secreting tumors, 8 had GH-secreting tumors and 1 prolactinoma. Complete resection and hormonal control was achieved in all microadenomas. Macroadenomas were completely removed in 6 patients, subtotal resection in 6 and partial resection in 11. Three patients had diabetes insipidus and 5 had CSF leaks treated with lumbar drainage. CONCLUSION: The endonasal endoscopic approach for pituitary tumors is effective and has low morbidity.OBJETIVO: Analisar aspectos técnicos, eficácia e morbidade do acesso transesfenoidal endonasal endoscópico para adenomas hipofisários. MÉTODO: Estudo retrospectivo de trinta pacientes consecutivos submetidos à ressecção endoscópica endonasal de adenomas hipofisários, entre janeiro de 2005 e setembro de 2008, com seguimento pós-operatório entre três e 36 meses. RESULTADOS: Foram operados 18 mulheres e 12 homens com idades variando entre 17 e 65 anos (média 44 anos. Entre os 30 casos operados, 23 eram macroadenomas e sete microadenomas. Doze pacientes apresentavam adenomas não-funcionantes, nove tumores secretores de ACTH, oito tumores secretores de GH e um prolactinoma. Ressecção macroscópica completa e controle endócrino foram conseguidos em todos microadenomas. Ressecção dos macroadenomas foi completa em seis pacientes, subtotal em seis e parcial em seis casos. Três pacientes desenvolveram diabetes insipidus e cinco tiveram fístula liqüórica p

  19. Analyses and treatments of postoperative nasal complications after endonasal transsphenoidal resection of pituitary neoplasms

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    Cheng, You; Xue, Fei; Wang, Tian-You; Ji, Jun-Feng; Chen, Wei; Wang, Zhi-Yi; Xu, Li; Hang, Chun-Hua; Liu, Xin-Feng

    2017-01-01

    Abstract In this study, we analyze and discuss the treatments of postoperative nasal complications after endonasal transsphenoidal resection of pituitary neoplasms (PNs). We performed 129 endonasal transsphenoidal resections of PNs and analyzed and treated cases with nasal complications. After endonasal transsphenoidal resection of PNs, there were 26 cases of postoperative nasal complications (20.1%), including nasal hemorrhage (4.8%), cerebrospinal fluid rhinorrhea (6.9%), sphenoid sinusitis (2.3%), atrophic rhinitis (1.6%), olfactory disorder (1.6%), perforation of nasal septum (0.8%), and nasal adhesion (2.3%). All patients clinically recovered after therapy, which included treatment of the cavity through nasal endoscopy, intranasal corticosteroids, and nasal irrigation. We propose that regular nasal endoscopic review, specific nasal medications, and regular nasal irrigation can effectively clear nasal mucosal hyperemia-induced edema and nasal/nasoantral secretions, as well as promote regeneration of nasal mucosa, prevent nasal adhesion, maintain the sinus cavity drainage, and accelerate the recovery of the physiological function of the paranasal sinus. Timely treatment of patients with nasal complications after endonasal transsphenoidal resections of PNs could greatly relieve the clinical symptoms. Nasal cleaning is very beneficial to patients after surgery recovery. PMID:28403108

  20. [Usefulness of endovascular treatment for delayed massive epistaxis following endoscopic endonasal transsphenoidal surgery: a case report].

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    Oka, Tetsuo; Sugiu, Kenji; Ishida, Joji; Hishikawa, Tomohito; Ono, Shigeki; Tokunaga, Koji; Date, Isao

    2012-01-01

    We report here a case of massive nasal bleeding from the sphenopalatine artery three weeks after endonasal transsphenoidal surgery. This 66-year-old male suffered from massive nasal bleeding with the status of hypovolemic shock. Under general anesthesia, an emergent angiography revealed an extravasation from the sphenopalatine artery. Trans-arterial embolization using coil and n-butyl-cyanoacrylate (NBCA) was performed following the diagnostic angiography. Complete occlusion of the injured artery was achieved. The patient showed good recovery from general anesthesia. Delayed nasal bleeding after endonasal transsphenoidal surgery is a rare but important complication. The sphenopalatine artery and its branch are located in the hidden inferior lateral corner of the sphenoid sinus and may be injured during enlargement of the sphenoid opening. When massive delayed nasal bleeding follows transsphenoidal surgery and damage of the internal carotid artery has been ruled out, endovascular treatment of the external carotid artery should be considered.

  1. Endonasal endoscopic transsphenoidal pituitary surgery: early experience and outcome in paediatric Cushing's disease.

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    Storr, Helen L; Drake, William M; Evanson, Jane; Matson, Matthew; Berney, Dan M; Grossman, Ashley B; Akker, Scott A; Monson, John P; Alusi, Ghassan; Savage, Martin O; Sabin, Ian

    2014-02-01

    Selective adenomectomy remains the first-line treatment for Cushing's disease (CD), until recently by microscopic transsphenoidal pituitary surgery. Endonasal transsphenoidal endoscopic surgery (ETES) is emerging as a novel, less invasive treatment for pituitary adenomas and has become the optimal surgical approach. There are no published series for the treatment of paediatric CD by ETES, and we report our centre's preliminary results. Retrospective analysis. Six paediatric patients (median age 15·8 years; range 11·7-17·0 years) fulfilled standard diagnostic criteria for CD. Preoperatively, no abnormality was identified on pituitary MR scanning in 3 (50%) patients, one had a macroadenoma. Bilateral petrosal sinus sampling demonstrated central ACTH secretion (IPS/P ACTH ratio ≥3·0, post-CRH) in 3/6 (50%) patients. The same neurosurgeon and endoscopic nasal surgeon undertook all the operations. Therapeutic outcome and rate of complications. Clinical recovery and biochemical 'cure' were achieved in 5 (83%) patients, and a corticotroph adenoma was confirmed histologically in all cured cases. One case developed post-operative CSF leak requiring lumbar drain insertion and patching. At a mean interval of 4·7 years (0·1-10·8 years) post-operatively, cured patients have shown no recurrence. One patient, with a large diffuse adenoma requiring more extensive surgery, has panhypopituitarism, and another patient has GH and gonadotrophin deficiencies. Our experience shows that ETES for removing corticotroph adenomas in children, in most cases not visualized on MRI, is minimally invasive and gave excellent post-operative recovery/results. In skilled hands, this technique provides an alternative to conventional transsphenoidal microscopic surgery in managing paediatric CD. © 2013 John Wiley & Sons Ltd.

  2. Endoscopic endonasal transsphenoidal surgery: surgical results of 228 pituitary adenomas treated in a pituitary center.

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    Gondim, Jackson A; Schops, Michele; de Almeida, João Paulo C; de Albuquerque, Lucas Alverne F; Gomes, Erika; Ferraz, Tânia; Barroso, Francisca Andréa C

    2010-01-01

    Pituitary tumors are challenging tumors in the sellar region. Surgical approaches to the pituitary have undergone numerous refinements over the last 100 years. The introduction of the endoscope have revolutionized pituitary surgery. The aim of this study is to report the results of a consecutive series of patients undergoing pituitary surgery using a pure endoscopic endonasal approach and to evaluate the efficacy and safety of this procedure. We reviewed the data of 228 consecutive patients who underwent endonasal transsphenoidal adenoma removal over an 10-year period. Pre- and post-operative hormonal status (at least 3 months after surgery) were analyzed and compared with clinical parameters presented by the patients. Tumor removal rate, endocrinological outcomes, and complications were retrospectively assessed in 228 patients with pituitary adenomas who underwent 251 procedures between December 1998 and December 2007. There were 93 nonfunctioning adenomas, 58 growth hormone-secreting, 41 prolactin-secreting, 28 adrenocorticotropin hormone secreting, 7 FSH-LH secreting and 1 thyroid-stimulating hormone-secreting adenomas. Gross total removal was achieved in 79.3% of the cases after a median follow-up of 61.5 months. The remission results for patients with nonfunctioning adenomas was 83% and for functioning adenomas were 76.3% (70.6% for GH hormone-secreting, 85.3% for prolactin hormone-secreting, 71.4% for ACTH hormone-secreting, 85.7% for FSH-LH hormone-secreting and 100% for TSH hormone-secreting), with no recurrence at the time of the last follow-up. Post-operative complications were present in 35 (13.9%) cases. The most frequent complications were temporary and permanent diabetes insipidus (six and two cases, respectively), syndrome of inappropriate antidiuretic hormone secretion (two cases) and CSF leaks (eight cases). There was no death related to the procedure in this series. The endoscopic endonasal approach for resection of pituitary adenomas, provides

  3. Low complication rate of sellar reconstruction by artificial dura mater during endoscopic endonasal transsphenoidal surgery.

    Science.gov (United States)

    Ye, Yuanliang; Wang, Fuyu; Zhou, Tao; Luo, Yi

    2017-12-01

    To evaluate effect of sellar reconstruction during pituitary adenoma resection surgery by the endoscopic endonasal transsphenoidal approach using artificial cerebral dura mater patch.This was a retrospective study of 1281 patients who underwent endoscopic transsphenoidal resection for the treatment of pituitary adenomas between December 2006 and May 2014 at the Neurosurgery Department of the People's Liberation Army General Hospital. The patients were classified into 4 grades according to intraoperative cerebrospinal fluid (CSF) leakage site. All patients were followed up for 3 months by telephone and outpatient visits.One thousand seventy three (83.7%) patients underwent sellar reconstruction using artificial dura matter patched outside the sellar region (method A), 106 (8.3%) using artificial dura matter patched inside the sellar region (method B), and 102 (8.0%) using artificial dura matter and a mucosal flap (method C). Method A was used for grade 0-1 leakage, method B for grade 1 to 2 leakage, and method C for grade 2 to 3 leakage. During the 3-month follow-up, postoperative CSF leakage was observed in 7 patients (0.6%): 2 among patients who underwent method B (1.9%) and 5 among those who underwent method C (4.9%). Meningitis was diagnosed in 13 patients (1.0%): 2 among patients who underwent method A (0.2%), 4 among those who underwent method B (3.8%), and 7 among those who underwent method C (6.7%).Compared with other reconstruction methods, sellar reconstruction surgery that only use artificial dura mater as repair material had a low rate of complications. Copyright © 2017 The Authors. Published by Wolters Kluwer Health, Inc. All rights reserved.

  4. Nasal and skull base anatomy of endoscopic endonasal transsphenoidal surgery with multi-detector computed tomography

    International Nuclear Information System (INIS)

    Hasegawa, Yuzo; Saeki, Naokatsu; Murai, Hisayuki; Horiguchi, Kentaro; Hanazawa, Toyoyuki; Okamoto, Miyoshi; Yanagawa, Noriyuki

    2008-01-01

    The endoscope is a new and highly useful instrument for transphenoidal surgery (TSS), and is generally used because of its minimally invasiveness. In addition, endoscopic transsphenoidal surgey (eTSS) has a potential for more radical tumor removal at the pituitary and the parasellar regions by wider visualization and more powerful illumination. To operate these regions safely, we need to know nasal and skull base anatomy under the endoscope which looks different from images under a microscope. In this paper, we demonstrated nasal and skull base anatomy with multi-detector computed tomography, which was performed in 23 recent patients with pituitary and parasellar legions. In the nasal legion, deviation of nasal septum and deviation of sphenoid ostium are important for endonasal approach of eTSS, and often determine the difficulty of surgery in the nasal cavity. Our study showed that deviation of nasal septum was seen in 26% of patients. Deviation of sphenoid ostium was 5.5±1.5 mm from the midline. The anatomy of sphenoid sinus plays a key role in our determination of the safety of a bony opening of the sella. In addition to sellar, presellar, and concha types, carotid prominence and optic prominence are important to determine the midline orientation. Development of carotid prominence was significantly related to the extent of lateral pneumatization of sphenoid sinus (P=0.0016). Reconstructed 3D-image of sphenoid sinus was very useful in visual understanding skull base anatomy. (author)

  5. Endoscopic endonasal transsphenoidal surgery: implementation of an operative and perioperative checklist.

    Science.gov (United States)

    Christian, Eisha; Harris, Brianna; Wrobel, Bozena; Zada, Gabriel

    2014-01-01

    Endoscopic endonasal surgery relies heavily on specialized operative instrumentation and optimization of endocrinological and other critical adjunctive intraoperative factors. Several studies and worldwide initiatives have previously established that intraoperative and perioperative surgical checklists can minimize the incidence of and prevent adverse events. The aim of this article was to outline some of the most common considerations in the perioperative and intraoperative preparation for endoscopic endonasal transsphenoidal surgery. The authors implemented and prospectively evaluated a customized checklist at their institution in 25 endoscopic endonasal operations for a variety of sellar and skull base pathological entities. Although no major errors were detected, near misses pertaining primarily to missing components of surgical equipment or instruments were identified in 9 cases (36%). The considerations in the checklist provided in this article can serve as a basic template for further customization by centers performing endoscopic endonasal surgery, where their application may reduce the incidence of adverse or preventable errors associated with surgical treatment of sellar and skull base lesions.

  6. Endoscopic endonasal transsphenoidal surgery in elderly patients with pituitary adenomas.

    Science.gov (United States)

    Gondim, Jackson A; Almeida, João Paulo; de Albuquerque, Lucas Alverne F; Gomes, Erika; Schops, Michele; Mota, Jose Italo

    2015-07-01

    With the increase in the average life expectancy, medical care of elderly patients with symptomatic pituitary adenoma (PA) will continue to grow. Little information exists in the literature about the surgical treatment of these patients. The aim of this study was to present the results of a single pituitary center in the surgical treatment of PAs in patients > 70 years of age. In this retrospective study, 55 consecutive elderly patients (age ≥ 70 years) with nonfunctioning PAs underwent endoscopic transsphenoidal surgery at the General Hospital of Fortaleza, Brazil, between May 2000 and December 2012. The clinical and radiological results in this group were compared with 2 groups of younger patients: surgery for treatment of PAs. The mean follow-up period was 50 months (range 12-144 months). The most common symptoms were visual impairment in 38 (69%) patients, headache in 16 (29%) patients, and complete ophthalmoplegia in 6 (10.9%). Elderly patients presented a higher incidence of ophthalmoplegia (p = 0.032) and a lower frequency of pituitary apoplexy before surgery (p transsphenoidal surgery for elderly patients with PAs may be associated with higher complication rates, especially secondary to early transitory complications, when compared with surgery performed in younger patients. Although the worst preoperative clinical status might be observed in this group, age alone is not associated with a worst final prognosis after endoscopic removal of nonfunctioning PAs.

  7. Expanded Endonasal Endoscopic Approach for Resection of an Infrasellar Craniopharyngioma.

    Science.gov (United States)

    Abou-Al-Shaar, Hussam; Blitz, Ari M; Rodriguez, Fausto J; Ishii, Masaru; Gallia, Gary L

    2016-11-01

    Craniopharyngiomas are uncommon benign locally aggressive epithelial tumors mostly located in the sellar and suprasellar regions. An infrasellar origin of these tumors is rare. The authors report a 22-year-old male patient with a purely infrasellar adamantinomatous craniopharyngioma centered in the nasopharynx with extension into the posterior nasal septum, sphenoid sinus, and clivus. Gross total resection was achieved using an expanded endonasal endoscopic transethmoidal, transsphenoidal, transpterygoid, and transclival approach. Follow-up at one year demonstrated no evidence of disease recurrence. Infrasellar craniopharyngioma should be included in the differential diagnosis of sinonasal masses even in the absence of sellar extension. Expanded endonasal endoscopic approaches provide excellent access to and visualization of such lesions and may obviate the need for postoperative radiotherapy when gross total resection is achieved. Copyright © 2016 Elsevier Inc. All rights reserved.

  8. Endoscopic Endonasal Versus Microscopic Transsphenoidal Surgery for Recurrent and/or Residual Pituitary Adenomas.

    Science.gov (United States)

    Esquenazi, Yoshua; Essayed, Walid I; Singh, Harminder; Mauer, Elizabeth; Ahmed, Mudassir; Christos, Paul J; Schwartz, Theodore H

    2017-05-01

    Surgery for recurrent/residual pituitary adenomas is increasingly being performed through endoscopic surgery. Whether this new technology has altered the indications and outcomes of surgery is unknown. We conducted a systematic review and meta-analysis of published studies to compare the indications and outcomes between microscopic and endoscopic approaches. A PubMed search was conducted (1985-2015) to identify surgical series of endoscopic endonasal and microscopic transsphenoidal resection of residual or recurrent pituitary adenomas. Data were extracted regarding tumor characteristics, surgical treatment, extent of resection, endocrine remission, visual outcome, and complications. Twenty-one studies met inclusion criteria. A total of 292 patients were in the endoscopic group, and 648 patients were in the microscopic group. Endoscopic cases were more likely nonfunctional (P < 0.001) macroadenomas (P < 0.001) with higher rates of cavernous sinus invasion (P = 0.012). The pooled rate of gross total tumor resection was 53.5% for the endoscopic group and 46.6% for the microscopic group. Endocrine remission was achieved in 53.0% and 46.7% of patients, and visual improvement occurred in 73.2% and 49.6% for the endoscopic and microscopic groups. Cerebrospinal fluid leak and pituitary insufficiency were higher in the endoscopic group. This meta-analysis indicates that the use of the endoscope to reoperate on residual or recurrent adenomas has only led to modest increases in resection rates. However, larger more complex cases are being tackled, so direct comparisons are misleading. The most dramatic change has been in visual improvement along with modest increases in risk. Reoperation for recurrent or residual adenomas is a safe and effective treatment option. Copyright © 2017 Elsevier Inc. All rights reserved.

  9. Meckel's cave access: anatomic study comparing the endoscopic transantral and endonasal approaches.

    Science.gov (United States)

    Van Rompaey, Jason; Suruliraj, Anand; Carrau, Ricardo; Panizza, Benedict; Solares, C Arturo

    2014-04-01

    Recent advances in endonasal endoscopy have facilitated the surgical access to the lateral skull base including areas such as Meckel's cave. This approach has been well documented, however, few studies have outlined transantral specific access to Meckel's. A transantral approach provides a direct pathway to this region obviating the need for extensive endonasal and transsphenoidal resection. Our aim in this study is to compare the anatomical perspectives obtained in endonasal and transantral approaches. We prepared 14 cadaveric specimens with intravascular injections of colored latex. Eight cadavers underwent endoscopic endonasal transpterygoid approaches to Meckel's cave. Six additional specimens underwent an endoscopic transantral approach to the same region. Photographic evidence was obtained for review. 30 CT scans were analyzed to measure comparative distances to Meckel's cave for both approaches. The endoscopic approaches provided a direct access to the anterior and inferior portions of Meckel's cave. However, the transantral approach required shorter instrumentation, and did not require clearing of the endonasal corridor. This approach gave an anterior view of Meckel's cave making posterior dissection more difficult. A transantral approach to Meckel's cave provides access similar to the endonasal approach with minimal invasiveness. Some of the morbidity associated with extensive endonasal resection could possibly be avoided. Better understanding of the complex skull base anatomy, from different perspectives, helps to improve current endoscopic skull base surgery and to develop new alternatives, consequently, leading to improvements in safety and efficacy.

  10. Endoscopic endonasal transsphenoidal surgery using the iArmS operation support robot: initial experience in 43 patients.

    Science.gov (United States)

    Ogiwara, Toshihiro; Goto, Tetsuya; Nagm, Alhusain; Hongo, Kazuhiro

    2017-05-01

    Objective The intelligent arm-support system, iArmS, which follows the surgeon's arm and automatically fixes it at an adequate position, was developed as an operation support robot. iArmS was designed to support the surgeon's forearm to prevent hand trembling and to alleviate fatigue during surgery with a microscope. In this study, the authors report on application of this robotic device to endoscopic endonasal transsphenoidal surgery (ETSS) and evaluate their initial experiences. Methods The study population consisted of 43 patients: 29 with pituitary adenoma, 3 with meningioma, 3 with Rathke's cleft cyst, 2 with craniopharyngioma, 2 with chordoma, and 4 with other conditions. All patients underwent surgery via the endonasal transsphenoidal approach using a rigid endoscope. During the nasal and sphenoid phases, iArmS was used to support the surgeon's nondominant arm, which held the endoscope. The details of the iArmS and clinical results were collected. Results iArmS followed the surgeon's arm movement automatically. It reduced the surgeon's fatigue and stabilized the surgeon's hand during ETSS. Shaking of the video image decreased due to the steadying of the surgeon's scope-holding hand with iArmS. There were no complications related to use of the device. Conclusions The intelligent armrest, iArmS, seems to be safe and effective during ETSS. iArmS is helpful for improving the precision and safety not only for microscopic neurosurgery, but also for ETSS. Ongoing advances in robotics ensure the continued evolution of neurosurgery.

  11. Time to Revive the Value of the Pseudocapsule in Endoscopic Endonasal Transsphenoidal Surgery for Growth Hormone Adenomas.

    Science.gov (United States)

    Xie, Tao; Liu, Tengfei; Zhang, Xiaobiao; Chen, Lingli; Luo, Rongkui; Sun, Wei; Hu, Fan; Yu, Yong; Gu, Ye; Lu, Zhiqiang

    2016-05-01

    To investigate the role of endoscopic endonasal transsphenoidal surgery and the pseudocapsule in the treatment of growth hormone adenomas. The study included 43 patients (age range, 21-64 years) with growth hormone adenomas treated with an endoscopic endonasal approach. We compared the tumor characteristics and surgical outcomes of cases with (group A, 21 cases, from November 2013 to January 2015) and without (group B, 22 cases, from October 2011 to October 2013) extra-pseudocapsule resection. The preoperative demographics, tumor characteristics, and surgical complications were not significantly different between groups A and B. Postoperative remission without adjuvant therapy was achieved in 18 of 21 cases (85.7%) in group A, which was significantly greater than that observed in group B (12 of 22 cases [54.4%]). In group A, the pseudocapsules were verified by endoscopy and histopathology. The pseudocapsule was removed en bloc with the whole adenoma in only 5 cases (23.8%). For the remaining 16 patients (76.2%), following extra-pseudocapsule dissection, incomplete pseudocapsule removals with intracapsule procedures were achieved. The combination of extra-pseudocapsule resection and endoscopy led to a high rate of gross total tumor resection and endocrinologicl remission in acromegalic patients compared with the group with intracapsular resection. Extra-pseudocapsule resection resulted in no additional postoperative complications. Copyright © 2016. Published by Elsevier Inc.

  12. Modified Graded Repair of Cerebrospinal Fluid Leaks in Endoscopic Endonasal Transsphenoidal Surgery

    Science.gov (United States)

    Park, Jae-Hyun; Choi, Jai Ho; Kim, Young-Il; Kim, Sung Won

    2015-01-01

    Objective Complete sellar floor reconstruction is critical to avoid postoperative cerebrospinal fluid (CSF) leakage during transsphenoidal surgery. Recently, the pedicled nasoseptal flap has undergone many modifications and eventually proved to be valuable and efficient. However, using these nasoseptal flaps in all patients who undergo transsphenoidal surgery, including those who had none or only minor CSF leakage, appears to be overly invasive and time-consuming. Methods Patients undergoing endoscopic endonasal transsphenoidal tumor surgery within a 5 year-period were reviewed. Since 2009, we classified the intraoperative CSF leakage into grades from 0 to 3. Sellar floor reconstruction was tailored to each leak grade. We did not use any tissue grafts such as abdominal fat and did not include any procedures of CSF diversions such as lumbar drainage. Results Among 200 cases in 188 patients (147 pituitary adenoma and 41 other pathologies), intraoperative CSF leakage was observed in 27.4% of 197 cases : 14.7% Grade 1, 4.6% Grade 2a, 3.0% Grade 2b, and 5.1% Grade 3. Postoperative CSF leakage was observed in none of the cases. Septal bone buttress was used for Grade 1 to 3 leakages instead of any other foreign materials. Pedicled nasoseptal flap was used for Grades 2b and 3 leakages. Unused septal bones and nasoseptal flaps were repositioned. Conclusion Modified classification of intraoperative CSF leaks and tailored repair technique in a multilayered fashion using an en-bloc harvested septal bone and vascularized nasoseptal flaps is an effective and reliable method for the prevention of postoperative CSF leaks. PMID:26279811

  13. Endoscopic repair of transsellar transsphenoidal meningoencephalocele; case report and review of approaches

    Directory of Open Access Journals (Sweden)

    Maryam Jalessi, M.D.

    2015-06-01

    Full Text Available We present an extremely rare case of transsellar transsphenoidal meningoencephalocele in a 36-year-old woman with pituitary dwarfism complaining of nasal obstruction. Imaging studies showed a bony defect in the sellar floor and sphenoid sinus with huge nasopharyngeal mass and 3rd ventricle involvement. Using endoscopic endonasal approach the sac was partially removed and the defect was reconstructed with fat and fascial graft, and buttressed with titanium mesh and septal flap. Visual field improvement was noticed post-operatively and no complication was encountered during follow-up. So, endoscopic endonasal approach with partial resection of the sac is a safe and effective treatment for this disease

  14. Endoscopic Endonasal Transsphenoidal Drainage of a Spontaneous Candida glabrata Pituitary Abscess.

    Science.gov (United States)

    Strickland, Ben A; Pham, Martin; Bakhsheshian, Joshua; Carmichael, John; Weiss, Martin; Zada, Gabriel

    2018-01-01

    Noniatrogenic pituitary abscess remains a rare clinical entity, and is the indication for surgery in abscess caused by Candida species, and also provide an intraoperative video showing the endoscopic management of this pathology. A 33-year-old woman presented with headache, hypopituitarism, and vision loss in the setting of diabetic ketoacidosis, and was found to have multiple abscesses in the liver, lung, kidney, and uterus. Brain magnetic resonance imaging revealed a 15-mm cystic sellar mass with restricted diffusion. The patient underwent urgent evacuation of the abscess via an endoscopic endonasal transsphenoidal route, with obvious purulent material filling the sella, later identified as Candida glabrata. Antimicrobial therapy was refined appropriately, and she exhibited significant improvement in neurologic function, although endocrinopathy has persisted. With timely management, including a combination of surgical drainage and appropriate antimicrobial therapy, neurologic outcomes are good in most cases of pituitary abscess; however, endocrinopathy often does not improve. Although most reported cases with identified causative organisms speciate bacteria, some cases are of fungal etiology and require different antimicrobial agents. This further underscores the importance of identifying the causative agent. Copyright © 2017 Elsevier Inc. All rights reserved.

  15. A practical 3D printed simulator for endoscopic endonasal transsphenoidal surgery to improve basic operational skills.

    Science.gov (United States)

    Wen, Guodao; Cong, ZiXiang; Liu, KaiDong; Tang, Chao; Zhong, Chunyu; Li, Liwen; Dai, XuJie; Ma, Chiyuan

    2016-06-01

    We aimed to present a practical three-dimensional (3D) printed simulator to comprehensively and effectively accelerate the learning curve of endoscopic endonasal transsphenoidal surgery (EETS). The 3D printed simulator consists of three parts: (1) skull frame, (2) the nasal passage and the nasal alar of the face, and (3) a modified sella turcica. We aimed to improve three basic operational skills of surgeons: drilling, curetting, and aspirating. Eighteen neurosurgeons and five post-graduates were recruited and consented for the training. For trainees, (1) as the training progressed, the scores increased gradually, (2) a significant increase in the average scores was observed in the tenth training compared to the first training, and (3) there is a significant decrease in trainee variability in the shortening of the gap. The 18 neurosurgeons were divided into three groups: experts, assistants, and observers. For all three basic operations, (1) the average score of experts was obviously higher than that of the assistants, observers, and trainees' tenth training and (2) the average scores of assistants and observers were obviously higher than that of trainees' first training. A significant high in the average score between the assistants and the observers was seen for aspirating, but not for drilling or curetting. For curetting and aspirating, the tenth training average score of trainees was obviously higher than that of assistants and observers. This 3D printed simulator allows different endoscopic basic operations to be simulated and improves the EETS techniques of surgeons. We believed it to be a practical, simple, and low-cost simulator.

  16. Single-surgeon fully endoscopic endonasal transsphenoidal surgery: outcomes in three-hundred consecutive cases.

    Science.gov (United States)

    Mamelak, Adam N; Carmichael, John; Bonert, Vivien H; Cooper, Odelia; Melmed, Shlomo

    2013-09-01

    The objective of this study was to evaluate outcomes of endoscopic transsphenoidal surgery using a single-surgeon technique as an alternative to the more commonly employed two-surgeon, three-hand method. Three hundred consecutive endoscopic transsphenoidal procedures performed over a 5 year period from 2006 to 2011 were reviewed. All procedures were performed via a binasal approach utilizing a single surgeon two handed technique with a pneumatic endoscope holder. Expanded enodnansal cases were excluded. Surgical technique, biochemical and surgical outcomes, and complications were analyzed. 276 patients underwent 300 consecutive surgeries with a mean follow-up period of 37 ± 22 months. Non-functioning pituitary adenoma (NFPA) was the most common pathology (n = 152), followed by growth hormone secreting tumors (n = 41) and Rathke's cleft cysts (n = 30). Initial gross total cyst drainage based on radiologic criteria was obtained in 28 cases of Rathke's cleft cyst, with 5 recurrences. For NFPA and other pathologies (n = 173) gross total resection was obtained in 137 cases, with a 92% concordance rate between observed and expected extent of resection. For functional adenoma, remission rates were 30/41 (73%) for GH-secreting, 12/12 (100%) for ACTH-secreting, and 8/17 (47%) for prolactin-secreting tumors. Post-operative complications included transient (11%) and permanent (1.4%) diabetes insipidus, hyponatremia (13%), and new anterior pituitary hormonal deficits (1.4%). CSF leak occurred in 42 cases (15%), and four patients required surgical repair. Two carotid artery injuries occurred, both early in the series. Epistaxis and other rhinological complications were noted in 10% of patients, most of which were minor and diminished as surgical experience increased. Fully endoscopic single surgeon transsphenoidal surgery utilizing a binasal approach and a pneumatic endoscope holder yields outcomes comparable to those reported with a two-surgeon method. Endoscopic outcomes

  17. Endoscopic Endonasal Approach in the Management of Rathke's Cleft Cysts.

    Directory of Open Access Journals (Sweden)

    Domenico Solari

    Full Text Available Rathke's cleft cysts (RCCs are quite uncommon sellar lesions that can extend or even arise in the suprasellar area. The purpose of this study is to evaluate the effectiveness of both standard and extended endoscopic endonasal approaches in the management of different located RCCs.We retrospectively analyzed a series of 29 patients (9 males, 20 females complaining of a RCC, who underwent a standard or an extended endoscopic transsphenoidal approach at the Division of Neurosurgery, Department of Neurosciences and Reproductive and Odontostomatological Sciences, of the Università degli Studi di Napoli "Federico II". Data regarding patients' demographics, clinical evaluation, cyst characteristics, surgical treatments, complications and outcomes were extracted from our electronic database (Filemaker Pro 11, File Maker Inc., Santa Clara, California, USA.A standard transsphenoidal approach was used in 19 cases, while the extended variation of the approach in 10 cases (5 purely suprasellar and 5 intra-suprasellar RCC. Cysts contents was fully drained in all the 29 cases, whilst a gross total removal, that accounts on the complete cyst wall removal, was achieved in an overall 55,1% of patients (16/29, specifically 36,8% (7/19 that received standard approach and 90% (9/10 of those that underwent to extended approach. We reported a 56.2% of recovery from headache, 38.5% of complete recovery and 53.8% of improvement from visual field defect and an overall 46.7% of improvement of the endocrine functions. Postoperative permanent DI rate was 10.3%, overall post-operative CSF leak rate 6.9%; recurrence/regrowth occurred in 4 patients (4/29, 13.8%, but only one required a second surgery.The endoscopic transsphenoidal approach for the removal of a symptomatic RCC offers several advantages in terms of visualization of the surgical field during both the exposure and removal of the lesion. The "extended" variation of the endoscopic approach provides a direct access

  18. Endoscopic Endonasal Approach for a Suprasellar Craniopharyngioma.

    Science.gov (United States)

    Zenonos, Georgios A; Snyderman, Carl H; Gardner, Paul A

    2018-04-01

    Objectives  The current video presents the nuances of an endoscopic endonasal approach to a suprasellar craniopharyngioma. Design  The video analyzes the presentation, preoperative workup and imaging, surgical steps and technical nuances of the surgery, the clinical outcome, and follow-up imaging. Setting  The patient was treated by a skull base team consisting of a neurosurgeon and an ENT surgeon, at a teaching academic institution. Participants  The case refers to a 67-year-old man who presented with vision loss and headaches, and was found to have a suprasellar mass, with imaging characteristics consistent with a craniopharyngioma. Main Outcome Measures  The main outcome measures consistent of the reversal of the patient symptoms (vision loss and headaches), the recurrence-free survival based on imaging, as well as the absence of any complications. Results  The patient's vision improved after the surgery; at his last follow-up there was no evidence of recurrence on imaging. Conclusions  The endoscopic endonasal approach is safe and effective in treating suprasellar craniopharyngiomas. The link to the video can be found at: https://youtu.be/p1VXbwnAWCo .

  19. Long-Term Endocrine Outcomes Following Endoscopic Endonasal Transsphenoidal Surgery for Acromegaly and Associated Prognostic Factors.

    Science.gov (United States)

    Babu, Harish; Ortega, Alicia; Nuno, Miriam; Dehghan, Aaron; Schweitzer, Aaron; Bonert, H Vivien; Carmichael, John D; Cooper, Odelia; Melmed, Shlomo; Mamelak, Adam N

    2017-08-01

    Long-term remission rates from endoscopic transsphenoidal surgery for acromegaly and their relationship to prognostic indicators of disease aggressiveness are not well documented. To investigate long-term remission rates in patients with acromegaly after endoscopic transsphenoidal surgery, and correlate this with molecular and radiographic markers of disease aggressiveness. We identified all patients undergoing endoscopic transsphenoidal surgery for acromegaly from 2005 to 2013 at Cedars-Sinai Pituitary Center. Hormonal remission was established by normal insulin-like growth factor (IGF)-1, basal serum growth hormone <2.5 ng/mL, and growth hormone suppression to <1 ng/mL following oral glucose tolerance test. Oral glucose tolerance test was performed at 3 months after surgery, and then as indicated. IGF-1 was measured at 3 months and then at least annually. We evaluated tumor granularity, nuclear expression of p21, Ki67 index, and extent of cavernous sinus invasion, and correlated these with remission status. Fifty-eight patients that underwent surgery had follow-up from 38 to 98 months (mean 64 ± 32.2 months). There were 21 microadenomas and 37 macroadenomas. Three months after surgery 40 of 58 patients (69%) were in biochemical remission. Four additional patients were in remission at 6 months after surgery, and 1 patient had recurrence within the first year after surgery. At last follow-up, 43 of 44 (74.1%) of patients remained in remission. Cavernous sinus invasion by tumor predicted failure to achieve remission. Prognostic markers of disease aggressiveness other than cavernous sinus invasion did not correlate with surgical outcome. Long-term remission after surgery alone was achieved in 74% of patients, indicating long-term efficacy of endoscopic surgery. Copyright © 2017 by the Congress of Neurological Surgeons

  20. Limited endoscopic transsphenoidal approach for cavernous sinus biopsy: illustration of 3 cases and discussion.

    Science.gov (United States)

    Graillon, T; Fuentes, S; Metellus, P; Adetchessi, T; Gras, R; Dufour, H

    2014-01-01

    Advances in transsphenoidal surgery and endoscopic techniques have opened new perspectives for cavernous sinus (CS) approaches. The aim of this study was to assess the advantages and disadvantages of limited endoscopic transsphenoidal approach, as performed in pituitary adenoma surgery, for CS tumor biopsy illustrated with three clinical cases. The first case was a 46-year-old woman with a prior medical history of parotid adenocarcinoma successfully treated 10 years previously. The cavernous sinus tumor was revealed by right third and sixth nerve palsy and increased over the past three years. A tumor biopsy using a limited endoscopic transsphenoidal approach revealed an adenocarcinoma metastasis. Complementary radiosurgery was performed. The second case was a 36-year-old woman who consulted for diplopia with right sixth nerve palsy and amenorrhea with hyperprolactinemia. Dopamine agonist treatment was used to restore the patient's menstrual cycle. Cerebral magnetic resonance imaging (MRI) revealed a right sided CS tumor. CS biopsy, via a limited endoscopic transsphenoidal approach, confirmed a meningothelial grade 1 meningioma. Complementary radiosurgery was performed. The third case was a 63-year-old woman with progressive installation of left third nerve palsy and visual acuity loss, revealing a left cavernous sinus tumor invading the optic canal. Surgical biopsy was performed using an enlarged endoscopic transsphenoidal approach to the decompress optic nerve. Biopsy results revealed a meningothelial grade 1 meningioma. Complementary radiotherapy was performed. In these three cases, no complications were observed. Mean hospitalization duration was 4 days. Reported anatomical studies and clinical series have shown the feasibility of reaching the cavernous sinus using an endoscopic endonasal approach. Trans-foramen ovale CS percutaneous biopsy is an interesting procedure but only provides cell analysis results, and not tissue analysis. However, radiotherapy and

  1. Endoscopic endonasal approach for mass resection of the pterygopalatine fossa

    Directory of Open Access Journals (Sweden)

    Jan Plzák

    Full Text Available OBJECTIVES: Access to the pterygopalatine fossa is very difficult due to its complex anatomy. Therefore, an open approach is traditionally used, but morbidity is unavoidable. To overcome this problem, an endoscopic endonasal approach was developed as a minimally invasive procedure. The surgical aim of the present study was to evaluate the utility of the endoscopic endonasal approach for the management of both benign and malignant tumors of the pterygopalatine fossa. METHOD: We report our experience with the endoscopic endonasal approach for the management of both benign and malignant tumors and summarize recent recommendations. A total of 13 patients underwent surgery via the endoscopic endonasal approach for pterygopalatine fossa masses from 2014 to 2016. This case group consisted of 12 benign tumors (10 juvenile nasopharyngeal angiofibromas and two schwannomas and one malignant tumor. RESULTS: No recurrent tumor developed during the follow-up period. One residual tumor (juvenile nasopharyngeal angiofibroma that remained in the cavernous sinus was stable. There were no significant complications. Typical sequelae included hypesthesia of the maxillary nerve, trismus, and dry eye syndrome. CONCLUSION: The low frequency of complications together with the high efficacy of resection support the use of the endoscopic endonasal approach as a feasible, safe, and beneficial technique for the management of masses in the pterygopalatine fossa.

  2. Endoscopic endonasal approach for mass resection of the pterygopalatine fossa

    Science.gov (United States)

    Plzák, Jan; Kratochvil, Vít; Kešner, Adam; Šurda, Pavol; Vlasák, Aleš; Zvěřina, Eduard

    2017-01-01

    OBJECTIVES: Access to the pterygopalatine fossa is very difficult due to its complex anatomy. Therefore, an open approach is traditionally used, but morbidity is unavoidable. To overcome this problem, an endoscopic endonasal approach was developed as a minimally invasive procedure. The surgical aim of the present study was to evaluate the utility of the endoscopic endonasal approach for the management of both benign and malignant tumors of the pterygopalatine fossa. METHOD: We report our experience with the endoscopic endonasal approach for the management of both benign and malignant tumors and summarize recent recommendations. A total of 13 patients underwent surgery via the endoscopic endonasal approach for pterygopalatine fossa masses from 2014 to 2016. This case group consisted of 12 benign tumors (10 juvenile nasopharyngeal angiofibromas and two schwannomas) and one malignant tumor. RESULTS: No recurrent tumor developed during the follow-up period. One residual tumor (juvenile nasopharyngeal angiofibroma) that remained in the cavernous sinus was stable. There were no significant complications. Typical sequelae included hypesthesia of the maxillary nerve, trismus, and dry eye syndrome. CONCLUSION: The low frequency of complications together with the high efficacy of resection support the use of the endoscopic endonasal approach as a feasible, safe, and beneficial technique for the management of masses in the pterygopalatine fossa. PMID:29069259

  3. Surgical treatment of non-functioning pituitary macroadenomas by the endoscopic endonasal approach in the elderly

    Directory of Open Access Journals (Sweden)

    Horacio Armando Marenco

    2015-09-01

    Full Text Available Over the past three decades, surgical series of elderly patients treated for pituitary adenomas have been published, all of which used the microscopic transsphenoidal or transcranial approach. The objective of this study was to retrospectively analyze the surgical results of our first 25 elderly patients with non-functioning pituitary macroadenoma (NFPM operated by the endoscopic endonasal approach (EEA. Preoperative visual loss was found in 92.8% of the cases, and 70.8% experienced visual improvement following surgery. Preoperative pituitary dysfunction was found in 69.2% of the cases and postoperative pituitary recovery occurred in 22.2% of them. Mean hospital stay was 6.7 days. The results of this study suggest that surgery remains the first line of treatment for NFPM in the elderly. Because age alone is not a barrier for surgery, patients should be selected for surgical treatment based on their symptoms and clinical condition, as defined by comorbidities.

  4. Imaging Evaluation of the Location and Fenestration of Sellar Floor during Endonasal Transsphenoidal Surgery in Patients with Pituitary Adenomas.

    Science.gov (United States)

    Wang, Shousen; Qin, Yong; Xiao, Deyong; Wu, Zhifeng; Wei, Liangfeng

    2018-05-03

    To evaluate the clinical value of three-dimensional (3D) CT reconstruction of the sphenoidal sinus separation in localizing sellar floor during endonasal transsphenoidal surgery, and determine the size and location of sellar floor fenestration. After exclusion,51 patients were eligible for study inclusion. A pre-operative CT scan of the paranasal sinus and CT scan and MRI of the pituitary gland were obtained. Sphenoidal sinus separation was reconstructed using Mimics 15.0 software and the quantity, shape, and orientation were observed and compared with intra-operative data, the purpose of which was to guide the localization of sellar floor. Anatomic variation of the sphenoidal sinus and adjacent structures, tumor and sella turcica morphology, minimal distance between the cavernous segment of the internal carotid artery(CSICA) bilaterally, and the shortest distance from the midline were measured. Based upon the shape of the sphenoidal sinus separation, sellar floor was accurately localized in all cases. Intra-operative sphenoidal sinus separation was consistent with pre-operative 3D CT reconstruction images. The sellar floor was extremely small in two patients, and insufficient fenestration of the sellar floor negatively affected tumor resection. Pre-operative 3D CT reconstruction is helpful for accurate and rapid localization of the saddle floor. The anatomic variation of sphenoidal sinus and adjacent structures, the characteristics of tumor and Sella, the minimum distance between bilateral CSICA and the shortest distance from the midline are helpful for the establishment of individualized Sellar bottom fenestration. Copyright © 2018. Published by Elsevier Inc.

  5. Endoscopic endonasal transsphenoidal surgery for patients aged over 80 years with pituitary adenomas: Surgical and follow-up results.

    Science.gov (United States)

    Fujimoto, Kenji; Yano, Shigetoshi; Shinojima, Naoki; Hide, Takuichiro; Kuratsu, Jun-Ichi

    2017-01-01

    With the rapid aging of the general population, the number of pituitary adenoma (PA) diagnosed in elderly patients is increasing. The aim of this study was to evaluate the efficacy of endoscopic endonasal transsphenoidal surgery (ETSS) for PA in patients aged ≥80 years. We retrospectively reviewed the medical records of all patients aged ≥80 years who underwent ETSS for PA at our hospital from January 2001 through December 2014. Treatment results were assessed by the extent of surgical removal, symptom improvement, postoperative complications, and Karnofsky performance status (KPS). The results were also compared with the surgical result of PA patients aged <80 years. Twelve patients aged ≥80 years underwent ETSS for PA. Recovery of visual function was observed in 11 patients (91.7%). Postoperative cerebrospinal fluid (CSF) leakage was observed in 3 patients. New hormonal replacement therapy was required in 2 patients. These complications had not affected patient prognosis. During the follow-up periods, deterioration of KPS was observed in 2 patients due to pneumonia or cerebral infarction. In total, 150 PA patients aged <80 years were compared with the patients aged ≥80 years. The percentage of total removal was significantly higher in the younger patient group than that in the older one (54.0% vs 16.6%, respectively; P = 0.016). Visual improvement was observed in 93.2% of the younger patient group, which was almost equal to that in the older one. ETSS is a safe and effective surgical technique in PA patients aged ≥80 years.

  6. Endoscopic Endonasal Transsphenoidal Surgery, A Reliable Method for Treating Primary and Recurrent/Residual Craniopharyngiomas: Nine Years of Experience.

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    Bal, Ercan; Öge, Kamil; Berker, Mustafa

    2016-10-01

    Craniopharyngioma resection is one of the most challenging surgical procedures. Herein, we describe our extended endoscopic endonasal transsphenoidal surgery (EETS) technique, and the results of 9 years of use on primary and recurrent/residual craniopharyngiomas. This study reviewed 28 EETSs in 25 patients with craniopharyngiomas between January 2006 and September 2015. The patients were divided into 2 groups, newly diagnosed patients (group A, n = 15), and patients having residual or recurrent tumors (group B, n = 10). There was no significant difference between the groups in terms of the largest tumor diameter (P = 0.495), and all patients underwent EETS. The clinical and ophthalmologic examinations, imaging studies, endocrinologic studies, and operative findings for these cases were reviewed retrospectively. The number of gross total resections in group A was 13/15, and 7/10 in group B. Three of the patients developed postoperative cerebrospinal fluid leakage (all in group A). There were no neurovascular or ophthalmologic complications, and no meningitis or mortality was observed. There has been a notable increase in the use of EETS in the treatment of craniopharyngiomas during the last decade. Despite its increased use in the treatment of primary craniopharyngiomas, its implementation for recurrent or residual craniopharyngiomas has been viewed with suspicion. In this study, the results have been presented separately for primary and recurrent/residual craniopharyngiomas, so that the results can be compared. Overall, EETS is a reliable and successful surgical treatment method for primary and recurrent/residual craniopharyngiomas. Copyright © 2016 Elsevier Inc. All rights reserved.

  7. Extended Endoscopic Endonasal Approach for Suprasellar Craniopharyngioma.

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    Locatelli, D; Pozzi, F; Agresta, G; Padovan, S; Karligkiotis, A; Castelnuovo, P

    2018-02-01

    Objectives  We illustrate a suprasellar craniopharyngiomas treated with an extended endoscopic endonasal approach (EEEA). Design  Case report of a 43-year-old male affected by cerebral lesion located in suprasellar region involving the third ventricle and compressing the neurovascular structures, causing an anterosuperior dislocation of the chiasma. There is a complete disruption of the pituitary stalk that can explain the clinical finding of partial anterior hypopituitarism and hyperprolactinemia. The lesion is characterized by a solid and cystic component. Considering the absence of lateral extension and the suprasellar location of the lesion, an EEEA is preferred. Setting  University Hospital "Ospedale di Circolo," Department of Neurosurgery, Varese, Italy. Participants  Neurosurgical and ENT Skull Base Team. Main Outcome Measures  A bilateral parasagittal approach is performed using a four-hand technique. The first step of the surgery is the preparation of the Hadad's flap. The approach is extended to the planum sphenoidalis to expose the suprasellar region. The lesion is completely removed employing also an ultrasound aspirator. Skull base reconstruction is performed with three-layer technique: graft of fat tissue, fascia lata, and nasoseptal flap. Results  No postoperative complications occurred. In the post-op, the patient presents a panhypopituitarism and an improvement in neurological status. The visual deficit remains stable. Post-op magnetic resonance imaging at 1 year documents the complete absence of pathological contrast enhancement. Conclusions  EEEA is a feasible approach in treating craniopharyngioma with suprasellar extension. The advantages include optimal visualization, good resection rate, and absence of brain retraction. The link to the video can be found at: https://youtu.be/IYm-8P1jbBo .

  8. Endoscopic Endonasal Approach to a Suprasellar Craniopharyngioma.

    Science.gov (United States)

    Todeschini, Alexandre B; Montaser, Alaa S; Shahein, Mostafa; Revuelta, Juan Manuel; Otto, Bradley A; Carrau, Ricardo L; Prevedello, Daniel M

    2018-04-01

    We present the case of a 57-year-old male who presented with progressive right side vision loss whose workup revealed a large suprasellar lesion with invasion of the third ventricle. The pituitary stalk was not visible. Hormonal panel showed no hormonal deficits. The initial diagnosis was of a type II transinfundibular craniopharyngioma (as classified by Kassam et al). An endoscopic endonasal transplanum transtuberculum approach was done using a standard binostril four-hand technique, with the patient positioned supine with the head turned to the right side and tilted to the left, fixed in a three-pin head clamp, under imaging guidance. The tumor was carefully dissected away from the optic apparatus while preserving the vessels, mainly the superior hypophyseal artery. The stalk was identified around the tumor and preserved. The third ventricle was entered and inspected at the end of the procedure and a near-total resection (a small residual in the right hypothalamus) with decompression of the optic apparatus was achieved. Reconstruction was done in a multilayered fashion, using collagen matrix and a nasoseptal flap. Patient had an uneventful postoperative stay and was discharged on POD 4, neurologically stable with no hormonal deficits. Pathology confirmed an adamantinomatous craniopharyngioma. Due to a small growth of the residual, patient underwent fractionated stereotactic radiation (50.4Gy in 28 sessions). He presented with panhypopituitarism 2 years after radiation therapy. At 3-month follow-up, his vision was back to normal and 6-year postoperative magnetic resonance imaging showed no signs of recurrence. The link to the video can be found at: https://youtu.be/chG7XIz7a_A .

  9. Extended Endoscopic Endonasal Approach for Craniopharyngioma Removal.

    Science.gov (United States)

    Messerer, Mahmoud; Maduri, Rodolfo; Daniel, Roy Thomas

    2018-02-01

    Objective  Endoscopic transsphenoidal extended endoscopic approach (EEA) represents a valid alternative to microsurgery for craniopharyngiomas removal, especially for retrochiasmatic lesions without large parasellar extension. The present video illustrates the salient surgical steps of the EEA for craniopahryngioma removal. Patient  A 52-year-old man presented with a bitemporal hemianopia and a bilateral decreased visual acuity. MRI showed a Kassam type III cystic craniopharyngioma with a solid component ( Fig. 1 , panels A and B). Surgical Procedure  The head is rotated 10 degrees toward the surgeons. The nasal step is started through the left nostril with a middle turbinectomy. A nasoseptal flap is harvested and positioned in the left choana. The binostril approach allows a large sphenoidotomy to expose the key anatomic landmarks. The craniotomy boundaries are the planum sphenoidale superiorly, the median opticocarotid recesses, the internal carotid artery laterally and the clival recess inferiorly. After dural opening and superior intercavernous sinus coagulation, the tumor is entirely removed ( Fig. 2 , panels A and B). Skull base reconstruction is ensured by fascia lata grafting and nasoseptal flap positioning. Results  Postoperative MRI showed the complete tumor resection ( Fig. 1 , panels C and D). At 3 months postoperatively, the bitemporal hemianopia regressed and the visual acuity improved. A novel left homonymous hemianopia developed secondary to optic tract manipulation. Conclusions  The extended EEA is a valid surgical approach for craniopharyngioma resection. A comprehensive knowledge of the sellar and parasellar anatomy is mandatory for safe tumor removal with decreased morbidity and satisfactory oncologic results. The link to the video can be found at: https://youtu.be/NrCPPnVK2qA .

  10. Surgical management of pituitary adenomas by transsphenoidal approach

    International Nuclear Information System (INIS)

    Liebert, W.; Szyfter, W.; Tokarz, F.; Szmeja, Z.; Paprzycki, W.

    1994-01-01

    In the years 1976-1993 we have performed 90 transsphenoidal approaches for pituitary adenomas. This paper presents a detail report concerning 23 cases, operated in the last 2 years, with CT and NMR documentation. A preoperative visual deficit was very common in this group of patients. In the postoperative period the dramatic improvement of the vision was observed in 86% of cases. In our opinion the transsphenoidal approach is very useful for the operation of the tumors with suprasellar expansion. (author)

  11. Prospective comparison of sinonasal outcomes after microscopic sublabial or endoscopic endonasal transsphenoidal surgery for nonfunctioning pituitary adenomas.

    Science.gov (United States)

    Pledger, Carrie L; Elzoghby, Mohamed A; Oldfield, Edward H; Payne, Spencer C; Jane, John A

    2016-08-01

    OBJECT Both endoscopic and microscopic transsphenoidal approaches are accepted techniques for the resection of pituitary adenomas. Although studies have explored patient outcomes for each technique individually, none have prospectively compared sinonasal and quality of life outcomes in a concurrent series of patients at the same institution, as has been done in the present study. METHODS Patients with nonfunctioning adenomas undergoing transsphenoidal surgery were assessed for sinonasal function, quality of life, and pain using the Sino-Nasal Outcome Test-20 (SNOT-20), the short form of the Nasal Obstruction Symptom Evaluation (NOSE) instrument, the SF-36, and a headache scale. Eighty-two patients undergoing either endoscopic (47 patients) or microscopic (35 patients) surgery were surveyed preoperatively and at 24-48 hours, 2 weeks, 4 weeks, 8 weeks, and 1 year after surgery. RESULTS Patients who underwent endoscopic and microscopic transsphenoidal surgery experienced a similar recovery pattern, showing an initial increase in symptoms during the first 2 weeks, followed by a return to baseline by 4 weeks and improvement beyond baseline functioning by 8 weeks. Patients who underwent endoscopic surgery experienced better sinonasal outcomes at 24-48 hours (SNOT total p = 0.015, SNOT rhinologic subscale [ssRhino] p surgery, no significant differences in sinonasal outcomes were observed between the 2 groups. Headache scales at 1 year improved in all dimensions except duration for both groups (total result 73%, p = 0.004; severity 46%, p surgery, both groups experienced significant improvements in mental health (13%, p = 0.005) and vitality (15%, p = 0.037). By 1 year after surgery, patients improved significantly in mental health (14%, p = 0.03), role physical (14%, p = 0.036), social functioning (16%, p = 0.009), vitality (22%, p = 0.002), and SF-36 total (10%, p = 0.024) as compared with preoperative measures. There were no significant differences at any time point

  12. Endoscopic endonasal repair of spontaneous sphenoid sinus lateral wall meningocele presenting with cerebrospinal fluid leak

    Directory of Open Access Journals (Sweden)

    Ali Erdem Yildirim

    2014-01-01

    Full Text Available Spontaneous sphenoid sinus lateral wall meningoceles are rare lesions with an unknown etiology. Endoscopic endonasal technique is a considerable route in the treatment of this condition. The aim of this paper is to report the etiology, surgical technique, and outcome in a patient repaired via endoscopic endonasal approach. A 51-year-old male patient applied with rhinorrhea started three months ago after an upper respiratory infection. There were no history of trauma or sinus operation. Biochemical analysis of the fluid was positive for beta-2-transferrin. This asypthomatic patient had undergone for repairment of lateral sphenoid sinus meningocele with endoscopic endonasal transsphenoidal approach. After endoscopic endonasal meningocele closure procedure no complications occured and a quick recovery was observed. Endoscopic endonasal approach is an effective and safe treatment modality of spontaneous lateral sphenoid sinus meningoceles and efficient in anterior skull base reconstruction.

  13. A transseptal approach in transsphenoidal surgery for pituitary (hypophyseal) tumors

    International Nuclear Information System (INIS)

    Gierek, T.; Galuszko-Ignasiak, B.; Krauze, J.; Rudnik, A.

    1994-01-01

    The authors described the direct transseptal approach in transsphenoidal surgery for hypophyseal tumors. This route gives a good insight into the area of the sella. The above mentioned method is also less destructive to nasal structures in the nasal cavity, because preserves the anterior nasal septum. It is uniformity of actually views of rhinological school. 20 patients were operated using this method and none of them noticed the changes of nasal airway and the sense of smell. (author)

  14. Intraoperative Neurophysiological Monitoring for Endoscopic Endonasal Approaches to the Skull Base: A Technical Guide

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    Harminder Singh

    2016-01-01

    Full Text Available Intraoperative neurophysiological monitoring during endoscopic, endonasal approaches to the skull base is both feasible and safe. Numerous reports have recently emerged from the literature evaluating the efficacy of different neuromonitoring tests during endonasal procedures, making them relatively well-studied. The authors report on a comprehensive, multimodality approach to monitoring the functional integrity of at risk nervous system structures, including the cerebral cortex, brainstem, cranial nerves, corticospinal tract, corticobulbar tract, and the thalamocortical somatosensory system during endonasal surgery of the skull base. The modalities employed include electroencephalography, somatosensory evoked potentials, free-running and electrically triggered electromyography, transcranial electric motor evoked potentials, and auditory evoked potentials. Methodological considerations as well as benefits and limitations are discussed. The authors argue that, while individual modalities have their limitations, multimodality neuromonitoring provides a real-time, comprehensive assessment of nervous system function and allows for safer, more aggressive management of skull base tumors via the endonasal route.

  15. Microscopic and endoscopic anatomical study of the extended transsphenoidal approach

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    HUANG Xin-tao

    2013-06-01

    Full Text Available Background Traditional transsphenoidal approach has less treatment effect in invasive pituitary adenoma. To remove tumors growing outside the sella become one of the challenges in neurosurgery. This study aims to study anatomical characteristics of the extended transsphenoidal approach for clinical operation. Methods A mimetic surgery was performed on 10 adult cadaver heads through extended transsphenoidal approach by endoscopy. The study data of related anatomic structures were measured. Results The distance from sphenoidal ostium to anterior nasal spine is (59.68 ± 4.28 mm (52.62-63.16 mm, to posterior nasal aperture is (12.88 ± 1.46 mm (10.47-15.61 mm. The incidence of optic nerve and internal carotid artery protuberance in the lateral wall of sphenoidal sinus is 11/20 and 17/20, respectivly. The medial wall of the cavernous sinus is comprised of one dural layer. The incidence of anterior intercavernous sinus, posterior intercavernous sinus, inferior intercavernous sinus and basilar sinus is 17/20, 12/20, 11/20 and 20/20, respectively. The distance between the bilateral hidden segment of internal carotid artery is (15.30 ± 1.25 mm (12.42-21.76 mm, between the bilateral inferior horizontal segment midpoint is (14.03 ± 1.19 mm (10.42-18.43 mm, between the bilateral anterior vertical segment is (18.87 ± 1.44 mm (16.75-24.88 mm, and between the bilateral inner edge of tuberculum sellae is (12.73 ± 0.94 mm (9.97-16.18 mm. In 7 cases (7/20, the intracavernous carotid is in direct contact with the sellar part of the medial wall; in all cases (20/20, the venous plexus extends into the space between the intracavernous carotid and the sphenoidal part of the medial wall. The incidence of the intracavernous carotid coursing along the inferior one third of the pituitary gland is 9/20, along the inferior two thirds of the pituitary gland is 7/20, along the all the thirds of the pituitary gland is 3/20, while below the level of the sellar floor is

  16. Elevated body mass index and risk of postoperative CSF leak following transsphenoidal surgery

    Science.gov (United States)

    Dlouhy, Brian J.; Madhavan, Karthik; Clinger, John D.; Reddy, Ambur; Dawson, Jeffrey D.; O’Brien, Erin K.; Chang, Eugene; Graham, Scott M.; Greenlee, Jeremy D. W.

    2012-01-01

    Object Postoperative CSF leakage can be a serious complication after a transsphenoidal surgical approach. An elevated body mass index (BMI) is a significant risk factor for spontaneous CSF leaks. However, there is no evidence correlating BMI with postoperative CSF leak after transsphenoidal surgery. The authors hypothesized that patients with elevated BMI would have a higher incidence of CSF leakage complications following transsphenoidal surgery. Methods The authors conducted a retrospective review of 121 patients who, between August 2005 and March 2010, underwent endoscopic endonasal transsphenoidal surgeries for resection of primarily sellar masses. Patients requiring extended transsphenoidal approaches were excluded. A multivariate statistical analysis was performed to investigate the association of BMI and other risk factors with postoperative CSF leakage. Results In 92 patients, 96 endonasal endoscopic transsphenoidal surgeries were performed that met inclusion criteria. Thirteen postoperative leaks occurred and required subsequent treatment, including lumbar drainage and/or reoperation. The average BMI of patients with a postoperative CSF leak was significantly greater than that in patients with no postoperative CSF leak (39.2 vs 32.9 kg/m2, p = 0.006). Multivariate analyses indicate that for every 5-kg/m2 increase in BMI, patients undergoing a transsphenoidal approach for a primarily sellar mass have 1.61 times the odds (95% CI 1.10–2.29, p = 0.016, by multivariate logistic regression) of having a postoperative CSF leak. Conclusions Elevated BMI is an independent predictor of postoperative CSF leak after an endonasal endoscopic transsphenoidal approach. The authors recommend that patients with BMI greater than 30 kg/m2 have meticulous sellar reconstruction at surgery and close monitoring postoperatively. PMID:22443502

  17. Mononostril versus Binostril Endoscopic Transsphenoidal Approach for Pituitary Adenomas: A Systematic Review and Meta-Analysis.

    Directory of Open Access Journals (Sweden)

    Guodao Wen

    Full Text Available Over the past several decades, the endoscopic endonasal transsphenoidal approach (EETA has gradually become a preferred option of pituitary adenomas surgery because of its minimal invasiveness and high efficiency. However, some EETA operations were performed through one nostril (mononostril, while other EETA operations were performed through both nostrils (binostril. Therefore, we conducted this study to compare the pros and cons of these two methods in an attempted to confirm which method is more effective.We executed a systematic literature search of PubMed, the Cochrane Library, and the Web of Science and Medline (1992-2015. The language is limited to English and all studies should meet the inclusion criteria. Comparisons were made for postoperative outcomes, complications, and other relevant parameters between the mononostril and the binostril group. Statistical analyses of categorical variables were undertaken by the use of Stata 12.0 and SPASS 19.0.Thirty studies, involving 4805 patients, were included. The two groups had similar results in GTR rate (included GTR rate of macroadenomas, hormonal remission rate, improvement in visual function, postoperative CSF leak, permanent diabetes insipidus, meningitis, and sinusitis. The binostril group had less temporary diabetes insipidus (2.9% vs. 5.3%, p = 0.022, less anterior pituitary insufficiency (2.3% vs. 6.4%, p = 0.000 and few hospitalization days (3.2 days vs. 4.4 days, p<0.05 than the mononostril group. However, the mononostril group had less rate of epistaxis (0.4% vs. 1.5%, p = 0.008 than the binostril group. For invasive macroadenomas, the binostril group seem to demonstrate a tendency towards better outcomes though there was no subgroup analysis between the two groups.The binostril approach had less temporary diabetes insipidus, anterior pituitary insufficiency, and a shorter length of hospital stay, although they demonstrated a higher rate of epistaxis than the mononstril group

  18. Anatomic comparison of the endonasal and transpetrosal approaches for interpeduncular fossa access.

    Science.gov (United States)

    Oyama, Kenichi; Prevedello, Daniel M; Ditzel Filho, Leo F S; Muto, Jun; Gun, Ramazan; Kerr, Edward E; Otto, Bradley A; Carrau, Ricardo L

    2014-01-01

    The interpeduncular cistern, including the retrochiasmatic area, is one of the most challenging regions to approach surgically. Various conventional approaches to this region have been described; however, only the endoscopic endonasal approach via the dorsum sellae and the transpetrosal approach provide ideal exposure with a caudal-cranial view. The authors compared these 2 approaches to clarify their limitations and intrinsic advantages for access to the interpeduncular cistern. Four fresh cadaver heads were studied. An endoscopic endonasal approach via the dorsum sellae with pituitary transposition was performed to expose the interpeduncular cistern. A transpetrosal approach was performed bilaterally, combining a retrolabyrinthine presigmoid and a subtemporal transtentorium approach. Water balloons were used to simulate space-occupying lesions. "Water balloon tumors" (WBTs), inflated to 2 different volumes (0.5 and 1.0 ml), were placed in the interpeduncular cistern to compare visualization using the 2 approaches. The distances between cranial nerve (CN) III and the posterior communicating artery (PCoA) and between CN III and the edge of the tentorium were measured through a transpetrosal approach to determine the width of surgical corridors using 0- to 6-ml WBTs in the interpeduncular cistern (n = 8). Both approaches provided adequate exposure of the interpeduncular cistern. The endoscopic endonasal approach yielded a good visualization of both CN III and the PCoA when a WBT was in the interpeduncular cistern. Visualization of the contralateral anatomical structures was impaired in the transpetrosal approach. The surgical corridor to the interpeduncular cistern via the transpetrosal approach was narrow when the WBT volume was small, but its width increased as the WBT volume increased. There was a statistically significant increase in the maximum distance between CN III and the PCoA (p = 0.047) and between CN III and the tentorium (p = 0.029) when the WBT volume

  19. Preoperative CT evaluation on nasal cavity for transsphenoidal approach

    International Nuclear Information System (INIS)

    Saeki, Naokatsu; Yamaura, Akira; Hoshi, Seiichiro; Sunada, Souichi; Sunami, Kenro

    1997-01-01

    Preoperative bone CT scans sliced parallel to the surgical plane were evaluated in 32 cases of transsphenoidal surgery. This method predicted patients with narrow nasal cavity, and helped to determine the rhinological maneuvers for providing a wider operative field. In addition, it helps to plan the need and extent of sella floor removal in re-operated cases. There was relatively little difference in the width and length of the nasal cavity between acromegalic and non-acromegalic patients. Hence, bone CT scans are useful in the preoperative evaluation of patients undergoing transsphenoidal surgery. (author)

  20. Endoscopic Endonasal Approach in Skull Base Chondrosarcoma Associated with Maffucci Syndrome: Case Series and Literature Review.

    Science.gov (United States)

    Beer-Furlan, André; Balsalobre, Leonardo; Vellutini, Eduardo A S; Stamm, Aldo C

    2016-01-01

    Maffucci syndrome is a nonhereditary disorder in which patients develop multiple enchondromas and cutaneous, visceral, or soft tissue hemangiomas. The potential malignant progression of enchondroma into a secondary chondrosarcoma is a well-known fact. Nevertheless, chondrosarcoma located at the skull base in patients with Maffuci syndrome is a very rare condition, with only 18 cases reported in the literature. We report 2 other cases successfully treated through an expanded endoscopic endonasal approach and discuss the condition based on the literature review. Skull base chondrosarcoma associated with Maffucci syndrome is a rare condition. The disease cannot be cured, therefore surgical treatment should be performed in symptomatic patients aiming for maximal tumor resection with function preservation. The endoscopic endonasal approach is a safe and reliable alternative for the management of these tumors. Copyright © 2016 Elsevier Inc. All rights reserved.

  1. Combined transnasal and transoral endoscopic approach to a transsphenoidal encephalocele in an infant.

    Science.gov (United States)

    Tan, Sien Hui; Mun, Kein Seong; Chandran, Patricia Ann; Manuel, Anura Michelle; Prepageran, Narayanan; Waran, Vicknes; Ganesan, Dharmendra

    2015-07-01

    This paper reports an unusual case of a transsphenoidal encephalocele and discusses our experience with a minimally invasive management. To the best of our knowledge, we present the first case of a combined endoscopic transnasal and transoral approach to a transsphenoidal encephalocele in an infant. A 17-day-old boy, who was referred for further assessment of upper airway obstruction, presented with respiratory distress and feeding difficulties. Bronchoscopy and imaging revealed a transsphenoidal encephalocele. At the age of 48 days, he underwent a combined endoscopic transnasal and transoral excision of the nasal component of the encephalocele. This approach, with the aid of neuronavigation, allows good demarcation of the extra-cranial neck of the transsphenoidal encephalocele. We were able to cauterize and carefully dissect the sac prior to excision. The defect of the neck was clearly visualized, and Valsalva manoeuvre was performed to exclude any CSF leak. As the defect was small, it was allowed to heal by secondary intention. The patient's recovery was uneventful, and he tolerated full feeds orally on day 2. Postoperative imaging demonstrated no evidence of recurrence of the nasal encephalocele. Endoscopic follow-up showed good healing of the mucosa and no cerebrospinal fluid leak. The surgical management of transsphenoidal encephalocele in neonates and infants is challenging. We describe a safe technique with low morbidity in managing such a condition. The combined endoscopic transnasal and transoral approach with neuronavigation is a minimally invasive, safe and feasible alternative, even for children below 1 year of age.

  2. Transfrontal and Transsphenoidal Approaches to Pediatric Craniopharyngioma: A National Perspective.

    Science.gov (United States)

    Lin, Yimo; Hansen, Daniel; Sayama, Christina M; Pan, I-Wen; Lam, Sandi

    2017-01-01

    This study compared transsphenoidal (TS) and transfrontal (TF) approaches to craniopharyngioma utilizing a national database. The Kids' Inpatient Database (2003, 2006, and 2009) was surveyed for patients with a diagnosis of craniopharyngioma who underwent a subset of surgical interventions to compare TS and TF surgery. Demographics, hospital variables, and complications/comorbidities were analyzed with multivariate regression. 314 admissions (TS = 104, TF = 210) were identified. The mean age was 14.8 (TS) versus 9.8 (TF) years (p < 0.001). The mean number of diagnoses was 4.6 (TS) versus 6.2 (TF) (p < 0.001). Diabetes insipidus was associated with 38% (TS) and 69% (TF). Cerebrospinal fluid (CSF) leak affected 19% TS and 4% TF resections. Other complications and comorbidities included postoperative stroke (2% TS vs. 5% TF), panhypopituitarism (5 vs. 8%), death (0 vs. 1%), cranial nerve deficits (1 vs. 6%), thrombotic events (7 vs. 17%), and seizures (0 vs. 12%). 98% of patients were discharged home after a mean 6-day length of stay (LOS) after TS, whereas 90% of TF patients had a LOS of 12 days. TS cases were more likely to be privately insured (68%) and from higher income brackets (61%) than TF ones (56 and 2%, respectively) (p < 0.05). In multivariate regression models adjusting for age, sex, race, number of diagnoses, surgical approach, hospital volume, and insurance type, the TS approach was associated with an increased incidence of CSF leak (OR 10, p < 0.001). More documented diagnoses (OR 16-60, p < 0.01) and TF approach (OR 2.6, p < 0.01) were associated with an increased incidence of other complications and comorbidities. Age younger than 10 (β-coefficient 2.3, p = 0.01), more diagnoses (β-coefficient 1.2, p < 0.001), and TF approach (β- coefficient 3.0, p < 0.01) were associated with increased LOS. A higher number of diagnoses were associated with nonhome discharge destinations (β-coefficient 1.29, p < 0.001). TS surgery was associated with an increased

  3. [The use of intraoperative Doppler ultrasound in endoscopic transsphenoidal surgery].

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    Sharipov, O I; Kutin, M A; Kalinin, P L; Fomichev, D V; Lukshin, V A; Kurnosov, A B

    2016-01-01

    Doppler ultrasound (DUS) has been widely used in neurosurgical practice to diagnose various cerebrovascular diseases. This technique is used in transsphenoidal surgery to identify the localization of intracranial arteries when making an approach or during tumor resection. To identify the cavernous segment of the internal carotid artery (ICA) and/or basilar artery during endoscopic transsphenoidal surgery, we used a combined device on the basis of a click line curette («Karl Storz») and a 16 MHz Doppler probe (Lassamed). The technique was used in 51 patients during both standard transsphenoidal surgery (23 cases) and transsphenoidal tumor resection through an extended approach (28 cases). Doppler ultrasound was used in different situations: to determine a trajectory of the endonasal transsphenoidal approach in the absence of the normal anatomical landmarks (16 cases), to define the limits of safe resection of a tumor located in the laterosellar region (7), and to implement an extended transsphenoidal endoscopic approach (28). Intraoperative Doppler ultrasound enabled identification of the cavernous segment of the internal carotid artery in 45 cases and the basilar artery in 2 cases; a blood vessel was not found in 4 cases. Injury to the cavernous segment of the internal carotid artery was observed only in 1 case. The use of the described combined device in transsphenoidal surgery turned Doppler ultrasound into an important and useful technique for visualization of the ICA within the tumor stroma as well as in the case of the changed skull base anatomy. Its use facilitates manipulations in a deep and narrow wound and enables inspection of the entire surface of the operative field in various planes, thereby surgery becomes safer due to the possibility of maximum investigation of the operative field.

  4. Endoscopic Endonasal Transplanum Transtuberculum Approach for the Resection of a Large Suprasellar Craniopharyngioma.

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    Mangussi-Gomes, João; Vellutini, Eduardo A; Truong, Huy Q; Pahl, Felix H; Stamm, Aldo C

    2018-04-01

    Objectives  To demonstrate an endoscopic endonasal transplanum transtuberculum approach for the resection of a large suprasellar craniopharyngioma. Design  Single-case-based operative video. Setting  Tertiary center with dedicated skull base team. Participants  A 72-year-old male patient diagnosed with a suprasellar craniopharyngioma. Main Outcomes Measured  Surgical resection of the tumor and preservation of the normal surrounding neurovascular structures. Results  A 72-year-old male patient presented with a 1-year history of progressive bitemporal visual loss. He also referred symptoms suggestive of hypogonadism. Neurological examination was unremarkable and endocrine workup demonstrated mildly elevated prolactin levels. Magnetic resonance images demonstrated a large solid-cystic suprasellar lesion, consistent with the diagnosis of craniopharyngioma. The lesion was retrochiasmatic, compressed the optic chiasm, and extended into the interpeduncular cistern ( Fig. 1 ). Because of that, the patient underwent an endoscopic endonasal transplanum transtuberculum approach. 1 2 3 The nasal stage consisted of a transnasal transseptal approach, with complete preservation of the patient's left nasal cavity. 4 The cystic component of the tumor was decompressed and its solid part was resected. It was possible to preserve the surrounding normal neurovascular structures ( Fig. 2 ). Skull base reconstruction was performed with a dural substitute, a fascia lata graft, and a right nasoseptal flap ( Video 1 ). The patient did well after surgery and referred complete visual improvement. However, he also presented pan-hypopituitarism on long-term follow-up. Conclusions  The endoscopic endonasal route is a good alternative for the resection of suprasellar lesions. It permits tumor resection and preservation of the surrounding neurovascular structures while avoiding external incisions and brain retraction. The link to the video can be found at: https://youtu.be/zmgxQe8w-JQ .

  5. The endoscopic endonasal approach is not superior to the microscopic transcranial approach for anterior skull base meningiomas-a meta-analysis.

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    Muskens, Ivo S; Briceno, Vanessa; Ouwehand, Tom L; Castlen, Joseph P; Gormley, William B; Aglio, Linda S; Zamanipoor Najafabadi, Amir H; van Furth, Wouter R; Smith, Timothy R; Mekary, Rania A; Broekman, Marike L D

    2018-01-01

    In the past decade, the endonasal transsphenoidal approach (eTSA) has become an alternative to the microsurgical transcranial approach (mTCA) for tuberculum sellae meningiomas (TSMs) and olfactory groove meningiomas (OGMs). The aim of this meta-analysis was to evaluate which approach offered the best surgical outcomes. A systematic review of the literature from 2004 and meta-analysis were conducted in accordance with the PRISMA guidelines. Pooled incidence was calculated for gross total resection (GTR), visual improvement, cerebrospinal fluid (CSF) leak, intraoperative arterial injury, and mortality, comparing eTSA and mTCA, with p-interaction values. Of 1684 studies, 64 case series were included in the meta-analysis. Using the fixed-effects model, the GTR rate was significantly higher among mTCA patients for OGM (eTSA: 70.9% vs. mTCA: 88.5%, p-interaction OGM (p-interaction = 0.33). CSF leak was significantly higher among eTSA patients for both OGM (eTSA: 25.1% vs. mTCA: 10.5%, p-interaction OGM resection (p-interaction = 0.10). Mortality was not significantly different between eTSA and mTCA patients for both TSM (p-interaction = 0.14) and OGM resection (p-interaction = 0.88). Random-effect models yielded similar results. In this meta-analysis, eTSA was not shown to be superior to mTCA for resection of both OGMs and TSMs.

  6. Endoscopic Endonasal Infrapetrous Transpterygoid Approach to the Petroclival Junction for Petrous Apex Chondrosarcoma: Technical Report.

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    Maurer, Adrian J; Bonney, Phillip A; Iser, Courtney R; Ali, Rohaid; Sanclement, Jose A; Sughrue, Michael E

    2015-07-01

    Chondrosarcomas of the skull base are rare tumors that present difficult management considerations due to the pathoanatomical relationships of the tumor to adjacent structures. We present the case of a 25-year-old female patient presenting with a chondrosarcoma of the right petrous apex extending inferiorly, medial to the cranial nerves. The tumor was resected via an endoscopic endonasal infrapetrous transpterygoid approach that achieved complete resection and an excellent long-term outcome with no complications. Technical nuances and potential pitfalls of the case are discussed in depth including measures to protect the carotid artery while performing the required drilling of the skull base to access the lesion.

  7. Gigant Transethmoidal Meningoencephalocele Operated by Full Endonasal Endoscopic Approach: Case Report

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    Omar Lopez Arbolay

    2012-01-01

    Full Text Available Intranasal meningoencephaloceles have historically been managed by neurosurgeons, although their main clinical manifestations are rhinological. Recent advances in endoscopic skull base surgery has significantly improved the treatment of these lesions and consequently diminished appreciable surgical morbidity. We report an ethmoidal meningoencephalocele case operated on by endonasal endoscopic approach for removal of the lesion and reconstructing the associated skull base. From this experience, we conclude that removal of the lesion and watertight closure of the skull base irrespective of the size of the mass and anterior skull base defect are the operation’s most important aspects.

  8. Gigantism treated by pure endoscopic endonasal approach in a case of McCune-Albright syndrome with sphenoid fibrous dysplasia: a case report.

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    Sharifi, Guive; Jalessi, Maryam; Sarvghadi, Farzaneh; Farhadi, Mohammad

    2013-12-01

    McCune-Albright syndrome (MAS) is an uncommon polyostotic manifestation of fibrous dysplasia in association with at least one endocrinopathy that is mostly associated with precocious puberty and hyperpigmented skin macules named café-au-lait spots. We present an atypical manifestation of McCune-Albright syndrome in a 19-year-old man with the uncommon association of polyostotic fibrous dysplasia and gigantism in the absence of café-au-lait spots and precocious puberty. He presented with a height increase to 202 cm in the previous 3 years, which had become more progressive in the few months prior. Physical examination revealed only a mild facial asymmetry; however, a computed tomography (CT) scan discovered vast areas of voluminous bones with ground-glass density and thickening involving the craniofacial bones and skull base. Magnetic resonance imaging (MRI) found a right stalk shift of the pituitary with a 20 mm pituitary adenoma. We describe the diagnostic and endoscopic endonasal transsphenoidal approach for excision of the tumor. Georg Thieme Verlag KG Stuttgart · New York.

  9. Extended Endoscopic Endonasal Approaches for Cerebral Aneurysms: Anatomical, Virtual Reality and Morphometric Study

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    Alberto Di Somma

    2014-01-01

    Full Text Available Introduction. The purpose of the present contribution is to perform a detailed anatomic and virtual reality three-dimensional stereoscopic study in order to test the effectiveness of the extended endoscopic endonasal approaches for selected anterior and posterior circulation aneurysms. Methods. The study was divided in two main steps: (1 simulation step, using a dedicated Virtual Reality System (Dextroscope, Volume Interactions; (2 dissection step, in which the feasibility to reach specific vascular territory via the nose was verified in the anatomical laboratory. Results. Good visualization and proximal and distal vascular control of the main midline anterior and posterior circulation territory were achieved during the simulation step as well as in the dissection step (anterior communicating complex, internal carotid, ophthalmic, superior hypophyseal, posterior cerebral and posterior communicating, basilar, superior cerebellar, anterior inferior cerebellar, vertebral, and posterior inferior cerebellar arteries. Conclusion. The present contribution is intended as strictly anatomic study in which we highlighted some specific anterior and posterior circulation aneurysms that can be reached via the nose. For clinical applications of these approaches, some relevant complications, mainly related to the endonasal route, such as proximal and distal vascular control, major arterial bleeding, postoperative cerebrospinal fluid leak, and olfactory disturbances must be considered.

  10. Transbasal versus endoscopic endonasal versus combined approaches for olfactory groove meningiomas: importance of approach selection.

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    Liu, James K; Silva, Nicole A; Sevak, Ilesha A; Eloy, Jean Anderson

    2018-04-01

    OBJECTIVE There has been much debate regarding the optimal surgical approach for resecting olfactory groove meningiomas (OGMs). In this paper, the authors analyzed the factors involved in approach selection and reviewed the surgical outcomes in a series of OGMs. METHODS A retrospective review of 28 consecutive OGMs from a prospective database was conducted. Each tumor was treated via one of 3 approaches: transbasal approach (n = 15), pure endoscopic endonasal approach (EEA; n = 5), and combined (endoscope-assisted) transbasal-EEA (n = 8). RESULTS The mean tumor volume was greatest in the transbasal (92.02 cm 3 ) and combined (101.15 cm 3 ) groups. Both groups had significant lateral dural extension over the orbits (transbasal 73.3%, p 95%) was achieved in 20% of transbasal and 37.5% of combined cases, all due to tumor adherence to the critical neurovascular structures. The rate of CSF leakage was 0% in the transbasal and combined groups, and there was 1 leak in the EEA group (20%), resulting in an overall CSF leakage rate of 3.6%. Olfaction was preserved in 66.7% in the transbasal group. There was no significant difference in length of stay or 30-day readmission rate between the 3 groups. The mean modified Rankin Scale score was 0.79 after the transbasal approach, 2.0 after EEA, and 2.4 after the combined approach (p = 0.0604). The mean follow-up was 14.5 months (range 1-76 months). CONCLUSIONS The transbasal approach provided the best clinical outcomes with the lowest rate of complications for large tumors (> 40 mm) and for smaller tumors (OGMs invading the sinonasal cavity. Careful patient selection using an individualized, tailored strategy is important to optimize surgical outcomes.

  11. Limitations of the endonasal endoscopic approach in treating olfactory groove meningiomas. A systematic review.

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    Shetty, Sathwik Raviraj; Ruiz-Treviño, Armando S; Omay, Sacit Bulent; Almeida, Joao Paulo; Liang, Buqing; Chen, Yu-Ning; Singh, Harminder; Schwartz, Theodore H

    2017-10-01

    To review current management strategies for olfactory groove meningioma (OGM)s and the recent literature comparing endoscopic endonasal (EEA) with traditional transcranial (TCA) approaches. A PubMed search of the recent literature (2011-2016) was performed to examine outcomes following EEA and TCA for OGM. The extent of resection, visual outcome, postoperative complications and recurrence rates were analyzed using percentages and proportions, the Fischer exact test and the Student's t-test using Graphpad PRISM 7.0Aa (San Diego, CA) software. There were 444 patients in the TCA group with a mean diameter of 4.61 (±1.17) cm and 101 patients in the EEA group with a mean diameter of 3.55 (± 0.58) cm (p = 0.0589). GTR was achieved in 90.9% (404/444) in the TCA group and 70.2% (71/101) in the EEA group (p OGMs.

  12. The Usefulness of the Endonasal Incisional Approach for the Treatment of Nasal Bone Fracture

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    Hyo Seong Kim

    2012-05-01

    Full Text Available BackgroundAmong all facial fractures, nasal bone fractures are the most common, and they have been reduced by closed reduction (CR for a long time. But several authors have reported suboptimal results when using CR, and the best method of nasal bone reduction is still being debated. We have found that indirect open reduction (IOR through an endonasal incisional approach is a useful method for more accurate reduction of the nasal bone.MethodsA retrospective chart review was performed of 356 patients who underwent reduction of a nasal bone fracture in our department from January, 2006, to July, 2011. We treated 263 patients with IOR. We assessed patients' and doctors' satisfaction with surgical outcomes after IOR or CR. We evaluated the frequency of nasal bleeding owing to mucosal injury, and followed the surgical outcomes of patients who had simultaneous dorsal augmentation rhinoplasty.ResultsAccording to the analysis of the satisfaction scores, both patients and doctors were significantly more satisfied in the IOR group than the CR group (P<0.05. Mucosal injury with nasal bleeding occurred much less in the IOR group (5.3% than the CR group (12.9%. Dorsal augmentation rhinoplasty with IOR was performed simultaneously in 34 cases. Most of them (31/34 showed satisfaction with the outcomes.ConclusionsIOR enables surgeons to manipulate the bony fragment directly through the endonasal incisional approach. However, we propose that CR is the proper technique for patients under 16 and for those with comminuted nasal bone fractures because submucosal dissection in IOR can damage the growth or circulation of nasal bone.

  13. Partial maxillectomy for ameloblastoma of the maxilla with infratemporal fossa involvement: A combined endoscopic endonasal and transoral approach.

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    Guha, A; Hart, L; Polachova, H; Chovanec, M; Schalek, P

    2018-02-21

    Ameloblastoma represents the most common epithelial odontogenic tumor. Because of the proximity of the maxillary tumors to the orbit and skull base, it should be managed as radically as possible. Maxillectomy, mainly via the transfacial or transoral approach, represents the most common type of surgical procedure. Drawback of these approaches is limited control of the superiomedial extent of the tumour in the paranasal area. We report the use of a combined endoscopic endonasal and transoral approach to manage maxillary plexiform ameloblastoma in a 48-year-old male patient. A combined endoscopic endonasal and transoral approach enabled the radical removal of tumour with a 1.5cm margin of radiographically intact bone with good control from both intrasinusal and intraoral aspects. Adequate visualization of the extent of the lesion (e.g. orbit, infratemporal fossa, anterior cranial base) had been achieved. Non-complicated healing was achieved. This technique of partial maxillectomy led to very good aesthetic and functional results. No recurrence had been noted during review appointments. The combination of endoscopic endonasal and transoral approach for a partial maxillectomy allows sufficient reduction of the defect, thus eliminating the necessity for reconstruction and reducing the morbidity associated with it. Copyright © 2018 Elsevier Masson SAS. All rights reserved.

  14. Endoscopic Endonasal Transturbinate Approach to the Pterygopalatine Fossa in the Management of Juvenile Nasopharyngeal Angiofibromas

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    Satoru Kodama

    2012-01-01

    Full Text Available Pterygopalatine fossa (PPF is a difficult-to-access anatomic area located behind the posterior wall of the maxillary sinus. Juvenile nasopharyngeal angiofibroma (JNA often affects this area, and the management of feeding artery to the tumor is important in the surgery. Endoscopic endonasal approach to the PPF without endangering all other nasal structures is useful in the management of JNA. We describe a new approach to the PPF, endoscopic transturbinate approach, which is effective in the management of JNA. Submucous inferior turbinoplasty was performed, and sphenopalatine artery, the feeder to the tumor, was identified at the sphenopalatine foramen. The posterior wall of maxillary sinus was removed. Internal maxillary artery was identified in the PPF and was ligated with a hemoclip. The tumor in the PPF was pushed into the nasal cavity. These procedures were all performed via submucous turbinate tunnel. Then, the tumor was successfully removed in en bloc from the nasal cavity by transnasal approach without ethmoidectomy. This approach improves accessibility and visualization in the PPF and potential to reduce intraoperative bleeding due to ligation of the feeder safely without touching the tumor. Endoscopic transturbinate approach is effective in the management of early stage of JNA.

  15. [Bath Plug Closure Method for Cerebrospinal Fluid Leakage by Endoscopic Endonasal Approach:Cooperative Treatment by Neurosurgeons and Otolaryngologists].

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    Kawaguchi, Tomohiro; Arakawa, Kazuya; Nomura, Kazuhiro; Ogawa, Yoshikazu; Katori, Yukio; Tominaga, Teiji

    2017-12-01

    Endoscopic endonasal surgery, an innovative surgical technique, is used to approach sinus lesions, lesions of the skull base, and intradural tumors. The cooperation of experienced otolaryngologists and neurosurgeons is important to achieve safe and reliable surgical results. The bath plug closure method is a treatment option for patients with cerebrospinal fluid(CSF)leakage. Although it includes dural and/or intradural procedures, surgery tends to be performed by otolaryngologists because its indications, detailed maneuvers, and pitfalls are not well recognized by neurosurgeons. We reviewed the cases of patients with CSF leakage treated by using the bath plug closure method with an endoscopic endonasal approach at our institution. Three patients were treated using the bath plug closure method. CSF leakage was caused by a meningocele in two cases and trauma in one case. No postoperative intracranial complications or recurrence of CSF leakage were observed. The bath plug closure method is an effective treatment strategy and allows neurosurgeons to gain in-depth knowledge of the treatment options for CSF leakage by using an endoscopic endonasal approach.

  16. Evolution of transoral approaches, endoscopic endonasal approaches, and reduction strategies for treatment of craniovertebral junction pathology: a treatment algorithm update.

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    Dlouhy, Brian J; Dahdaleh, Nader S; Menezes, Arnold H

    2015-04-01

    The craniovertebral junction (CVJ), or the craniocervical junction (CCJ) as it is otherwise known, houses the crossroads of the CNS and is composed of the occipital bone that surrounds the foramen magnum, the atlas vertebrae, the axis vertebrae, and their associated ligaments and musculature. The musculoskeletal organization of the CVJ is unique and complex, resulting in a wide range of congenital, developmental, and acquired pathology. The refinements of the transoral approach to the CVJ by the senior author (A.H.M.) in the late 1970s revolutionized the treatment of CVJ pathology. At the same time, a physiological approach to CVJ management was adopted at the University of Iowa Hospitals and Clinics in 1977 based on the stability and motion dynamics of the CVJ and the site of encroachment, incorporating the transoral approach for irreducible ventral CVJ pathology. Since then, approaches and techniques to treat ventral CVJ lesions have evolved. In the last 40 years at University of Iowa Hospitals and Clinics, multiple approaches to the CVJ have evolved and a better understanding of CVJ pathology has been established. In addition, new reduction strategies that have diminished the need to perform ventral decompressive approaches have been developed and implemented. In this era of surgical subspecialization, to properly treat complex CVJ pathology, the CVJ specialist must be trained in skull base transoral and endoscopic endonasal approaches, pediatric and adult CVJ spine surgery, and must understand and be able to treat the complex CSF dynamics present in CVJ pathology to provide the appropriate, optimal, and tailored treatment strategy for each individual patient, both child and adult. This is a comprehensive review of the history and evolution of the transoral approaches, extended transoral approaches, endoscopie assisted transoral approaches, endoscopie endonasal approaches, and CVJ reduction strategies. Incorporating these advancements, the authors update the

  17. Ectopic pituitary null cell adenoma arising from the infundibulum in the third ventricle: A successful endonasal transsphenoidal resection after long-term follow-up MR imaging – A technical note

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    Yuichiro Yoneoka, M.D., Ph.D.

    2017-12-01

    Conclusion: To our best knowledge, this is the first case with long-term preoperative follow-up images, which can bridge the knowledge gap in operations of third ventricle ectPA as following: (1 Truly third ventricle ectPA can exist, (2 the third ventricle ectPA extended into the sella turcica along the pituitary stalk, (3 this ectPA can arise from the suprasellar peri-infundibular ectopic pituitary cells or the pars tuberalis of the adenohypophysis, and therefore adhere to the optic chiasm, (4 thus neurosurgeons should take great care in resection of ectPA arising from the infundibulum, and (5 it can be resected through an endoscopic extended transsphenoidal approach.

  18. Surgical resection of pituitary adenoma via neuroendoscopic single-nostril transsphenoidal approach: a clinical analysis

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    Gang-ge CHENG

    2015-06-01

    Full Text Available Objective To explore the technique and clinical efficacy of single-nostril transsphenoidal neuroendoscopic resection of pituitary adenomas. Methods A total of 47 patients with pituitary adenoma, among them 21 were male and 26 female, aged 15-70 years old with a mean of 42.7 years, were treated with neuroendoscopic single-nostril transsphenoidal surgical resection in the Air Force General Hospital of PLA from August 2007 to August 2013. Clinical data were analyzed retrospectively, including the operative results, complications, and follow up results. Results Post-operative MRI revealed that the tumor was totally removed in 38 (80.9% patients, and subtotally in 9 (19.1%, the tumors were large and had invaded the cavernous sinus. Post-operative improvement of clinical symptoms was achieved in 40 (85.1% patients, among them, headache disappeared in 35 patients, vision and visual field improved in 30 patients. Among the 47 patients, an increase in prolactin hormone (PRH type was seen in 29, an increase in growth hormone (GH type in 6, and non-functioning pituitary carcinoma in 12 patients. In 80% (28/36 of the patients hormone secretion was improved after the operation, including 23 of PRH type and 5 of GH type. Post-operative complications were diabetes insipidus in 10 patients, cerebrospinal fluid leakage in 8 and meningitis in one. All the patients were followed up for 6 months up to 6 years, and no death occurred. Conclusion Single-nostril transsphenoidal endoscopic surgery consists of many advantages, such as minimal trauma, clear visual field, higher total resection rate, and rapid recovery after operation, therefore it is a safe and effective approach for the resection of pituitary adenomas. DOI: 10.11855/j.issn.0577-7405.2015.05.15

  19. Endoscopic Endonasal Management of Craniopharyngioma.

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    Zacharia, Brad E; Amine, Muhamad; Anand, Vijay; Schwartz, Theodore H

    2016-02-01

    Craniopharyngioma is a rare clinical entity that poses a significant management challenge given their location and propensity to recur. As part of a minimally disruptive treatment paradigm, the expanded endonasal approach has the potential to improve rates of resection, improve postoperative visual recovery, and minimize surgical morbidity. This article updates the otolaryngologic community on the basic principles and techniques regarding the incorporation of the endoscopic, endonasal approach in the management paradigm of craniopharyngioma. Copyright © 2016 Elsevier Inc. All rights reserved.

  20. Endoscopic Endonasal Approach for Resection of a Pediatric Craniopharyngioma: Operative Video and Technical Nuances.

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    Liu, James K; Eloy, Jean Anderson

    2018-04-01

    We present a pediatric case of a retrochiasmatic craniopharyngioma in the suprasellar region with third ventricular extension that was resected through a purely endoscopic endonasal approach (EEA) via the transplanum transtuberculum corridor. The patient is a 12-year-old boy who presented with progressive visual loss and panhypopituitarism. The EEA allows direct visualization of the undersurface of the optic chiasm and hypothalamus so that safe and meticulous tumor dissection can be performed to preserve these critical neurovascular structures. This video atlas demonstrates the operative technique and surgical nuances of the endoscopic skull base approach, microdissection of the tumor from the critical neurovascular structures, and multilayered reconstruction of the skull base defect with a nasoseptal flap. A gross total resection was achieved, and the patient was neurologically intact with improved visual acuity and visual fields. In summary, the EEA via the transplanum transtuberculum corridor is an important strategy in the armamentarium for surgical management of pediatric craniopharyngiomas. The link to the video can be found at: https://youtu.be/bmgO_PMRHPk .

  1. Supraorbital Versus Endoscopic Endonasal Approaches for Olfactory Groove Meningiomas: A Cost-Minimization Study.

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    Gandhoke, Gurpreet S; Pease, Matthew; Smith, Kenneth J; Sekula, Raymond F

    2017-09-01

    To perform a cost-minimization study comparing the supraorbital and endoscopic endonasal (EEA) approach with or without craniotomy for the resection of olfactory groove meningiomas (OGMs). We built a decision tree using probabilities of gross total resection (GTR) and cerebrospinal fluid (CSF) leak rates with the supraorbital approach versus EEA with and without additional craniotomy. The cost (not charge or reimbursement) at each "stem" of this decision tree for both surgical options was obtained from our hospital's finance department. After a base case calculation, we applied plausible ranges to all parameters and carried out multiple 1-way sensitivity analyses. Probabilistic sensitivity analyses confirmed our results. The probabilities of GTR (0.8) and CSF leak (0.2) for the supraorbital craniotomy were obtained from our series of 5 patients who underwent a supraorbital approach for the resection of an OGM. The mean tumor volume was 54.6 cm 3 (range, 17-94.2 cm 3 ). Literature-reported rates of GTR (0.6) and CSF leak (0.3) with EEA were applied to our economic analysis. Supraorbital craniotomy was the preferred strategy, with an expected value of $29,423, compared with an EEA cost of $83,838. On multiple 1-way sensitivity analyses, supraorbital craniotomy remained the preferred strategy, with a minimum cost savings of $46,000 and a maximum savings of $64,000. Probabilistic sensitivity analysis found the lowest cost difference between the 2 surgical options to be $37,431. Compared with EEA, supraorbital craniotomy provides substantial cost savings in the treatment of OGMs. Given the potential differences in effectiveness between approaches, a cost-effectiveness analysis should be undertaken. Copyright © 2017 Elsevier Inc. All rights reserved.

  2. Pure endoscopic expanded endonasal approach for olfactory groove and tuberculum sellae meningiomas.

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    Khan, Osaama H; Krischek, Boris; Holliman, Damian; Klironomos, George; Kucharczyk, Walter; Vescan, Allan; Gentili, Fred; Zadeh, Gelareh

    2014-06-01

    The expanded endoscopic endonasal (EEE) approach for the removal of olfactory groove (OGM) and tuberculum sellae (TSM) meningiomas is currently becoming an acceptable surgical approach in neurosurgical practice, although it is still controversial with respect to its outcomes, indications and limitations. Here we provide a review of the available literature reporting results with use of the EEE approach for these lesions together with our experience with the use of the endoscope as the sole means of visualization in a series of patients with no prior surgical biopsy or resection. Surgical cases between May 2006 and January 2013 were retrospectively reviewed. Twenty-three patients (OGM n=6; TSM n=17) were identified. In our series gross total resection (GTR) was achieved in 4/6 OGM (66.7%) and 11/17 (64.7%) TSM patients. Vision improved in the OGM group (2/2) and 8/11 improved in the TSM group with no change in visual status in the remaining three patients. Post-operative cerebrospinal fluid (CSF) leak occurred in 2/6 (33%) OGM and 2/17 (11.8%) TSM patients. The literature review revealed a total of 19 OGM and 174 TSM cases which were reviewed. GTR rate was 73% for OGM and 56.3% for TSM. Post-operative CSF leak was 30% for OGM and 14% for TSM. With careful patient selection and a clear understanding of its limitations, the EEE technique is both feasible and safe. However, longer follow-ups are necessary to better define the appropriate indications and ideal patient population that will benefit from the use of these newer techniques. Crown Copyright © 2013. Published by Elsevier Ltd. All rights reserved.

  3. Outcomes following Purely Endoscopic Endonasal Resection of Pituitary adenomas

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    Rezaul Amin

    2013-01-01

    Full Text Available Background: The use of endoscope for the management of pituitary adenoma is not new. The better magnification and illumination provided by the endoscope gives better outcome than microscopic pituitary surgery. Objective: To find out the benefits of endoscope in relation to microscopic surgery. Materials and Methods: We performed 45 cases of pituitary adenoma surgery by endoscopic endonasal approach from July 2008 to July 2010. Results: Forty five cases underwent endoscopic transsphenoidal approach. Gross total removal was done in 35 cases and subtotal removal was done in 10 cases. Residual tumours were seen in 10 cases (22% in postoperative follow-up MRI scan. Visual improvement was satisfactory, and hormonal improvement of functional adenoma was nice. Postoperative visual acuity and visual field were improved in 75% cases. There were 37% cases of temporary diabetes insipidus and about 4.5% cases of permanent diabetes insipidus. The average duration of follow-up was 20 months. One patient required reexploration to correct visual deterioration in the immediate postoperative period. There were 4.5% cases of CSF leak and 6.6% mortality. Mortality was due to electrolyte imbalance and improper management of infection and hydrocephalus. Conclusion: Endoscopic endonasal pituitary surgery now has become a gold standard surgery for most of the pituitary adenomas because of its better advantages in relation to microscopic surgery and less complications and less hospital stay.

  4. A panoramic view of the skull base: systematic review of open and endoscopic endonasal approaches to four tumors.

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    Graffeo, Christopher S; Dietrich, August R; Grobelny, Bartosz; Zhang, Meng; Goldberg, Judith D; Golfinos, John G; Lebowitz, Richard; Kleinberg, David; Placantonakis, Dimitris G

    2014-08-01

    Endoscopic endonasal surgery has been established as the safest approach to pituitary tumors, yet its role in other common skull base lesions has not been established. To answer this question, we carried out a systematic review of reported series of open and endoscopic endonasal approaches to four major skull base tumors: olfactory groove meningiomas (OGM), tuberculum sellae meningiomas (TSM), craniopharyngiomas (CRA), and clival chordomas (CHO). Data from 162 studies containing 5,701 patients were combined and compared for differences in perioperative mortality, gross total resection (GTR), cerebrospinal fluid (CSF) leak, neurological morbidity, post-operative visual function, post-operative anosmia, post-operative diabetes insipidus (DI), and post-operative obesity/hyperphagia. Weighted average rates for each outcome were calculated using relative study size. Our findings indicate similar rates of GTR and perioperative mortality between open and endoscopic approaches for all tumor types. CSF leak was increased after endoscopic surgery. Visual function symptoms were more likely to improve after endoscopic surgery for TSM, CRA, and CHO. Post-operative DI and obesity/hyperphagia were significantly increased after open resection in CRA. Recurrence rates per 1,000 patient-years of follow-up were higher in endoscopy for OGM, TSM, and CHO. Trends for open and endoscopic surgery suggested modest improvement in all outcomes over time. Our observations suggest that endonasal endoscopy is a safe alternative to craniotomy and may be preferred for certain tumor types. However, endoscopic surgery is associated with higher rates of CSF leak, and possibly increased recurrence rates. Prospective study with long-term follow-up is required to verify these preliminary observations.

  5. A comparison of trans-cranial and trans-sphenoidal approaches for vision improvement due to pitutary adenomas

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    Fakhr Tabatabai SA

    1997-07-01

    Full Text Available To improve visual disturbance, optic nerve decompression can be performed via transcranial or tran-sphenoidal approaches. Although the surgical exposure in transcranial approach is favourable, yet the optic nerve's presence in the field may make it vulnerable to damage. Of fighty patients with different types of pituitary adenomas, 35 cases with medium-sized (1-3 cm tumors have been studied in a randomized clinical trial during a three year period, to compare the applicability of these approaches. While short hospital stay with better visual outcome was observed in fifteen trans-sphenoidal cases, in comparison to 20 trans-cranial cases, however the preoperative visual status and underlying disorders were similar in both groups. Decompressing the optic apparatus, trans-sphenoidally, seems beneficial, where there are no contraindications for the procedure in medium-sized pituitary adenomas

  6. A road map to the internal carotid artery in expanded endoscopic endonasal approaches to the ventral cranial base.

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    Labib, Mohamed A; Prevedello, Daniel M; Carrau, Ricardo; Kerr, Edward E; Naudy, Cristian; Abou Al-Shaar, Hussam; Corsten, Martin; Kassam, Amin

    2014-09-01

    Injuring the internal carotid artery (ICA) is a feared complication of endoscopic endonasal approaches. To introduce a comprehensive ICA classification scheme pertinent to safe endoscopic endonasal cranial base surgery. Anatomic dissections were performed in 33 cadaveric specimens (bilateral). Anatomic correlations were analyzed. Based on anatomic correlations, the ICA may be described as 6 distinct segments: (1) parapharyngeal (common carotid bifurcation to ICA foramen); (2) petrous (carotid canal to posterolateral aspect of foramen lacerum); (3) paraclival (posterolateral foramen lacerum to the superomedial aspect of the petrous apex); (4) parasellar (superomedial petrous apex to the proximal dural ring); (5) paraclinoid (from the proximal to the distal dural rings); and (6) intradural (distal ring to ICA bifurcation). Corresponding surgical landmarks included the Eustachian tube, the fossa of Rosenmüller, and levator veli palatini for the parapharyngeal segment; the vidian canal and V3 for the petrous segment; the fibrocartilage of foramen lacerum, foramen rotundum, maxillary strut, lingular process of the sphenoid bone, and paraclival protuberance for the paraclival segment; the sellar floor and petrous apex for the parasellar segment; and the medial and lateral opticocarotid and lateral tubercular recesses, as well as the distal osseous arch of the carotid sulcus for the paraclinoid segment. The proposed endoscopic classification outlines key anatomic reference points independent of the vessel's geometry or the sinonasal pneumatization, thus serving as (1) a practical guide to navigate the ventral cranial base while avoiding injury to the ICA and (2) further foundation for a modular access system.

  7. Recent Evolution of Endoscopic Endonasal Surgery for Treatment of Pituitary Adenomas

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    NISHIOKA, Hiroshi

    2017-01-01

    For the treatment of pituitary tumors, microscopic transsphenoidal surgery has been considered the “gold standard” since the late 1960s. Over the last two decades, however, a worldwide shift towards endoscopic endonasal surgery is in progress for many reasons. These include a wide panoramic view, improved illumination, an ability to look around anatomical corners using angled tip and, in addition, application to the extended approaches for parasellar tumors. Both endoscopic and microscopic approaches appear equally effective for nonfunctioning adenomas without significant suprasellar or lateral extensions, whereas the endoscopic approach may improve outcomes associated with the extent of resection and postoperative complications for larger tumors. Despite many theoretical benefits in the endoscopic surgery, remission rates of functioning adenomas do not substantially differ between the approaches in experienced hands. The endoscopic approach is a valid alternative to the microscopic approach for adenomas. The benefits will be more appreciated in the extended surgery for parasellar tumors. PMID:28239067

  8. Endoscopic treatment of trans-sellar trans-sphenoidal encephalocele associated with morning glory syndrome presenting with non-traumatic cerebrospinal fluid rhinorrhea.

    Science.gov (United States)

    Sasani, M; Ozer, A F; Aydin, A L

    2009-03-01

    Basal encephaloceles are rare, accounting for about 1.5% of all encephaloceles. The trans-sellar trans-sphenoidal encephalocele variety is the rarest. Morning glory syndrome is often associated with basal encephalocele. Spontaneous cerebrospinal fluid (CSF) rhinorrheas are the least common of these, accounting for only 3% to 5% of all CSF rhinorrheas. The authors describe the outcome of a 10-year follow-up study of a 26-year-old male patient with a spontaneous CSF rhinorrhea occurring trans-sphenoidal encephalocele associated with bilateral morning glory syndrome that was treated with an endoscopic endonasal approach. Endoscopic exploration of the sella floor was performed and closed with abdomen fat packing and muscle fascia. The postoperative course was uneventful. A follow-up magnetic resonance (MR) image at 6 months postoperatively showed extension of encephalocele in the sphenoidal sinus, which was repaired. The patient had no further CSF rhinorrhea and showed no ophthalmologic changes over a follow-up period of over 10 years. Ophthalmologic findings such as strabismus, in association with anomalies of the optic nerve, should alert the physician to the possible presence of an unrecognized skull base midline defect and encephalocele before CSF leakage is seen. The authors believe that a surgeon who has equal confidence in performing the endoscopic endonasal and conventional microscopic trans-sphenoidal approaches should choose the less invasive surgery.

  9. Transsphenoidal surgery for pituitary tumors from microsurgery to the endoscopic surgery. Single surgeon's experience

    International Nuclear Information System (INIS)

    Iwai, Yoshiyasu; Yoshimura, Masaki; Terada, Aiko; Yamanaka, Kazuhiro; Koshimo, Naomi

    2011-01-01

    We reviewed results of the surgical outcome of pituitary tumors treated via the transsphenoidal approach between January, 1994 and January, 2010 at our institution. This data included 100 patients (124 procedures) treated through the sublabial transsphenoidal approach and 45 patients (54 procedures) treated through the endoscopic endonasal (bilateral nostrils) transsphenoidal approach performed by a single surgeon. The extent of tumor removal was significantly improved with endoscopic surgery; adjuvant gamma knife radiosurgery was needed for 65% of patients undergoing microsurgery vs. 30% for patients who had endoscopic surgery (p<0.0001). Patients who underwent endoscopic surgery had less intraoperative blood loss (mean volume: 100 mL for microsurgery patients vs. 30 mL for endoscopic surgery patients, p<0.0001), less pain, and less need for postoperative hormone replacement therapy (19% for microsurgery patients vs. 6% for endoscopic surgery patients; p<0.05). Cerebrospinal fluid (CSF) leakage and meningitis were experienced in one microsurgery patient (1%) and one endoscopic surgery patient (2.2%). Endoscopic surgery is a reasonable alternative to microsurgery and our experience supports the concept that an otolaryngologist/neurosurgeon team skilled in endoscopic techniques and pituitary surgery can safely make the transition from microsurgery to endoscopic surgery. (author)

  10. Endoscopic endonasal approach for craniopharyngioma: the importance of the relationship between pituitary stalk and tumor.

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    Dho, Yun-Sik; Kim, Yong Hwy; Se, Young-Bem; Han, Doo Hee; Kim, Jung Hee; Park, Chul-Kee; Wang, Kyu-Chang; Kim, Dong Gyu

    2017-09-29

    OBJECTIVE The endoscopic endonasal approach (EEA) is commonly used for the treatment of craniopharyngioma; therefore, it is essential to analyze outcomes in order to understand the benefits and drawbacks. The goal of this paper was to evaluate the clinical features and outcomes associated with this treatment approach. METHODS From July 2010 to March 2016, 82 adult craniopharyngioma patients underwent an EEA at the authors' institution. Of these cases, intraoperative records and immediate postoperative MR images were available for 68 patients. The patients underwent systemized endocrinological evaluation. Eighteen of 68 patients who underwent EEA for recurrence or regrowth of residual lesions after previous surgical management were excluded in the analysis of the anatomical tumor classification. The authors retrospectively analyzed preoperative clinical features and previous anatomical classifications, focusing on the relationship of the pituitary stalk and tumor, to determine predictive factors for the clinical outcome, such as the extent of resection, visual function, endocrinological function, recurrence rate, and complications. RESULTS The mean tumor size was 2.5 cm (3.1 cm for primary tumors and 1.9 cm for recurrent lesions). Gross-total resection (GTR) was achieved in 62 (91.1%) patients (48 [96.0%] patients with primary tumors and 14 [77.8%] patients with recurrent tumors). The rate of GTR was higher in the primary group than in the group with recurrence (p = 0.038). The overall pre- and postoperative visual impairment scale (VIS) scores were 40.8 and 22.1, respectively (50.9 and 14.3 in the primary group and 30.7 and 29.9 in patients with recurrence, respectively). The improvement rate in VIS score was higher in the primary group than in the recurrent group (p = 0.001). Endocrinological function was improved in 4 patients (5.9%) and deteriorated in 32 of 68 patients (47.1%). Tumor invasion into the center of the pituitary stalk affected the postoperative

  11. Endoscopic endonasal approach for the treatment of a large clival giant cell tumor complicated by an intraoperative internal carotid artery rupture

    Directory of Open Access Journals (Sweden)

    Iacoangeli M

    2013-01-01

    Full Text Available Maurizio Iacoangeli,1 Alessandro Di Rienzo,1 Massimo Re,2 Lorenzo Alvaro,1 Niccolò Nocchi,1 Maurizio Gladi,1 Maurizio De Nicola,3 Massimo Scerrati11Department of Neurosurgery, Università Politecnica delle Marche, Umberto I General Hospital, Ancona, Italy; 2Department of Ear, Nose, and Throat Surgery, Università Politecnica delle Marche, Umberto I General Hospital, Ancona, Italy; 3Department of Radiology, Interventional Radiology Section, Università Politecnica delle Marche, Umberto I General Hospital, Ancona, ItalyAbstract: Giant cell tumors (GCTs are primary bone neoplasms that rarely involve the skull base. These lesions are usually locally aggressive and require complete removal, including the surrounding apparently healthy bone, to provide the best chance of cure. GCTs, as well as other lesions located in the clivus, can nowadays be treated by a minimally invasive fully endoscopic extended endonasal approach. This approach ensures a more direct route to the craniovertebral junction than other possible approaches (transfacial, extended lateral, and posterolateral approaches. The case reported is a clival GCT operated on by an extended endonasal approach that provides another contribution on how to address one of the most feared complications attributed to this approach: a massive bleed due to an internal carotid artery injury.Keywords: clival giant cell tumor, endoscopic endonasal approach, internal carotid artery injury, minimally invasive surgery

  12. Transsphenoidal surgery assisted by a new guidance device: results of a series of 747 cases.

    Science.gov (United States)

    Tao, Yang; Jian-wen, Gu; Yong-qin, Kuang; Li-bin, Yang; Hai-dong, Huang; Wen-tao, Yang; Xue-min, Xing

    2011-10-01

    The objective of this study is to report the efficacy and safety of microsurgical transsphenoidal surgery using a frame for sella guidance in a series of patients with untreated pituitary adenoma. In this study, seven hundred and forty-seven patients undergoing transsphenoidal resection of a pituitary adenoma involving use of the frame were included. Follow-up of twelve to one hundred months was performed in all patients. During the procedures using the frame, pituitary adenomas were fully exposed, and no cavernous sinus haemorrhage due to anteroposterior displacement or internal carotid artery lesion due to right-and-left deviation occurred. The duration of the surgical procedure ranged from 28 min to 87 min with a mean of 44 min. The most frequent tumour type was prolactin-secreting adenoma (32.4%), followed by clinically non-functioning adenoma (NFPA) (28.5%), growth hormone-secreting adenoma (25.0%), and adrenocorticotropin-secreting adenoma (13.7%). Normalisation of visual defects occurred in 226 (42.2%) of the 535 patients with visual disturbances. Normalisation of hormone occurred in 458 of 551 patients with endocrine-active tumour in the follow-up period. Two patients died as a consequence of surgery. The endonasal transsphenoidal technique is a safe, quick, and effective approach to pituitary adenomas. Our guidance frame allows the surgeon to open and close the wound rapidly, which avoids trajectory deviation and shortens the duration of the surgical procedure. Copyright © 2011 Elsevier B.V. All rights reserved.

  13. Second-stage transsphenoidal approach (TSA) for highly vascular pituicytomas in children.

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    Kim, Young Gyu; Park, Young Seok

    2015-06-01

    A pituicytoma in the sellar area is extremely rare in children and, due to its highly vascularized nature, can be difficult to address using the transsphenoid approach (TSA) to surgery. Here, we report a rare case of a pituicytoma that was completely removed from a child through a staged operation using the TSA. A 13-year-old girl was admitted with a 1-year history of visual disturbance and amenorrhea. Visual field examination showed left total blindness and right temporal hemianopsia. Laboratory results revealed hormonal levels all within normal ranges. Brain magnetic resonance imaging (MRI) showed a homogeneous, highly enhancing sellar and suprasellar mass, typically suggestive of a pituitary adenoma. TSA surgery revealed the tumor had a rubbery-firm consistency, hypervascularity, and profuse bleeding. We removed the tumor partially and planned a second-stage operation. Gross total removal is the treatment of choice for this type of tumor. Attempted resection of these presumed adenomas or meningiomas using the TSA often results in unexpectedly heavy intraoperative bleeding due to the high vascularity of this rare tumor, making surgery challenging, especially in children where the tumor is within a relatively narrow corridor. While pituicytomas are a rare differential diagnosis for sellar or parasellar tumors in children, total removal by second-stage TSA surgery is indicated in the case of profuse bleeding or uncertainty of biopsy. Following first-stage TSA surgery and pathologic confirmation of pituicytoma, the strategy is typically gross total removal during second-stage TSA surgery. Although very rare in children, a pituicytoma should be included in the differential diagnosis of a mass in the sellar area if the tumor is highly enhancing or very vascular. Second-stage TSA surgery is another strategy when the pathology is not clear during the first-stage TSA surgery.

  14. Surgical Outcome of Endoscopic Endonasal Surgery for Non-Functional Pituitary Adenoma by a Team of Neurosurgeons and Otolaryngologists Adenoma by a Team of Neurosurgeons and Otolaryngologists.

    Science.gov (United States)

    Kikuchi, Ryogo; Toda, Masahiro; Tomita, Toshiki; Ogawa, Kaoru; Yoshida, Kazunari

    2017-01-01

    This study aimed to assess the efficacy of endoscopic endonasal surgery, conducted by a team of neurosurgeons and otolaryngologists. We studied 40 patients who were undergoing surgery for primary non-functional pituitary adenomas with Knosp grades 1 to 3, at Keio University Hospital between 2005 and 2012. We compared the endoscopic endonasal transsphenoidal approach (team-eTSS; T-eTSS), with a microscopic transsphenoidal approach (mTSS). Analyses were conducted for differences between the two groups in tumor resection rates, operating durations, and complications from the non-functional pituitary adenomas. We also compared the heminostril and binostril approaches for T-eTSS. Tumor resection rates were higher when the surgeries were conducted by T-eTSS than mTSS. In particular, when the maximum tumor diameter was more than 25 mm, resection rates were significantly higher for T-eTSS than for mTSS. There were no unexpected complications in either group. There was no significant difference in resection rates between the heminostril and binostril approaches when T-eTSS was performed. T-eTSS is an efficacious surgical option for non-functional pituitary adenomas, particularly when the adenoma is of large size. Benefits of the heminostril approach are evident.

  15. Endoscopic endonasal surgery for giant pituitary adenomas: advantages and limitations.

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    Koutourousiou, Maria; Gardner, Paul A; Fernandez-Miranda, Juan C; Paluzzi, Alessandro; Wang, Eric W; Snyderman, Carl H

    2013-03-01

    Giant pituitary adenomas (> 4 cm in maximum diameter) represent a significant surgical challenge. Endoscopic endonasal surgery (EES) has recently been introduced as a treatment option for these tumors. The authors present the results of EES for giant adenomas and analyze the advantages and limitations of this technique. The authors retrospectively reviewed the medical files and imaging studies of 54 patients with giant pituitary adenomas who underwent EES and studied the factors affecting surgical outcome. Preoperative visual impairment was present in 45 patients (83%) and partial or complete pituitary deficiency in 28 cases (52%), and 7 patients (13%) presented with apoplexy. Near-total resection (> 90%) was achieved in 36 patients (66.7%). Vision was improved or normalized in 36 cases (80%) and worsened in 2 cases due to apoplexy of residual tumor. Significant factors that limited the degree of resection were a multilobular configuration of the adenoma (p = 0.002) and extension to the middle fossa (p = 0.045). Cavernous sinus invasion, tumor size, and intraventricular or posterior fossa extension did not influence the surgical outcome. Complications included apoplexy of residual adenoma (3.7%), permanent diabetes insipidus (9.6%), new pituitary insufficiency (16.7%), and CSF leak (16.7%, which was reduced to 7.4% in recent years). Fourteen patients underwent radiation therapy after EES for residual mass or, in a later stage, for recurrence, and 10 with functional pituitary adenomas received medical treatment. During a mean follow-up of 37.9 months (range 1-114 months), 7 patients were reoperated on for tumor recurrence. Three patients were lost to follow-up. Endoscopic endonasal surgery provides effective initial management of giant pituitary adenomas with favorable results compared with traditional microscopic transsphenoidal and transcranial approaches.

  16. Panorama of Reconstruction of Skull Base Defects: From Traditional Open to Endonasal Endoscopic Approaches, from Free Grafts to Microvascular Flaps

    Science.gov (United States)

    Reyes, Camilo; Mason, Eric; Solares, C. Arturo

    2014-01-01

    Introduction A substantial body of literature has been devoted to the distinct characteristics and surgical options to repair the skull base. However, the skull base is an anatomically challenging location that requires a three-dimensional reconstruction approach. Furthermore, advances in endoscopic skull base surgery encompass a wide range of surgical pathology, from benign tumors to sinonasal cancer. This has resulted in the creation of wide defects that yield a new challenge in skull base reconstruction. Progress in technology and imaging has made this approach an internationally accepted method to repair these defects. Objectives Discuss historical developments and flaps available for skull base reconstruction. Data Synthesis Free grafts in skull base reconstruction are a viable option in small defects and low-flow leaks. Vascularized flaps pose a distinct advantage in large defects and high-flow leaks. When open techniques are used, free flap reconstruction techniques are often necessary to repair large entry wound defects. Conclusions Reconstruction of skull base defects requires a thorough knowledge of surgical anatomy, disease, and patient risk factors associated with high-flow cerebrospinal fluid leaks. Various reconstruction techniques are available, from free tissue grafting to vascularized flaps. Possible complications that can befall after these procedures need to be considered. Although endonasal techniques are being used with increasing frequency, open techniques are still necessary in selected cases. PMID:25992142

  17. Value of free-run electromyographic monitoring of lower cranial nerves in endoscopic endonasal approach to skull base surgeries.

    Science.gov (United States)

    Thirumala, Parthasarathy D; Mohanraj, Santhosh Kumar; Habeych, Miguel; Wichman, Kelley; Chang, Yue-Fang; Gardner, Paul; Snyderman, Carl; Crammond, Donald J; Balzer, Jeffrey

    2012-08-01

    Objective The main objective of this study was to evaluate the value of free-run electromyography (f-EMG) monitoring of cranial nerves (CNs) VII, IX, X, XI, and XII in skull base surgeries performed using endoscopic endonasal approach (EEA) to reduce iatrogenic CN deficits. Design We retrospectively identified 73 patients out of 990 patients who had EEA in our institution who had at least one CN monitored. In each CN group, we classified patients who had significant (SG) f-EMG activity as group I and those who did not as group II. Results We monitored a total of 342 CNs. A total of 62 nerves had SG f-EMG activity including CN VII = 18, CN IX = 16, CN X = 13, CN XI = 5, and CN XII = 10. No nerve deficit was found in the nerves that had significant activity during procedure. A total of five nerve deficits including (CN IX = 1, CN X = 2, CN XII = 2) were observed in the group that did not display SG f-EMG activity during surgery. Conclusions f-EMG seems highly sensitive to surgical manipulations and in locating CNs. It seems to have limited value in predicting postoperative neurological deficits. Future studies to evaluate the EMG of lower CNs during EEA procedures need to be done with both f-EMG and triggered EMG.

  18. Contemporary indications for transsphenoidal pituitary surgery.

    Science.gov (United States)

    Miller, Brandon A; Ioachimescu, Adriana G; Oyesiku, Nelson M

    2014-12-01

    To analyze current indications for transsphenoidal pituitary surgery. The current literature regarding transsphenoidal surgery for all subtypes of pituitary adenomas and other sellar lesions was examined. Alternate approaches for pituitary surgery were also reviewed. Transsphenoidal surgery continues to be the mainstay of surgical treatment for pituitary tumors, and has good outcomes in experienced hands. Pre- and postoperative management of pituitary tumors remains an important part of the treatment of patients with pituitary tumors. Even as medical and surgical treatment for pituitary tumors evolves, transsphenoidal surgery remains a mainstay of treatment. Outcomes after transshenoidal surgery have improved over time. Neurosurgeons must be aware of the indications, risks and alternatives to transsphenoidal pituitary surgery. Copyright © 2014 Elsevier Inc. All rights reserved.

  19. Endocrinological outcomes following endoscopic and microscopic transsphenoidal surgery in 113 patients with acromegaly.

    Science.gov (United States)

    Sarkar, Sauradeep; Rajaratnam, Simon; Chacko, Geeta; Chacko, Ari George

    2014-11-01

    To describe outcomes and complications in patients undergoing transsphenoidal surgery for acromegaly using the 2010 consensus criteria for biochemical remission. Retrospective review of 113 treatment naïve patients who underwent transsphenoidal surgery with the endoscopic (n=66) and the endonasal microscopic technique (n=47). Cure was defined if the age and sex-adjusted IGF-1 level was normal and either the basal GH was transsphenoidal surgery did not differ significantly overall (28.8% versus 36.2%). On univariate analysis, a preoperative GH level Transsphenoidal surgery remains the first line of treatment for patients with acromegaly, but invasive adenomas will frequently require adjuvant therapy. Copyright © 2014 Elsevier B.V. All rights reserved.

  20. Transsellar transsphenoidal encephalocele: a series of four cases.

    Science.gov (United States)

    Rathore, Yashpal S; Sinha, Sumit; Mahapatra, A K

    2011-01-01

    Transsellar transsphenoidal encephalocele is the least common type of basal encephalocele. We present a series of four cases of transsellar transsphenoidal encephalocele. Clinical findings, imaging reviews, surgical repair techniques and postoperative morbidity are discussed with the relevant literature. Non contrast CT scan head with 3D reconstruction and magnetic resonance imaging should be done in all patients of transsphenoidal encephalocele. Endocrine assessment is also essential. Repair of a transsphenoidal encephalocele should be coordinated between a team of neurosurgeons and ENT surgeon. Our surgical outcome supports the transpalatal/ transnasal approach over the transcranial approach.

  1. The Usefulness of the Endonasal Incisional Approach for the Treatment of Nasal Bone Fracture

    Directory of Open Access Journals (Sweden)

    Hyo Seong Kim

    2012-05-01

    Full Text Available Background Among all facial fractures, nasal bone fractures are the most common, andthey have been reduced by closed reduction (CR for a long time. But several authors havereported suboptimal results when using CR, and the best method of nasal bone reduction isstill being debated. We have found that indirect open reduction (IOR through an endonasalincisional approach is a useful method for more accurate reduction of the nasal bone.Methods A retrospective chart review was performed of 356 patients who underwentreduction of a nasal bone fracture in our department from January, 2006, to July, 2011.We treated 263 patients with IOR. We assessed patients’ and doctors’ satisfaction withsurgical outcomes after IOR or CR. We evaluated the frequency of nasal bleeding owing tomucosal injury, and followed the surgical outcomes of patients who had simultaneous dorsalaugmentation rhinoplasty.Results According to the analysis of the satisfaction scores, both patients and doctors weresignificantly more satisfied in the IOR group than the CR group (P<0.05. Mucosal injury withnasal bleeding occurred much less in the IOR group (5.3% than the CR group (12.9%. Dorsalaugmentation rhinoplasty with IOR was performed simultaneously in 34 cases. Most of them(31/34 showed satisfaction with the outcomes.Conclusions IOR enables surgeons to manipulate the bony fragment directly through theendonasal incisional approach. However, we propose that CR is the proper technique forpatients under 16 and for those with comminuted nasal bone fractures because submucosaldissection in IOR can damage the growth or circulation of nasal bone.

  2. Expanded Endoscopic Endonasal Resection of Retrochiasmatic Craniopharyngioma.

    Science.gov (United States)

    Davanzo, Justin R; Goyal, Neerav; Zacharia, Brad E

    2018-02-01

    This video abstract demonstrates the use of the expanded endoscopic endonasal approach for the resection of a retrochiasmatic craniopharyngioma. These tumors are notoriously difficult to treat, and many approaches have been tried to facilitate safe and effective resection. The endoscopic endonasal approach has been increasingly utilized for selected sellar/suprasellar pathology. We present the case of a 39-year-old man who was found to have a cystic, partially calcified suprasellar mass consistent with a craniopharyngioma. To facilitate robust skull base repair, a vascularized nasoseptal flap was harvested. A wide sphenoidotomy was performed and the sella and tuberculum were exposed. After the dural opening and arachnoid dissection, the stalk was identified, merging seamlessly with the tumor capsule. The lesion was then internally debulked with the use of an ultrasonic aspirator. The capsule was then dissected off of the optic chiasm, thalamus, and hypothalamus. The cavity was inspected with an angled endoscope to ensure complete resection. A multilayered reconstruction was performed using autologous fascia lata, the previously harvested nasoseptal flap, and dural sealant. Postoperatively, the patient did have expected panhypopituitarism but remained neurologically intact and had improvement in his vision. In conclusion, this video demonstrates how an expanded endonasal approach can be used to safely resect a craniopharyngioma, even when in close proximity to delicate structures such as the optic chiasm. The link to the video can be found at: https://youtu.be/tahjHmrXhc4 .

  3. Comprehensive review on endonasal endoscopic sinus surgery

    Science.gov (United States)

    Weber, Rainer K.; Hosemann, Werner

    2015-01-01

    Endonasal endoscopic sinus surgery is the standard procedure for surgery of most paranasal sinus diseases. Appropriate frame conditions provided, the respective procedures are safe and successful. These prerequisites encompass appropriate technical equipment, anatomical oriented surgical technique, proper patient selection, and individually adapted extent of surgery. The range of endonasal sinus operations has dramatically increased during the last 20 years and reaches from partial uncinectomy to pansinus surgery with extended surgery of the frontal (Draf type III), maxillary (grade 3–4, medial maxillectomy, prelacrimal approach) and sphenoid sinus. In addition there are operations outside and beyond the paranasal sinuses. The development of surgical technique is still constantly evolving. This article gives a comprehensive review on the most recent state of the art in endoscopic sinus surgery according to the literature with the following aspects: principles and fundamentals, surgical techniques, indications, outcome, postoperative care, nasal packing and stents, technical equipment. PMID:26770282

  4. Two- versus four-handed techniques for endonasal resection of orbital apex tumors.

    Science.gov (United States)

    Craig, John R; Lee, John Y K; Petrov, Dmitriy; Mehta, Sonul; Palmer, James N; Adappa, Nithin D

    2015-01-01

    Open versus endonasal resection of orbital apex (OA) tumors is generally based on tumor size, location, and pathology. For endonasal resection, two- and four-handed techniques have been reported, but whether one technique is more optimal based on these tumor features has not been evaluated. To determine whether two- versus four-handed techniques result in better outcomes after endoscopic resection of OA tumors, and whether either technique is better suited for intra- versus extraconal location and for benign versus malignant pathology. A retrospective review of all expanded endonasal approaches for OA tumors was performed at a single institution from 2009 to 2013. A PubMed database search was also performed to review series published on endonasal OA tumor resection. Across all the cases reviewed, the following data were recorded: two- versus four-handed techniques, intra- versus extraconal tumor location, and benign versus malignant pathology. The relationship between these variables and resection extent was analyzed by the Fisher exact test. Postoperative visual status and complications were also reviewed. Ten cases from the institution and 94 cases from 17 publications were reviewed. Both two- and four-handed techniques were used to resect extra- and intraconal OA tumors, for both benign and malignant pathology. Four-handed techniques included a purely endonasal approach and a combined endonasal-orbital approach. On univariate analysis, the strongest predictor of complete resection was benign pathology (p = 0.005). No significant difference was found between the extent of resection and a two- versus a four-handed technique. Visual status was improved or unchanged in 94% of cases, and other complications were rare. Benign tumors that involve the medial extraconal and posterior inferomedial intraconal OA can be treated by either two- or four-handed endonasal techniques. Selecting two- versus four-handed techniques and endonasal versus endonasal-orbital four

  5. Endoscopic Transsphenoidal Resection of Craniopharyngioma.

    Science.gov (United States)

    Liew, Kong Yew; Narayanan, Prepageran; Waran, Vicknes

    2018-02-01

    Objectives  To demonstrate, step-by-step, the technique and efficacy of endoscopic transsphenoidal approach in resection of a suprasellar craniopharyngioma. Design  The video shows a step-by-step approach to the resection, covering the exposure, access, resection, and confirmation of resection and reconstruction. Setting  The surgery was performed in the University of Malaya Medical Centre, a tertiary referral center in the capital of Malaysia. Participants  Surgery was performed jointly by Professor Prepageran from the department of otorhinolaryngology and Professor Vicknes Waran from the division of neurosurgery. Both surgeons are from the University of Malaya. Video compilation, editing, and voice narration was done by Dr. Kong Yew Liew. Main Outcome Measures  Completeness of resection and avoidance of intra- and postoperative complications. Results  Based on intraoperative views and MRI findings, the tumor was completely resected with the patient suffering only transient diabetes insipidus. Conclusion  Central suprasellar tumors can be removed completely via an endoscopic transsphenoidal approach with minimal morbidity to the patient. The link to the video can be found at: https://youtu.be/ZNIHfk12cYg .

  6. Transcranial Evacuation of Atypical Progressive Supradiaphragmatic Hematoma After Transsphenoidal Complete Resection of Pituitary Adenoma.

    Science.gov (United States)

    Metwali, Hussam; Fahlbusch, Rudolf

    2017-06-01

    Supradiaphragmatic hematoma is a type of hematoma that occurs after transsphenoidal (TS) resection of pituitary adenoma and requires special management. Two patients had symptomatic supradiaphragmatic hematomas after total TS resection of pituitary adenomas in the absence of vascular anomalies. Both patients also had hydrocephalus at the time of diagnosis of the hematoma. The initial endoscopic endonasal inspection showed no subdiaphragmatic bleeding. The hematoma was evacuated via a frontolateral approach after insertion of an external ventricular drain (EVD). The supradiaphragmatic hematoma could be clinically and radiologically distinguished. It presented early with visual deterioration without headache. The patients developed hydrocephalus, which was associated with deterioration of level of consciousness. Radiologically, the hematoma filled the suprasellar space and was associated with the extension of bleeding in the basal cisterns. Recovery was good in both patients. There were no permanent neurologic deficits. The EVD was removed in both patients. One patient required a ventriculoperitoneal shunt because of delayed hydrocephalus. Supradiaphragmatic hematoma can be clinically and radiologically distinguished from other types of hematoma occurring after TS resection of pituitary adenoma. Transcranial surgery should be performed to manage supradiaphragmatic hematoma, when symptomatic. Insertion of an EVD at the time of evacuation is mandatory to relax the brain and to alleviate the hydrocephalus. Copyright © 2017 Elsevier Inc. All rights reserved.

  7. Comparison of endoscopic endonasal and bifrontal craniotomy approaches for olfactory groove meningiomas: A matched pair analysis of outcomes and frontal lobe changes on MRI.

    Science.gov (United States)

    de Almeida, John R; Carvalho, Felipe; Vaz Guimaraes Filho, Francisco; Kiehl, Tim-Rasmus; Koutourousiou, Maria; Su, Shirley; Vescan, Allan D; Witterick, Ian J; Zadeh, Gelareh; Wang, Eric W; Fernandez-Miranda, Juan C; Gardner, Paul A; Gentili, Fred; Snyderman, Carl H

    2015-11-01

    We compare the outcomes and postoperative MRI changes of endoscopic endonasal (EEA) and bifrontal craniotomy (BFC) approaches for olfactory groove meningiomas (OGM). All patients who underwent either BFC or EEA for OGM were eligible. Matched pairs were created by matching tumor volumes of an EEA patient with a BFC patient, and matching the timing of the postoperative scans. The tumor dimensions, peritumoral edema, resectability issues, and frontal lobe changes were recorded based on preoperative and postoperative MRI. Postoperative fluid-attenuated inversion recovery (FLAIR) hyperintensity and residual cystic cavity (porencephalic cave) volume were compared using univariable and multivariable analyses. From a total of 70 patients (46 EEA, 24 BFC), 10 matched pairs (20 patients) were created. Three patients (30%) in the EEA group and two (20%) in the BFC had postoperative cerebrospinal fluid leaks (p=0.61). Gross total resections were achieved in seven (70%) of the EEA group and nine (90%) of the BFC group (p=0.26), and one patient from each group developed a recurrence. On postoperative MRI, there was no significant difference in FLAIR signal volumes between EEA and BFC approaches (6.9 versus 13.3 cm(3); p=0.17) or in porencephalic cave volumes (1.7 versus 5.0 cm(3); p=0.11) in univariable analysis. However, in a multivariable analysis, EEA was associated with less postoperative FLAIR change (p=0.02) after adjusting for the volume of preoperative edema. This study provides preliminary evidence that EEA is associated with quantifiable improvements in postoperative frontal lobe imaging. Copyright © 2015 Elsevier Ltd. All rights reserved.

  8. Oronasal complications in patients after transsphenoidal hypophyseal surgery Complicações oronasais em pacientes pós-abordagem hipofisária via transesfenoidal

    Directory of Open Access Journals (Sweden)

    Carolina Petry

    2009-06-01

    Full Text Available Transsphenoidal surgery is the most commonly used surgical procedure to handle the hypophyseal region, sometimes associated with oronasal complications. MATERIAL AND METHODS/AIM: To evaluate prospectively (specific questionnaire, clinical evaluation undiagnosed chronic oronasal complications in patients submitted to conventional transsphenoidal adenomectomy surgery, operated at different neurosurgery services more than 6 months ago. RESULTS: 49 patients were evaluated, 37/45 presented macroadenoma. 28,5% were submitted to more than one intervention, 2/5 transsphenoidally. Transsphenoidal approach 92.8% through sublabial route. No patient had spontaneous complaint. With the specific questionnaire 63.2% presented complaints. One patient presented an oronasal fistula, 1 stenosis of the nasal valve area with external nasal deformity. Rhinoscopy detected alterations in 77.5%, nasal endoscopy in 87.7%. Septal perforation was present in 10/12 patients with scabs and 2 with purulent secretion. All 4 patients submitted to 2 transsphenoidal approaches presented septal perforation and nasal synechiae. In the endonasal, synechiae (2, alteration in medium meatus (1 and stenosis of the nasal valve area (1 were observed. Only two patients presented normal evaluation. CONCLUSION: A high incidence of nasal complications after conventional transsphenoidal surgery observed through examination and not reported spontaneously point to the need of otorhinolaryngological investigation complemented by nasal endoscopy in patients submitted to procedures through this route.A cirurgia transesfenoidal é o procedimento cirúrgico mais utilizado para abordagem da região hipofisária, sendo por vezes associada a complicações oronasais. MATERIAL E MÉTODOS/OBJETIVO: Estudo prospectivo, através de questionário específico e avaliação clínica complicações oronasais crônicas não-diagnosticadas, em pacientes submetidos à cirurgia transesfenoidal convencional em

  9. [Endoscopic endonasal detection of cerebrospinal fluid leakage with topical fluorescein].

    Science.gov (United States)

    Sato, Taku; Kishida, Yugo; Watanabe, Tadashi; Tani, Akiko; Tada, Yasuhiro; Tamura, Takamitsu; Ichikawa, Masahiro; Sakuma, Jun; Omori, Koichi; Saito, Kiyoshi

    2013-08-01

    We evaluated the effectiveness of intraoperative topical application of fluorescein to detect the leakage point of cerebrospinal fluid(CSF)rhinorrhea. Three patients with CSF rhinorrhea were treated with an endoscopic endonasal technique. Ten percent fluorescein was topically used for intraoperative localization of the leak site. A change of the fluorescein color from brown to green due to dilation of CSF were recognized as evidence of CSF rhinorrhea. We repeated the procedure to detect any small defects. All CSF rhinorrheas were successfully repaired by this endoscopic endonasal approach. Topical application of fluorescein is simple and sensitive for identifying intraoperative CSF rhinorrhea.

  10. Endoscopic versus microscopic trans-sphenoidal pituitary surgery: a systematic review and meta-analysis

    NARCIS (Netherlands)

    Goudakos, J. K.; Markou, K. D.; Georgalas, C.

    2011-01-01

    Endoscopic trans-sphenoidal surgery has been increasingly replacing microscopic surgery as the state of the art trans-sphenoidal approach. To assess the efficacy and safety of pure endoscopic approach in comparison with microscopic approach in pituitary surgery. Literature review and meta-analysis.

  11. [Endonasal Dacryocystorhinostomy (DCR) with Transcanalicular Endoillumination (TCE) of the Saccus Lacrimalis].

    Science.gov (United States)

    Hefner, J; Klask, J; Gerding, H

    2016-04-01

    Endonasal dacryocystorhinostomy (DCR) has been established as a standard procedure of lacrimal surgery, since it causes much less tissue damage than ab externo procedures. Diffiulties in visualization of the target area has been a limitation to the transnasal approach. An improvement of the classical endonasal DCR was achieved by the introduction of a transcanalicular endoillumination (TCE) of the lacrimal sac using a 23-Gauge vitreoretinal light probe, which can easily be intubated into the cannaliculi and advanced into the the lacrimal sac. Illumination of the lacrimal sac guides the endonasal approach and facilitates the creation of a lacrimal bypass. In our standard procedure a bicanalicular silicone intubation through the osteotomy is finally placed. Due to the introduction of TCE of the lacrimal sac, the surgical procedure of endonasal DCR became less traumatic and needed a significantly reduced operating time. Georg Thieme Verlag KG Stuttgart · New York.

  12. Trans-sphenoidal excision of craniopharyngiomas.

    Directory of Open Access Journals (Sweden)

    Nagpal R

    1991-04-01

    Full Text Available Craniopharyngiomas have been by and large excised by the transcranial route. Since 1982, 11 patients have been operated by the traus-sphensidal route in the department. The clinical features with which they were presented, diagnostic investigations, details of surgical procedures and follow-up analysis is being presented here. A retrospective study of radiological investigation was done to determine the features that help decide the choice of surgical approach to these lesions. Only lesions that were primarily intrasellar, cystic and those that expanded the sella could be treated by the trans-sphenoidal route. Associated suprasellar extensions could also be removed. Predominantly calcified or firm, fleshy tumours lent themselves poorly to removal by the trans-sphenoidal route.

  13. Experimental assessment of energy requirements and tool tip visibility for photoacoustic-guided endonasal surgery

    Science.gov (United States)

    Lediju Bell, Muyinatu A.; Dagle, Alicia B.; Kazanzides, Peter; Boctor, Emad M.

    2016-03-01

    Endonasal transsphenoidal surgery is an effective approach for pituitary adenoma resection, yet it poses the serious risk of internal carotid artery injury. We propose to visualize these carotid arteries, which are hidden by bone, with an optical fiber attached to a surgical tool and a transcranial ultrasound probe placed on the patient's temple (i.e. intraoperative photoacoustic imaging). To investigate energy requirements for vessel visualization, experiments were conducted with a phantom containing ex vivo sheep brain, ex vivo bovine blood, and 0.5-2.5 mm thick human cadaveric skull specimens. Photoacoustic images were acquired with 1.2-9.3 mJ laser energy, and the resulting vessel contrast was measured at each energy level. The distal vessel boundary was difficult to distinguish at the chosen contrast threshold for visibility (4.5 dB), which was used to determine the minimum energies for vessel visualization. The blood vessel was successfully visualized in the presence of the 0-2.0 mm thick sphenoid and temporal bones with up to 19.2 dB contrast. The minimum energy required ranged from 1.2-5.0 mJ, 4.2-5.9 mJ, and 4.6-5.2 mJ for the 1.0 temporal and 0-1.5 mm sphenoid bones, 1.5 mm temporal and 0-0.5 mm sphenoid bones, and 2.0 mm temporal and 0-0.5 mm sphenoid bones, respectively, which corresponds to a fluence range of 4-21 mJ/cm2. These results hold promise for vessel visualization within safety limits. In a separate experiment, a mock tool tip was placed, providing satisfactory preliminary evidence that surgical tool tips can be visualized simultaneously with blood vessels.

  14. Peculiarities of the Perioperative Care of Elderly Patients Undergoing Endoscopic Transsphenoidal Removal of Tumors in the Chiasmatic-Sellar Area

    Directory of Open Access Journals (Sweden)

    Alexey B. Kurnosov

    2017-01-01

    Full Text Available Nowadays, in the age of rapid introduction of digital and fiber-optic technologies in neurosurgery, a technique for removal of tumors in the chiasmatic-sellar area via an endoscopic transsphenoidal endonasal approach is actively developed; this technique is considered less invasive and is well tolerated by patients, thus permitting to operate patients with somatic complications, as well as the elderly. Taking into account these facts, as well as world statistic data indicating a continuous trend of population aging in developed countries, including Russia, optimization of the perioperative care of elderly patients with a tumor of the chiasmatic-sellar area becomes the problem of highest priority. In order to solve it, this review discusses the basic peculiarities of the perioperative management of elderly patients (characteristics of their somatic status and possible variants of the pre-operational state with a pathology in the chiasmatic-sellar region; it also presents the modern and most acceptable alternative solutions of this difficult problem (introduction of modern methods of anesthesia, management of the postoperative cognitive dysfunction, postoperative pain syndrome, and postoperative nausea and vomiting. 

  15. Endoscopic transsphenoidal surgery for cholesterol granulomas involving the petrous apex

    NARCIS (Netherlands)

    Georgalas, C.; Kania, R.; Guichard, J.-P.; Sauvaget, E.; Tran Ba Huy, P.; Herman, P.

    2008-01-01

    Surgery for cholesterol granulomas involving the petrous apex has traditionally been performed via a lateral skull base approach. We present a case-series of four cholesterol granulomas treated through the endoscopic-transsphenoid approach over the last 10 years. Drainage was successful and

  16. Endoscopic trans-sphenoidal drainage of petrous apex cholesterol ...

    African Journals Online (AJOL)

    Cholesterol granulomas of the petrous apex are rare lesions that pose challenging surgical decisions and approaches when attempting surgical drainage. In this article we present 2 cases of successful surgical management using an endoscopic trans-sphenoidal approach and review the requirements and considerations ...

  17. CT after transsphenoidal surgery

    International Nuclear Information System (INIS)

    Tazawa, Satoru

    1991-01-01

    Two hundred and ten CT studies of 95 patients after transsphenoidal surgery were reviewed. Spheno-ethmoid opacificaiton, intrasellar hematoma and gas bubbles were noted within 2 weeks after surgery. Bone defect of the sellar floor and bone stent were seen on coronal scans in most cases. The packing material frequently disappeared on follow-up studies. Hormonal assessment of the functioning tumor, according to which the effect of treatment was evaluated, was correlated with CT findings. Because differentiation between postoperative changes and residual mass was difficult, there was no definite CT criteria to indicate residual functioning tumor except upward convexity of the diaphragma sellae on CT more than 3 months after surgery. Initial follow up CT study is recommended to be performed at about 3 months after surgery, at which time the immediate postoperative inflammatory changes have been disappeared. The incidence of recurrence was 3/47 (6%), which was shown on follow-up CT from 4 to 10 years after surgery. Therefore, subsequent CT study should be done in every year or two, taking the clinical symptoms and hormonal data into consideration. (author)

  18. CT after transsphenoidal surgery

    Energy Technology Data Exchange (ETDEWEB)

    Tazawa, Satoru [Tohoku Univ., Sendai (Japan). School of Medicine

    1991-03-01

    Two hundred and ten CT studies of 95 patients after transsphenoidal surgery were reviewed. Spheno-ethmoid opacificaiton, intrasellar hematoma and gas bubbles were noted within 2 weeks after surgery. Bone defect of the sellar floor and bone stent were seen on coronal scans in most cases. The packing material frequently disappeared on follow-up studies. Hormonal assessment of the functioning tumor, according to which the effect of treatment was evaluated, was correlated with CT findings. Because differentiation between postoperative changes and residual mass was difficult, there was no definite CT criteria to indicate residual functioning tumor except upward convexity of the diaphragma sellae on CT more than 3 months after surgery. Initial follow up CT study is recommended to be performed at about 3 months after surgery, at which time the immediate postoperative inflammatory changes have been disappeared. The incidence of recurrence was 3/47 (6%), which was shown on follow-up CT from 4 to 10 years after surgery. Therefore, subsequent CT study should be done in every year or two, taking the clinical symptoms and hormonal data into consideration. (author).

  19. Transsphenoidal hypophysectomy: postsurgical CT findings

    International Nuclear Information System (INIS)

    Dolinskas, C.A.; Simeone, F.A.

    1985-01-01

    Transsphenoidal surgery produces changes in the paranasal sinuses and sella that should be familiar to radiologists in view of frequency of this type of surgery. Some of these changes, such as soft-tissue-density debris in the sinuses, are transient. Fat and other packing material identifiable in the sinuses and sella after surgery is permanent. The procedure is associated with a variety of complications that are readily detectable by computed tomography (CT). These include bleeding, compression of parasellar structures by packing material, cerebrospinal fluid leaks, and pneumocephalus. After a transsphenoidal procedure, with or without follow-up radiation therapy, residual enhancing intrasellar and parasellar lesions may still be identified

  20. Anaesthesia for transsphenoidal surgery in a patient with extreme gigantism.

    Science.gov (United States)

    Chan, V W; Tindal, S

    1988-03-01

    The management of anaesthesia for transsphenoidal removal of a pituitary adenoma in a true pituitary giant with acromegaly is described. Problems which may be anticipated in such a patient and an approach to their management are discussed, with particular emphasis upon the need for thorough preoperative assessment of the upper airway and the provision of adequate pulmonary ventilation during anaesthesia.

  1. Efficacy of sellar opening in the pituitary adenoma resection of transsphenoidal surgery influences the degree of tumor resection.

    Science.gov (United States)

    Wang, Shousen; Qin, Yong; Xiao, Deyong; Wei, Liangfeng

    2017-07-24

    Endonasal transsphenoidal microsurgery is often adopted in the resection of pituitary adenoma, and has showed satisfactory treatment and minor injuries. It is important to accurately localize sellar floor and properly incise the bone and dura matter. Fifty-one patients with pituitary adenoma undergoing endonasal transsphenoidal microsurgery were included in the present study. To identify the scope of sellar floor opening, CT scan of the paranasal sinus and MRI scan of the pituitary gland were performed for each subject. Intraoperatively, internal carotid artery injury, leakage of cerebrospinal fluid, and tumor texture were recorded, and postoperative complications and residual tumors were identified. The relative size of sellar floor opening significantly differed among the pituitary micro-, macro- and giant adenoma groups, and between the total and partial tumor resection groups. The ratio of sellar floor opening area to maximal tumor area was significantly different between the total and partial resection groups. Logistic regression analysis revealed that the ratio of sellar floor opening area to the largest tumor area, tumor texture, tumor invasion and age were independent prognostic factors. The vertical distance between the top point of sellar floor opening and planum sphenoidale significantly differed between the patients with and without leakage of cerebrospinal fluid. These results together indicated that relatively insufficient sellar floor opening is a cause of leading to residual tumor, and the higher position of the opening and closer to the planum sphenoidale are likely to induce the occurrence of leakage of cerebrospinal fluid.

  2. Transsphenoidal surgery in Cushing disease: The challenging microadenoma (Local experience

    Directory of Open Access Journals (Sweden)

    Zakaria Wael K.

    2018-03-01

    Full Text Available Background: Cushing disease is uncommon challenging disease. The adenomas are usually small in size in most case making the disease diagnosis and management is sometimes difficult. In some cases, the tumor cannot be identified on imaging studies and in many cases the adenoma is eccentric in location adding more difficulties to the trans-sphenoid approach for excision of such tricky tumors.

  3. Abordajes transesfenoidales: primera opción para lesiones de región selar con criterio quirúrgico Transsphenoidal approaches: first option for injuries of the sellar region with surgical criterion

    Directory of Open Access Journals (Sweden)

    Omar López Arbolay

    2004-12-01

    surgical approaches used for their solution are transcranial and transsphenoidal. We analized the results of sellar surgery during the last 8 years at "Hermanos Ameijeiras" Hospital through variables such as approach, type of injury, imaging and endocrinological characteristics, postoperative evolution, mortality and complications. 273 injuries were operated on (18 transcranial and 255 transphenoidal, 222 adenomas (150 functioning and 72 nonfunctioning, 27 arachnoidoceles, 13 fistulas of cerebrospinal fluid and other 11 tumoral injuries. The nonofunctioning adenomas were 70 macroadenomas and 2 microadenomas, whereas the functioning were 84 macroadenomas and 66 microadenomas. The control was always higher in microadenomas. 53,8 % of the fistulas were resolved. In patients with empty sella, the campimetric defect improved in 69,2 % and fistula was solved in 71,4 %. The evaluation by images in the postoperative of the rest of the injuries showed that of 6 craniopharyngiomas, total exeresis was attained in 5 predominantly cystic, and partial exeresis in one. The rest of the injuries were totally resected. Operative morbidity was 18,31 % in the whole series. It was significantly lower in the transsphenoidal approaches. Mortality was only present in transcranial approaches and it accounted for 0.73. The results in this study show that the transsphenoidal approaches are useful and reliable methods to treat sellar injuries.

  4. Outcomes of revision external dacryocystorhinostomy and nasal intubation by bicanalicular silicone tubing under endonasal endoscopic guidance.

    Science.gov (United States)

    Ari, Seyhmus; Kürşat Cingü, Abdullah; Sahin, Alparslan; Gün, Ramazan; Kiniş, Vefa; Caça, Ihsan

    2012-01-01

    To evaluate the long-term treatment outcomes in patients who underwent revision of external dacryocystorhinostomy (DCR) and nasal intubation by bicanalicular silicone tubing (BSTI) under endonasal endoscopic guidance. Data from 28 patients with recurrent dacryocystitis were retrospectively reviewed. Revision external DCR and bicanalicular nasal intubation by silicone tubing under endonasal endoscopic guidance was performed in 28 eyes of 28 patients. The patients were evaluated with respect to the reason of recurrence, time to recurrence, time to revision, duration of follow-up and surgical success. Endoscopic endonasal examination detected an osteotomy-side obstruction by the excessive granulation tissue in 24 patients (86%), nasal septal deviation in three patients (10%) and nasal polyp in one patient (4%). Recurrence occurred after a mean duration of 5.3±3.7 months following the first operation. The mean time between the first DCR operation and the revision DCR was 11.5 ± 9.3 months. After a mean follow-up of 14.9±7.8 months, the rate of anatomic success alone was 85% (24/28); the rate of subjective success was 78% (22/28). Revision external DCR and bicanalicular nasal intubation by silicone tubing under endonasal endoscopic guidance can be recommended in patients with recurrent dacryocystitis as a surgical approach that achieves satisfactory objective and subjective success rates.

  5. Mechanism and surgical management of transsellar transsphenoidal encephalocele.

    Science.gov (United States)

    Yang, Zhijun; Wang, Zhenmin; Wang, Bo; Liu, Pinan

    2015-12-01

    We performed a retrospective study to assess the mechanisms and surgical strategies for transsellar transsphenoid encephalocele, a rare type of basal encephalocele. Its clinical presentations include multiple endocrine disturbances, visual deficits, cerebrospinal fluid rhinorrhea and dyspnea. However, little is known about the occurrence and optimal treatment of this disease. We retrospectively reviewed six patients who were treated in our hospital from October 2003 to September 2013; five male patients and one female, with an average age of 10 years (range: 2 - 28). We collected data on their general condition, medical history, clinical features, and outcomes. An endoscopic transsphenoidal approach was used for five patients, and one refused surgery. All patients had similar imaging findings, and their pituitary gland could not be seen on MRI. Five of the patients showed gradual disease progression. The clinical symptoms were endocrine disturbance (n=6), decreased visual acuity (n=5), dyspnea (n=3) and cerebrospinal fluid rhinorrhea (n=2). Three of the patients also had a cleft palate. Two patients suffered serious symptoms of fever, tachyarrhythmia, and electrolyte disturbance postoperatively. After a long follow-up period, the symptoms remained stable or improved in all patients postoperatively, but worsened in the patient who did not have a surgical intervention. No mortalities were recorded. This disease may result from pituitary dysplasia, and the symptoms develop as the patients grow. Surgical interventions can be helpful for symptom management, the optimal treatment being a transsphenoidal approach. Those patients with milder symptoms preoperatively have a better prognosis. Copyright © 2015 Elsevier Ltd. All rights reserved.

  6. Hemi-transseptal Approach for Pituitary Surgery: A Follow-Up Study

    Science.gov (United States)

    Fnais, Naif; Maio, Salvatore Di; Edionwe, Susan; Zeitouni, Anthony; Sirhan, Denis; Valdes, Constanza J.; Tewfik, Marc A.

    2016-01-01

    Objectives The hemi-transseptal (Hemi-T) approach was developed to overcome the potential drawbacks of the nasoseptal flap (NSF) in endoscopic endonasal transsphenoidal skull base surgery. In this study, we describe further refinements on the Hemi-T approach, and report long-term outcomes as compared with traditional methods of skull base reconstruction. Design A retrospective case-control study. Setting Montreal Neurological Institute and Jewish General Hospital, Montreal, Canada. Participants Patients who underwent endoscopic endonasal transsphenoidal approach to skull base pathology. Main Outcome Measures Operative time, CSF rhinorrhea, and postoperative nasal morbidity. Results A total of 105 patients underwent the Hemi-T approach versus 40 controls. Operative time was shorter using the Hemi-T technique (180.51 ± 56.9 vs. 202.9 ± 62 minutes; p = 0.048). The rates of nasal morbidity (septal perforation [5/102 vs. 6/37; p = 0.029] and mucosal adhesion [11/102 vs. 10/39 p = 0.027]), fascia lata harvest (21/100 vs. 18/39; p = 0.0028), and postoperative CSF leak rates (7/100 vs. 9/38; p = 0.006) were lower in the Hemi-T group. Conclusion Advantages of the Hemi-T approach over traditional exposure techniques include preservation of the nasal vascular pedicle, shorter operative time, reduced fascia lata harvest rates, and decreased nasal morbidity. PMID:28321378

  7. Advanced virtual endoscopy for endoscopic transsphenoidal pituitary surgery.

    Science.gov (United States)

    Wolfsberger, Stefan; Neubauer, André; Bühler, Katja; Wegenkittl, Rainer; Czech, Thomas; Gentzsch, Stephan; Böcher-Schwarz, Hans-Gerd; Knosp, Engelbert

    2006-11-01

    Virtual endoscopy (vE) is the navigation of a camera through a virtual anatomical space that is computationally reconstructed from radiological image data. Inside this three-dimensional space, arbitrary movements and adaptations of viewing parameters are possible. Thereby, vE can be used for noninvasive diagnostic purposes and for simulation of surgical tasks. This article describes the development of an advanced system of vE for endoscopic transsphenoidal pituitary surgery and its application to teaching, training, and in the routine clinical setting. The vE system was applied to a series of 35 patients with pituitary pathology (32 adenomas, three Rathke's cleft cysts) operated endoscopically via the transsphenoidal route at the Department of Neurosurgery of the Medical University Vienna between 2004 and 2006. The virtual endoscopic images correlated well with the intraoperative view. For the transsphenoidal approach, vE improved intraoperative orientation by depicting anatomical landmarks and variations. For planning a safe and tailored opening of the sellar floor, transparent visualization of the pituitary adenoma and the normal gland in relation to the internal carotid arteries was useful. According to our experience, vE can be a valuable tool for endoscopic transsphenoidal pituitary surgery for training purposes and preoperative planning. For the novice, it can act as a simulator for endoscopic anatomy and for training surgical tasks. For the experienced pituitary surgeon, vE can depict the individual patient's anatomy, and may, therefore, improve intraoperative orientation. By prospectively visualizing unpredictable anatomical variations, vE may increase the safety of this surgical procedure.

  8. Endovascular Management of Vascular Injury during Transsphenoidal Surgery

    OpenAIRE

    Çinar, C.; Bozkaya, H.; Parildar, M.; Oran, I.

    2013-01-01

    Vascular injury is an unusual and serious complication of transsphenoidal surgery. We aimed to define the role of angiography and endovascular treatment in patients with vascular injuries occurring during transsphenoidal surgery.

  9. [Endonasal versus trans-canalicular endoscopic dacriocystorhinostomy using diode laser. Surgical techniques and outcomes].

    Science.gov (United States)

    Piédrola Maroto, David; Franco Sánchez, Javier; Reyes Eldblom, Robin; Monje Vega, Elena; Conde Jiménez, Manuel; Ortiz Rueda, Manuel

    2008-01-01

    To evaluate the benefits and disadvantages of the endoscopic endonasal versus transcanalicular approaches using diode laser, and to compare their clinical outcomes. A total of 127 patients were operated on, 80 of them with the endonasal approach (Group I) and 47 with the transcanalicular technique (Group II). Epiphora improved completely in 67 patients in Group I (83.7 %) while the other 13 (16.2 %) continued to present the same symptoms. In Group II, a successful result was achieved in 39 patients (82.9 %) and 8 (17 %) of them had to be re-operated because of the persistence of epiphora. The surgical outcomes are similar with both laser techniques. The main advantages of using diode laser are that it does not require general anaesthesia, the lower intra- and peri-operative morbidity, the lack of nasal packing and the greater ease of performing additional interventions if it fails. The only real disadvantage of laser procedures is the high cost.

  10. Ethmoidal encephalocele associated with cerebrospinal fluid fistula: indications and results of mini-invasive transnasal approach.

    Science.gov (United States)

    Fraioli, Mario Francesco; Umana, Giuseppe Emanuele; Fiorucci, Giulia; Fraioli, Chiara

    2014-03-01

    Anterior skull base defects with encephalocele in adults are quite rare and can be a cause of spontaneous rhinoliquorrhea; however, cerebrospinal fluid (CSF) fistula can be not rarely misdiagnosed for several months or years. Five adult patients affected by ethmoidal encephalocele with CSF fistula were treated in our institute from 2006 through to 2011. Onset of clinical history was represented by rhinoliquorrhea, which was precociously recognized in only 1 patient; in the other 4, it was misdiagnosed for a period ranging from 11 months to 5 years. After clinical diagnosis of CSF fistula and after brain magnetic resonance imaging, ethmoidal encephalocele was evident in all patients; preoperative study was completed by spiral computed tomography scan, to clearly identify the skull base bone defect. All patients were operated on by transsphenoidal endonasal endoscope-assisted microsurgical approach through 1 nostril. The herniated brain was coagulated and removed, and reconstruction of cranial base was performed. Postoperative rhinoliquorrhea or other complications did not occur in any patient at short and late follow-up. All patients were discharged after a few days. Endonasal endoscope-assisted microsurgical approach was effective in exposing and repairing the ethmoidal bone defect; tridimensional vision and wide lateral and superior exposition of the operative field were possible in each patient, thanks to the use of microscope and angulated endoscope.

  11. Endoscopic endonasal double flap technique for reconstruction of large anterior skull base defects: technical note.

    Science.gov (United States)

    Dolci, Ricardo Landini Lutaif; Todeschini, Alexandre Bossi; Santos, Américo Rubens Leite Dos; Lazarini, Paulo Roberto

    2018-04-19

    One of the main concerns in endoscopic endonasal approaches to the skull base has been the high incidence and morbidity associated with cerebrospinal fluid leaks. The introduction and routine use of vascularized flaps allowed a marked decrease in this complication followed by a great expansion in the indications and techniques used in endoscopic endonasal approaches, extending to defects from huge tumours and previously inaccessible areas of the skull base. Describe the technique of performing endoscopic double flap multi-layered reconstruction of the anterior skull base without craniotomy. Step by step description of the endoscopic double flap technique (nasoseptal and pericranial vascularized flaps and fascia lata free graft) as used and illustrated in two patients with an olfactory groove meningioma who underwent an endoscopic approach. Both patients achieved a gross total resection: subsequent reconstruction of the anterior skull base was performed with the nasoseptal and pericranial flaps onlay and a fascia lata free graft inlay. Both patients showed an excellent recovery, no signs of cerebrospinal fluid leak, meningitis, flap necrosis, chronic meningeal or sinonasal inflammation or cerebral herniation having developed. This endoscopic double flap technique we have described is a viable, versatile and safe option for anterior skull base reconstructions, decreasing the incidence of complications in endoscopic endonasal approaches. Copyright © 2018 Associação Brasileira de Otorrinolaringologia e Cirurgia Cérvico-Facial. Published by Elsevier Editora Ltda. All rights reserved.

  12. [Staged transcranial and transsphenoidal surgery for giant pituitary adenomas: a retrospective study of 21 cases].

    Science.gov (United States)

    Liao, D Y; Liu, Z Y; Zhang, J; Ren, Q Q; Liu, X Y; Xu, J G

    2018-05-08

    Objective: To investigate the effect of the second-stage transcranial and transsphenoidal approach for giant pituitary tumors. Methods: A retrospective review of 21 patients, who had undergone the transcranial surgery and then transsphenoidal surgery for giant pituitary adenomas from 2012 to 2015 in the neurosurgery department of West China Hospital, was performed. Visual findings, endocrine presentation, complications, and tumor types were collected. All data were based on clinical feature, MRI, and follow-up. Results: Among the 21 cases, gross total resection of tumor was achieved in 7 of all patients, subtotal in 11, and partial in 3. No intracranial hemorrhage or death occurred postoperatively. Postoperative infectionoccurred in one patient and cerebrospinal fluid leakage occurred in 3 patients. Four patients recovered after treatment. Conclusion: According to the clinical feature and MRI, it is safe and effective to choose the transcranial surgery and then transsphenoidal surgery for specific giant pituitary adenomas, which can improve treatment effects and reduce postoperative complications.

  13. Cerebrospinal fluid rhinorrhoea following transsphenoidal surgery for pituitary adenoma: experience in a Chinese centre.

    Science.gov (United States)

    Zhang, C; Ding, X; Lu, Y; Hu, L; Hu, G

    2017-08-01

    The aim of this study was to elucidate the risk factors for cerebrospinal fluid (CSF) rhinorrhoea following transsphenoidal surgery and discuss its prevention and treatments. We retrospectively reviewed 474 consecutive cases of pituitary adenoma treated with 485 transsphenoidal surgical procedures from January 2008 to December 2011 in our department. We analysed the incidence of intra- and post-operative CSF leakage and outcomes of various repair strategies. Intra-operative CSF leakage was encountered in 85 cases (17.9%), and post-operative CSF rhinorrhoea in 13 cases (2.7%). Seven of the 13 patients with post-operative CSF rhinorrhoea did not experience intra-operative CSF leakage; three of these patients had adrenocorticotropic hormone-secreting adenomas. Of the remaining 6 patients with both intra- and post-operative CSF leakage, 2 were treated for giant invasive prolactinomas, and 2 had previously undergone transsphenoidal surgery. In eight patients, the leak was resolved by lumbar puncture, lumbar external drainage, resting in a semi-reclining position, or other conservative treatment. Two CSF leaks were repaired with gelatine foam and fibrin glue using a transsphenoidal approach, and two with autologous fat graft and sellar floor reconstruction using a transnasal endoscopic approach. After undergoing two transnasal endoscopic repairs, one patient with post-operative CSF rhinorrhoea was successfully treated by further lumbar subarachnoid drainage. In conclusion, procedures using gelatine foam, fibrin glue and autologous fat graft are common and effective techniques for the management of CSF rhinorrhoea after transsphenoidal surgery. When a CSF leak is detected during transsphenoidal surgery, thorough sellar reconstruction and long-term follow-up are necessary. © Copyright by Società Italiana di Otorinolaringologia e Chirurgia Cervico-Facciale, Rome, Italy.

  14. [Neurophysiological identification of the cranial nerves in endoscopic endonasal surgery of skull base tumors].

    Science.gov (United States)

    Shkarubo, A N; Ogurtsova, A A; Moshchev, D A; Lubnin, A Yu; Andreev, D N; Koval', K V; Chernov, I V

    2016-01-01

    Intraoperative identification of the cranial nerves is a useful technique in removal of skull base tumors through the endoscopic endonasal approach. Searching through the scientific literature found one pilot study on the use of triggered electromyography (t-EMG) for identification of the VIth nerve in endonasal endoscopic surgery of skull base tumors (D. San-Juan, et al, 2014). The study objective was to prevent iatrogenic injuries to the cranial nerves without reducing the completeness of tumor tissue resection. In 2014, 5 patients were operated on using the endoscopic endonasal approach. Surgeries were performed for large skull base chordomas (2 cases) and trigeminal nerve neurinomas located in the cavernous sinus (3). Intraoperatively, identification of the cranial nerves was performed by triggered electromyography using a bipolar electrode (except 1 case of chordoma where a monopolar electrode was used). Evaluation of the functional activity of the cranial nerves was carried out both preoperatively and postoperatively. Tumor resection was total in 4 out of 5 cases and subtotal (chordoma) in 1 case. Intraoperatively, the IIIrd (2 patients), Vth (2), and VIth (4) cranial nerves were identified. No deterioration in the function of the intraoperatively identified nerves was observed in the postoperative period. In one case, no responses from the VIth nerve on the right (in the cavernous sinus region) were intraoperatively obtained, and deep paresis (up to plegia) of the nerve-innervated muscles developed in the postoperative period. The nerve function was not impaired before surgery. The t-EMG technique is promising and requires further research.

  15. Risk factors for meningitis after transsphenoidal surgery

    NARCIS (Netherlands)

    van Aken, M. O.; de Marie, S.; van der Lely, A. J.; Singh, R.; van den Berge, J. H.; Poublon, R. M.; Fokkens, W. J.; Lamberts, S. W.; de Herder, W. W.

    1997-01-01

    To evaluate possible risk factors for meningitis, we retrospectively reviewed 228 transsphenoidal operations (in which a standard regimen of amoxicillin prophylaxis was used) for sellar pathology. The incidence of meningitis was 3.1% (seven of 228 cases). Cultures of preoperative specimens from the

  16. Pituitary abscess following transsphenoidal surgery: the experience of 12 cases from a single institution.

    Science.gov (United States)

    Wang, Lei; Yao, Yong; Feng, Feng; Deng, Kan; Lian, Wei; Li, Guilin; Wang, Renzhi; Xing, Bing

    2014-09-01

    To explore possible reasons for the incidence of a pituitary abscess following transsphenoidal surgery and determine the most effective treatment. A series of 12 patients who had undergone transsphenoidal surgery in other hospitals before being treated at Peking Union Medical College Hospital were reviewed. The presence of a pituitary abscess was confirmed when pus was intraoperatively observed within the sella turcica. All patients were treated with debridement of the abscess, nine among whom through a transsphenoidal approach and the other three via a craniotomy, followed by antibiotic treatment and hormone replacement therapy. The mean follow-up time was 27.0 months (range from 3.0 to 79.0 months). Headache (92%), panhypopituitarism (58%) and visual disturbance (50%) were the most common clinical indicators of a pituitary abscess. Imaging tests demonstrated a pituitary mass in all patients, with seven (58%) manifested with typical magnetic resonance features of an abscess. Ten patients (83%) were correctly diagnosed preoperatively. During surgical exploration, six presented with severe inflammation or an abscess within the sphenoidal sinus. Causative organisms were identified in five patients (42%). After surgical and antibiotic therapies, all patients fully recovered except for two presenting with severe visual impairment. Six patients (50%) required hormone replacement therapy. Retrograde infection from the sphenoid sinus may be a vital mechanism underlying the formation of a pituitary abscess following transsphenoidal surgery. Debridement of the abscess through surgical approaches combined with antibiotic treatment has been found to yield positive outcomes. Copyright © 2014 Elsevier B.V. All rights reserved.

  17. Repeated transsphenoidal surgery or gamma knife radiosurgery in recurrent cushing disease after transsphenoidal surgery.

    Science.gov (United States)

    Bodaghabadi, Mohammad; Riazi, Hooman; Aran, Shima; Bitaraf, Mohammad Ali; Alikhani, Mazdak; Alahverdi, Mahmud; Mohamadi, Masoumeh; Shalileh, Keivan; Azar, Maziar

    2014-03-01

    This study compared Gamma knife radiosurgery (GKRS) and repeated transsphenoidal adenomectomy (TSA) to find the best approach for recurrence of Cushing disease (CD) after unsuccessful first TSA. Fifty-two patients with relapse of CD after TSA were enrolled and randomly underwent a second surgery or GKRS as the next therapeutic approach. They were followed for a mean period of 3.05 ± 0.8 years by physical examination and hormone measurement as well as magnetic resonance imaging. No significant difference was observed in sex ratio, mean age, adenoma type, follow-up duration, and initial hormone level between the two groups. No significant relationship was found between preoperative 24-hour free urine cortisol and disease-free months or tumor volume among both groups. Our statistical analysis showed higher recurrence-free interval in the GKRS group compared with TSA group. With longer recurrence-free interval, GKRS could be considered a good treatment alternative to repeated TSA in recurrent CD. Georg Thieme Verlag KG Stuttgart · New York.

  18. Predictors of sinonasal quality of life and nasal morbidity after fully endoscopic transsphenoidal surgery.

    Science.gov (United States)

    Little, Andrew S; Kelly, Daniel; Milligan, John; Griffiths, Chester; Prevedello, Daniel M; Carrau, Ricardo L; Rosseau, Gail; Barkhoudarian, Garni; Otto, Bradley A; Jahnke, Heidi; Chaloner, Charlene; Jelinek, Kathryn L; Chapple, Kristina; White, William L

    2015-06-01

    Despite the increasing application of endoscopic transsphenoidal surgery for pituitary lesions, the prognostic factors that are associated with sinonasal quality of life (QOL) and nasal morbidity are not well understood. The authors examine the predictors of sinonasal QOL and nasal morbidity in patients undergoing fully endoscopic transsphenoidal surgery. An exploratory post hoc analysis was conducted of patients who underwent endoscopic pituitary surgery and were enrolled in a prospective multicenter QOL study. End points of the study included patient-reported sinonasal QOL and objective nasal endoscopy findings. Multivariate models were developed to determine the patient and surgical factors that correlated with QOL at 2 weeks through 6 months after surgery. This study is a retrospective review of a subgroup of patients studied in the clinical trial "Rhinological Outcomes in Endonasal Pituitary Surgery" (clinical trial no. NCT01504399, clinicaltrials.gov ). Data from 100 patients who underwent fully endoscopic transsphenoidal surgery were included. Predictors of a lower postoperative sinonasal QOL at 2 weeks were use of nasal splints (p = 0.039) and female sex at the trend level (p = 0.061); at 3 months, predictors of lower QOL were the presence of sinusitis (p = 0.025), advancing age (p = 0.044), and use of absorbable nasal packing (p = 0.014). Health status (multidimensional QOL) was also predictive at 2 weeks (p = 0.001) and 3 months (p surgery. The mean time (± SEM) to absence of nasal crusting was 16.3 ± 2.1 weeks, mucopurulence was 6.2 ± 1.1 weeks, and synechia was 4.4 ± 0.5 weeks. Use of absorbable nasal packing was associated with more severe mucopurulence. Sinonasal QOL following endoscopic pituitary surgery reaches a nadir at 2 weeks and recovers by 3 months postoperatively. Use of absorbable packing and nasal splints, while used in a minority of patients, negatively correlates with early sinonasal QOL. Sinonasal QOL and overall health status are

  19. Nasal symptoms following endoscopic transsphenoidal pituitary surgery: assessment using the General Nasal Patient Inventory.

    Science.gov (United States)

    Wang, Yi Yuen; Srirathan, Vinothan; Tirr, Erica; Kearney, Tara; Gnanalingham, Kanna K

    2011-04-01

    The endoscopic approach for pituitary tumors is a recent innovation and is said to reduce the nasal trauma associated with transnasal transsphenoidal surgery. The authors assessed the temporal changes in the rhinological symptoms following endoscopic transsphenoidal surgery for pituitary lesions, using the General Nasal Patient Inventory (GNPI). The GNPI was administered to 88 consecutive patients undergoing endoscopic transsphenoidal surgery at 3 time points (presurgery, 3-6 months postsurgery, and at final follow-up). The total GNPI score and the scores for the individual GNPI questions were calculated and differences between groups were assessed once before surgery, several months after surgery, and at final follow-up. Of a maximum possible score of 135, the mean GNPI score at 3-6 months postsurgery was only 12.9 ± 12 and was not significantly different from the preoperative score (10.4 ± 13) or final follow-up score (10.3 ± 10). Patients with functioning tumors had higher GNPI scores than those with nonfunctioning tumors for each of these time points (p surgery, with partial recovery (nasal sores and bleeding) or complete recovery (nasal blockage, painful sinuses, and unpleasant nasal smell) by final follow-up (p transsphenoidal surgery is a well-tolerated minimally invasive procedure for pituitary fossa lesions. Overall patient-assessed nasal symptoms do not change, but some individual symptoms may show a mild worsening or overall improvement.

  20. Intraoperative Magnetic Resonance Imaging During Endoscopic Transsphenoidal Surgery of Growth Hormone-Secreting Pituitary Adenomas.

    Science.gov (United States)

    Netuka, David; Májovský, Martin; Masopust, Václav; Belšán, Tomáš; Marek, Josef; Kršek, Michal; Hána, Václav; Ježková, Jana; Hána, Václav; Beneš, Vladimír

    2016-07-01

    The effect of intraoperative magnetic resonance imaging (iMRI) on the extent of sellar region tumors treated endonasally has been described in previous research. However, the effects of iMRI on endocrinologic outcome of growth hormone-secreting adenomas have been studied in only a few small cohort studies. Inclusion criteria were primary transsphenoidal surgery for growth hormone-secreting adenoma from January 2009 to December 2014, a minimum follow-up of 1 year, complete endocrinologic data, at least 1 iMRI, and at least 2 postoperative magnetic resonance images. The cohort consisted of 105 patients (54 females, 51 males) with a mean age of 48.3 years (range, 7-77 years). There were 16 microadenomas and 89 macroadenomas. Endocrinologic remission in the whole cohort was achieved in 64 of the patients (60.9%). Resection after iMRI was attempted in 22 of the cases (20.9%). Resection after iMRI led to hormonal remission in 9 cases (8.6%). Endocrinologic postoperative deficit was observed in 10 cases (12.5%). Postoperative cerebrospinal fluid leakage indicated the necessity to reoperate in 3 cases (3.8%). No neurologic deterioration was observed. iMRI influences not only the morphologic extent of pituitary adenomas resection but also the endocrinologic results. We encourage the routine application of iMRI in pituitary adenoma surgery, including hormone-secreting pituitary tumors. Copyright © 2016 Elsevier Inc. All rights reserved.

  1. Transsellar transsphenoidal encephalocele: A series of four cases

    OpenAIRE

    Yashpal S Rathore; Sumit Sinha; A K Mahapatra

    2011-01-01

    Transsellar transsphenoidal encephalocele is the least common type of basal encephalocele. We present a series of four cases of transsellar transsphenoidal encephalocele. Clinical findings, imaging reviews, surgical repair techniques and postoperative morbidity are discussed with the relevant literature. Non contrast CT scan head with 3D reconstruction and magnetic resonance imaging should be done in all patients of transsphenoidal encephalocele. Endocrine assessment is also essential. Repair...

  2. Outcome of Endoscopic Transsphenoidal Surgery for Acromegaly.

    Science.gov (United States)

    Kim, Jung Hee; Hur, Kyu Yeon; Lee, Jung Hyun; Lee, Ji Hyun; Se, Young-Bem; Kim, Hey In; Lee, Seung Hoon; Nam, Do-Hyun; Kim, Seong Yeon; Kim, Kwang-Won; Kong, Doo-Sik; Kim, Yong Hwy

    2017-08-01

    Endoscopic transsphenoidal surgery has recently been introduced in pituitary surgery. We investigated outcomes and complications of endoscopic surgery in 2 referral centers in Korea. We enrolled 134 patients with acromegaly (microadenomas, n = 15; macroadenomas, n = 119) who underwent endoscopic transsphenoidal surgery at Seoul National University Hospital (n = 74) and Samsung Medical Center (n = 60) between January 2009 and March 2016. Remission was defined as having a normal insulin-like growth factor-1 and a suppressed growth hormone (GH) surgery, normal pituitary function was maintained in 34 patients (25.4%). Sixty-four patients (47.7%) presented complete (n = 59, 44.0%) or incomplete (n = 5, 3.7%) recovery of pituitary function. Hypopituitarism persisted in 20 patients (14.9%) and worsened in 16 patients (11.9%). Postoperatively, transient diabetes insipidus was reported in 52 patients (38.8%) but only persisted in 2 patients (1.5%). Other postoperative complications were epistaxis (n = 2), cerebral fluid leakage (n = 4), infection (n = 1), and intracerebral hemorrhage (n = 1). Endoscopic transsphenoidal surgery for acromegaly presented high remission rates and a low incidence of endocrine deficits and complications. Regardless of surgical techniques, invasive pituitary tumors were associated with poor outcome. Copyright © 2017 Elsevier Inc. All rights reserved.

  3. Combined endoscopic approach in the management of suprasellar craniopharyngioma.

    Science.gov (United States)

    Deopujari, Chandrashekhar E; Karmarkar, Vikram S; Shah, Nishit; Vashu, Ravindran; Patil, Rahul; Mohanty, Chandan; Shaikh, Salman

    2018-05-01

    Craniopharyngiomas are dysontogenic tumors with benign histology but aggressive behavior. The surgical challenges posed by the tumor are well recognized. Neuroendoscopy has recently contributed to its surgical management. This study focuses on our experience in managing craniopharyngiomas in recent years, highlighting the role of combined endoscopic trans-ventricular and endonasal approach. Ninety-two patients have been treated for craniopharyngioma from 2000 to 2016 by the senior author. A total of 125 procedures, microsurgical (58) and endoscopic (67), were undertaken. Combined endoscopic approach was carried out in 18 of these patients, 16 children and 2 young adults. All of these patients presented with a large cystic suprasellar mass associated with hydrocephalus. In the first instance, they were treated with a transventricular endoscopic procedure to decompress the cystic component. This was followed by an endonasal transsphenoidal procedure for excision within the next 2 to 6 days. All these patients improved after the initial cyst decompression with relief of hydrocephalus while awaiting remaining tumor removal in a more elective setting. Gross total resection could be done in 84% of these patients. Diabetes insipidus was the most common postsurgical complication seen in 61% patients in the immediate period but was persistent in only two patients at 1-year follow-up. None of the children in this group developed morbid obesity. There was one case of CSF leak requiring repair after initial surgery. Peri-operative mortality was seen in one patient secondary to ventriculitis. The patients who benefit most from the combined approach are those who present with raised intracranial pressure secondary to a large tumor with cyst causing hydrocephalus. Intraventricular endoscopic cyst drainage allows resolution of hydrocephalus with restoration of normal intracranial pressure, gives time for proper preoperative work up, and has reduced incidence of CSF leak after

  4. Endoscopic endonasal pituitary adenomas surgery: the surgical experience of 178 consecutive patients and learning curve of two neurosurgeons.

    Science.gov (United States)

    Shou, Xuefei; Shen, Ming; Zhang, Qilin; Zhang, Yichao; He, Wenqiang; Ma, Zengyi; Zhao, Yao; Li, Shiqi; Wang, Yongfei

    2016-11-30

    We aim to study surgical technique and analyze the related factors affecting tumor total removal and postoperative endocrinological remission for endoscopic endonasal pituitary adenomas surgery. We retrospectively analyzed 178 endoscopic endonasal pituitary adenomas surgery from March 2011 to May 2014. Endonasal approach included the routine transnasal-sphenoidal approach, transnasal- maxillary sinus approach in four cases and transnasal-clivus approach in one case. According to postoperative imaging data and endocrine examination results, total removal was achieved in 129 patients (72.5%), and endocrinological remission was achieved in 38 patients with functional adenomas (44.1%). Statistical analysis of the clinical data showed that total removal rate was much closely related to tumor volume (P = 0.006), and tumor invasiveness (P < 0.001). In this study, we found tumor sizes and invasion of cavernous sinus were related to total removal rate and endocrinological remission rate; the direction and degree of tumor invasion, and the surgeon's experience were the key influence factors of the endocrinological remission rate for invasive functional pituitary adenomas.

  5. Transient nerve damage following intubation for trans-sphenoidal hypophysectomy

    NARCIS (Netherlands)

    Evers, KA; Eindhoven, GB; Wierda, JMKH

    1999-01-01

    Purpose: To describe a case of transient lingual and hypoglossal nerve damage following intubation for a transsphenoidal hypophysectomy. Clinical features: A 56-yr-old acromegalic man was scheduled for trans-sphenoidal hypophysectomy. He had been treated with octreotide six months previously which

  6. Extended endoscopic endonasal surgery using three-dimensional endoscopy in the intra-operative MRI suite for supra-diaphragmatic ectopic pituitary adenoma.

    Science.gov (United States)

    Fuminari, Komatsu; Hideki, Atsumi; Manabu, Osakabe; Mitsunori, Matsumae

    2015-01-01

    We describe a supra-diaphragmatic ectopic pituitary adenoma that was safely removed using the extended endoscopic endonasal approach, and discuss the value of three-dimensional (3D) endoscopy and intra-operative magnetic resonance imaging (MRI) to this type of procedure. A 61-year-old-man with bitemporal hemianopsia was referred to our hospital, where MRI revealed an enhanced suprasellar tumor compressing the optic chiasma. The tumor extended on the planum sphenoidale and partially encased the right internal carotid artery. An endocrinological assessment indicated normal pituitary function. The extended endoscopic endonasal approach was taken using a 3D endoscope in the intraoperative MRI suite. The tumor was located above the diaphragma sellae and separated from the normal pituitary gland. The pathological findings indicated non-functioning pituitary adenoma and thus the tumor was diagnosed as a supra-diaphragmatic ectopic pituitary adenoma. Intra-operative MRI provided useful information to minimize dural opening and the supra-diaphragmatic ectopic pituitary adenoma was removed from the complex neurovascular structure via the extended endoscopic endonasal approach under 3D endoscopic guidance in the intra-operative suite. Safe and effective removal of a supra-diaphragmatic ectopic pituitary adenoma was accomplished via the extended endoscopic endonasal approach with visual information provided by 3D endoscopy and intra-operative MRI.

  7. Non-endoscopic Mechanical Endonasal Dacryocystorhinostomy

    Directory of Open Access Journals (Sweden)

    Mohammad Etezad Razavi

    2011-01-01

    Full Text Available To circumvent the disadvantages of endoscopic dacryocystorhinostomy such as small rhinostomy size, high failure rate and expensive equipment, we hereby introduce a modified technique of non-endoscopic mechanical endonasal dacryocystorhinostomy (NE-MEDCR. Surgery is performed under general anesthesia with local decongestion of the nasal mucosa. A 20-gauge vitrectomy light probe is introduced through the upper canaliculus until it touches the bony medial wall of the lacrimal sac. While directly viewing the transilluminated target area, a nasal speculum with a fiber optic light carrier is inserted. An incision is made vertically or in a curvilinear fashion on the nasal mucosa in the lacrimal sac down to the bone using a Freer periosteum elevator. Approximately 1 to 1.5 cm of nasal mucosa is removed with Blakesley forceps. Using a lacrimal punch, the thick bone of the frontal process of the maxilla is removed and the inferior half of the sac is uncovered. The lacrimal sac is tented into the surgical site with the light probe and its medial wall is incised using a 3.2 mm keratome and then excised using the Blakesley forceps. The procedure is completed by silicone intubation. The NE-MEDCR technique does not require expensive instrumentation and is feasible in any standard ophthalmic surgical setting.

  8. Outcome of endoscopy-assisted microscopic extended transsphenoidal surgery for suprasellar craniopharyngiomas

    Directory of Open Access Journals (Sweden)

    Hidetoshi eIkeda

    2012-02-01

    Full Text Available Objectives. Craniopharyngiomas are difficult to treat. The extended transsphenoidal approach has recently been described in several small series. We describe the usefulness of microscopy-assisted angled endoscopy for visualizing vital structures such as tumor attachment or tumor invasion to the pituitary stalk to achieve confident radical tumor removal.Design and Participants. Between 2006 and 2010, 15 patients underwent the microscopy-assisted extended transsphenoidal approach for resection of entirely suprasellar craniopharyngiomas. 14 patients had the transinfundibular type, and one had the transinfundibular type with the extension to third ventricle. We observed color change within the pituitary stalk by endoscopy. The pituitary stalk was cut intentionally in ten patients, because of suspected tumor invasion surrounding the stalk. Main Outcome Measures and Results. Total removal was accomplished in nine patients. Pathological specimens from the pituitary stalk showed tumor invasion spreading over the surface of the pituitary stalk, shown by a discolored pituitary stalk, and this was essential for confident radical tumor removal. Even after stalk resection, postoperative DI was minimal when a bright signal on T1 in the posterior lobe was not confirmed on preoperative magnetic resonance imaging. Conclusion. Confident radical tumor removal is possible with the introduction of the endoscopy-assisted microscopic extended transsphenoidal approach.

  9. Transient Exacerbation of Nasal Symptoms following Endoscopic Transsphenoidal Surgery for Pituitary Tumors: A Prospective Study.

    Science.gov (United States)

    Davies, Benjamin M; Tirr, Erica; Wang, Yi Yuen; Gnanalingham, Kanna K

    2017-06-01

    Object  Endoscopic transsphenoidal surgery is the commonest approach to pituitary tumors. One disadvantage of this approach is the development of early postoperative nasal symptoms. Our aim was to clarify the peak onset of these symptoms and their temporal evolution. Methods  The General Nasal Patient Inventory (GNPI) was administered to 56 patients undergoing endoscopic transsphenoidal surgery for pituitary tumors preoperatively and at 1 day, 3 days, 2 weeks, 3 months, and 6 to 12 months postoperatively. Most patients underwent surgery for pituitary adenomas ( N  = 49; 88%) and through a uninostril approach ( N  = 55; 98%). Total GNPI (0-135) and scores for the 45 individual components were compared. Results  GNPI scores peaked at 1 to 3 days postoperatively, with rapid reduction to baseline by 2 weeks and below baseline by 6 to 12 months postsurgery ( p  surgery ( p  transsphenoidal pituitary surgery is common, but transient, more so in the functioning subgroup. Nasal symptoms improve below baseline by 6 to 12 months, without the need for specific long-term postoperative interventions in the vast majority of patients.

  10. Sellar Floor Reconstruction with the Medpor Implant Versus Autologous Bone After Transnasal Transsphenoidal Surgery: Outcome in 200 Consecutive Patients.

    Science.gov (United States)

    Liebelt, Brandon D; Huang, Meng; Baskin, David S

    2015-08-01

    The Medpor porous polyethylene implant provides benefits to perform sellar floor reconstruction when indicated. This material has been used for cranioplasty and reconstruction of skull base defects and facial fractures. We present the most extensive use of this implant for sellar floor reconstruction and document the safety and benefits provided by this unique implant. The medical charts for 200 consecutive patients undergoing endonasal transsphenoidal surgery from April 2008 through December 2011 were reviewed. Material used for sellar floor reconstruction, pathologic diagnosis, immediate inpatient complications, and long-term complications were documented and analyzed. Outpatient follow-up was documented for a minimum of 1-year duration, extending in some patients up to 5 years. Of the 200 consecutive patients, 136 received sellar floor cranioplasty using the Medpor implant. Postoperative complications included 6 complaints of sinus irritation or drainage, 1 postoperative cerebrospinal fluid leak requiring operative re-exploration, 1 event of tension pneumocephalus requiring operative decompression, 1 case of aseptic meningitis, 1 subdural hematoma, and 1 case of epistaxis. The incidence of these complications did not differ from the autologous nasal bone group in a statistically significant manner. Sellar floor reconstruction remains an important part of transsphenoidal surgery to prevent postoperative complications. Various autologous and synthetic options are available to reconstruct the sellar floor, and the Medpor implant is a safe and effective option. The complication rate after surgery is equivalent to or less frequent than other methods of reconstruction and the implant is readily incorporated into host tissue after implantation, minimizing infectious risk. Copyright © 2015 Elsevier Inc. All rights reserved.

  11. Neurophysiological Identification of Cranial Nerves During Endoscopic Endonasal Surgery of Skull Base Tumors: Pilot Study Technical Report.

    Science.gov (United States)

    Shkarubo, Alexey Nikolaevich; Chernov, Ilia Valerievich; Ogurtsova, Anna Anatolievna; Moshchev, Dmitry Aleksandrovich; Lubnin, Andrew Jurievich; Andreev, Dmitry Nicolaevich; Koval, Konstantin Vladimirovich

    2017-02-01

    Intraoperative identification of cranial nerves is crucial for safe surgery of skull base tumors. Currently, only a small number of published papers describe the technique of trigger electromyography (t-EMG) in endoscopic endonasal removal of such tumors. To assess the effectiveness of t-EMG in preventing intraoperative cranial nerve damage in endoscopic endonasal surgery of skull base tumors. Nine patients were operated on using the endoscopic endonasal approach within a 1-year period. The tumors included large skull base chordomas and trigeminal neurinomas localized in the cavernous sinus. During the surgical process, cranial nerve identification was carried out using monopolar and bipolar t-EMG methods. Assessment of cranial nerve functional activity was conducted both before and after tumor removal. We mapped 17 nerves in 9 patients. Third, fifth, and sixth cranial nerves were identified intraoperatively. There were no cases of postoperative functional impairment of the mapped cranial nerves. In one case we were unable to get an intraoperative response from the fourth cranial nerve and observed its postoperative transient plegia (the function was normal before surgery). t-EMG allows surgeons to control the safety of cranial nerves both during and after skull base tumor removal. Copyright © 2016 Elsevier Inc. All rights reserved.

  12. Large Intracranial Aneurysm after Transsphenoidal Surgery for Pituitary Macroadenoma

    OpenAIRE

    Yoon, Kyeong-Wook; Cho, Chun-Sung; Lee, Sang-Koo

    2014-01-01

    Uncontrolled cerebrospinal fluid (CSF) leakage after transsphenoidal surgery (TSS) for pituitary adenoma can lead to meningitis. Intracranial mycotic pseudoaneurysm is a rare complication in central nervous system infection. Large single pseudoaneurysm is more uncommon. Most mycotic aneurysms occur due to endocarditis. The present patient had no heart problem and was infected by CSF leakage after transsphenoidal surgery. We present a case of large ruptured mycotic pseudoaneurysm as a complica...

  13. Primary Endoscopic Transnasal Transsphenoidal Surgery for Giant Pituitary Adenoma.

    Science.gov (United States)

    Kuo, Chao-Hung; Yen, Yu-Shu; Wu, Jau-Ching; Chang, Peng-Yuan; Chang, Hsuan-Kan; Tu, Tsung-Hsi; Huang, Wen-Cheng; Cheng, Henrich

    2016-07-01

    Giant pituitary adenoma (>4 cm) remains challenging because the optimal surgical approach is uncertain. Consecutive patients with giant pituitary adenoma who underwent endoscopic transnasal transsphenoidal surgery (ETTS) as the first and primary treatment were retrospectively reviewed. Inclusion criteria were tumor diameter ≥4 cm in at least 1 direction, and tumor volume ≥10 cm(3). Exclusion criteria were follow-ups surgery. Residual and recurrent tumors (n = 30) were managed with 1 of the following: Gamma Knife radiosurgery (GKRS), reoperation (redo ETTS), both GKRS and ETTS, medication, conventional radiotherapy, or none. At last follow-up, most of the patients had favorable outcomes, including 8 (21.1%) who were cured and 29 (76.3%) who had a stable residual condition without progression. Only 1 (2.6%) had late recurrence at 66 months after GKRS. The overall progression-free rate was 97.4%, with few complications. In this series of giant pituitary adenoma, primary (ie, the first) ETTS yielded complete resection and cure in 21.1%. Along with adjuvant therapies, including GKRS, most patients (97.4%) were stable and free of disease progression. Therefore, primary ETTS appeared to be an effective surgical approach for giant pituitary adenoma. Copyright © 2016 Elsevier Inc. All rights reserved.

  14. Extended Endoscopic Endonasal Resection of a Suprasellar and Third Ventricular Retrochiasmatic Craniopharyngioma with a Narrow Pituitary Gland-Optic Chiasm Interval: Techniques to Optimize Resection.

    Science.gov (United States)

    Kenning, Tyler J; Pinheiro-Neto, Carlos D

    2018-04-01

    The extended endoscopic endonasal approach can be utilized to surgically treat pathology within the suprasellar space. This relies on a sufficient corridor and interval between the superior aspect of the pituitary gland and the optic chiasm. Tumors located in the retrochiasmatic space and within the third ventricle, however, may not have a widened interval through which to work. With mass effect on the superior and posterior aspect of the optic chiasm, the corridor between the chiasm and the pituitary gland might even be further narrowed. This may negate the possibility of utilizing the endoscopic endonasal approach for the management of pathology in this location. We present a case of a retrochiasmatic craniopharyngioma with a narrow resection corridor that was treated with the extended endoscopic approach and we review techniques to potentially overcome this limitation. The link to the video can be found at: https://youtu.be/ogRZj-aBqeQ .

  15. Clival chordomas: considerations after 16 years of endoscopic endonasal surgery.

    Science.gov (United States)

    Zoli, Matteo; Milanese, Laura; Bonfatti, Rocco; Faustini-Fustini, Marco; Marucci, Gianluca; Tallini, Giovanni; Zenesini, Corrado; Sturiale, Carmelo; Frank, Giorgio; Pasquini, Ernesto; Mazzatenta, Diego

    2018-02-01

    OBJECTIVE In the past decade, the role of the endoscopic endonasal approach (EEA) has relevantly evolved for skull base tumors. In this study, the authors review their surgical experience with using an EEA in the treatment of clival chordomas, which are deep and infiltrative skull base lesions, and they highlight the advantages and limitations of this ventral approach. METHODS All consecutive cases of chordoma treated with an EEA between 1998 and 2015 at a single institution are included in this study. Preoperative assessment consisted of neuroimaging (MRI and CT with angiography sequences) and endocrinological, neurological, and ophthalmological evaluations, which were repeated 3 months after surgery and annually thereafter. Postoperative adjuvant therapies were considered. RESULTS Sixty-five patients (male/female ratio 1:0.9) were included in this study. The median age was 48 years (range 9-80 years). Gross-total resection (GTR) was achieved in 47 cases (58.7%). On univariate analysis, primary procedures (p = 0.001), location in the superior or middle third of the clivus (p = 0.043), extradural location (p = 0.035), and histology of conventional chordomas (p = 0.013) were associated with a higher rate of GTR. The complication rate was 15.1%, and there were no perioperative deaths. Most complications did not result in permanent sequelae and included 2 CSF leaks (2.5%), 5 transient cranial nerve VI palsies (6.2%), and 2 internal carotid artery injuries (2.5%), which were treated with coil occlusion of the internal carotid artery without neurological deficits. Three patients (3.8%) presented with complications resulting in permanent neurological deficits due to a postoperative hematoma (1.2%) causing a hemiparesis, and 2 permanent ophthalmoplegias (2.5%). Seventeen patients (26.2%) have died of tumor progression over the course of follow-up (median 52 months, range 7-159 months). Based on Kaplan-Meier analysis, the survival rate was 77% at 5 years and 57% at 10

  16. Effectiveness of caudal septal extension graft application in endonasal septoplasty

    Directory of Open Access Journals (Sweden)

    Yunus Karadavut

    Full Text Available Abstract Introduction Septal deviation is a common disease seen in daily otorhinolaryngology practice and septoplasty is a commonly performed surgical procedure. Caudal septum deviation is also a challenging pathology for ear, nose, and throat specialists. Many techniques are defined for caudal septal deviation. Objective To evaluate the effectiveness of caudal septal extension graft (CSEG application in patients who underwent endonasal septoplasty for a short and deviated nasal septum. Methods Forty patients with nasal septal deviation, short nasal septum, and weak nasal tip support who underwent endonasal septoplasty with or without CSEG placement between August 2012 and June 2013 were enrolled in this study. Twenty patients underwent endonasal septoplasty with CSEG placement. The rest of the group, who rejected auricular or costal cartilage harvest for CSEG placement, underwent only endonasal septoplasty without any additional intervention. Using the Nasal Obstruction Symptom Evaluation (NOSE and Rhinoplasty Outcome Evaluation (ROE questionnaires, pre- and post-operative acoustic rhinometer measurements were evaluated to assess the effect of CESG placement on nasal obstruction. Results In the control group, preoperative and postoperative minimal cross-sectional areas (MCA1 were 0.44 ± 0.10 cm2 and 0.60 ± 0.11 cm2, respectively (p < 0.001. In the study group, pre- and postoperative MCA1 values were 0.45 ± 0.16 cm2 and 0.67 ± 0.16 cm2, respectively (p < 0.01. In the control group, the nasal cavity volume (VOL1 value was 1.71 ± 0.21 mL preoperatively and 1.94 ± 0.17 mL postoperatively (p < 0.001. In the study group, pre- and postoperative VOL1s were 1.72 ± 0.15 mL and 1.97 ± 0.12 mL, respectively (p < 0.001. Statistical analysis of postoperative MCA1 and VOL1 values in the study and the control groups could not detect any significant intergroup difference (p = 0.093 and 0.432, respectively. In the study group, mean nasolabial angles were

  17. Nasopharyngeal Mass Diagnosed as Transsphenoidal Encephalocele in an Adult Patient.

    Science.gov (United States)

    Ertas, Burak; Aksoy, Elif Ayanoglu; Unal, Omer Faruk

    2015-11-01

    Transsphenoidal encephalocele, a rare congenital malformation, is generally diagnosed during childhood when investigating the reason for complaints such as nasal obstruction and recurring cerebrospinal fluid fistula. In this adult patient, the authors identified an asymptomatic transsphenoidal encephalocele after requested monitoring of a pedunculated mass detected in the nasopharynx during nasal endoscopy. After evaluation, the authors decided to follow the patient. Few cases of transsphenoidal encephalocele have been reported, and even fewer have been reported in older patients, with no other anomaly or symptoms. The success of surgical treatment for these masses is debatable. The authors did not consider surgery for this asymptomatic case. With this case presentation, the authors wish to emphasize that without making radiologic assessments of any masses identified in a nasopharyngeal examination, it would be inappropriate to perform a biopsy or any intervention.

  18. Transsphenoidal Surgery for Pituitary Tumors and Other Sellar Masses.

    Science.gov (United States)

    Owen, Tina J; Martin, Linda G; Chen, Annie V

    2018-01-01

    Transsphenoidal surgery is an option for dogs and cats with functional and nonfunctional pituitary masses or other sellar and parasellar masses. An adrenocorticotropic hormone-secreting tumor causing Cushing disease is the most common clinically relevant pituitary tumor in dogs, and the most common pituitary tumor seen in cats is a growth hormone-secreting tumor causing acromegaly. Transsphenoidal surgery can lead to rapid resolution of clinical signs and provide a cure for these patients. Because of the risks associated with this surgery, it should only be attempted by a cohesive pituitary surgery group with a sophisticated medical and surgical team. Copyright © 2017 Elsevier Inc. All rights reserved.

  19. A rare cause of short stature: transsphenoidal encephalocele.

    Science.gov (United States)

    Bayram, Özhan; Sebahat, Ağladıoğlu Yılmaz; Kadir, Ağladıoğlu; Ali, Koçyiğit

    2014-12-01

    Basal encephaloceles are rare, accounting for about 1.5% of all encephaloceles. Transsphenoidal encephaloceles represent less than 5% of basal encephaloceles. Respiratory and feeding difficulties due to mass effect in the oral or nasal cavity and episodes of recurrent meningitis are the main clinical features. Diagnosis is established in the first year of life, but without characteristic facies, the diagnosis can be delayed to adolescence or adulthood. We report the case of a 10-year-old boy who presented with short stature and eventually was diagnosed with a growth hormone deficiency because of mass effect of transsphenoidal encephalocele. Unusual presentation of an encephalocele as a short stature is described.

  20. Two-Dimensional High Definition Versus Three-Dimensional Endoscopy in Endonasal Skull Base Surgery: A Comparative Preclinical Study.

    Science.gov (United States)

    Rampinelli, Vittorio; Doglietto, Francesco; Mattavelli, Davide; Qiu, Jimmy; Raffetti, Elena; Schreiber, Alberto; Villaret, Andrea Bolzoni; Kucharczyk, Walter; Donato, Francesco; Fontanella, Marco Maria; Nicolai, Piero

    2017-09-01

    Three-dimensional (3D) endoscopy has been recently introduced in endonasal skull base surgery. Only a relatively limited number of studies have compared it to 2-dimensional, high definition technology. The objective was to compare, in a preclinical setting for endonasal endoscopic surgery, the surgical maneuverability of 2-dimensional, high definition and 3D endoscopy. A group of 68 volunteers, novice and experienced surgeons, were asked to perform 2 tasks, namely simulating grasping and dissection surgical maneuvers, in a model of the nasal cavities. Time to complete the tasks was recorded. A questionnaire to investigate subjective feelings during tasks was filled by each participant. In 25 subjects, the surgeons' movements were continuously tracked by a magnetic-based neuronavigator coupled with dedicated software (ApproachViewer, part of GTx-UHN) and the recorded trajectories were analyzed by comparing jitter, sum of square differences, and funnel index. Total execution time was significantly lower with 3D technology (P < 0.05) in beginners and experts. Questionnaires showed that beginners preferred 3D endoscopy more frequently than experts. A minority (14%) of beginners experienced discomfort with 3D endoscopy. Analysis of jitter showed a trend toward increased effectiveness of surgical maneuvers with 3D endoscopy. Sum of square differences and funnel index analyses documented better values with 3D endoscopy in experts. In a preclinical setting for endonasal skull base surgery, 3D technology appears to confer an advantage in terms of time of execution and precision of surgical maneuvers. Copyright © 2017 Elsevier Inc. All rights reserved.

  1. The posterior nasoseptal flap: A novel technique for closure after endoscopic transsphenoidal resection of pituitary adenomas

    Science.gov (United States)

    Barger, James; Siow, Matthew; Kader, Michael; Phillips, Katherine; Fatterpekar, Girish; Kleinberg, David; Zagzag, David; Sen, Chandranath; Golfinos, John G.; Lebowitz, Richard; Placantonakis, Dimitris G.

    2018-01-01

    Background: While effective for the repair of large skull base defects, the Hadad-Bassagasteguy nasoseptal flap increases operative time and can result in a several-week period of postoperative crusting during re-mucosalization of the denuded nasal septum. Endoscopic transsphenoidal surgery for pituitary adenoma resection is generally not associated with large dural defects and high-flow cerebrospinal fluid (CSF) leaks requiring extensive reconstruction. Here, we present the posterior nasoseptal flap as a novel technique for closure of skull defects following endoscopic resection of pituitary adenomas. This flap is raised in all surgeries during the transnasal exposure using septal mucoperiosteum that would otherwise be discarded during the posterior septectomy performed in binostril approaches. Methods: We present a retrospective, consecutive case series of 43 patients undergoing endoscopic transsphenoidal resection of a pituitary adenoma followed by posterior nasoseptal flap placement and closure. Main outcome measures were extent of resection and postoperative CSF leak. Results: The mean extent of resection was 97.16 ± 1.03%. Radiographic measurement showed flap length to be adequate. While a defect in the diaphragma sellae and CSF leak were identified in 21 patients during surgery, postoperative CSF leak occurred in only one patient. Conclusions: The posterior nasoseptal flap provides adequate coverage of the surgical defect and is nearly always successful in preventing postoperative CSF leak following endoscopic transsphenoidal resection of pituitary adenomas. The flap is raised from mucoperiosteum lining the posterior nasal septum, which is otherwise resected during posterior septectomy. Because the anterior septal cartilage is not denuded, raising such flaps avoids the postoperative morbidity associated with the larger Hadad-Bassagasteguy nasoseptal flap. PMID:29527390

  2. Outcome of Transsphenoidal Surgery for Cushing Disease: A Single-Center Experience Over 32 Years.

    Science.gov (United States)

    Chandler, William F; Barkan, Ariel L; Hollon, Todd; Sakharova, Alla; Sack, Jayson; Brahma, Barunashish; Schteingart, David E

    2016-02-01

    Transsphenoidal surgery is the standard approach for treating Cushing disease. Evidence is needed to document effectiveness. To analyze results of transsphenoidal surgery in 276 consecutive patients, including 19 children. Medical records were reviewed for patients treated initially with surgery for Cushing disease from 1980 to 2012. Radiographic features, pathology, remissions, recurrences, and complications were recorded. Patients were categorized for statistical analysis based on tumor size (microadenomas, macroadenomas, and negative imaging) and remission type (type 1 = morning cortisol ≤3 μg/dL; type 2 = morning cortisol normal). Females comprised 78% of patients and were older than men. Imaging showed 50% microadenomas, 13% macroadenomas, and 37% negative for tumor. Remission rates for microadenomas, macroadenomas, and negative imaging were 89%, 66%, and 71%, respectively. Patients with microadenomas were more likely to have type 1 remission. Pathology showed adrenocorticotropic hormone-secreting adenomas in 82% of microadenomas, in 100% of macroadenomas, and in 43% of negative imaging. The incidence of hyperplasia was 8%. The finding of hyperplasia or no tumor on pathology predicted treatment failure. The recurrence rate was 17%, with an average time to recurrence of 4.0 years. Patients with type 1 remission had a lower rate of recurrence (13% type 1 vs 50% type 2) and a longer time to recurrence. Children had similar imaging findings, remission rates, and pathology. There were no operative deaths. Transsphenoidal surgery provides a safe and effective treatment for Cushing disease. For both adults and children, the best outcomes occurred in patients with microadenomas and/or those with type 1 remission.

  3. Long-term follow-up on Cushing disease patient after transsphenoidal surgery

    Directory of Open Access Journals (Sweden)

    Insook Jeong

    2014-09-01

    Full Text Available Cushing disease is caused by excessive adrenocorticotropic hormone (ACTH production by the pituitary adenoma. Transsphenoidal surgery is its first-line treatment. The incidence of Cushing disease in children and adolescents is so rare that long-term prognoses have yet to be made in most cases. We followed-up on a 16-year-old male Cushing disease patient who presented with rapid weight gain and growth retardation. The laboratory findings showed increased 24-hour urine free cortisol and lack of overnight cortisol suppression by low-dose dexamethasone test. The serum cortisol and 24-hour urine free cortisol, by high-dose dexamethasone test, also showed a lack of suppression, and a bilateral inferior petrosal sinus sampling suggested lateralization of ACTH secretion from the right-side pituitary gland. However, after a right hemihypophysectomy by the transsphenoidal approach, the 24-hour urine free cortisol levels were persistently high. Thus the patient underwent a total hypophysectomy, since which time he has been treated with hydrocortisone, levothyroxine, recombinant human growth hormone, and testosterone enanthate. Intravenous bisphosphonate for osteoporosis had been administered for three years. At his current age of 26 years, his final height had attained the target level range; his bone mineral density was normal, and his pubic hair was Tanner stage 4. This report describes the long-term treatment course of a Cushing disease patient according to growth profile, pubertal status, and responses to hormone replacement therapy. The clinical results serve to emphasize the importance of growth optimization, puberty, and bone health in the treatment management of Cushing disease patients who have undergone transsphenoidal surgery.

  4. Long-term follow-up on Cushing disease patient after transsphenoidal surgery.

    Science.gov (United States)

    Jeong, Insook; Oh, Moonyeon; Kim, Ja Hye; Cho, Ja Hyang; Choi, Jin-Ho; Yoo, Han-Wook

    2014-09-01

    Cushing disease is caused by excessive adrenocorticotropic hormone (ACTH) production by the pituitary adenoma. Transsphenoidal surgery is its first-line treatment. The incidence of Cushing disease in children and adolescents is so rare that long-term prognoses have yet to be made in most cases. We followed-up on a 16-year-old male Cushing disease patient who presented with rapid weight gain and growth retardation. The laboratory findings showed increased 24-hour urine free cortisol and lack of overnight cortisol suppression by low-dose dexamethasone test. The serum cortisol and 24-hour urine free cortisol, by high-dose dexamethasone test, also showed a lack of suppression, and a bilateral inferior petrosal sinus sampling suggested lateralization of ACTH secretion from the right-side pituitary gland. However, after a right hemihypophysectomy by the transsphenoidal approach, the 24-hour urine free cortisol levels were persistently high. Thus the patient underwent a total hypophysectomy, since which time he has been treated with hydrocortisone, levothyroxine, recombinant human growth hormone, and testosterone enanthate. Intravenous bisphosphonate for osteoporosis had been administered for three years. At his current age of 26 years, his final height had attained the target level range; his bone mineral density was normal, and his pubic hair was Tanner stage 4. This report describes the long-term treatment course of a Cushing disease patient according to growth profile, pubertal status, and responses to hormone replacement therapy. The clinical results serve to emphasize the importance of growth optimization, puberty, and bone health in the treatment management of Cushing disease patients who have undergone transsphenoidal surgery.

  5. Accuracy of a novel photoacoustic-based approach to surgical guidance performed with and without a da Vinci robot

    Science.gov (United States)

    Gandhi, Neeraj; Kim, Sungmin; Kazanzides, Peter; Lediju Bell, Muyinatu A.

    2017-03-01

    Minimally invasive surgery carries the deadly risk of rupturing major blood vessels, such as the internal carotid arteries hidden by bone in endonasal transsphenoidal surgery. We propose a novel approach to surgical guidance that relies on photoacoustic-based vessel separation measurements to assess the extent of safety zones during these type of surgical procedures. This approach can be implemented with or without a robot or navigation system. To determine the accuracy of this approach, a custom phantom was designed and manufactured for modular placement of two 3.18-mm diameter vessel-mimicking targets separated by 10-20 mm. Photoacoustic images were acquired as the optical fiber was swept across the vessels in the absence and presence of teleoperation with a research da Vinci Surgical System. When the da Vinci was used, vessel positions were recorded based on the fiber position (calculated from the robot kinematics) that corresponded to an observed photoacoustic signal. In all cases, compounded photoacoustic data from a single sweep displayed the four vessel boundaries in one image. Amplitude- and coherence-based photoacoustic images were used to estimate vessel separations, resulting in 0.52-0.56 mm mean absolute errors, 0.66-0.71 mm root mean square errors, and 65-68% more accuracy compared to fiber position measurements obtained through the da Vinci robot kinematics. Results indicate that with further development, photoacoustic image-based measurements of anatomical landmarks could be a viable method for real-time path planning in multiple interventional photoacoustic applications.

  6. Vascular Complications of Intercavernous Sinuses during Transsphenoidal Surgery: An Anatomical Analysis Based on Autopsy and Magnetic Resonance Venography.

    Directory of Open Access Journals (Sweden)

    Xuefei Deng

    Full Text Available Vascular complications induced by intercavernous sinus injury during dural opening in the transsphenoidal surgery may contribute to incomplete tumour resections. Preoperative neuro-imaging is of crucial importance in planning surgical approach. The aim of this study is to correlate the microanatomy of intercavernous sinuses with its contrast-enhanced magnetic resonance venography (CE-MRV.Eighteen human adult cadavers and 24 patients were examined based on autopsy and CE-MRV. Through dissection of the cadavers and CE-MRV, the location, shape, number, diameter and type of intercavernous sinuses were measured and compared.Different intercavernous sinuses were identified by their location and shape in all the cadavers and CE-MRV. Compared to the cadavers, CE-MRV revealed 37% of the anterior intercavernous sinus, 48% of the inferior intercavernous sinus, 30% of the posterior intercavernous sinus, 30% of the dorsum sellae sinus and 100% of the basilar sinus. The smaller intercavernous sinuses were not seen in the neuro-images. According to the presence of the anterior and inferior intercavernous sinus, four types of the intercavernous sinuses were identified in cadavers and CE-MRV, and the corresponding operative space in the transsphenoidal surgical approach was implemented.The morphology and classification of the cavernous sinus can be identified by CE-MRV, especially for the larger vessels, which cause bleeding more easily. Therefore, CE-MRV provides a reliable measure for individualized preoperative planning during transsphenoidal surgery.

  7. Vascular Complications of Intercavernous Sinuses during Transsphenoidal Surgery: An Anatomical Analysis Based on Autopsy and Magnetic Resonance Venography.

    Science.gov (United States)

    Deng, Xuefei; Chen, Shijun; Bai, Ya; Song, Wen; Chen, Yongchao; Li, Dongxue; Han, Hui; Liu, Bin

    2015-01-01

    Vascular complications induced by intercavernous sinus injury during dural opening in the transsphenoidal surgery may contribute to incomplete tumour resections. Preoperative neuro-imaging is of crucial importance in planning surgical approach. The aim of this study is to correlate the microanatomy of intercavernous sinuses with its contrast-enhanced magnetic resonance venography (CE-MRV). Eighteen human adult cadavers and 24 patients were examined based on autopsy and CE-MRV. Through dissection of the cadavers and CE-MRV, the location, shape, number, diameter and type of intercavernous sinuses were measured and compared. Different intercavernous sinuses were identified by their location and shape in all the cadavers and CE-MRV. Compared to the cadavers, CE-MRV revealed 37% of the anterior intercavernous sinus, 48% of the inferior intercavernous sinus, 30% of the posterior intercavernous sinus, 30% of the dorsum sellae sinus and 100% of the basilar sinus. The smaller intercavernous sinuses were not seen in the neuro-images. According to the presence of the anterior and inferior intercavernous sinus, four types of the intercavernous sinuses were identified in cadavers and CE-MRV, and the corresponding operative space in the transsphenoidal surgical approach was implemented. The morphology and classification of the cavernous sinus can be identified by CE-MRV, especially for the larger vessels, which cause bleeding more easily. Therefore, CE-MRV provides a reliable measure for individualized preoperative planning during transsphenoidal surgery.

  8. New endoscope shaft for endoscopic transsphenoidal pituitary surgery.

    NARCIS (Netherlands)

    Lindert, E.J. van; Grotenhuis, J.A.

    2005-01-01

    OBJECTIVE: To describe a new endoscope shaft developed for suction-aspiration during endoscopic transsphenoidal pituitary surgery. METHODS: A custom-made shaft for a Wolf endoscope (Richard Wolf GmbH, Knittlingen, Germany) was developed with a height of 10 mm and a width of 5 mm, allowing an

  9. Observation alone after transsphenoidal surgery for nonfunctioning pituitary macroadenoma

    NARCIS (Netherlands)

    Dekkers, O. M.; Pereira, A. M.; Roelfsema, F.; Voormolen, J. H. C.; Neelis, K. J.; Schroijen, M. A.; Smit, J. W. A.; Romijn, J. A.

    2006-01-01

    Transsphenoidal surgery is the treatment of choice for nonfunctioning pituitary macroadenomas (NFMA). In this study we evaluated the long-term effects of a treatment strategy in which postoperative radiotherapy was not routinely applied to patients with NFMA. This was a retrospective follow-up

  10. Predictors of resource utilization in transsphenoidal surgery for Cushing disease.

    Science.gov (United States)

    Little, Andrew S; Chapple, Kristina

    2013-08-01

    The short-term cost associated with subspecialized surgical care is an increasingly important metric and economic concern. This study sought to determine factors associated with hospital charges in patients undergoing transsphenoidal surgery for Cushing disease in an effort to identify the drivers of resource utilization. The authors analyzed the Nationwide Inpatient Sample (NIS) hospital discharge database from 2007 to 2009 to determine factors that influenced hospital charges in patients who had undergone transsphenoidal surgery for Cushing disease. The NIS discharge database approximates a 20% sample of all inpatient admissions to nonfederal US hospitals. A multistep regression model was developed that adjusted for patient demographics, acuity measures, comorbidities, hospital characteristics, and complications. In 116 hospitals, 454 transsphenoidal operations were performed. The mean hospital charge was $48,272 ± $32,060. A multivariate regression model suggested that the primary driver of resource utilization was length of stay (LOS), followed by surgeon volume, hospital characteristics, and postoperative complications. A 1% increase in LOS increased hospital charges by 0.60%. Patient charges were 13% lower when performed by high-volume surgeons compared with low-volume surgeons and 22% lower in large hospitals compared with small hospitals. Hospital charges were 12% lower in cases with no postoperative neurological complications. The proposed model accounted for 46% of hospital charge variance. This analysis of hospital charges in transsphenoidal surgery for Cushing disease suggested that LOS, hospital characteristics, surgeon volume, and postoperative complications are important predictors of resource utilization. These findings may suggest opportunities for improvement.

  11. Preoperative clonidine use in trans-sphenoidal pituitary adenoma surgeries - a randomized controlled trial.

    Science.gov (United States)

    Bajaj, Jitin; Mittal, Radhe Shyam; Sharma, Achal

    2017-02-01

    Pituitary masses are common lesions accounting for about 15-20% of all brain tumours. Oozing blood is an annoyance in microscopic sublabial trans-sphenoidal approach for these masses. There have been many ways of reducing the ooze, having their own pros and cons. To find out the efficacy and safety of clonidine in reducing blood loss in pituitary adenoma surgery through a randomized masked trial. It was a prospective randomized controlled trial done. Total 50 patients of pituitary adenomas were randomized into two groups. Group A (25 patients) was given 200 μg clonidine orally, while Group B (25 patients) was given placebo. Surgeon, anaesthesiologist and patient were blinded for the trial. Sublabial trans-septal trans-sphenoidal approach to sella and excision of mass was performed in each patient. Patients were studied for pre-, intra- and post-operative blood pressure and heart rate, pre- and post-operative imaging findings, intra-operative blood loss, bleeding grading by surgeon, surgeon's satisfaction about condition of specific part and quality of surgical field, operative time and extent of resection. Blood loss during the surgery, operative time and bleeding grading by the surgeon were found significantly less in the clonidine group, while quality of surgical field, condition of the specific part and extent of resection were found significantly better in the clonidine group (p value trans-sphenoidal microscopic pituitary adenoma surgeries.

  12. The "suprasellar notch," or the tuberculum sellae as seen from below: definition, features, and clinical implications from an endoscopic endonasal perspective.

    Science.gov (United States)

    de Notaris, Matteo; Solari, Domenico; Cavallo, Luigi M; D'Enza, Alfonso Iodice; Enseñat, Joaquim; Berenguer, Joan; Ferrer, Enrique; Prats-Galino, Alberto; Cappabianca, Paolo

    2012-03-01

    The tuberculum sellae is a bony elevation ridge that lines up the anterior aspect of the sella, dividing it from the chiasmatic groove. The recent use of the endoscopic endonasal transtuberculum approach has provided surgeons with a method to reach the suprasellar area, offering a new surgical point of view somehow "opposite" of this area. The authors of this study aimed to define the tuberculum sellae as seen from the endoscopic endonasal view while also providing CT-based systematic measurements to objectively detail the anatomical features of such a structure, which was renamed the "suprasellar notch." The authors analyzed routine skull CT scans from 24 patients with no brain pathology or fractures and measured the interoptic distance at the level of the limbus sphenoidale, the chiasmatic groove sulcal length and width, and the angle of the suprasellar notch. Indeed, the suprasellar notch was defined as the angle between 2 lines, the first passing through the tuberculum sellae midpoint and perpendicular to the cribriform plate, and a second line passing between 2 points, the midpoints of the limbus sphenoidale and the tuberculum sellae. Moreover, the authors performed on 15 cadaveric heads an endoscopic endonasal transplanum transtuberculum approach with the aid of a neuronavigator to achieve a step-by-step comparison with the radiological data. The whole CT scanning set was statistically analyzed to determine the statistical interdependency of the suprasellar notch angle with the other 3 measurements, that is, the sulcal length at the midline, the interoptic distance at the optic canal entrance, and the interoptic distance at the limbus. Based on the endoscopic endonasal view and CT imaging analysis, the authors identified a certain anatomical variability and thus introduced a new classification of the suprasellar notch: Type I, angle 138°. They then analyzed the surgical implications of the endoscopic endonasal approach to the suprasellar area, which could be

  13. Postoperative Cerebral Vasospasm Following Transsphenoidal Pituitary Adenoma Surgery.

    Science.gov (United States)

    Eseonu, Chikezie I; ReFaey, Karim; Geocadin, Romergryko G; Quinones-Hinojosa, Alfredo

    2016-08-01

    Cerebral vasospasm following a transsphenoidal resection of a pituitary adenoma is a devastating occurrence that can lead to delayed cerebral ischemia and poor neurologic outcome if not diagnosed and treated in a timely manner. The etiology of this condition is not well understood but can lead to significant arterial vasospasm that causes severe ischemic insults. In this paper, we identify common presenting symptoms and essential management strategies to treat this harmful disease. A retrospective case report and literature review of presentation, treatment, and outcome of cerebral vasospasm following transsphenoidal surgery. We present 1 case and review 12 known cases in the literature on vasospasm following transsphenoidal surgery. Mean age was 48 (±13.8) years. There were 46.2% male patients. Factors associated with vasospasm, such as cerebral spinal fluid leaks following surgery, were seen in 38.5% of cases, and postoperative subarachnoid hemorrhage (SAH) was seen in 84.6% of cases. Hemiparesis was the presenting symptom of delayed cerebral ischemia in 61.5% of cases. For management, maintaining at least a euvolemic volume status was used in 76.9%, induced hypertension was used in 61.5%, and nimodipine was administered in 46.2% of cases. Patients returned to their neurologic baseline in 61.5% of cases, had new permanent deficits in 7.7% of cases, and died in 30.8% of cases. Cerebral vasospasm following transsphenoidal surgery is a dangerous disease that can lead to a high likelihood of mortality if not identified and treated. Early postoperative events, such as peritumoral subarachnoid hemorrhage and hemiparesis, may be factors associated with post-transsphenoidal surgery vasospasm. Effective treatment options used in patients that regained complete neurologic recovery were by inducing hypertension, maintaining euvolemia, and administering nimodipine. Copyright © 2016 Elsevier Inc. All rights reserved.

  14. Repeated transsphenoidal pituitary surgery (TS) via the endoscopic technique: a good therapeutic option for recurrent or persistent Cushing's disease (CD).

    NARCIS (Netherlands)

    Wagenmakers, M.A.; Netea-Maier, R.T.; Lindert, E.J. van; Timmers, H.J.L.M.; Grotenhuis, J.A.; Hermus, A.R.M.M.

    2009-01-01

    BACKGROUND: No data on results of repeated transsphenoidal surgery via the endoscopic technique for patients with persistent or recurrent Cushing's disease are available. DESIGN AND PATIENTS: We retrospectively evaluated the remission rates and complications of repeated transsphenoidal surgery via

  15. Transsphenoidal pituitary resection with intraoperative MR guidance: preliminary results

    Science.gov (United States)

    Pergolizzi, Richard S., Jr.; Schwartz, Richard B.; Hsu, Liangge; Wong, Terence Z.; Black, Peter M.; Martin, Claudia; Jolesz, Ferenc A.

    1999-05-01

    The use of intraoperative MR image guidance has the potential to improve the precision, extent and safety of transsphenoidal pituitary resections. At Brigham and Women's Hospital, an open-bore configuration 0.5T MR system (SIGNA SP, GE Medical Systems, Milwaukee, WI) has been used to provide image guidance for nine transsphenoidal pituitary adenoma resections. The intraoperative MR system allowed the radiologist to direct the surgeon toward the sella turcica successfully while avoiding the cavernous sinus, optic chiasm and other sensitive structures. Imaging performed during the surgery monitored the extent of resection and allowed for removal of tumor beyond the surgeon's view in five cases. Dynamic MR imaging was used to distinguish residual tumor from normal gland and postoperative changes permitting more precise tumor localization. A heme-sensitive long TE gradient echo sequence was used to evaluate for the presence of hemorrhagic debris. All patients tolerated the procedure well without significant complications.

  16. Immediate postoperative complications in transsphenoidal pituitary surgery: A prospective study

    Directory of Open Access Journals (Sweden)

    Tumul Chowdhury

    2014-01-01

    Full Text Available Background: Considering the important role of pituitary gland in regulating various endocrine axes and its unique anatomical location, various postoperative complications can be anticipated resulting from surgery on pituitary tumors. We examined and categorized the immediate postoperative complications according to various tumor pathologies. Materials and Methods: We carried out a prospective study in 152 consecutive patients and noted various postoperative complications during neurosurgical intensive care unit stay (within 48 hrs of hospital stay in patients undergoing transsphenoidal removal of pituitary tumors. Results: In our series, various groups showed different postoperative complications out of which, cerebrospinal fluid leak was the commonest followed by diabetes insipidus, postoperative nausea and vomiting, and hematoma at operation site. Conclusion: Various immediate postoperative complications can be anticipated in transsphenoidal pituitary surgery even though, it is considered to be relatively safe.

  17. Delayed Complications After Transsphenoidal Surgery for Pituitary Adenomas.

    Science.gov (United States)

    Alzhrani, Gmaan; Sivakumar, Walavan; Park, Min S; Taussky, Philipp; Couldwell, William T

    2018-01-01

    Perioperative complications after transsphenoidal surgery for pituitary adenomas have been well documented in the literature; however, some complications can occur in a delayed fashion postoperatively, and reports are sparse about their occurrence, management, and outcome. Here, we describe delayed complications after transsphenoidal surgery and discuss the incidence, temporality from the surgery, and management of these complications based on the findings of studies that reported delayed postoperative epistaxis, delayed postoperative cavernous carotid pseudoaneurysm formation and rupture, vasospasm, delayed symptomatic hyponatremia, hypopituitarism, hydrocephalus, and sinonasal complications. Our findings from this review revealed an incidence of 0.6%-3.3% for delayed postoperative epistaxis at 1-3 weeks postoperatively, 18 reported cases of delayed carotid artery pseudoaneurysm formation at 2 days to 10 years postoperatively, 30 reported cases of postoperative vasospasm occurring 8 days postoperatively, a 3.6%-19.8% rate of delayed symptomatic hyponatremia at 4-7 days postoperatively, a 3.1% rate of new-onset hypopituitarism at 2 months postoperatively, and a 0.4%-5.8% rate of hydrocephalus within 2.2 months postoperatively. Sinonasal complications are commonly reported after transsphenoidal surgery, but spontaneous resolutions within 3-12 months have been reported. Although the incidence of some of these complications is low, providing preoperative counseling to patients with pituitary tumors regarding these delayed complications and proper postoperative follow-up planning is an important part of treatment planning. Copyright © 2017 Elsevier Inc. All rights reserved.

  18. Bony Regeneration of the Sella after Transsphenoidal Pituitary Surgery.

    Science.gov (United States)

    Yahia-Cherif, Mehdi; Delpierre, Isabelle; Hassid, Sergio; De Witte, Olivier

    2016-04-01

    The purpose of this study is to demonstrate the possible bony regrowth of the sella after transsphenoidal surgery without any intraoperative sellar reconstruction. Radiologic findings of the sella were reviewed in patients with pituitary tumors treated by transsphenoidal surgery. In 17 patients who had postoperative cranial computed tomography scans, bony regeneration of the sellar floor was evaluated by comparing immediate and late postoperative scans. The bony opening reduction was measured in transverse and sagittal planes. The median bony opening diameter in the transverse plane was 8.8 mm (interquartile range [IQR] 5.7-11.4) on the first scan and 4.2 mm (IQR 0.8-6.8) on the second scan. In the sagittal plane, it was 4.8 mm (IQR 1.8-6.8) on the first scan and 2.9 mm (IQR 1.6-3.9) on the second scan. These changes occurred in a median time of 36 months (IQR 22-42). There was a statistically significant decrease of the bony opening diameters in both the transverse and sagittal planes (P transsphenoidal pituitary surgery. Copyright © 2016 Elsevier Inc. All rights reserved.

  19. Outcomes of endonasal endoscopic dacryocystorhinostomy after maxillectomy in patients with paranasal sinus and skull base tumors.

    Science.gov (United States)

    Abu-Ghanem, Sara; Ben-Cnaan, Ran; Leibovitch, Igal; Horowitz, Gilad; Fishman, Gadi; Fliss, Dan M; Abergel, Avraham

    2014-06-01

    Maxillectomy followed by radiotherapy and/or chemotherapy can result in lacrimal blockage and the need for subsequent dacryocystorhinostomy (DCR). Endonasal endoscopic DCR, as opposed to external DCR, allows better accuracy and leaves no scar. To date no report was published regarding the results of endoscopic DCR in these patients. The current study presents a retrospective review of all patients with paranasal and skull base tumors who developed nasolacrimal duct blockage after ablative maxillectomy with or without radiotherapy and/or chemotherapy and underwent endonasal endoscopic DCR between January 2006 and October 2012 in a tertiary reference medical center. According to our results, ten patients underwent 11 subsequent endonasal endoscopic DCR. There were 6 men and 4 women with a median age of 55 years (range, 19-81 years); four suffered from benign tumors and six had malignant tumors. All underwent maxillectomy. Six received high-dose radiotherapy. Time interval between primary ablative surgery and endonasal endoscopic DCR was 18 months (range, 7-118 months). Silicone stents were removed after median period of 11 weeks (range, 1-57 weeks). Nine out of ten patients experienced symptomatic improvement following one endonasal endoscopic DCR. One patient had recurrent epiphora and underwent a successful endonasal endoscopic revision DCR. In conclusion, endonasal endoscopic DCR in patients with paranasal and skull base tumors, who previously underwent maxillectomy, is generally successful and not associated with a high rate of complications or failure. Moreover, our findings may suggest that silicone stents can be removed shortly after the operation with high success rate.

  20. Multi-slice computed tomography-assisted endoscopic transsphenoidal surgery for pituitary macroadenoma: a comparison with conventional microscopic transsphenoidal surgery.

    Science.gov (United States)

    Tosaka, Masahiko; Nagaki, Tomohito; Honda, Fumiaki; Takahashi, Katsumasa; Yoshimoto, Yuhei

    2015-11-01

    Intraoperative computed tomography (iCT) is a reliable method for the detection of residual tumour, but previous single-slice low-resolution computed tomography (CT) without coronal or sagittal reconstructions was not of adequate quality for clinical use. The present study evaluated the results of multi-slice iCT-assisted endoscopic transsphenoidal surgery for pituitary macroadenoma. This retrospective study included 30 consecutive patients with newly diagnosed or recurrent pituitary macroadenoma with supradiaphragmatic extension who underwent endoscopic transsphenoidal surgery using iCT (eTSS+iCT group), and control 30 consecutive patients who underwent conventional endoscope-assisted transsphenoidal surgery (cTSS group). The tumour volume was calculated by multiplying the tumour area by the slice thickness. Visual acuity and visual field were estimated by the visual impairment score (VIS). The resection extent, (preoperative tumour volume - postoperative residual tumour volume)/preoperative tumour volume, was 98.9% (median) in the eTSS+iCT group and 91.7% in the cTSS group, and had significant difference between the groups (P = 0.04). Greater than 95 and >90% removal rates were significantly higher in the eTSS+iCT group than in the cTSS group (P = 0.02 and P = 0.001, respectively). However, improvement in VIS showed no significant difference between the groups. The rate of complications also showed no significant difference. Multi-slice iCT-assisted endoscopic transsphenoidal surgery may improve the resection extent of pituitary macroadenoma. Multi-slice iCT may have advantages over intraoperative magnetic resonance imaging in less expensive, short acquisition time, and that special protection against magnetic fields is not needed.

  1. Radiation therapy rather than prior surgery reduces extent of resection during endonasal endoscopic reoperation for craniopharyngioma.

    Science.gov (United States)

    Younus, Iyan; Forbes, Jonathan A; Ordóñez-Rubiano, Edgar G; Avendano-Pradel, Rafael; La Corte, Emanuele; Anand, Vijay K; Schwartz, Theodore H

    2018-07-01

    Radiation therapy is often advocated for residual or recurrent craniopharyngioma following surgical resection to prevent local recurrence. However, radiation therapy is not always effective and may render tumors more difficult to remove. If this is the case, patients may benefit more from reoperation if gross total resection can be achieved. Nevertheless, there is little data on the impact of radiation on reoperations for craniopharyngioma. In this study, we sought to analyze whether a history of previous radiation therapy (RT) affected extent of resection in patients with recurrent craniopharyngiomas subsequently treated with reoperation via endoscopic endonasal approach (EEA). The authors reviewed a prospectively acquired database of EEA reoperations of craniopharyngiomas over 13 years at Weill Cornell, NewYork-Presbyterian Hospital. All procedures were performed by the senior author. The operations were separated into two groups based on whether the patient had surgery alone (group A) or surgery and RT (group B) prior to recurrence. A total of 24 patients (16 male, 8 female) who underwent surgery for recurrent craniopharyngioma were identified. The average time to recurrence was 7.64 ± 4.34 months (range 3-16 months) for group A and 16.62 ± 12.1 months (range 6-45 months) for group B (p < 0.05). The average tumor size at recurrence was smaller in group A (1.85 ± 0.72 cm; range 0.5-3.2) than group B (2.59 ± 0.91 cm; range 1.5-4.6; p = 0.00017). Gross total resection (GTR) was achieved in 91% (10/11) of patients in group A and 54% (7/13) of patients in group B (p = 0.047). There was a near significant trend for higher average Karnofsky performance status (KPS) score at last follow-up for group A (83 ± 10.6) compared with group B (70 ± 16.3, p = 0.056). While RT for residual or recurrent craniopharyngioma may delay time to recurrence, ability to achieve GTR with additional surgery is reduced. In the case of

  2. Coincident intrasellar persistent trigeminal artery and craniopharyngioma: case report and implications for transsphenoidal surgery

    Directory of Open Access Journals (Sweden)

    Justin Seltzer, B.A.

    2014-12-01

    Surgeons performing endonasal skull base operations should be vigilant for the presence of PTAs and related vascular anomalies on MR imaging. Noninvasive vascular imaging can confirm and assist with preoperative planning.

  3. [Endonasal endoscopic surgery in the treatment of spontaneous or post-traumatic cerebrospinal fluid (csf) leaks].

    Science.gov (United States)

    Nallet, E; Decq, P; Bezzo, A; Le Lievre, G; Peynegre, R; Coste, A

    1998-10-01

    The incidence and the risk of meningitidis justify treatment in all cases of cerebrospinal fluid rhinorrhea with spontaneous etiology or after traumatic injury. Endonasal surgery with endoscopic instruments provides many advantages compared with transcranial or transfacial approach used by neurosurgeons. We report our experience and our surgical technique in the treatment of CSF leaks in 5 patients. Intrathecal injection of fluoresceine was very useful in all cases for detecting the CSF leak. Total or selected ethmoidectomy depended on the localization of the leakage. Wide sphenoidotomy enables detection and repair of CSF leaks from the sphenoid cavity. A free graft of inferior turbinal mucosal was used to repair the breache. This rapid low morbidity surgery offered secure closure of rhinorrhea in 4 cases after one procedure and in 1 case after two procedures with an average follow up of 22 months. Cerebrospinal fluid rhinorrhea can be managed in first line therapy with endoscopic intranasal surgical techniques when they are localized in the anterior ethmoid or in the sphenoid cavity.

  4. Complications Following Primary and Revision Transsphenoidal Surgeries for Pituitary Tumors

    Science.gov (United States)

    Krings, James G.; Kallogjeri, Dorina; Wineland, Andre; Nepple, Kenneth G.; Piccirillo, Jay F.; Getz, Anne E.

    2014-01-01

    Objective This study aimed to determine the incidence of major complications following both primary and revision transsphenoidal pituitary surgery. Major complications included endocrinopathic, skull base, orbital, hemorrhagic and thromboembolic complications, respiratory failure, and death. Secondarily, this study aimed to examine factors associated with the occurrence of complications. Study Design Retrospective cohort analysis of California and Florida all-payer databases from 2005-2008. Methods The major complication rate following both primary and revision transsphenoidal pituitary surgery was calculated. Bivariate analyses were performed to investigate the relationship of patient characteristics with complication occurrence, and a multivariate model was constructed to determine risk factors associated with these complications. Results 5,277 primary cases and 192 revision cases met inclusion criteria. There was a non-significant absolute difference of 3.09% (95% CI −11.00 to 16.14) between the rate of complications following primary (n=443; 8.39%) and revision (n=22; 11.46%) surgeries. Multivariate analyses showed that patients with Medicare (OR=1.74; 95% CI 1.17 to 2.61), Medicaid (OR=2.13; 95% CI 1.59 to 2.86), or a malignant neoplasm (OR=3.10; 95% CI 1.62 to 5.93) were more likely to have complications. Conclusions The rate of major complications following transsphenoidal pituitary surgery is lower than earlier retrospective reports. The overall complication rate following revision surgery was not significantly different from primary surgery. Insurance status and a diagnosis of a malignant neoplasm were associated with a higher rate of complications. PMID:25263939

  5. Gross total resection of pituitary adenomas after endoscopic vs. microscopic transsphenoidal surgery: a meta-analysis.

    Science.gov (United States)

    Almutairi, Reem D; Muskens, Ivo S; Cote, David J; Dijkman, Mark D; Kavouridis, Vasileios K; Crocker, Erin; Ghazawi, Kholoud; Broekman, Marike L D; Smith, Timothy R; Mekary, Rania A; Zaidi, Hasan A

    2018-05-01

    Microscopic transsphenoidal surgery (mTSS) is a well-established method to address adenomas of the pituitary gland. Endoscopic transsphenoidal surgery (eTSS) has become a viable alternative, however. Advocates suggest that the greater illumination, panoramic visualization, and angled endoscopic views afforded by eTSS may allow for higher rates of gross total tumor resection (GTR). The aim of this meta-analysis was to determine the rate of GTR using mTSS and eTSS. A meta-analysis of the literature was conducted using PubMed, EMBASE, and Cochrane databases through July 2017 in accordance with PRISMA guidelines. Seventy case series that reported GTR rate in 8257 pituitary adenoma patients were identified. For all pituitary adenomas, eTSS (GTR=74.0%; I 2  = 92.1%) was associated with higher GTR as compared to mTSS (GTR=66.4%; I 2  = 84.0%) in a fixed-effect model (P-interaction  0.05). No significant publication bias was identified for any of the outcomes. Among patients who were not randomly allocated to either approach, eTSS resulted in a higher rate of GTR as compared to mTSS for all patients and for NFPA patients alone, but only in a fixed-effect model. For FPA, however, eTSS did not seem to offer a significantly higher rate of GTR. These conclusions should be interpreted with caution because of the nature of the included non-comparative studies.

  6. Cost-Effectiveness of Endoscopic Versus Microscopic Transsphenoidal Surgery for Pituitary Adenoma.

    Science.gov (United States)

    Ament, Jared D; Yang, Zhuo; Khatchadourian, Vic; Strong, Edward B; Shahlaie, Kiarash

    2018-02-01

    Endoscopic transsphenoidal surgery (ETPS) has become increasingly popular for resection of pituitary tumors, whereas microscopic transsphenoidal surgery (MTPS) also remains a commonly used approach. The economic sustainability of new techniques and technologies is rarely evaluated in the neurosurgical skull base literature. The aim of this study was to determine the cost-effectiveness of ETPS compared with MTPS. A Markov model was constructed to conduct a cost-utility analysis of ETPS versus MTPS from a single-payer health care perspective. Data were obtained from previously published outcomes studies. Costs were based on Medicare reimbursement rates, considering covariates such as complications, length of stay, and operative time. The base case adopted a 2-year follow-up period. Univariate and multivariate sensitivity analyses were conducted. On average, ETPS costs $143 less and generates 0.014 quality-adjusted life years (QALYs) compared with MTPS over 2 years. The incremental cost-effectiveness ratio (ICER) is -$10,214 per QALY, suggesting economic dominance. The QALY benefit increased to 0.105 when modeled to 10 years, suggesting that ETPS becomes even more favorable over time. ETPS appears to be cost-effective when compared with MTPS because the ICER falls below the commonly accepted $50,000 per QALY benchmark. Model limitations and assumptions affect the generalizability of the conclusion; however, ongoing efforts to improve rhinologic morbidity related to ETPS would appear to further augment the marginal cost savings and QALYs gained. Further research on the cost-effectiveness of ETPS using prospective data is warranted. Copyright © 2017 Elsevier Inc. All rights reserved.

  7. Clinical outcome of endonasal KTP laser assisted dacryocystorhinostomy

    Directory of Open Access Journals (Sweden)

    Carrie Sean

    2005-03-01

    Full Text Available Abstract Background To evaluate the clinical outcome of primary endonasal laser assisted dacryocystorhinostomy (ENL-DCR using the potassium-titanyl-phosphate laser. Methods We retrospectively reviewed all primary ENL-DCRs performed within a period of twelve months by the same combined Ophthalmology and Otorhinolaringology team in Freeman Hospital, Newcastle upon Tyne, UK. The main outcome measure for success was resolution or significant improvement of epiphora. Details of surgery, intraoperative and postoperative complications, as well as pathology associated with failure were also studied. Patients were followed up for at least 12 months. Results A total of 41 consecutive ENL-DCRs on 29 patients (22 females, 7 males, mean age 75 years were analysed. All patients had bicanalicular silicone intubation for at least 4 months. The success rate at 12 months postoperatively was 78.1%. Pathology associated with failure included: intranasal pathology (12.2%, mucocele (7.3%, and systemic sarcoidosis (2.4%. No significant intra-operative complications were recorded. Conclusion The ENL-DCR with potassium-titanyl-phosphate laser can be considered as a safe and efficient primary procedure for the treatment of nasolacrimal duct obstruction.

  8. Anatomical and computed tomographic analysis of the transcochlear and endoscopic transclival approaches to the petroclival region.

    Science.gov (United States)

    Mason, Eric; Van Rompaey, Jason; Carrau, Ricardo; Panizza, Benedict; Solares, C Arturo

    2014-03-01

    Advances in the field of skull base surgery aim to maximize anatomical exposure while minimizing patient morbidity. The petroclival region of the skull base presents numerous challenges for surgical access due to the complex anatomy. The transcochlear approach to the region provides adequate access; however, the resection involved sacrifices hearing and results in at least a grade 3 facial palsy. An endoscopic endonasal approach could potentially avoid negative patient outcomes while providing a desirable surgical window in a select patient population. Cadaveric study. Endoscopic access to the petroclival region was achieved through an endonasal approach. For comparison, a transcochlear approach to the clivus was performed. Different facets of the dissections, such as bone removal volume and exposed surface area, were computed using computed tomography analysis. The endoscopic endonasal approach provided a sufficient corridor to the petroclival region with significantly less bone removal and nearly equivalent exposure of the surgical target, thus facilitating the identification of the relevant anatomy. The lateral approach allowed for better exposure from a posterolateral direction until the inferior petrosal sinus; however, the endonasal approach avoided labyrinthine/cochlear destruction and facial nerve manipulation while providing an anteromedial viewpoint. The endonasal approach also avoided external incisions and cosmetic deficits. The endonasal approach required significant sinonasal resection. Endoscopic access to the petroclival region is a feasible approach. It potentially avoids hearing loss, facial nerve manipulation, and cosmetic damage. © 2013 The American Laryngological, Rhinological and Otological Society, Inc.

  9. MR imaging of pituitary macroadenomas before and after transsphenoidal surgery

    International Nuclear Information System (INIS)

    Hald, J.K.; Nakstad, P.H.; Kollevold, T.; Bakke, S.J.; Skalpe, I.O.

    1992-01-01

    MR findings before and after transsphenoidal surgery were evaluated in 6 cases. T1-weighted (TR/TE 600/20) sagittal and coronal images with 2 or 4 acquisitions were obtained, using 3-mm slice thickness and 0.3-mm interslice gaps. Of 18 MR examinations, 13 included coronal i.v. contrast medium enhanced images. Image quality, sinus cavernosus invasion, identification of normal pituitary tissue and tumor size were examined. All MR studied clearly demonstrated the macroadenomas whether 2 or 4 acquisitions were used, and whether i.v. contrast medium was administered or not. Surgically confirmed sinus cavernosus infiltration was seen in 4 patients. The pituitary stalk was identified separate from the tumor in 2 patients, and the gland in one. There was reduction in tumor size over time, indicating that final radiologic assessment after transsphenoidal surgery is best performed 4 to 6 months postoperatively. It should not be necessary to routinely include i.v. contrast medium injection in the postoperative evaluation of macroadenomas. (orig.)

  10. Transsphenoidal microsurgery in the treatment of acromegaly and gigantism.

    Science.gov (United States)

    Arafah, B U; Brodkey, J S; Kaufman, B; Velasco, M; Manni, A; Pearson, O H

    1980-03-01

    Twenty-five patients with acromegaly and 3 patients with gigantism underwent transsphenoidal microsurgery in an attempt to remove the tumor and preserve normal pituitary function whenever possible. An adenoma was identified and removed in 27 of 28 patients. Evaluation 3--6 months postoperatively revealed a GH level less than 5 ng/ml in 29 patients, 5--10 ng/ml in 4 patients and 11--29 ng/ml in 4 other patients. Dynamics of GH secretion were normal in 11 patients who had normal pituitary function and are considered cured. Two patients with low or undetectable GH levels are also considered cured at the expense of being hypopituitary. Three of 7 patients with normal basal GH levels but abnormal dynamics of GH secretion relapsed within 1 yr. Eleven of the 13 patients considered cured did not have extrasellar extension, while 14 of the 15 patients not cured had extrasellar extension. Five patients who were not cured with surgery received radiation therapy. Three patients were treated with an ergot derivative, Lergotrile mesylate, after surgery and radiation therapy failed to normalize GH levels. Transsphenoidal microsurgery is an optimal form of therapy for patients with acromegaly or gigantism, especially those with no extrasellar extension. Dynamics of GH secretion are very useful in evaluating the completeness of adenoma removal.

  11. Pure endoscopic transsphenoidal surgery for treatment of acromegaly: results of 67 cases treated in a pituitary center.

    Science.gov (United States)

    Gondim, Jackson A; Almeida, João Paulo; de Albuquerque, Lucas Alverne F; Gomes, Erika; Schops, Michele; Ferraz, Tania

    2010-10-01

    Acromegaly is a chronic disease related to the excess of growth hormone (GH) and insulin-like growth factor–I secretion, usually by pituitary adenomas. Traditional treatment of acromegaly consists of surgery, drug therapy, and eventually radiotherapy. The introduction of endoscopy as an additional tool for surgical treatment of pituitary adenomas and, therefore, acromegaly represents an important advance of pituitary surgery in the recent years. The aim of this retrospective study is to evaluate the results of pure transsphenoidal endoscopic surgery in a series of patients with acromegaly who were operated on by a pituitary specialist surgeon. The authors discuss the advantages, outcome, complications, and factors related to the success of the endoscopic approach in cases of GHsecreting adenomas. The authors retrospectively analyzed data from cases involving patients with GH-secreting adenomas who underwent pure transsphenoidal endoscopic surgery at the Department of Neurosurgery of the General Hospital in Fortaleza, Brazil, between 2000 and 2009. Tumors were classified according to size as micro- or macroadenomas, and tumor extension was analyzed based on suprasellar/parasellar extension and sella floor destruction. All patients were followed up for at least 1 year. The criteria of disease control were GH levels transsphenoidal surgery for treatment of acromegaly. Disease control was obtained in 50 cases (74.6%). The rate of treatment success was higher in patients with microadenomas (disease control achieved in 12 [85.7%] of 14 cases) than in those with larger lesions. Suprasellar/parasellar extension and high levels of sella floor erosion were associated with lower rates of disease control (p = 0.01 and p = 0.02, respectively). Complications related to the endoscopic surgery included epistaxis (6.0%), transitory diabetes insipidus (4.5%), and 1 case of seizure (1.5%). Endoscopic transsphenoidal surgery represents an effective option for treatment of patients

  12. Endoscopic Endonasal Surgery for Purely Intrathird Ventricle Craniopharyngioma.

    Science.gov (United States)

    Nishioka, Hiroshi; Fukuhara, Noriaki; Yamaguchi-Okada, Mitsuo; Yamada, Shozo

    2016-07-01

    Extended endoscopic transsphenoidal surgery (EETS) is a safe and effective treatment for many suprasellar craniopharyngiomas, including those with third-ventricle involvement. Craniopharyngioma entirely within the third ventricle (purely intraventricular type), however, is generally regarded unsuitable for treatment with EETS. Three patients underwent total removal of a purely intraventricular craniopharyngioma with inferior extension via EETS by direct incision of the bulging, stretched ventricular floor and fine dissection from the ventricular wall. In 2 patients with an anteriorly displaced chiasm, the space between the chiasm and pituitary stalk created a wide corridor to the ventricle, whereas in the third case, in which the infrachiasmal space was somewhat narrowed, partial sacrifice of the pituitary gland was necessary to obtain sufficient space. Despite preservation of the stalk in 2 patients, hypopituitarism and diabetes insipidus developed after surgery. There was no other complication including obesity. Selected patients with purely intraventricular craniopharyngioma can be treated effectively and safely with EETS. Those with inferior extension in the interpeduncular fossa and anterior displacement of the chiasm may be suitable candidates. Copyright © 2016 Elsevier Inc. All rights reserved.

  13. Endoscopic Endonasal Resection of Retrochiasmatic Craniopharyngioma with Fascia Lata Button and Nasoseptal Flap Reconstruction.

    Science.gov (United States)

    Kshettry, Varun R; Nyquist, Gurston; Evans, James J

    2018-02-01

    Surgery for craniopharyngiomas can be challenging due to the involvement of multiple critical neurovascular structures. The expanded endoscopic endonasal approach can provide superior access to suprasellar craniopharyngiomas, particularly with retrochiasmatic extension and significant hypothalamic involvement. We describe the surgical technique used to treat a 30-year-old patient who presented with 4 weeks of worsening vision, fatigue, and memory loss. His vision was counting fingers at 1 feet on the right and 20/800 on the left with a temporal hemianopsia. Laboratory evaluation demonstrated central hypoadrenalism, hypothyroidism, and hypogonadism. Imaging showed a large solid and cystic suprasellar mass. The transtubercular approach with removal of the lateral tubercular strut can provide wide bilateral access to the opticocarotid region. The superior intercavernous sinus must be coagulated and ligated. Initial arachnoid dissection is centered at the midline, mobilizing the superior hypophyseal branches to the optic apparatus laterally. The cyst capsule is opened and care is taken to minimize spillage of cyst fluid into the subarachnoid space. Central debulking and then extracapsular dissection is performed under direct visualization using sharp dissection. Reconstruction of the dura is performed with an inlay/onlay fascia lata button that is held together with four sutures that hold the graft edges against the native dural edges. This is followed by vascularized nasoseptal flap reconstruction. No lumbar drain or nonabsorbable packing is required. The patient's vision had dramatic improvement and by 1 week postoperatively was 20/20 with full visual fields. Postoperative diabetes insipidus was managed with nasal desmopressin. Postoperative MRI demonstrated complete removal. The link to the video can be found at: https://youtu.be/QQxCNUcq1qg .

  14. Efficacy of transsphenoidal surgery in achieving biochemical cure of growth hormone-secreting pituitary adenomas among patients with cavernous sinus invasion: a systematic review and meta-analysis.

    Science.gov (United States)

    Briceno, Vanessa; Zaidi, Hasan A; Doucette, Joanne A; Onomichi, Kaho B; Alreshidi, Amer; Mekary, Rania A; Smith, Timothy R

    2017-05-01

    Growth hormone-secreting pituitary adenomas in adults can result in severe craniofacial disfigurement and potentially fatal medical complications. Surgical resection leading to remission of the disease is dependent on complete surgical resection of the tumor. Lesions that invade the cavernous sinus may not be safely accessible via an endonasal transsphenoidal surgery (TSS), and the rates of biochemical remission of patients with residual disease vary widely in the literature. We conducted a meta-analysis to examine the prevalence of biochemical remission after TSS among patients with growth hormone-secreting pituitary adenomas with and without cavernous sinus invasion. Embase, PubMed, and Cochrane Library databases were searched for relevant publications. Fourteen studies with 972 patients with biochemically confirmed growth hormone-secreting pituitary adenomas were included in the meta-analysis. The overall remission prevalence under a fixed-effect model was 47.6% (95% CI = 40.8-54.4%) for patients with invasive macroadenomas (I 2  = 74.6%, p < 0.01); 76.4% (95% CI = 72.2-80.1%) for patients with non-invasive macroadenomas (I 2  = 59.6%, p = 0.03); and 74.2% (95% CI = 66.3-80.7%) for patients with non-invasive microadenomas (I 2  = 36.4, p = 0.10). The significant difference among the three groups resulted from the difference between patients with or without cavernous sinus invasion (p = 0.01) and not from the size of adenomas among those without cavernous sinus invasion (p = 0.66). The prevalence of biochemical remission in patients with cavernous sinus invasion was lower than in patients without cavernous sinus invasion after TSS for acromegaly.

  15. Predictors and Rates of Delayed Symptomatic Hyponatremia after Transsphenoidal Surgery: A Systematic Review [corrected].

    Science.gov (United States)

    Cote, David J; Alzarea, Abdulaziz; Acosta, Michael A; Hulou, Mohamed Maher; Huang, Kevin T; Almutairi, Hamoud; Alharbi, Ahmad; Zaidi, Hasan A; Algrani, Majed; Alatawi, Ahmad; Mekary, Rania A; Smith, Timothy R

    2016-04-01

    Delayed symptomatic hyponatremia (DSH) is a known complication of transsphenoidal surgery that can lead to prolonged hospital stay, readmission, and in rare cases, death. Many potential predictors for development of DSH have been investigated. A better understanding of DSH risk can lead to better patient outcomes. We performed a systematic review to determine the rates and predictors of DSH after both endoscopic transsphenoidal surgery and microscopic transsphenoidal surgery. A systematic search of the literature was conducted using MEDLINE/PUBMED, EMBASE, and Cochrane databases. Inclusion criteria were 1) case series with at least 10 cases reported, 2) adult patients who underwent eTSS or mTSS for pituitary tumors, and 3) reported occurrence of DSH (defined as serum sodium level transsphenoidal surgery. Copyright © 2016 Elsevier Inc. All rights reserved.

  16. Cerebrospinal fluid leakage during transsphenoidal surgery: postoperative external lumbar drainage reduces the risk for meningitis

    NARCIS (Netherlands)

    van Aken, M. O.; Feelders, R. A.; de Marie, S.; van de Berge, J. H.; Dallenga, A. H. G.; Delwel, E. J.; Poublon, R. M. L.; Romijn, J. A.; van der Lely, A. J.; Lamberts, S. W. J.; de Herder, W. W.

    2004-01-01

    Postoperative meningitis is a well known complication of transsphenoidal surgery (TSS). The objective of this study was to evaluate whether postoperative external cerobrospinal fluid (CSF) drainage in case of intraoperative CSF-leakage, reduces the risk of postoperative meningitis. We

  17. Selective occlusion of a carotid sinus cavernous fistula after transsphenoidal hypophysectomy

    International Nuclear Information System (INIS)

    Lins, E.; Dietrich, U.; Wappenschmidt, J.

    1987-01-01

    A case of carotid cavernous sinus fistula following transsphenoidal hypophysectomy is reported. A selective occlusion of the fistula with patency of the carotid artery was achieved by means of a detachable balloon catheter. (orig.) [de

  18. Trigemino-cardiac reflex: occurrence of asystole during trans-sphenoidal adenomectomy: a case report.

    Science.gov (United States)

    Jeon, Dae Geun; Kang, Bong Jin; Hur, Tae Won

    2014-09-01

    The trigemino-cardiac reflex has been reported to occur during various craniofacial surgeries or procedures including manipulation of the trigeminal ganglion, tumor resection in the cerebellopontine angle, various facial reconstructions and trans-sphenoidal adenomectomy. Regarding risk factors during trans-sphenoidal adenomectomy, invasiveness closely related to the size of tumor and the degree of manipulation of cavernous sinus wall have been reported. We report the case of a 40-year-old female patient who had a relatively small-sized (trans-sphenoidal operation of the wall of the cavernous sinus, which strongly suggests the importance of careful manipulation of the cavernous sinus wall. In addition to reporting this rare complication of trans-sphenoidal adenomectomy, we reviewed its clinical management by performing a literature search.

  19. Trigemino-cardiac reflex: occurrence of asystole during trans-sphenoidal adenomectomy: a case report

    OpenAIRE

    Jeon, Dae Geun; Kang, Bong Jin; Hur, Tae Won

    2014-01-01

    The trigemino-cardiac reflex has been reported to occur during various craniofacial surgeries or procedures including manipulation of the trigeminal ganglion, tumor resection in the cerebellopontine angle, various facial reconstructions and trans-sphenoidal adenomectomy. Regarding risk factors during trans-sphenoidal adenomectomy, invasiveness closely related to the size of tumor and the degree of manipulation of cavernous sinus wall have been reported. We report the case of a 40-year-old fem...

  20. Image guidance in trans-sphenoidal surgery for giant pituitary adenomas: Luxury or necessity?

    OpenAIRE

    Deepak Agrawal

    2012-01-01

    Background: In spite of availability of image guidance (neuronavigation) at major centers around the world, most trans-sphenoidal surgeries for pituitary adenomas continue to be done under fluoroscopic control. On the other hand, the high mortality and morbidity for giant pituitary adenomas is mainly due to inadequate tumor removal. Aims and Objectives: The objective of this study was to study to utility of image guidance in trans-sphenoidal surgeries for optimizing tumor removal in giant pit...

  1. Comparative evaluation of atenolol and clonidine premedication on cardiovascular response to nasal speculum insertion during trans-sphenoid surgery for resection of pituitary adenoma: A prospective, randomised, double-blind, controlled study

    Directory of Open Access Journals (Sweden)

    Devendra Gupta

    2011-01-01

    Full Text Available Severe cardiovascular responses in the form of tachycardia and hypertension following nasal speculum insertion occur during sublabial rhinoseptal trans-sphenoid approach for resection of small pituitary tumours. We compare the effects of preoperative administration of clonidine (α-2 agonist and atenolol (α-blocker over haemodynamic response, caused by speculum insertion during trans-sphenoid pituitary resection. We enrolled 66 patients in age range 18-65 years, of ASA I-II, and of either sex undergoing elective sublabial rhinoseptal trans-sphenoidal hypophysectomy. Group I (control received placebo, group II (clonidine received tablet clonidine 5 μg/kg, and group III (atenolol received tablet atenolol 0.5 mg/kg. The heart rate increased on speculum insertion and 5 and 10 minutes following speculum insertion as compared to the pre-speculum values in the control group, while no change in the heart rate was observed in other groups (P<0.05. There was a rise in the mean arterial pressure during and 5, 10, and 15 minutes after nasal speculum insertion in the control group, whereas it was not seen in other groups (P<0.05. We therefore suggest that oral clonidine and oral atenolol (given 2 hours prior to surgery is an equally effective and safe method of attenuating haemodynamic response caused by nasal speculum insertion during trans-sphenoid pituitary resection.

  2. A comparative analysis of online education resources for patients undergoing endoscopic transsphenoidal surgery.

    Science.gov (United States)

    Fahey, Natalie; Patel, Vimal; Rosseau, Gail

    2014-12-01

    Endoscopic transsphenoidal surgery has become the most commonly performed surgical procedure for pituitary tumor removal. As such, there are many patient-oriented educational materials on the technique available online for members of the public who desire to learn more about the surgery. It has been recommended that educational resources be written to the national average reading level, which in the United States is between sixth and seventh grade. This study assesses the reading level of the educational materials currently available online for endoscopic transsphenoidal surgery and determines whether these resources are written at a suitable comprehension level for most readers. Sixteen patient educational resources describing endoscopic transsphenoidal surgery were identified online and assessed using 4 standard readability assessments. Patient educational resources written for endoscopic transsphenoidal surgery are written far above the recommended reading level of sixth grade. The online educational resources written for patients about endoscopic transsphenoidal surgery are above the recommended reading level for patient education materials. Further revisions to simplify these resources on endoscopic transsphenoidal surgery are needed to ensure that most patients can comprehend this important material and make informed decisions about their health care. Copyright © 2014. Published by Elsevier Inc.

  3. Perioperative management and complications in patients with obstructive sleep apnea undergoing transsphenoidal surgery: Our institutional experience.

    Science.gov (United States)

    Rahimi, Eiman; Mariappan, Ramamani; Tharmaradinam, Suresh; Manninen, Pirjo; Venkatraghavan, Lashmi

    2014-07-01

    Patients with endocrine diseases such as acromegaly and Cushing's disease have a high prevalence of obstructive sleep apnea (OSA). There is controversy regarding the use of continuous positive airway pressure (CPAP) following transsphenoidal surgery. The aim of this study was to compare the perioperative management and complications, in patients with or without OSA undergoing transsphenoidal surgery. After Research Ethics Board approval, we retrospectively reviewed the charts of all patients who underwent transsphenoidal surgery in our institution from 2006 to 2011. Information collected included patients' demographics, pathology of lesion, history of OSA, anesthetic and perioperative management and incidence of perioperative complications. Patients with sleep study proven OSA were compared with a control group, matched for age, sex and pathology of patients without OSA. Statistical analysis was performed using t-test and Chi-square test and the P transsphenoidal surgery, 105 patients were found to be at risk for OSA by a positive STOP-BANG scoring assessment. Preoperative sleep study testing was positive for OSA in 38 patients. Post-operative hypoxemia (SpO2 transsphenoidal surgery can be treated in most but not all patients with high flow oxygen using the face mask. We were able to safely use CPAP in a very small number of patients but caution is needed to prevent complications. Further prospective studies are needed to determine the safe use of CPAP in patients after transsphenoidal surgery.

  4. Endoscopic endonasal skull base surgery: advantages, limitations, and our techniques to overcome cerebrospinal fluid leakage: technical note.

    Science.gov (United States)

    Ishii, Yudo; Tahara, Shigeyuki; Teramoto, Akira; Morita, Akio

    2014-01-01

    In recent years, resections of midline skull base tumors have been conducted using endoscopic endonasal skull base (EESB) approaches. Nevertheless, many surgeons reported that cerebrospinal fluid (CSF) leakage is still a major complication of these approaches. Here, we report the results of our 42 EESB surgeries and discuss the advantages and limits of this approach for resecting various types of tumors, and also report our technique to overcome CSF leakage. All 42 cases involved midline skull base tumors resected using the EESB technique. Dural incisions were closed using nasoseptal flaps and fascia patch inlay sutures. Total removal of the tumor was accomplished in seven pituitary adenomas (33.3%), five craniopharyngiomas (62.5%), five tuberculum sellae meningiomas (83.3%), three clival chordomas (100%), and one suprasellar ependymoma. Residual regions included the cavernous sinus, the outside of the intracranial part of the internal carotid artery, the lower lateral part of the posterior clivus, and the posterior pituitary stalk. Overall incidence of CSF leakage was 7.1%. Even though the versatility of the approach is limited, EESB surgery has many advantages compared to the transcranial approach for managing mid-line skull base lesions. To avoid CSF leakage, surgeons should have skills and techniques for complete closure, including use of the nasoseptal flap and fascia patch inlay techniques.

  5. Transsphenoidal Surgery for Mixed Pituitary Gangliocytoma-Adenomas.

    Science.gov (United States)

    Shepard, Matthew J; Elzoghby, Mohamed A; Ghanim, Daffer; Lopes, M Beatriz S; Jane, John A

    2017-12-01

    Most sellar gangliocytomas are discovered with a concurrent pituitary adenoma, also known as a mixed gangliocytoma-adenoma (MGA). MGAs are rare, with fewer than 100 cases reported in the literature to date and only 1 previously documented surgical series. Because MGAs are radiologically indistinguishable from pituitary adenomas, they are often diagnosed after surgery. Combined with the paucity of clinical outcome data for these tumors, this makes their diagnosis and management challenging. Here we describe the clinical presentation and outcomes of 10 individuals who were diagnosed with a MGA at a single institution. This retrospective case series study included patients diagnosed with a combined sellar MGA between 1993 and 2016. This series comprised 10 patients, mean age of 44 years (range, 28-63 years) diagnosed with an MGA. The mean tumor size was 1.6 cm (range, 0.4-2.4 cm). Five patients presented with acromegaly, and 1 patient had recurrent Cushing disease. Transsphenoidal surgery was performed in all cases, and gross total resection was achieved in 7 patients (70%). Histologically, 9 of the 10 MGAs were identified as mixed somatotroph adenoma-gangliocytomas. The median duration of follow-up was 74 months (range, 2-180 months). Following adjuvant treatment (n = 3), all patients with acromegaly (n = 4) achieved biochemical remission, and no patient experienced recurrence of the pituitary tumor with a median radiographic follow-up of 48 months. MGAs are often associated with a hypersecretory adenoma. Transsphenoidal surgery is well tolerated by most patients, and when performed in combination with adjuvant therapy, a low rate of recurrence and reversal of preoperative endocrinopathy can be expected. Copyright © 2017 Elsevier Inc. All rights reserved.

  6. Post-operative diabetes insipidus after endoscopic transsphenoidal surgery.

    Science.gov (United States)

    Schreckinger, Matthew; Walker, Blake; Knepper, Jordan; Hornyak, Mark; Hong, David; Kim, Jung-Min; Folbe, Adam; Guthikonda, Murali; Mittal, Sandeep; Szerlip, Nicholas J

    2013-12-01

    Diabetes insipidus (DI) after endoscopic transsphenoidal surgery (ETSS) can lead to increased morbidity, longer hospital stays, and increased medication requirements. Predicting which patients are at high risk for developing DI can help direct services to ensure adequate care and follow-up. The objective of this study was to review our institution's experience with ETSS and determine which clinical/laboratory variables are associated with DI in this patient population. The authors wanted to see if there was an easily determined single value that would help predict which patients develop DI. This represents the largest North American series of this type. We retrospectively reviewed the charts of patients who had undergone ETSS for resection of sellar and parasellar pathology between 2006 and 2011. We examined patient and tumor characteristics and their relationship to postoperative DI. Out of 172 endoscopic transsphenoidal surgeries, there were 15 cases of transient DI (8.7%) and 14 cases of permanent DI (8.1%). Statistically significant predictors of postoperative DI (p 1-deamino-8-D-arginine vasopressin. An increase in serum sodium of ≥2.5 mmol/L is a positive marker of development of DI with 80% specificity, and a postoperative serum sodium of ≥145 mmol/L is a positive indicator with 98% specificity. Identifying perioperative risk factors and objective indicators of DI after ETSS will help physicians care for patients postoperatively. In this large series, we demonstrated that there were multiple perioperative risk factors for the development of DI. These findings, which are consistent with other reports from microscopic surgical series, will help identify patients at risk for diabetes insipidus, aid in planning treatment algorithms, and increase vigilance in high risk patients.

  7. The transition from microscopic to endoscopic transsphenoidal surgery: the experience at Brigham and Women's Hospital.

    Science.gov (United States)

    Laws, Edward R; Barkhoudarian, Garni

    2014-12-01

    As interest and enthusiasm for the use of the endoscope in transsphenoidal anterior skull base and pituitary surgery increases, neurosurgeons are increasingly adopting endoscopic technology and associated novel concepts. Often this involves a transition from the standard operating microscope as the main means of visualization to the operating endoscope (2D or 3D) during surgery. The authors' experience with this transition is described, including the rationale, advantages and disadvantages of the two surgical techniques. The successful use of endoscopic surgery for a large variety of pathological problems involving the anterior skull base and the pituitary region is presented. Perceived advantages for the patient and the surgeon are described, as is the occasional need for transition back to the microscopic approach. The endoscopic approach and its allied technology are here to stay. They are useful and occasionally preferable methods for treating a variety of suitable lesions involving the anterior skull base. The importance of incorporating the basic principles of skull base surgery is emphasized. Copyright © 2014 Elsevier Inc. All rights reserved.

  8. Spontaneous reossification of the sella in transsphenoidal reoperation associated with strontium ranelate

    Directory of Open Access Journals (Sweden)

    Maria Mercedes Pineyro

    2017-07-01

    Full Text Available Spontaneous reossification of the sellar floor after transsphenoidal surgery has been rarely reported. Strontium ranelate, a divalent strontium salt, has been shown to increase bone formation, increasing osteoblast activity. We describe an unusual case of a young patient with Cushing’s disease who was treated with strontium ranelate for low bone mass who experienced spontaneous sellar reossification after transsphenoidal surgery. A 21-year-old male presented with Cushing’s features. His past medical history included delayed puberty diagnosed at 16 years, treated with testosterone for 3 years without further work-up. He was diagnosed with Cushing’s disease initially treated with transsphenoidal surgery, which was not curative. The patient did not come to follow-up visits for more than 1 year. He was prescribed strontium ranelate 2 g orally once daily for low bone mass by an outside endocrinologist, which he received for more than 1 year. Two years after first surgery he was reevaluated and persisted with active Cushing’s disease. Magnetic resonance image revealed a left 4 mm hypointense mass, with sphenoid sinus occupation by a hyperintense material. At repeated transsphenoidal surgery, sellar bone had a very hard consistency; surgery was complicated and the patient died. Sellar reossification negatively impacted surgery outcomes in this patient. While this entity is possible after transsphenoidal surgery, it remains unclear whether strontium ranelate could have affected sellar ossification.

  9. Transsphenoidal surgery and diabetes mellitus: An analysis of inpatient data and complications.

    Science.gov (United States)

    Pines, Morgan J; Raikundalia, Milap D; Svider, Peter F; Baredes, Soly; Liu, James K; Eloy, Jean Anderson

    2015-10-01

    Transsphenoidal surgery (TSS) has emerged as the standard approach for pituitary resection due to its minimally invasive nature. There has been little analysis examining the impact of diabetes mellitus (DM) on patients undergoing TSS. In this study, we characterize DM's association with postoperative TSS complications. In addition to analysis of associated charges and patient demographics, we performed comparison of complication rates between DM and non-DM patients who have undergone TSS in recent years. The Nationwide Inpatient Sample, a database encompassing nearly 8 million inpatient hospitalizations, was evaluated for patients undergoing TSS from 2002 to 2010. Of 12,938 TSS patients, 2,173 (16.8%) had a DM diagnosis. The non-DM cohort was younger (50.1 y ± 16.6SD vs. 56.8 y ± 14.1; P complications, and had a lesser incidence of diabetes insipidus (P complications was present only among patients diabetics when compared to non-DM blacks. DM is associated with greater length of stay and hospital charges among TSS patients. DM patients undergoing TSS have a significantly greater incidence of pulmonary and fluid/electrolyte complications among patients under the age of 60, and greater risk for urinary/renal complications across all ages. Despite a theoretical concern due to an impaired wound-healing in DM patients, association with cerebrospinal fluid rhinorrhea was only noted among black diabetics. 2C. © 2015 The American Laryngological, Rhinological and Otological Society, Inc.

  10. Endoscopic transsphenoidal surgery for cushing disease: techniques, outcomes, and predictors of remission.

    Science.gov (United States)

    Starke, Robert M; Reames, Davis L; Chen, Ching-Jen; Laws, Edward R; Jane, John A

    2013-02-01

    The efficacy of endoscopic transsphenoidal surgery (ETS) for Cushing disease has not been clearly established. To assess efficacy of a pure endoscopic approach for treatment of Cushing disease and determine predictors of remission. A prospectively acquired database of 61 patients undergoing ETS was reviewed. Remission was defined as postoperative morning serum cortisol of Cushing [100%], macroadenomas [87%]). At 2- to 3-month evaluations, 45 of 49 patients (91.8%) were in remission. Fifty patients were followed for at least 12 months (mean, 28 months; range, 12-72). Forty-two (84%) achieved remission from a single ETS. In these patients, there was no significant difference in remission rates between microadenomas (93%), magnetic resonance imaging-negative (70%), and macroadenomas (77%). Patients with history of previous surgery (n = 14, 23%) were 9 times less likely to achieve follow-up remission (P = .021). In-house cortisol level of Cushing disease provides high rates of remission with low rates of complications regardless of size. Although patients with a history of previous surgery are less likely to achieve remission, the majority can still achieve remission following treatment.

  11. Investigation of effectiveness of surgical treatment of chronic dacryocystitis - endonasal dacryocystorhinostomy

    Directory of Open Access Journals (Sweden)

    Borodulya V.L.

    2017-10-01

    Full Text Available Prolonged and conti­nuous lacrimation (symptom of epiphora causes discomfort, inclination to conjunctiva infect, reduces visual acuity and ultimately the quality of life of the patient. Despite the fact that there is a large number of various surgical interventions to restore tearing in patients with chronic dacryocystitis, the problem of lacrimation remains relevant. We have studied the operation of endonasal dacryocystorhinostomy and its long-term consequences. Surgical intervention in endonasal dacryocystorhinostomy is aimed at eliminating lacrimation by eliminating stenosis and forming a new combination of the cavity of the laryngeal canal with the nasal cavity, as well as the sanation of purulent foci of infection in the throat. There were 8 surgical interventions. Period of observation of patients in the postoperative period by ophthalmologist and ENT-doctor is from 1.5 to 2 years. The evaluation of the result was carried out in 6 months or more after the operation. A complete recovery with the recovery of the tear excretion in the nasal cavity has been achieved in all patients. The formed rhinostoma was wide, well functioning. Thus, endonasal dacryocystorhinostomy is a highly effective and should be a method of choice for inflammation of the lacrimal sac at any stage of development.

  12. Magnetic resonance imaging of plugged homograft fat after transsphenoidal surgery

    International Nuclear Information System (INIS)

    Kameda, Hideki

    1989-01-01

    The auther studied the changes of magnetic resonance (MR) images of the epidural transplanted homograft fats in dogs and the intrasellar plugged homograft fats after the transsphenoidal pituitary surgeries (TS). Twenty-eight MR images of 18 patients were examined on 23 days to 1708 days after TS. After the epidural transplantation of the homologous fatty tissue in dog, its T 1 relaxation time (T 1 ) was significantly prolonged (p 2 relaxation time (T 2 ) was significantly shortened (p 1 -weighted or T 2 -weighted image. Over one year after TS, the homografts showed low signal intensities in either T 1 -weighted or T 2 -weighted images. Therefore they were differentiated from the pituitary glands and adenomas. The histopathological studies showed the epidural transplanted homografts had many macrophages, liquefaction and were finally replaced by connective tissues. From this study, it was concluded that the homograft fat can be differentiated from the pituitary gland and adenoma by MR image and changes of T 1 and T 2 may be induced by increasing of free water, macrophage and fibrosis. (author)

  13. Repeated transsphenoidal surgery for resection of pituitary adenoma.

    Science.gov (United States)

    Wang, Shousen; Xiao, Deyong; Wang, Rumi; Wei, Liangfeng; Hong, Jingfang

    2015-03-01

    To investigate the surgical strategy of repeated microscopic transsphenoidal surgery (TSS) for treatment of pituitary adenoma, surgical techniques and treatment outcomes for 29 patients with pituitary adenoma were reviewed and analyzed. There were 17 patients who underwent TSS 18 times and 12 patients who underwent TSS 13 times. The interval between each TSS ranged from 3 months to 18 years, with a median time of 4 years. The tumor height was 15 to 45 mm on the last surgery. Among the 29 patients, 16 patients underwent total tumor resection, 11 patients underwent subtotal resection, and 2 patients underwent partial resection. Cerebrospinal fluid leak occurred in 10 patients. Among 24 patients who were followed up effectively, 1 patient developed abducens paralysis after surgery, 1 patient had chronic diabetes insipidus, and 1 patient received steroid-dependent alternative treatment. The repeated TSS may present satisfied outcomes in experienced hands. The upper edge of the posterior choanae should be identified to ensure the right orientation. The openings of the anterior wall of the sphenoid sinus and the sellar floor should be appropriately expanded to improve tumor exposure. The artificial materials should be identified and removed carefully. Intraoperative cerebrospinal fluid leakage should be managed well.

  14. Training to acquire psychomotor skills for endoscopic endonasal surgery using a personal webcam trainer.

    Science.gov (United States)

    Hirayama, Ryuichi; Fujimoto, Yasunori; Umegaki, Masao; Kagawa, Naoki; Kinoshita, Manabu; Hashimoto, Naoya; Yoshimine, Toshiki

    2013-05-01

    Existing training methods for neuroendoscopic surgery have mainly emphasized the acquisition of anatomical knowledge and procedures for operating an endoscope and instruments. For laparoscopic surgery, various training systems have been developed to teach handling of an endoscope as well as the manipulation of instruments for speedy and precise endoscopic performance using both hands. In endoscopic endonasal surgery (EES), especially using a binostril approach to the skull base and intradural lesions, the learning of more meticulous manipulation of instruments is mandatory, and it may be necessary to develop another type of training method for acquiring psychomotor skills for EES. Authors of the present study developed an inexpensive, portable personal trainer using a webcam and objectively evaluated its utility. Twenty-five neurosurgeons volunteered for this study and were divided into 2 groups, a novice group (19 neurosurgeons) and an experienced group (6 neurosurgeons). Before and after the exercises of set tasks with a webcam box trainer, the basic endoscopic skills of each participant were objectively assessed using the virtual reality simulator (LapSim) while executing 2 virtual tasks: grasping and instrument navigation. Scores for the following 11 performance variables were recorded: instrument time, instrument misses, instrument path length, and instrument angular path (all of which were measured in both hands), as well as tissue damage, max damage, and finally overall score. Instrument time was indicated as movement speed; instrument path length and instrument angular path as movement efficiency; and instrument misses, tissue damage, and max damage as movement precision. In the novice group, movement speed and efficiency were significantly improved after the training. In the experienced group, significant improvement was not shown in the majority of virtual tasks. Before the training, significantly greater movement speed and efficiency were demonstrated in

  15. Transsphenoidal surgery for pituitary gigantism and galactorrhea in a 3.5 year old child.

    Science.gov (United States)

    Flitsch, J; Lüdecke, D K; Stahnke, N; Wiebel, J; Saeger, W

    2000-05-01

    The management of pituitary macroadenomas which lead to gigantism may require multiple therapeutical approaches, including medical treatment, surgery, and radiation therapy. Transsphenoidal surgery (TSS) during early childhood that achieves total removal of a growth hormone (GH) secreting tumor is rarely reported. The surgeon is confronted with special problems regarding the infantile anatomy. In this case, a 3.5 year old child, the youngest successfully treated by TSS so far, suffered from a GH- and prolactin (PRL) secreting macroadenoma of the pituitary gland. The girl initially presented with an increasing growth rate, later with breast development, and finally, at the age of 2.8 years, with galactorrhea and secretion of blood from the nipples. Increased levels of GH [122 micrograms/l], insulin-like growth factor (IGF-1) [830 micrograms/l], insulin-like growth factor binding protein 3 (IGFBP-3) [8.6 mg/l] and PRL [590 micrograms/l] were found. MRI scans revealed a macroadenoma of 2.7 cm diameter. An eight-week trial of relatively low dose dopamine agonists led to a reduction of PRL, while the GH- and IGF-1 levels remained unchanged; the tumor showed only little shrinkage. Since there was chiasma compression, we opted for early TSS. A complete tumor removal was achieved despite the difficulties of a narrow approach. After TSS, low levels of GH, IGF-1, and PRL documented a complete tumor removal, but persistent diabetes insipidus and anterior lobe deficits resulted from surgery. In summary, if primary medical therapy alone is unable to adequately reduce hormone hypersecretion and tumor size in early childhood, TSS is recommended. Thus, radiation therapy may be reserved for surgical failure.

  16. Endoscopic Versus Microscopic Transsphenoidal Surgery in the Treatment of Pituitary Adenoma: A Systematic Review and Meta-Analysis.

    Science.gov (United States)

    Li, Aijun; Liu, Weisheng; Cao, Peicheng; Zheng, Yuehua; Bu, Zhenfu; Zhou, Tao

    2017-05-01

    Inconsistent findings have been reported regarding the efficacy and safety of endoscopic and microscopic transsphenoidal surgery for pituitary adenoma. This study aimed to assess the benefits and shortcomings of these surgical methods in patients with pituitary adenoma. The electronic databases PubMed, Embase, and the Cochrane Library were systematically searched, as well as proceedings of major meetings. Eligible studies with a retrospective or prospective design that evaluated endoscopic versus microscopic methods in patients with pituitary adenoma were included. Primary outcomes included gross tumor removal, cerebrospinal fluid leak, diabetes insipidus, and other complications. Overall, 23 studies (4 prospective and 19 retrospective) assessing 2272 patients with pituitary adenoma were included in the final analysis. Endoscopic transsphenoidal surgery was associated with a higher incidence of gross tumor removal (odds ratio, 1.52; 95% confidence interval, 1.11-2.08; P = 0.009) than those with microscopic transsphenoidal surgery. In addition, endoscopic transsphenoidal surgery had no significant effect on the risk of cerebrospinal fluid leak, compared with microscopic transsphenoidal surgery. Furthermore, endoscopic transsphenoidal surgery was associated with a 22% reduction in risk of diabetes insipidus compared with microscopic transsphenoidal surgery, but the difference was not statistically significant. Endoscopic transsphenoidal surgery significantly reduced the risk of septal perforation (odds ratio, 0.29; 95% confidence interval, 0.11-0.78; P = 0.014) and was not associated with the risk of meningitis, epistaxis, hematoma, hypopituitarism, hypothyroidism, hypocortisolism, total mortality, and recurrence. Endoscopic transsphenoidal surgery is associated with higher gross tumor removal and lower incidence of septal perforation in patients with pituitary adenoma. Future large-scale prospective randomized controlled trials are needed to verify these findings

  17. Combined Endoscopic Transorbital and Endonasal Repair of High Flow Orbital Apex/Middle Fossa Cerebrospinal Fluid Leak with a Nasoseptal Flap.

    Science.gov (United States)

    Lucke-Wold, Brandon; Mendez, Gustavo; Cua, David; Akins, Paul; Gillham, Haley; Ciporen, Jeremy

    2018-01-01

    High flow orbital apex or middle fossa cerebrospinal fluid (CSF) leaks can be life threatening and complex to repair. These leaks associated with large dural defects are most commonly repaired with an open temporalis muscle patch or free flaps, but these flaps do not always stop the leak. A 65-year-old patient presented two years after orbital exenteration and radiation for squamous cell carcinoma. He developed multi-organism meningitis and pneumocephalus secondary to a large high-flow orbital apex/middle fossa CSF leak. To repair the leak, a combined endoscopic transorbital/endonasal approach with pedicled nasospetal flap and dermis fat graft was used. We describe the unique endoscopic technique that was used to treat the life threatening high flow orbital apex/middle fossa CSF leak. The technique allowed the use of the transposed pedicled flap, which is an alternative to the free flap in controlling CSF leak. Cisternogram post-operatively and clinical exam confirmed resolution of CSF leak. Although a critically ill patient at admission with a modified Rankin scale (MRS) of 5, he was discharged home on continued IV antibiotic therapy with a MRS of 3. Endoscopic evaluation at three months after treatment showed the effectiveness of the flap and he continued to improve clinically. This is the first case to describe a combined endoscopic transorbital and endonasal repair of high flow orbital apex/middle fossa CSF leak with a pedicled nasoseptal flap. These techniques can be utilized during initial reconstruction after orbital exenteration or as a salvage flap.

  18. Management strategy for treatment of vasospasm following transsphenoidal excision of craniopharyngioma.

    Science.gov (United States)

    Nash, Robert; Elwell, V; Brew, S; Powell, M; Grieve, J P

    2016-11-01

    We describe two cases of clinical and radiographic vasospasm after transsphenoidal resection of a craniopharyngioma. We review the literature on the association of vasospasm and craniopharyngioma and examine management options. Given the lack of evidence for the optimal management of these patients, treatment in concordance with protocols for vasospasm due to subarachnoid haemorrhage is recommended.

  19. Evaluation of the factors predicting the outcome of transsphenoidal microsurgery in patients with premenopausal microprolactinoma

    International Nuclear Information System (INIS)

    Tsugu, Hitoshi; Emoto, Makoto; Oshiro, Shinya; Komatsu, Fuminari; Sakamoto, Seisaburo; Ohta, Mika; Fukushima, Takeo

    2008-01-01

    Although cabergoline is an effective first-line treatment for prolactinoma, transsphenoidal microsurgery remains useful for the treatment of microprolactinoma. We investigated the factors that predict the outcome of transsphenoidal microsurgery and also evaluated indications for this method in patients with prolactinoma. We reviewed the cases of 21 premenopausal patients with prolactinoma, who had undergone magnetic resonance imaging (MRI). The clinical characteristics, preoperative prolactin level, adenoma size, MIB-1 labeling index, and cavernous sinus invasion were evaluated. Cavernous sinus invasion was graded according to Knosp's MRI classification. The preoperative prolactin level (P=0.0268) and grade of cavernous sinus invasion (P=0.0284) were statistically significant predictors of a surgical cure for patients with prolactinoma. As a result, transsphenoidal microsurgery is considered to be an effective therapy for appropriately selected premenopausal patients with prolactinoma. We believe that patients with either low Knosp's grade (0 or 1) and/or a preoperative prolactin level of <100 ng/ml would benefit most from transsphenoidal microsurgery as a first-line treatment. (author)

  20. Successful treatment of acromegaly in a diabetic cat with transsphenoidal hypophysectomy

    NARCIS (Netherlands)

    Meij, B.P.|info:eu-repo/dai/nl/164045805; Auriemma, E.|info:eu-repo/dai/nl/304834734; Grinwis, G.C.M.|info:eu-repo/dai/nl/141470909; Buijtels, J.J.C.W.M.|info:eu-repo/dai/nl/304830844; Kooistra, H.S.|info:eu-repo/dai/nl/205285864

    2010-01-01

    J Feline Med Surg. 2010 May;12(5):406-10. Successful treatment of acromegaly in a diabetic cat with transsphenoidal hypophysectomy. Meij BP, Auriemma E, Grinwis G, Buijtels JJ, Kooistra HS. Department of Clinical Sciences of Companion Animals, Faculty of Veterinary Medicine, Utrecht University,

  1. Vision-related quality of life after transsphenoidal surgery for pituitary adenoma.

    Science.gov (United States)

    Okamoto, Yoshifumi; Okamoto, Fumiki; Yamada, Shozo; Honda, Maiko; Hiraoka, Takahiro; Oshika, Tetsuro

    2010-07-01

    PURPOSE. To use the 25-item National Eye Institute Visual Function Questionnaire (VFQ-25) to evaluate vision-related quality of life (VR-QOL) in patients with pituitary adenoma who undergo transsphenoidal surgery. METHODS. The VFQ-25 was self-administered by 74 patients with pituitary adenoma before and 3 months after surgery. Pre- and postoperative clinical data were collected, including age, sex, tumor type and size, logarithm of minimum angle of resolution best corrected visual acuity (logMAR BCVA), critical flicker fusion frequency, static perimetry scores (mean deviation [MD] and corrected pattern SD [CPSD]), duration of ocular symptoms, and number of systemic comorbidities. RESULTS. Seventy-four patients with a mean age of 48.2 years were studied. Transsphenoidal surgery for pituitary adenoma significantly improved logMAR BCVA and critical fusion flicker frequency in the worse-seeing eye and MD and CPSD scores in both the better- and worse-seeing eyes (P transsphenoidal surgery can dramatically improve VR-QOL in pituitary adenoma and that the preoperative VFQ-25 composite score and visual field disturbance in the better-seeing eye are particularly important predictors associated with the postoperative VR-QOL. The use of VFQ-25 provides a more comprehensive overview of the effectiveness of transsphenoidal surgery.

  2. The impact of transsphenoidal surgery on neurocognitive function : A systematic review

    NARCIS (Netherlands)

    Alsumali, Adnan; Cote, David J.; Regestein, Quentin R.; Crocker, Erin; Alzarea, Abdulaziz; Zaidi, Hasan A.; Bi, Wenya Linda; Dawood, Hassan Y.; Broekman, Marike L D; van Zandvoort, Martine J.E.; Mekary, Rania A.; Smith, Timothy R.

    2017-01-01

    Background Cognitive impairment following transsphenoidal surgery (TSS) among patients with pituitary tumors has been intermittently reported and is not well established. We performed a systematic review to summarize the impact of TSS on cognitive function. Methods We conducted a systematic search

  3. Trans-sphenoidal encephalocele in association with Dandy-Walker complex and cardiovascular anomalies

    Energy Technology Data Exchange (ETDEWEB)

    Joy, H.M.; Barker, C.S. [Wessex Neurological Centre, Southampton (United Kingdom); Small, J.H. [Dept. of Radiology, Royal Bournemouth Hospital (United Kingdom); Armitage, M. [Bournemouth Diabetes and Endocrine Centre, Royal Bournemouth Hospital (United Kingdom)

    2001-01-01

    We present a case of trans-sphenoidal encephalomeningocele in association with a posterior cranial fossa malformation which fulfils the criteria for the Dandy-Walker complex. Congenital cardiovascular defects were also present. An abnormality of neural crest development may be responsible for the combined occurrence of these anomalies. (orig.)

  4. Outcome of Cushing's disease following transsphenoidal surgery in a single center over 20 years.

    LENUS (Irish Health Repository)

    Hassan-Smith, Zaki K

    2012-04-01

    Historically, Cushing\\'s disease (CD) was associated with a 5-yr survival of just 50%. Although advances in CD management have seen mortality rates improve, outcome from transsphenoidal surgery (TSS), the current first-line treatment, varies significantly between centers.

  5. Evaluation of adenohypophyseal reserve in patients carrier of hypophyseal adenoma treated by trans-sphenoidal surgery

    International Nuclear Information System (INIS)

    Drubscky, A.T.

    1980-01-01

    Fifteen patients carrier hypophyseal adenomas, with ages varying between 16 to 53 years were studied. The patients presented sella changes to the conventional plane radiographies and were submited a surgery treatment, with acess to hypophysis by the trans-sphenoidal way. (author)

  6. Morbidity of repeat transsphenoidal surgery assessed in more than 1000 operations.

    Science.gov (United States)

    Jahangiri, Arman; Wagner, Jeffrey; Han, Sung Won; Zygourakis, Corinna C; Han, Seunggu J; Tran, Mai T; Miller, Liane M; Tom, Maxwell W; Kunwar, Sandeep; Blevins, Lewis S; Aghi, Manish K

    2014-07-01

    OBJECT.: While transsphenoidal surgery is associated with low morbidity, the degree to which morbidity increases after reoperation remains unclear. The authors determined the morbidity associated with repeat versus initial transsphenoidal surgery after 1015 consecutive operations. The authors conducted a 5-year retrospective review of the first 916 patients undergoing transsphenoidal surgery at their institution after a pituitary center of expertise was established, and they analyzed morbidities. The authors analyzed 907 initial and 108 repeat transsphenoidal surgeries performed in 916 patients (9 initial surgeries performed outside the authors' center were excluded). The most common diagnoses were endocrine inactive (30%) or active (36%) adenomas, Rathke's cleft cysts (10%), and craniopharyngioma (3%). Morbidity of initial surgery versus reoperation included diabetes insipidus ([DI] 16% vs 26%; p = 0.03), postoperative hyponatremia (20% vs 16%; p = 0.3), new postoperative hypopituitarism (5% vs 8%; p = 0.3), CSF leak requiring repair (1% vs 4%; p = 0.04), meningitis (0.4% vs 3%; p = 0.02), and length of stay ([LOS] 2.8 vs 4.5 days; p = 0.006). Of intraoperative parameters and postoperative morbidities, 1) some (use of lumbar drain and new postoperative hypopituitarism) did not increase with second or subsequent reoperations (p = 0.3-0.9); 2) some (DI and meningitis) increased upon second surgery (p = 0.02-0.04) but did not continue to increase for subsequent reoperations (p = 0.3-0.9); 3) some (LOS) increased upon second surgery and increased again for subsequent reoperations (p surgery (p = 0.3) but went on to increase upon subsequent reoperations (p = 0.001-0.02). Multivariate analysis revealed that operation number, but not sex, age, pathology, radiation therapy, or lesion size, increased the risk of CSF leak, meningitis, and increased LOS. Separate analysis of initial versus repeat transsphenoidal surgery on the 2 most common benign pituitary lesions

  7. First Application of 7T Magnetic Resonance Imaging in Endoscopic Endonasal Surgery of Skull Base Tumors

    Science.gov (United States)

    Barrett, Thomas F; Dyvorne, Hadrien A; Padormo, Francesco; Pawha, Puneet S; Delman, Bradley N; Shrivastava, Raj K; Balchandani, Priti

    2018-01-01

    Background Successful endoscopic endonasal surgery for the resection of skull base tumors is reliant on preoperative imaging to delineate pathology from the surrounding anatomy. The increased signal-to-noise ratio afforded by 7T MRI can be used to increase spatial and contrast resolution, which may lend itself to improved imaging of skull base. In this study, we apply a 7T imaging protocol to patients with skull base tumors and compare the images to clinical standard of care. Methods Images were acquired at 7T on 11 patients with skull base lesions. Two neuroradiologists evaluated clinical 1.5T, 3T, and 7T scans for detection of intracavernous cranial nerves and ICA branches. Detection rates were compared. Images were utilized for surgical planning and uploaded to a neuronavigation platform and used to guide surgery. Results Image analysis yielded improved detection rates of cranial nerves and ICA branches at 7T. 7T images were successfully incorporated into preoperative planning and intraoperative neuronavigation. Conclusion Our study represents the first application of 7T MRI to the full neurosurgical workflow for endoscopic endonasal surgery. We detected higher rates of cranial nerves and ICA branches at 7T MRI compared to 3T and 1.5 T, and found that integration of 7T into surgical planning and guidance was feasible. These results suggest a potential for 7T MRI to reduce surgical complications. Future studies comparing standardized 7T, 3T, and 1.5 T MRI protocols in a larger number of patients are warranted to determine the relative benefit of 7T MRI for endonasal endoscopic surgical efficacy. PMID:28359922

  8. First Application of 7-T Magnetic Resonance Imaging in Endoscopic Endonasal Surgery of Skull Base Tumors.

    Science.gov (United States)

    Barrett, Thomas F; Dyvorne, Hadrien A; Padormo, Francesco; Pawha, Puneet S; Delman, Bradley N; Shrivastava, Raj K; Balchandani, Priti

    2017-07-01

    Successful endoscopic endonasal surgery for the resection of skull base tumors is reliant on preoperative imaging to delineate pathology from the surrounding anatomy. The increased signal-to-noise ratio afforded by 7-T MRI can be used to increase spatial and contrast resolution, which may lend itself to improved imaging of the skull base. In this study, we apply a 7-T imaging protocol to patients with skull base tumors and compare the images with clinical standard of care. Images were acquired at 7 T on 11 patients with skull base lesions. Two neuroradiologists evaluated clinical 1.5-, 3-, and 7-T scans for detection of intracavernous cranial nerves and internal carotid artery (ICA) branches. Detection rates were compared. Images were used for surgical planning and uploaded to a neuronavigation platform and used to guide surgery. Image analysis yielded improved detection rates of cranial nerves and ICA branches at 7 T. The 7-T images were successfully incorporated into preoperative planning and intraoperative neuronavigation. Our study represents the first application of 7-T MRI to the full neurosurgical workflow for endoscopic endonasal surgery. We detected higher rates of cranial nerves and ICA branches at 7-T MRI compared with 3- and 1.5-T MRI, and found that integration of 7 T into surgical planning and guidance was feasible. These results suggest a potential for 7-T MRI to reduce surgical complications. Future studies comparing standardized 7-, 3-, and 1.5-T MRI protocols in a larger number of patients are warranted to determine the relative benefit of 7-T MRI for endonasal endoscopic surgical efficacy. Copyright © 2017 Elsevier Inc. All rights reserved.

  9. Ligadura endoscópica endonasal da artéria esfenopalatina para epistaxe severa

    Directory of Open Access Journals (Sweden)

    Santos Rodrigo P.

    2002-01-01

    Full Text Available Introdução: A epistaxe severa, geralmente associada a fatores predisponentes como hipertensão arterial sistêmica e coagulopatia, é uma doença desafiadora, e pode necessitar de uma abordagem cirúrgica nos casos que não respondem ao tratamento conservador, como cauterização e tamponamento nasal. Objetivo: avaliar os resultados da ligadura endoscópica endonasal da artéria esfenopalatina no tratamento da epistaxe severa refratária à abordagem terapêutica conservadora. Forma de estudo: Clínico prospectivo. Material e Método: foram avaliados doze casos de pacientes submetidos à ligadura endoscópica endonasal da artéria esfenopalatina no tratamento da epistaxe severa não responsiva ao tratamento conservador, observando-se a história clínica, os fatores predisponentes, a evolução e as complicações deste procedimento. Resultados: a idade média foi de 50,9 anos, e a distribuição por sexo foi de 33% do sexo feminino e 67% do sexo masculino; 33% apresentaram HAS e 16,6% coagulopatia (hepatopatia como fatores predisponentes. Um paciente (8,3% apresentou ressangramento após o procedimento cirúrgico. Discussão: a ligadura endoscópica endonasal da artéria esfenopalatina representa uma abordagem segura e garante um controle satisfatório do sangramento, com índice de ressangramento de 8,3% entre os nossos casos. Conclusão: a ligadura endoscópica endonasal da artéria esfenopalatina representa uma opção cirúrgica adequada, pois não apresenta as complicações das técnicas anteriores, atinge um controle satisfatório do sangramento e pode ser realizada por otorrinolaringologistas habituados à cirurgia endoscópica nasal.

  10. Dexmedetomidine could enhance surgical satisfaction in Trans-sphenoidal resection of pituitary adenoma.

    Science.gov (United States)

    Salimi, Alireza; Sharifi, Guive; Bahrani, Houshang; Mohajerani, Seyed A; Jafari, Alireza; Safari, Farhad; Jalessi, Maryam; Mirkheshti, Alireza; Mottaghi, Kamran

    2017-02-01

    Excessive bleeding is an unwanted complication of trans-sphenoidal resection of pituitary adenoma due to increases in intracranial pressure (ICP) and hemodynamic instability. Dexmedetomidine (Dex) anα2-agonists is the drug of choice in intensive care units (ICU) and cardiac surgeries to control abrupt changes in hemodynamic. Severe cardiovascular responses occur during trans-sphenoidal resection (TSR) of the pituitary adenoma despite adequate depth of anesthesia. The aim of this paper was to determine the effect of Dexmedetomidine on bleeding as primary outcome, and surgeon's satisfaction and hemodynamic stability as secondary outcomes in patients undergoing trans-sphenoidal resection of pituitary adenoma. Total numbers of 60 patients between 18-65 years old and candidate for elective trans-sphenoidal resection of pituitary adenoma were randomLy allocated to two groups; Dexmedetomidine infusion (0.6µg/kg/hour) or normal saline infusion. Mean arterial pressure (MAP), heart rate (HR), dose of hypnotics and narcotics during surgery, bleeding, and surgeon's satisfaction were recorded. Propofol maintenance dose (µg/kg/min) and total Fentanyl use (µg) were significantly lower in Dex group compare to control group (P=0.01 and 0.003, respectively). Total bleeding amount during operation in Dex group was significantly lower than control group (P=0.012). Surgeon's satisfaction was significantly higher in Dex group at the end of surgery. MAP and heart rate throughout surgery were significantly lower in Dex group compare to control group (P=0.001). Dexmedetomidine infusion (0.6µg/kg/hour) could reduce bleeding and provide surgeon's satisfaction during trans-sphenoidal resection of pituitary adenoma.

  11. Safe Corridor to Access Clivus for Endoscopic Trans-Sphenoidal Surgery: A Radiological and Anatomical Study.

    Directory of Open Access Journals (Sweden)

    Ye Cheng

    Full Text Available Penetration of the clivus is required for surgical access of the brain stem. The endoscopic transclivus approach is a difficult procedure with high risk of injury to important neurovascular structures. We undertook a novel anatomical and radiological investigation to understand the structure of the clivus and neurovascular structures relevant to the extended trans-nasal trans-sphenoid procedure and determine a safe corridor for the penetration of the clivus.We examined the clivus region in the computed tomographic angiography (CTA images of 220 adults, magnetic resonance (MR images of 50 adults, and dry skull specimens of 10 adults. Multiplanar reconstruction (MPR of the CT images was performed, and the anatomical features of the clivus were studied in the coronal, sagittal, and axial planes. The data from the images were used to determine the anatomical parameters of the clivus and neurovascular structures, such as the internal carotid artery and inferior petrosal sinus.The examination of the CTA and MR images of the enrolled subjects revealed that the thickness of the clivus helped determine the depth of the penetration, while the distance from the sagittal midline to the important neurovascular structures determined the width of the penetration. Further, data from the CTA and MR images were consistent with those retrieved from the examination of the cadaveric specimens.Our findings provided certain pointers that may be useful in guiding the surgery such that inadvertent injury to vital structures is avoided and also provided supportive information for the choice of the appropriate endoscopic equipment.

  12. Pre-operative assessment of patients undergoing endoscopic, transnasal, transsphenoidal pituitary surgery.

    Science.gov (United States)

    Lubbe, D; Semple, P

    2008-06-01

    To demonstrate the importance of pre-operative ear, nose and throat assessment in patients undergoing endoscopic, transsphenoidal surgery for pituitary tumours. Literature pertaining to the pre-operative otorhinolaryngological assessment and management of patients undergoing endoscopic anterior skull base surgery is sparse. We describe two cases from our series of 59 patients undergoing endoscopic pituitary surgery. The first case involved a young male patient with a large pituitary macroadenoma. His main complaint was visual impairment. He had no previous history of sinonasal pathology and did not complain of any nasal symptoms during the pre-operative neurosurgical assessment. At the time of surgery, a purulent nasal discharge was seen emanating from both middle meati. Surgery was abandoned due to the risk of post-operative meningitis, and postponed until the patient's chronic rhinosinusitis was optimally managed. The second patient was a 47-year-old woman with a large pituitary macroadenoma, who presented to the neurosurgical department with a main complaint of diplopia. She too gave no history of previous nasal problems, and she underwent uneventful surgery using the endoscopic, transnasal approach. Two weeks after surgery, she presented to the emergency unit with severe epistaxis. A previous diagnosis of hereditary haemorrhagic telangiectasia was discovered, and further surgical and medical intervention was required before the epistaxis was finally controlled. Pre-operative otorhinolaryngological assessment is essential prior to endoscopic pituitary or anterior skull base surgery. A thorough otorhinolaryngological history will determine whether any co-morbid diseases exist which could affect the surgical field. Nasal anatomy can be assessed via nasal endoscopy and sinusitis excluded. Computed tomography imaging is a valuable aid to decisions regarding additional procedures needed to optimise access to the pituitary fossa.

  13. Cerebral Venous Sinus Thrombosis Following Second Transsphenoidal Surgery: Report of a Rare Complication and Review of Literature.

    Science.gov (United States)

    Miao, Zhuangzhuang; Zhang, Zhuo; Chen, Juan; Wang, Junwen; Zhang, Huaqiu; Lei, Ting

    2018-02-01

    Cushing disease, induced by a pituitary adrenocorticotropic hormone (ACTH)-secreting adenoma, is associated with high risk of stroke. At present, transsphenoidal surgery remains the first line of therapy. Cerebral venous sinus thrombosis (CVST) is an uncommon form of stroke with variable presentations. There are no previous reports of its occurrence in patients with Cushing disease following transsphenoidal surgery. We report a patient with Cushing disease who sustained CVST several days after a second transsphenoidal surgery. With adequate care and treatment, along with timely diagnosis, the patient made a near-complete recovery with only minor sequelae. In view of the poor outcome of untreated CVST, symptoms such as severe headache, nausea and vomiting, and cerebrospinal fluid leakage after transsphenoidal surgery could be of valuable assistance in early diagnosis, allowing immediate medical intervention with consequent improved prognosis. Copyright © 2017 Elsevier Inc. All rights reserved.

  14. Predictors of endoscopic transsphenoidal surgery outcome in acromegaly: patient and tumor characteristics evaluated by magnetic resonance imaging

    NARCIS (Netherlands)

    van Bunderen, Christa C.; van Varsseveld, Nadège C.; Baayen, Johannes C.; van Furth, Wouter R.; Aliaga, Esther Sanchez; Hazewinkel, Marieke J.; Majoie, Charles B. L. M.; Freling, Nicole J. M.; Lips, Paul; Fliers, Eric; Bisschop, Peter H.; Drent, Madeleine L.

    2013-01-01

    The availability of various first-line treatment modalities for acromegaly and evolving surgical techniques emphasize the need for accurately defined predictors of surgical outcome. We retrospectively analysed the outcome of 30 patients with acromegaly after initial endoscopic transsphenoidal

  15. Meningitis caused by Enterococcus casseliflavus with refractory cerebrospinai fluid leakage following endoscopic endonasal removal of skull base chondrosarcoma

    Institute of Scientific and Technical Information of China (English)

    2011-01-01

    To the Editor:Meningitis caused by Enterococcus casseliflavus (E.casseliflavus) is extremely rare.Here we report an unusual case of meningitis caused by E.casseliflavus coexisting with refractory cerebrospinal fluid (CSF) leakage following endoscopic endonasal resection of skull base chondrosarcoma.

  16. Endoscopic approach to the infratemporal fossa

    Directory of Open Access Journals (Sweden)

    Ahmed Youssef

    2014-06-01

    Conclusions: Endoscopic endonasal transpterygoid approach is considered one of the most useful surgical solutions to manage selected tumors that involve the infratemporal fossa. A good understanding of the endoscopic anatomy of infratemporal fossa allows safe and complete resection of lesions arising or extending to infratemporal fossa.

  17. Successful endonasal dacryocystorhinostomy in a patient with Wegener’s granulomatosis

    Directory of Open Access Journals (Sweden)

    P Eloy

    2009-11-01

    Full Text Available P Eloy, E Leruth, B Bertrand, Ph RombauxENT and HNS department, Cliniques Universitaires de Mont-Godinne, Université Catholique de Louvain, 5530, Yvoir, BelgiumAbstract: Wegener’s granulomatosis (WG is one form of idiopathic autoimmune vasculitis. The disease has a predilection for the upper and lower respiratory tracts (lungs, nose, sinus, and kidneys. WG may be systemic, severe, and potentially lethal, but it may also be limited to the otolaryngological area or to the eyes and the orbits. Obstruction of the lacrimal pathway is a possible complication of the disease that affects approximately 7% of patients with WG. It usually occurs as a direct extension of sinonasal disease and typically is a late manifestation. Management of such a condition is generally viewed as difficult. We report the case of a patient with a quiescent WG limited to the otolaryngological area. This patient presented a bilateral obstruction of the nasolacrimal ducts caused by bilateral extensive adhesions in the nasal cavity. Because she had several episodes of left-side acute dacryocystitis which necessitated several courses of broad-spectrum antibiotics, she successfully underwent an endonasal endoscopic dacryocystorhinostomy using a diode laser and powered instrumentation. The authors describe the clinical case, the surgical technique, and review the literature.Keywords: Wegener’s granulomatosis, recurrent dacryocystitis, endonasal DCR, diode, laser, powered instrumentation

  18. Resident simulation training in endoscopic endonasal surgery utilizing haptic feedback technology.

    Science.gov (United States)

    Thawani, Jayesh P; Ramayya, Ashwin G; Abdullah, Kalil G; Hudgins, Eric; Vaughan, Kerry; Piazza, Matthew; Madsen, Peter J; Buch, Vivek; Sean Grady, M

    2016-12-01

    Simulated practice may improve resident performance in endoscopic endonasal surgery. Using the NeuroTouch haptic simulation platform, we evaluated resident performance and assessed the effect of simulation training on performance in the operating room. First- (N=3) and second- (N=3) year residents were assessed using six measures of proficiency. Using a visual analog scale, the senior author scored subjects. After the first session, subjects with lower scores were provided with simulation training. A second simulation served as a task-learning control. Residents were evaluated in the operating room over six months by the senior author-who was blinded to the trained/untrained identities-using the same parameters. A nonparametric bootstrap testing method was used for the analysis (Matlab v. 2014a). Simulation training was associated with an increase in performance scores in the operating room averaged over all measures (p=0.0045). This is the first study to evaluate the training utility of an endoscopic endonasal surgical task using a virtual reality haptic simulator. The data suggest that haptic simulation training in endoscopic neurosurgery may contribute to improvements in operative performance. Limitations include a small number of subjects and adjudication bias-although the trained/untrained identity of subjects was blinded. Further study using the proposed methods may better describe the relationship between simulated training and operative performance in endoscopic Neurosurgery. Copyright © 2016 Elsevier Ltd. All rights reserved.

  19. Endoscopic Endonasal Surgery for Remission of Cushing Disease Caused by Ectopic Intracavernous Macroadenoma: Case Report and Literature Review.

    Science.gov (United States)

    Koutourousiou, Maria; Winstead, Welby I

    2017-02-01

    Complete surgical resection of an adrenocorticotropic hormone (ACTH)-secreting pituitary adenoma is the gold standard of treatment of Cushing disease. Ectopic location of these adenomas is an extremely rare condition that may compromise the diagnosis and surgical success. We present the first case of an ectopic intracavernous ACTH-secreting macroadenoma totally resected with endoscopic endonasal surgery (EES). A 36-year-old woman presented with Cushing syndrome. Increased ACTH, serum cortisol, and free urine cortisol levels were identified; however, pituitary magnetic resonance imaging failed to show a pituitary tumor; instead, a parasellar lesion in the left cavernous sinus (CS) was noticed. Inferior petrosal sinus sampling showed a significant central to peripheral and lateralized left-sided ACTH gradient. The patient underwent EES. No tumor was found in the sella; however, the left CS was widely explored and a tumor was found lateral to the paraclival segment of the carotid artery. There were no complications after EES. Pathology confirmed the diagnosis of an ACTH-secreting adenoma. During the immediate postoperative course, serum cortisol levels decreased lower than 5 μg/dL. Postoperative magnetic resonance imaging showed complete tumor resection. At 20 months follow-up, the patient remained in clinical and biochemical remission of Cushing disease. Only 12 cases of ectopic intracavernous ACTH-secreting adenomas have been reported and all were microadenomas. The presence of an ectopic ACTH-secreting macroadenoma in the CS represents a surgical challenge. EES is the ideal approach for complete resection of ectopic intracavernous adenomas, allowing for a wide exploration of the CS with no surgical complications. Copyright © 2016 Elsevier Inc. All rights reserved.

  20. [Identification and management of intra-operative suspicious tissues in 20 transsphenoidal surgery cases].

    Science.gov (United States)

    Liu, Jun-Feng; Ke, Chang-Shu; Chen, Xi; Xu, Yu; Zhang, Hua-Qiu; Chen, Juan; Gan, Chao; Li, Chao-Xi; Lei, Ting

    2013-05-01

    To determine appropriate protocols for the identification and management of intra operative suspicious tissues during transsphenoidal surgery. Clinical data and pathological reports of 20 patients with intra-operative suspicious tissues during transsphenoidal surgeries were analyzed retrospectively. The methods for discriminating between adenoma and normal pituitary tissues were reviewed. The postoperative pathological reports revealed that adenoma and normal pituitary tissues coexisted in 9 samples, while 5 samples were identified as normal pituitary tissues, 2 as adenoma tissues, and 4 as other tissues. Adenomas were distinguished from normal pituitary tissues on the basis of intra-operative appearance, texture, blood supply and possible existence of boundary. If decisions are difficult to made during surgeries from the appearance of the suspicious tissues, pathological examinations are advised as a guidance for the next steps.

  1. Delayed cerebrospinal fluid leakage 10 years after transsphenoidal surgery and gamma knife surgery. Case report

    International Nuclear Information System (INIS)

    Ogawa, Yoshikazu; Tominaga, Teiji

    2007-01-01

    A 38-year-old woman presented with repeated episodes of meningitis. She had undergone transsphenoidal tumor removal followed by gamma knife irradiation in 1994. Complete remission was achieved. Intermittent cerebrospinal fluid (CSF) leakage began in 2004, and transsphenoidal surgery was performed for direct repair of the skull base defect. Operative findings showed that the sellar floor was uncovered, and CSF continuously escaped through the cyanoacrylate polymer framework of the previous repair. Reconstruction used autologous muscle pieces and cyanoacrylate polymer adhesive. The CSF leakage was presumably due to delayed radiation damage to the mucous membrane of the skull base. Several methods for reconstruction of the sellar floor have been proposed, which all rely on tissue regeneration including the arachnoid, dura mater, and mucus membrane of the sphenoidal sinus. Preservation of the arachnoid membrane and minimizing removal of the mucous membrane are essential, especially if postoperative irradiation is anticipated. (author)

  2. The use of image-guidance during transsphenoidal pituitary surgery in the United States

    Science.gov (United States)

    Chung, Thomas K.; Riley, Kristen O.

    2015-01-01

    Background: Intraoperative image guidance is a useful modality for transsphenoidal pituitary surgery. However, the outcomes associated with this technology have not been systematically evaluated. Objective: The purpose of the study was to quantify complication rates with and without the use of image guidance during transsphenoidal pituitary surgery using a nationwide database with broadly applicable results. Methods: A retrospective analysis of the Nationwide Inpatient Sample was performed from 2007 to 2011. Transsphenoidal pituitary resections for adenomas were identified by International Classification of Diseases-9th Revision, Clinical Modification code. The effect of image guidance on cerebrospinal fluid (CSF) leak complications and cost-benefit was analyzed. Results: A total of 48,848 transsphenoidal pituitary resections were identified, of which 77.5% were partial resections and 22.5% were complete. Pathologic indications included benign (89.3%), malignant primary (0.6%), and malignant secondary (0.4%). Complications included same-stay death (0.4%), CSF leak (8.8%), postoperative CSF rhinorrhea (1.9%), diabetes insipidus (12.4%), and meningitis (0.4%). Image guidance was employed in 7% (n = 3401) of all cases. When analyzed by modality, computed tomography (CT)-assisted procedures had lower CSF rhinorrhea rates (1.1%) compared with cases with no image guidance (1.9%), whereas magnetic resonance (MR)-assisted procedures had the highest rates (2.7%, χ2 p surgery had significantly shorter length of stay (2.9 days) versus no image guidance (3.7 days, p surgery is associated with a lower rate of CSF leak, shorter length of stay, and lower cost compared with patients without image guidance. Further studies that control for severity and extent of disease are warranted to confirm this finding. PMID:25975254

  3. Flow diversion in the treatment of carotid injury and carotid-cavernous fistula after transsphenoidal surgery

    Science.gov (United States)

    Lum, Cheemum; Ahmed, Muhammad E; Glikstein, Rafael; dos Santos, Marlise P; Lesiuk, Howard; Labib, Mohamed; Kassam, Amin B

    2015-01-01

    We describe a case of iatrogenic carotid injury with secondary carotid-cavernous fistula (CCF) treated with a silk flow diverter stent placed within the injured internal carotid artery and coils placed within the cavernous sinus. Flow diverters may offer a simple and potentially safe vessel-sparing option in this rare complication of transsphenoidal surgery. The management options are discussed and the relevant literature is reviewed. PMID:26015526

  4. Endoscopic Transsphenoidal Surgery Outcomes in 331 Nonfunctioning Pituitary Adenoma Cases After a Single Surgeon Learning Curve.

    Science.gov (United States)

    Kim, Jung Hee; Lee, Jung Hyun; Lee, Ji Hyun; Hong, A Ram; Kim, Yoon Ji; Kim, Yong Hwy

    2018-01-01

    The outcomes of recent endoscopic surgery of nonfunctioning pituitary adenomas (NFPAs) are controversial when compared with traditional microscopic surgery. We aimed to assess the outcomes of endoscopic transsphenoidal surgeries performed by 1 surgeon with 7 years of experience and elucidate the predictive factors for surgical outcomes for NFPAs. We included 331 patients (155 men and 176 women) with clinical NFPAs who underwent transsphenoidal surgery because of visual symptoms by a single surgeon in Seoul National University Hospital from March 2010 to May 2016. We assessed the tumor removal rate, hormonal outcomes, visual outcomes, and complications. The gross total resection rate of endoscopic transsphenoidal surgery for NFPAs by a single surgeon was 74.9%. Cavernous sinus invasion, a high Knosp grade, large tumor size, previous surgery, and lack of surgical experience in the neurosurgeon elevated the risk for residual tumors. Visual deficits were improved in 73.4% of the patients, which was associated with tumor size, preoperative visual impairment score, previous radiation, and surgical experience. Hormonal status was improved in 15.4% and aggravated in 32.9% after surgery. There were no predictors for hormonal recovery. Transient diabetes insipidus (DI) was the most common complication (9.1%), and among these patients, 3.0% had persistent DI. Endoscopic transsphenoidal surgery by a well-experienced surgeon was an effective and safe treatment for NFPAs, but the hormonal outcomes were not changed compared with previous reports of microscopic surgery. Large tumor size and cavernous sinus invasion were still the barriers for achieving total resection. Copyright © 2017 Elsevier Inc. All rights reserved.

  5. Intraoperative Ultrasound in Patients Undergoing Transsphenoidal Surgery for Pituitary Adenoma: Systematic Review [corrected].

    Science.gov (United States)

    Marcus, Hani J; Vercauteren, Tom; Ourselin, Sebastien; Dorward, Neil L

    2017-10-01

    Transsphenoidal surgery is the gold standard for pituitary adenoma resection. However, despite advances in microsurgical and endoscopic techniques, some pituitary adenomas can be challenging to cure. We sought to determine whether, in patients undergoing transsphenoidal surgery for pituitary adenoma, intraoperative ultrasound is a safe and effective technologic adjunct. The PubMed database was searched between January 1996 and January 2016 to identify relevant publications that 1) featured patients undergoing transsphenoidal surgery for pituitary adenoma, 2) used intraoperative ultrasound, and 3) reported on safety or effectiveness. Reference lists were also checked, and expert opinions were sought to identify further publications. Ultimately, 10 studies were included, comprising 1 cohort study, 7 case series, and 2 case reports. One study reported their prototype probe malfunctioned, leading to false-positive results in 2 cases, and another study' prototype probe was too large to safely enter the sphenoid sinus in 2 cases. Otherwise, no safety issues directly related to use of intraoperative ultrasound were reported. In the only comparative study, remission occurred in 89.7% (61/68) of patients with Cushing disease in whom intraoperative ultrasound was used, compared with 83.8% (57/68) in whom it was not. All studies reported that surgeons anecdotally found intraoperative ultrasound helpful. Although there is limited and low-quality evidence available, the use of intraoperative ultrasound appears to be a safe and effective technologic adjunct to transsphenoidal surgery for pituitary adenoma. Advances in ultrasound technology may allow for more widespread use of such devices. Copyright © 2017 Elsevier Inc. All rights reserved.

  6. The impact of transsphenoidal surgery on glucose homeostasis and insulin resistance in acromegaly.

    Science.gov (United States)

    Stelmachowska-Banaś, Maria; Zieliński, Grzegorz; Zdunowski, Piotr; Podgórski, Jan; Zgliczyński, Wocjiech

    2011-01-01

    Impaired glucose tolerance and overt diabetes mellitus are frequently associated with acro-megaly. The aim of this study was to find out whether these alterations could be reversed after transsphenoidal surgery. Two hundred and thirty-nine acromegalic patients were studied before and 6-12 months after transsphenoidal surgery. Diagnosis of active acromegaly was established on the basis of widely recognized criteria. In each patient, glucose and insulin concentrations were assessed during the 75 γ oral glucose tolerance test (OGTT). To estimate insulin resistance, we used homeostasis model assessment (HOMA-IR) and the quantitative insulin sensitivity check index (QUICKI). At the moment of diagnosis, diabetes mellitus was present in 25% of the acromegalic patients. After surgery, the pre-valence of diabetes mellitus normalized to the level present in the general Polish population. We found a statistically significant reduction after surgery in plasma glucose levels both fasting (89.45 ± 13.92 mg/dL vs. 99.12 ± 17.33 mg/dL, p surgery compared to the moment of diagnosis (15.44 ± 8.80 mIU/mL vs. 23.40 ± 10.24 mIU/mL, p transsphenoidal surgery, there was a significant reduction in HOMA-IR (3.08 vs. 6.76, p surgery in fasting glucose and insulin levels between patients with controlled and in-adequately controlled disease. We conclude that in acromegalic patients glucose homeostasis alterations and insulin sensitivity can be normalized after transsphenoidal surgery, even if strict biochemical cure criteria are not fulfilled.

  7. Significant Improvement in Chronic Persistent Headaches Caused by Small Rathke Cleft Cysts After Transsphenoidal Surgery

    OpenAIRE

    Fukui, Issei; Hayashi, Yasuhiko; Kita, Daisuke; Sasagawa, Yasuo; Oishi, Masahiro; Tachibana, Osamu; Nakada, Mitsutoshi

    2017-01-01

    Purpose Rathke cleft cysts (RCC) usually are asymptomatic and can be observed via the use of conservative methods. Some patients with RCCs, however, have severe headaches even if they are small enough to be confined to the sella, and these small RCCs seldom have been discussed. This study presents an investigation into clinical characteristics of small RCCs associated with severe headaches, demonstrating efficacy and safety of endoscopic transsphenoidal surgery (ETSS) to relieve headaches. Me...

  8. Bilateral endoscopic endonasal marsupialization of nasopalatine duct cyst

    Directory of Open Access Journals (Sweden)

    Yohei Honkura

    2015-02-01

    Full Text Available Nasopalatine duct cysts are the most common non-odontogenic cysts in the maxilla, and are conventionally treated through a sublabial or palatine approach. Recently, the endoscopic approach has been used, but experience is extremely limited. We treated a 29-year-old male with nasopalatine duct cyst by endoscopic marsupialization, but paresthesia of the incisor region occurred after surgery. This paresthesia gradually remitted within 6 months. The nasopalatine nerve, which innervates the upper incisor region, enters two lateral canals separately at the nasal floor and exits the central main canal at the palate. Damage to the bilateral nasopalatine nerves might lead to paresthesia, so we recommend careful examination for nerve fibers during endoscopic surgery, especially if fenestration is performed on both sides.

  9. Safety of remifentanil in transsphenoidal surgery: A single-center analysis of 540 patients.

    Science.gov (United States)

    Cote, David J; Burke, William T; Castlen, Joseph P; King, Chih H; Zaidi, Hasan A; Smith, Timothy R; Laws, Edward R; Aglio, Linda S

    2017-04-01

    Although some studies have examined the efficacy and safety of remifentanil in patients undergoing neurosurgical procedures, none has examined its safety in transsphenoidal operations specifically. In this study, all transsphenoidal operations performed by a single author from 2008 to 2015 were retrospectively reviewed to evaluate the safety of remifentanil in a consecutive series of patients. During the study period, 540 transsphenoidal operations were identified. Of these, 443 (82.0%) patients received remifentanil intra-operatively; 97 (18.0%) did not. The two groups were well-matched with regard to demographic categories, comorbidities, and pre-operative medications (p>0.05), except pre-operative tobacco use (p=0.021). Patients were also well-matched with regard to radiographic features and surgical techniques. Patients who received remifentanil were more likely to harbor a macroadenoma (78.1% vs. 67.0%, p=0.025), and had slightly longer anesthesia time on average (269.2minvs. 239.4min, p=0.024). All pathologic diagnoses were well-matched between the two groups, except that patients receiving remifentanil were more likely to harbor a non-functioning adenoma (46.5% vs. 26.8%, ptranssphenoidal surgery, remifentanil was found to be a safe anesthetic adjunct. There were no significant differences in post-operative hospital course or complications in patients who did and did not receive intra-operative remifentanil. Copyright © 2016 Elsevier Ltd. All rights reserved.

  10. Fatal antiphospholipid syndrome following endoscopic transnasal-transsphenoidal surgery for a pituitary tumor: A case report.

    Science.gov (United States)

    Li, Chiao-Zhu; Li, Chiao-Ching; Hsieh, Chih-Chuan; Lin, Meng-Chi; Hueng, Dueng-Yuan; Liu, Feng-Chen; Chen, Yuan-Hao

    2017-01-01

    The fatal type of antiphospholipid syndrome is a rare but life-threating condition. It may be triggered by surgery or infection. Endoscopic transnasal-transsphenoidal surgery is a common procedure for pituitary tumor. We report a catastrophic case of a young woman died of fatal antiphospholipid syndrome following endoscopic transnasal-transsphenoidal surgery. A 31-year-old woman of a history of stroke received endoscopic transnasal-transsphenoidal surgery for a pituitary tumor. The whole procedure was smooth. However, the patient suffered from acute delirium on postoperative day 4. Then, her consciousness became comatose state rapidly with dilatation of pupils. Urgent magnetic resonance imaging of brain demonstrated multiple acute lacunar infarcts. The positive antiphosphoipid antibody and severe thrombocytopenia were also noted. Fatal antiphospholipid syndrome was diagnosed. Plasma exchange, corticosteroids, anticoagulant agent were prescribed. The hemodynamic condition was gradually stable. However, the consciousness was still in deep coma. The patient died of organ donation 2 months later. If patients have a history of cerebral stroke in their early life, such as a young stroke, the APS and higher risk of developing fatal APS after major surgery should be considered. The optimal management of APS remains controversial. The best treatment strategies are only early diagnosis and aggressive therapies combing of anticoagulant, corticosteroid, and plasma exchange. The intravenous immunoglobulin is prescribed for patients with refractory APS.

  11. Incidence and Risk Factors for Prolonged Hospitalization and Readmission after Transsphenoidal Pituitary Surgery.

    Science.gov (United States)

    Bur, Andrés M; Brant, Jason A; Newman, Jason G; Hatten, Kyle M; Cannady, Steven B; Fischer, John P; Lee, John Y K; Adappa, Nithin D

    2016-10-01

    To evaluate the incidence and factors associated with 30-day readmission and to analyze risk factors for prolonged hospital length of stay following transsphenoidal pituitary surgery. Retrospective longitudinal claims analysis. American College of Surgeons National Surgical Quality Improvement Program. The database of the American College of Surgeons National Surgical Quality Improvement Program was queried for patients who underwent transsphenoidal pituitary surgery (Current Procedural Terminology code 61548 or 62165) between 2005 and 2014. Patient demographic information, indications for surgery, and incidence of hospital readmission and length of stay were reviewed. Risk factors for readmission and prolonged length of stay, defined as >75th percentile for the cohort, were identified through logistic regression modeling. A total of 1006 patients were included for analysis. Mean hospital length of stay after surgery was 4.1 ± 0.2 days. Predictors of prolonged length of stay were operative time (P surgery between 2012 and 2014, 7.2% (n = 38) required hospital readmission. History of congestive heart failure (CHF) was a predictor of hospital readmission (P = 0.03, OR = 12.7, 95% CI = 1.1-144.0). This review of a large validated surgical database demonstrates that CHF is an independent predictor of hospital readmission after transsphenoidal surgery. Although CHF is a known risk factor for postoperative complications, it poses unique challenges to patients with potential postoperative pituitary dysfunction. © American Academy of Otolaryngology—Head and Neck Surgery Foundation 2016.

  12. Time Course of Resolution of Hyperprolactinemia After Transsphenoidal Surgery Among Patients Presenting with Pituitary Stalk Compression.

    Science.gov (United States)

    Zaidi, Hasan A; Cote, David J; Castlen, Joseph P; Burke, William T; Liu, Yong-Hui; Smith, Timothy R; Laws, Edward R

    2017-01-01

    Primary lactotroph disinhibition, or stalk effect, occurs when mechanical compression of the pituitary stalk disrupts the tonic inhibition by dopamine released by the hypothalamus. The resolution of pituitary stalk effect-related hyperprolactinemia postoperatively has not been studied in a large cohort of patients. We performed a retrospective review to investigate the time course of recovery of lactotroph disinhibition after transsphenoidal surgery. Medical records were retrospectively reviewed for all patients undergoing transsphenoidal surgery with the senior author from April 2008 to November 2014. Of 556 pituitary adenomas, 289 (52.0%) were eliminated: 77 (13.9%) had an immunohistochemically confirmed prolactinoma, 119 (21.4%) patients had previous surgery, 93 (16.7%) had incomplete medical records, leaving 267 patients (48.0%) for final analysis. Of these patients, 72 (27.0%) had increased serum prolactin levels (≥23.3 ng/mL), suggestive of pituitary stalk effect (maximum prolactin level = 148.0 ng/mL). Patients with stalk effect were more likely than those with normal serum prolactin levels to present with menstrual dysfunction (29.7% vs. 19.4%; P Transsphenoidal surgery can provide durable normalization of serum prolactin levels and related symptoms caused by pituitary stalk compression-related lactotroph disinhibition. Copyright © 2016 Elsevier Inc. All rights reserved.

  13. Outcome of Microscopic Transsphenoidal Surgery in Cushing Disease: A Case Series of 96 Patients.

    Science.gov (United States)

    Shirvani, Manochehr; Motiei-Langroudi, Rouzbeh; Sadeghian, Homa

    2016-03-01

    To analyze the results of transsphenoidal surgery in patients with Cushing disease and outcome. Retrospective analysis of the records of 96 patients with Cushing disease from 1997 to 2012. There were 73 females and 23 males, with a mean follow-up of 44 months (range, 3-13 years). The sex ratio was significantly different in children and teenagers versus adults. Magnetic resonance imaging showed microadenoma, macroadenoma, and no adenoma in 66, 18, and 12 patients, respectively. There was no surgical mortality. Early remission (normal 24-hour urinary free cortisol and basal serum cortisol transsphenoidal surgery that resulted in remission in 12 patients (70.6%). The other 5 patients were referred for gamma knife radiosurgery or bilateral adrenalectomy. Transsphenoidal surgery is a safe and highly efficient procedure in the treatment of Cushing disease. Macroadenomas, cavernous sinus invasion, and harder tumor consistencies, however, are associated with lower remission rates (higher disease persistence) and younger age, higher preoperative cortisol levels, and longer follow-up periods are associated with higher recurrence. Copyright © 2016 Elsevier Inc. All rights reserved.

  14. Impact of obstructive sleep apnea in transsphenoidal pituitary surgery: An analysis of inpatient data.

    Science.gov (United States)

    Chung, Sei Y; Sylvester, Michael J; Patel, Varesh R; Zaki, Michael; Baredes, Soly; Liu, James K; Eloy, Jean Anderson

    2018-05-01

    Although previous studies have reported increased perioperative complications among obstructive sleep apnea (OSA) patients undergoing any surgery requiring general anesthesia, there is a paucity of literature addressing the impact of OSA on postoperative transsphenoidal surgery (TSS) complications. The aim of this study was to analyze postoperative outcomes in transsphenoidal pituitary surgery patients with OSA. Secondarily, we examined patient characteristics and comorbidities. Retrospective analysis. The 2002 to 2013 National Inpatient Sample was queried for patients undergoing TSS for pituitary neoplasm. Patients with an additional diagnosis of OSA were identified, and compared to a non-OSA cohort. There were 17,777 patients identified; 5.0% (N = 889) had an additional diagnosis of OSA. The OSA cohort had more comorbidities including diabetes mellitus, congestive heart failure, chronic pulmonary disease, coagulopathy, hypertension, hypothyroidism, liver disease, obesity, peripheral vascular disease, renal failure, acromegaly, and Cushing's syndrome. Postoperatively, OSA was independently associated with increased risks of tracheostomy (P = .015) and hypoxemia (P transsphenoidal pituitary surgery, OSA was associated with higher rates of certain pulmonary and airway complications. OSA was not associated with increased non-pulmonary/airway complications or inpatient mortality, despite older average age and higher comorbidity rates. 2C. Laryngoscope, 128:1027-1032, 2018. © 2017 The American Laryngological, Rhinological and Otological Society, Inc.

  15. Symptomatic Vasospasms as a Life-Threatening Complication After Transsphenoidal Surgery.

    Science.gov (United States)

    Osterhage, Katharina; Czorlich, Patrick; Burkhardt, Till R; Rotermund, Roman; Grzyska, Ulrich; Flitsch, Jörg

    2018-02-01

    To identify symptomatic vasospasms as a rare complication after transsphenoidal surgery, with emphasis on management and outcomes. In this retrospective study, the medical records of 1997 patients who underwent microscopic transsphenoidal surgery at our hospital between 2008 and 2016 were analyzed regarding postoperative vasospasm events, clinical management, and neurologic outcomes. Four patients (0.2%) were identified who developed neurologic deficits in the postoperative phase caused by proven vasospasms due to subarachnoid hemorrhage (SAH). All 4 patients were treated according to current state-of-the-art recommendations for SAH-triggered vasospasms and, as ultima ratio, intra-arterial spasmolysis. Nonetheless, all patients developed multilocular ischemic infarctions. Three patients recovered with no or only slight neurologic deficits (2 with a Glasgow Outcome Score [GOS] of 5; 1 with a GOS of 4), and 1 patient died, at 24 days after surgery. Although a rare complication, vasospasms after transsphenoidal surgery can lead to severe and multilocular ischemic infarctions with a wide variety of neurologic impairments. This rare complication should be considered in patients with unexpected postoperative neurologic deficits. Computed tomography (CT)/magnetic resonance imaging and (contrast-enhanced) CT/magnetic resonance angiography are appropriate diagnostic tools. Treatment of vasospasms, including the option of intra-arterial spasmolysis, should not be delayed. Copyright © 2017. Published by Elsevier Inc.

  16. Comparison of propofol versus sevoflurane on thermoregulation in patients undergoing transsphenoidal pituitary surgery: A preliminary study

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    Tumul Chowdhury

    2012-01-01

    Full Text Available Purpose: General anesthesia causes inhibition of thermoregulatory mechanisms. Propofol has been reported to cause more temperature fall, but in case of deliberate mild hypothermia, both sevoflurane and propofol were comparable. Thermoregulation is found to be disturbed in cases of pituitary tumors. We aimed to investigate which of the two agents, sevoflurane or propofol, results in better preservation of thermoregulation in patients undergoing transsphenoidal excision of pituitary tumors. Methods: Twenty-six patients scheduled to undergo transsphenoidal removal of pituitary adenomas were randomly allocated to receive propofol or sevoflurane anesthesia. Baseline esophageal temperature was noted. Times for temperature to fall by 1°C or 35°C and to return to baseline were also comparable ( P>0.05. After that warmer was started at 43°C and time to rise to baseline was noted. Duration of surgery, total blood loss, and total fluid intake were also noted. If any, side effects such as delayed arousal and recovery from muscle relaxant were noted. Results: The demographics of the patients were comparable. Duration of surgery and total blood loss were comparable in the two groups. The time for temperature to fall by 1°C or 35°C and time to return to baseline was also comparable ( P>0.05. No side effects related to body temperature were noted. Conclusion: Both propofol and sevoflurane show similar effects in maintaining thermal homeostasis in patients undergoing transsphenoidal pituitary surgery.

  17. Initial Experiments with the Leap Motion as a User Interface in Robotic Endonasal Surgery.

    Science.gov (United States)

    Travaglini, T A; Swaney, P J; Weaver, Kyle D; Webster, R J

    The Leap Motion controller is a low-cost, optically-based hand tracking system that has recently been introduced on the consumer market. Prior studies have investigated its precision and accuracy, toward evaluating its usefulness as a surgical robot master interface. Yet due to the diversity of potential slave robots and surgical procedures, as well as the dynamic nature of surgery, it is challenging to make general conclusions from published accuracy and precision data. Thus, our goal in this paper is to explore the use of the Leap in the specific scenario of endonasal pituitary surgery. We use it to control a concentric tube continuum robot in a phantom study, and compare user performance using the Leap to previously published results using the Phantom Omni. We find that the users were able to achieve nearly identical average resection percentage and overall surgical duration with the Leap.

  18. Initial Experiments with the Leap Motion as a User Interface in Robotic Endonasal Surgery

    Science.gov (United States)

    Travaglini, T. A.; Swaney, P. J.; Weaver, Kyle D.; Webster, R. J.

    2016-01-01

    The Leap Motion controller is a low-cost, optically-based hand tracking system that has recently been introduced on the consumer market. Prior studies have investigated its precision and accuracy, toward evaluating its usefulness as a surgical robot master interface. Yet due to the diversity of potential slave robots and surgical procedures, as well as the dynamic nature of surgery, it is challenging to make general conclusions from published accuracy and precision data. Thus, our goal in this paper is to explore the use of the Leap in the specific scenario of endonasal pituitary surgery. We use it to control a concentric tube continuum robot in a phantom study, and compare user performance using the Leap to previously published results using the Phantom Omni. We find that the users were able to achieve nearly identical average resection percentage and overall surgical duration with the Leap. PMID:26752501

  19. Image guidance in trans-sphenoidal surgery for giant pituitary adenomas: Luxury or necessity?

    Directory of Open Access Journals (Sweden)

    Deepak Agrawal

    2012-01-01

    Full Text Available Background: In spite of availability of image guidance (neuronavigation at major centers around the world, most trans-sphenoidal surgeries for pituitary adenomas continue to be done under fluoroscopic control. On the other hand, the high mortality and morbidity for giant pituitary adenomas is mainly due to inadequate tumor removal. Aims and Objectives: The objective of this study was to study to utility of image guidance in trans-sphenoidal surgeries for optimizing tumor removal in giant pituitary adenomas. Materials and Methods: This was a prospective study carried out over a two years (January 2009-December 2010 in the Department of Neurosurgery, All India Institute of Medical Sciences. Patients with giant pituitary adenomas who underwent trans-sphenoidal surgery by the author were included. All surgeries were done under image-guidance only and no fluoroscopy was employed. Trajectory was defined using the image guidance and bone work done accordingly to optimize tumor removal. All patients had a contrast CT of the head done within 48 h of surgery to see for residual tumor. Observations and Results: Sixteen patients with pituitary adenomas were operated using only image-guidance in the study period. Twelve patients had virgin tumors and four patients had recurrent/residual tumors. In four patients, noncontrast MR images were used in for image guidance and contrast CT images were used in the rest. The mean set up time for image-guidance was 11 min (range 7-15 min. The mean ′′overall accuracy of registration′′ was 1.6 mm (range 1.4-2.1 mm. The mean operating time was 72 min (range 52-96 min. In all cases, midline and the relation of the carotid artery to the sella could be confirmed using the image-guidance. There were no intraoperative complications. Postoperative scans showed residual tumor in nine patients. The residual tumor was 25% in one patient (with a fibrous recurrent/residual tumor. Conclusions: Image guidance markedly improves

  20. Transsphenoidal surgery in patients with acromegaly: operative strategies for overcoming technically challenging anatomical variations.

    Science.gov (United States)

    Zada, Gabriel; Cavallo, Luigi M; Esposito, Felice; Fernandez-Jimenez, Julio Cesar; Tasiou, Anastasia; De Angelis, Michelangelo; Cafiero, Tullio; Cappabianca, Paolo; Laws, Edward R

    2010-10-01

    In addition to difficulties with anesthetic and medical management, transsphenoidal operations in patients with longstanding acromegaly are associated with inherent intraoperative challenges because of anatomical variations that occur frequently in these patients. The object of this study was to review the overall safety profile and anatomical/technical challenges associated with transsphenoidal surgery in patients with acromegaly. The authors performed a retrospective analysis of 169 patients who underwent endoscopic transsphenoidal operations for growth hormone-secreting adenomas to assess the incidence of surgical complications. A review of frequently occurring anatomical challenges and operative strategies employed during each phase of the operation to address these particular issues was performed. Of 169 cases reviewed, there was no perioperative mortality. Internal carotid artery injury occurred in 1 patient (0.6%) with complex sinus anatomy, who remained neurologically intact following endovascular unilateral carotid artery occlusion. Other complications included: significant postoperative epistaxis (5 patients [3%]), transient diabetes insipidus (5 patients [3%]), delayed symptomatic hyponatremia (4 patients [2%]), CSF leak (2 patients [1%]), and pancreatitis (1 patient [0.6%]). Preoperative considerations in patients with acromegaly should include a cardiopulmonary evaluation and planning regarding intubation and other aspects of the anesthetic technique. During the nasal phase of the transsphenoidal operation, primary challenges include maintaining adequate visualization and hemostasis, which is frequently compromised by redundant, edematous nasal mucosa and bony hypertrophy of the septum and the nasal turbinates. During the sphenoid phase, adequate bony removal, optimization of working space, and correlation of imaging studies to intraoperative anatomy are major priorities. The sellar phase is frequently challenged by increased sellar floor thickness

  1. Endosphenoidal coil for intraoperative magnetic resonance imaging of the pituitary gland during transsphenoidal surgery.

    Science.gov (United States)

    Chittiboina, Prashant; Talagala, S Lalith; Merkle, Hellmut; Sarlls, Joelle E; Montgomery, Blake K; Piazza, Martin G; Scott, Gretchen; Ray-Chaudhury, Abhik; Lonser, Russell R; Oldfield, Edward H; Koretsky, Alan P; Butman, John A

    2016-12-01

    OBJECTIVE Pituitary MR imaging fails to detect over 50% of microadenomas in Cushing's disease and nearly 80% of cases of dural microinvasion. Surface coils can generate exceptionally high-resolution images of the immediately adjacent tissues. To improve imaging of the pituitary gland, a receive-only surface coil that can be placed within the sphenoid sinus (the endosphenoidal coil [ESC]) during transsphenoidal surgery (TSS) was developed and assessed. METHODS Five cadaver heads were used for preclinical testing of the ESC. The ESC (a double-turn, 12-mm-diameter surface coil made from 1-mm-diameter copper wire) was developed to obtain images in a 1.5-T MR scanner. The ESC was placed (via a standard sublabial TSS approach) on the anterior sella face. Clinical MR scans were obtained using the 8-channel head coil and ESC as the receiver coils. Using the ESC, ultra-high-resolution, 3D, balanced fast field echo (BFFE) and T1-weighted imaging were performed at resolutions of 0.25 × 0.25 × 0.50 mm 3 and 0.15 × 0.15 × 0.30 mm 3 , respectively. RESULTS Region-of-interest analysis indicated a 10-fold increase in the signal-to-noise ratio (SNR) of the pituitary when using the ESC compared with the 8-channel head coil. ESC-related improvements (p anterior pituitary gland surface. High-resolution BFFE MR imaging obtained using ESC revealed a number of anatomical features critical to pituitary surgery that were not visible on 8-channel MR imaging, including the pituitary capsule, the intercavernous sinus, and microcalcifications in the pars intermedia. These ESC imaging findings were confirmed by the pathological correlation with whole-mount pituitary sections. CONCLUSIONS ESC can significantly improve SNR in the sellar region intraoperatively using current 1.5-T MR imaging platforms. Improvement in SNR can provide images of the sella and surrounding structures with unprecedented resolution. Clinical use of this ESC may allow for MR imaging detection of previously occult

  2. Endosphenoidal coil for intraoperative magnetic resonance imaging of the pituitary gland during transsphenoidal surgery

    Science.gov (United States)

    Chittiboina, Prashant; Talagala, S. Lalith; Merkle, Hellmut; Sarlls, Joelle E.; Montgomery, Blake K.; Piazza, Martin G.; Scott, Gretchen; Ray-Chaudhury, Abhik; Lonser, Russell R.; Oldfield, Edward H.; Koretsky, Alan P.; Butman, John A.

    2016-01-01

    OBJECTIVE Pituitary MR imaging fails to detect over 50% of microadenomas in Cushing’s disease and nearly 80% of cases of dural microinvasion. Surface coils can generate exceptionally high-resolution images of the immediately adjacent tissues. To improve imaging of the pituitary gland, a receive-only surface coil that can be placed within the sphenoid sinus (the endosphenoidal coil [ESC]) during transsphenoidal surgery (TSS) was developed and assessed. METHODS Five cadaver heads were used for preclinical testing of the ESC. The ESC (a double-turn, 12-mm-diameter surface coil made from 1-mm-diameter copper wire) was developed to obtain images in a 1.5-T MR scanner. The ESC was placed (via a standard sublabial TSS approach) on the anterior sella face. Clinical MR scans were obtained using the 8-channel head coil and ESC as the receiver coils. Using the ESC, ultra–high-resolution, 3D, balanced fast field echo (BFFE) and T1-weighted imaging were performed at resolutions of 0.25 × 0.25 × 0.50 mm3 and 0.15 × 0.15 × 0.30 mm3, respectively. RESULTS Region-of-interest analysis indicated a 10-fold increase in the signal-to-noise ratio (SNR) of the pituitary when using the ESC compared with the 8-channel head coil. ESC-related improvements (p pituitary gland surface. High-resolution BFFE MR imaging obtained using ESC revealed a number of anatomical features critical to pituitary surgery that were not visible on 8-channel MR imaging, including the pituitary capsule, the intercavernous sinus, and microcalcifications in the pars intermedia. These ESC imaging findings were confirmed by the pathological correlation with whole-mount pituitary sections. CONCLUSIONS ESC can significantly improve SNR in the sellar region intraoperatively using current 1.5-T MR imaging platforms. Improvement in SNR can provide images of the sella and surrounding structures with unprecedented resolution. Clinical use of this ESC may allow for MR imaging detection of previously occult pituitary

  3. Outcome of functional endonasal sinus surgery with and without CT-navigation.

    Science.gov (United States)

    Tschopp, Kurt P; Thomaser, Esther G

    2008-06-01

    Computer-assisted surgery (CAS) has found widespread use in functional endonasal sinus surgery (FESS) over the past few years. The present study investigates if CAS leads to a better outcome in FESS. All patients who underwent endonasal sphenoethmoidectomy were enrolled in a prospective, non-randomized case-control study. The procedures were done without CAS (group A) in 2003 and with CAS (group B) in 2004, using a Stryker navigation unit. Sixty-two patients (113 sphenoidectomies) were included in group A and 61 patients (109 sphenoidectomies) in group B. The underlying disease was recurrent chronic sinusitis or polyposis nasi in all patients except for inverted papilloma in one patient from group A and in two patients from group B. The follow-up period was 12 months. Symptom scores were assessed preoperatively and at 12 months postoperatively, using a questionnaire. A CT-scan was obtained in all patients preoperatively and at 6 months postoperatively. No significant difference was found between group A and B, neither with respect to symptom scores at 12 months postoperatively, nor in postoperative CT-scans. The operation strategy did not change by the introduction of CAS. The frontal sinuses were entered in group A and B in 59% and 64% of the patients, respectively. All parameters improved significantly postoperatively, compared to the preoperative values. As far as complications are concerned, two anterior orbital injuries and one retrobulbar haematoma occurred in group A and one postoperative lacrimal stenosis in group B. CAS does not lead to a better clinical outcome in FESS. Our data suggest that the rate of complications may be reduced using CAS. However, studies with a much larger number of patients would be necessary in order to definitely answer the question of whether CAS reduce complications in FESS.

  4. [Does CT-navigation improve the outcome of functional endonasal sinus surgery?].

    Science.gov (United States)

    Thomaser, E G; Tschopp, K

    2007-08-01

    Computer-assisted surgery (CAS) has found widespread use in functional endonasal sinus surgery (FESS) over the past few years. The present study investigates if CAS leads to a better outcome in FESS. All patients who underwent endonasal sphenoethmoidectomy were enrolled in a prospective, non-randomized study. The procedures were done without CAS (group A) in 2003 and in 2004 with CAS (group B), using a Stryker navigation unit. 62 patients (113 sphenoidectomies) were included in group A and 61 patients (109 sphenoidectomies) in group B. The underlying disease was recurrent chronic sinusitis or polyposis nasi in all patients except for inverted papilloma in one patient of group A and in two patients of group B. The follow-up period was 6 months. Preoperatively and at 6 months postoperatively, a CT-scan was obtained and symptom scores were assessed using a questionnaire. No significant difference was found between group A and B with respect to symptom scores, and CT-scans preoperatively and at 6 months postoperatively. The operation strategy did not change by the introduction of CAS. The frontal sinus was entered in group A and B in 59% and 64%, respectively. All parameters significantly improved postoperatively, compared to the preoperative values. As far as complications are concerned, two anterior orbital injuries and one retrobulbar haematoma occurred in group A and one postoperative lacrimal stenosis in group B. CAS does not lead to a better clinical outcome in FESS. Our data suggest that the rate of complications may be reduced using CAS. However, studies with a much larger number of patients would be necessary for a definite answer to this issue.

  5. Changes in cytokines in tears after endoscopic endonasal dacryocystorhinostomy for primary acquired nasolacrimal duct obstruction.

    Science.gov (United States)

    Lee, J K; Kim, T H

    2014-05-01

    We attempted to compare the cytokine composition of tears between primary acquired nasolacrimal duct (NLD) obstruction and normal controls. We investigated the changes in cytokines in tears after endoscopic endonasal dacryocystorhinostomy (DCR). Eighteen patients underwent endonasal DCR, with seven patients undergoing bilateral DCR, resulting in twenty-five DCRs in total. Eleven contralateral un-operated eyes were used as normal controls. Silicone stents were removed 3 months after surgery. Tear samples were collected from all eyes before surgery, and at 1 month, 2 months, 3 months, and 4 months after surgery. The level of interleukin (IL)-1β, IL-2, IL-6, IL-10, transforming growth factor (TGF)-β2, fibroblast growth factor (FGF)-2, and vascular endothelial growth factor (VEGF) in the tears was measured. The concentrations of IL-2, IL-6, IL-10, VEGF, and FGF-2 were significantly higher in eyes with NLD obstruction than controls before surgery (P=0.006, 0.018, 0.002, 0.048, and 0.039, respectively). Most inflammatory cytokines (IL-1β, IL-2, IL-6, VEGF, and FGF-2) were higher in the tears of the DCR group compared with the controls during the postoperative follow-up, but then rapidly decreased to the level of the controls after removal of the silicone stent. The recurred eyes showed a higher level of TGF-β2 and FGF-2 in tears compared with the eyes that showed good surgical results (Ptear levels of inflammatory cytokines were higher in eyes with NLD obstruction than controls. The changes in cytokine level during the postoperative period showed the importance of cytokine analysis in understanding wound healing after DCR.

  6. Management of odontogenic cysts by endonasal endoscopic techniques: A systematic review and case series.

    Science.gov (United States)

    Marino, Michael J; Luong, Amber; Yao, William C; Citardi, Martin J

    2018-01-01

    Odontogenic cysts and tumors of the maxilla may be amendable to management by endonasal endoscopic techniques, which may reduce the morbidity associated with open procedures and avoid difficult reconstruction. To perform a systematic review that evaluates the feasibility and outcomes of endoscopic techniques in the management of different odontogenic cysts. A case series of our experience with these minimally invasive techniques was assembled for insight into the technical aspects of these procedures. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses was used to identify English-language studies that reported the use of endoscopic techniques in the management of odontogenic cysts. Several medical literature data bases were searched for all occurrences in the title or abstract of the terms "odontogenic" and "endoscopic" between January 1, 1950, and October 1, 2016. Publications were evaluated for the technique used, histopathology, complications, recurrences, and the follow-up period. A case series of patients who presented to a tertiary rhinology clinic and who underwent treatment of odontogenic cysts by an endoscopic technique was included. A systematic review identified 16 case reports or series that described the use of endoscopic techniques for the treatment of odontogenic cysts, including 45 total patients. Histopathologies encountered were radicular (n = 16) and dentigerous cysts (n = 10), and keratocystic odontogenic tumor (n = 12). There were no reported recurrences or major complications for a mean follow-up of 29 months. A case series of patients in our institution identified seven patients without recurrence for a mean follow-up of 10 months. Endonasal endoscopic treatment of various odontogenic cysts are described in the literature and are associated with effective treatment of these lesions for an average follow-up period of >2 years. These techniques have the potential to reduce morbidity associated with the resection of these

  7. Transcanalicular Laser-Assisted Dacryocystorhinostomy With Endonasal Augmentation in Primary Nasolacrimal Duct Obstruction: Our Experience.

    Science.gov (United States)

    Goel, Ruchi; Nagpal, Smriti; Kumar, Sushil; Meher, Ravi; Kamal, Saurabh; Garg, Sonam

    To evaluate and compare the success rate of transcanalicular laser-assisted dacryocystorhinostomy with endonasal augmentation, with and without intubation, in patients suffering from primary acquired nasolacrimal duct obstruction, at 1 year of follow up. A prospective, randomized interventional pilot study was conducted at a tertiary care center, in accordance with the guidelines of Declaration of Helsinki. Sixty eyes of 60 adult patients with primary acquired nasolacrimal duct obstruction were included. The participants were divided randomly into 2 equal groups (A and B-without and with bicanalicular intubation, respectively). An osteotomy was first created using 980 nm diode laser (set at 8W continuous mode) transcanalicularly and then enlarged intranasally using Blakesley's nasal forceps, followed by bicanalicular silicon intubation in group B patients. The tubes were removed at the end of 8 weeks. The ostium size was assessed endoscopically at 8 weeks and again at the end of follow up, at 1 year. A successful outcome was defined in terms of ostium patency at the end of 1 year. The results were analyzed at the end of a follow up of 1 year, using various statistical tests (p < 0.05). The mean age of the patients was 35.3 ± 15.89 years, with 23 male and 37 female patients, the 2 groups having a similar male:female ratio. An overall success rate of 90% was achieved at the end of 1 year with no statistically significant difference between the groups. Postoperative complications like tube displacement and punctal, canalicular injury were more in the intubated group. The average osteotomy size was 8.06 ± 5.4 mm at the end of 1 year. Transcanalicular laser-assisted dacryocysto rhinostomy, with endonasal augmentation, is a scarless, effective, daycare procedure, for treatment of primary acquired nasolacrimal duct obstruction with no additional advantage offered by silicone intubation.

  8. СOMPARATIVE EFFICIENCY OF USE OF METHYLETHYLPYRIDINOL BY THE ENDONASAL ELECTROPHORESIS AND PARABULBAR INJECTIONS AT THE CHORIORETINAL DYSTROPHY

    Directory of Open Access Journals (Sweden)

    A. M. Razumovskaya

    2017-01-01

    Full Text Available Research objective: comparative assessment of efficiency of use of Emoxypin® by an endonasal electrophoresis and parabulbar injections at a chorioretinal dystrophy. Methods: 71 patients (average age of 55±3 years suffering from a chorioretinal dystrophy of various genesis were in the study. The ophthalmologic examination included: evaluation of visual acuity, a field of vision, a visual fatigue, a condition of bulbar microcirculation (the general conjunctiva index. Besides, electrophysiological examination was conducted, including critical frequency of merge of flickers and electric sensitivity of an eye. The patients were divided into 2 groups. The main group (28 patients received Emoxypin® with endonasal electrophoresis and group B (43 patients received Emoxypin® by parabulbar injections. Results: Results of the statistical analysis in both groups showed visual acuity increasment, expansion of borders of a field of vision, depression of visual fatigability, indicators of electrophysiological examination and bulbar microcirculation improved. Conclusion: The comparative assessment of efficiency of use of Emoxypin® by an endonasal electrophoresis and parabulbar injections at a chorioretinal dystrophic various a genesis showed appreciable medical effect in the course of restoration of visual functions which in some cases (18% even better effect observed at parabulbar injections.

  9. A Comparison of Dexmedetomidine and Clonidine in Attenuating the Hemodynamic Responses at Various Surgical Stages in Patients Undergoing Elective Transnasal Transsphenoidal Resection of Pituitary Tumors.

    Science.gov (United States)

    Jan, Summaira; Ali, Zulfiqar; Nisar, Yasir; Naqash, Imtiaz Ahmad; Zahoor, Syed Amer; Langoo, Shabir Ahmad; Azhar, Khan

    2017-01-01

    Transsphenoidal approach to pituitary tumors is a commonly performed procedure with the advantage of a rapid midline access to the sella with minimal complications. It may be associated with wide fluctuations in hemodynamic parameters due to intense noxious stimulus at various stages of the surgery. As duration of the surgery is short and the patients have nasal packs, it is prudent to use an anesthestic technique with an early predictable recovery. A total of 60 patients of either sex between 18 and 65 years of age, belonging to the American Society of Anesthesiologists I and II who were undergoing elective transnasal transsphenoidal pituitary surgery were chosen for this study. Patients were randomly allocated into two groups, Group C (clonidine) and Group D (dexmedetomidine), with each group consisting of 30 patients. Patients in Group C received 200 μg tablet of clonidine and those in Group D received a pantoprazole tablet as placebo at the same time. Patients in the Group D received an intravenous infusion of dexmedetomidine diluted in 50 ml saline (200 μg in 50 ml saline) 10 min before induction and patients in Group C received 0.9% normal saline (50 ml) as placebo. The hemodynamic variables (heart rate, mean arterial pressure) were noted at various stages of the surgery. Statistical analysis of the data was performed. A total of 60 patients were recruited. The mean age, sex, weight and duration of surgery among the two groups were comparable ( P > 0.05). Both dexmedetomidine and clonidine failed to blunt the increase in hemodynamic responses (heart rate and blood pressure) during intubation, nasal packing, speculum insertion and extubation. However when the hemodynamic response was compared between the patients receiving dexmedetomidine and clonidine it was seen that patients who received dexmedetomidine had a lesser increase in heart rate and blood pressure ( P < 0.05) when compared to clonidine. A continuous intravenous infusion of dexmedetomidine as

  10. A new modified speculum guided single nostril technique for endoscopic transnasal transsphenoidal surgery: an analysis of nasal complications.

    Science.gov (United States)

    Waran, Vicknes; Tang, Ing Ping; Karuppiah, Ravindran; Abd Kadir, Khairul Azmi; Chandran, Hari; Muthusamy, Kalai Arasu; Prepageran, Narayanan

    2013-12-01

    Abstract The endoscopic transnasal, transsphenoidal surgical technique for pituitary tumour excision has generally been regarded as a less invasive technique, ranging from single nostril to dual nostril techniques. We propose a single nostril technique using a modified nasal speculum as a preferred technique. We initially reviewed 25 patients who underwent pituitary tumour excision, via endoscopic transnasal transsphenoidal surgery, using this new modified speculum-guided single nostril technique. The results show shorter operation time with reduced intra- and post-operative nasal soft tissue injuries and complications.

  11. Clinical characteristics of acromegalic patients with empty sella and their outcomes following transsphenoidal surgery.

    Science.gov (United States)

    Sasagawa, Yasuo; Hayashi, Yasuhiko; Tachibana, Osamu; Oishi, Masahiro; Fukui, Issei; Iizuka, Hideaki; Nakada, Mitsutoshi

    2017-08-01

    To analyze the clinical characteristics of acromegalic patients with empty sella (ES, herniation of the subarachnoid space within the sella turcica) and the impact of ES on transsphenoidal surgery in such patients. Seventy-eight patients, newly diagnosed with acromegaly who underwent transsphenoidal surgery were included. ES was defined as the pituitary gland and adenoma occupying less than 50% of the sella turcica on midsagittal magnetic resonance (MR) imaging. Twelve patients (15.4%), predominantly female (10 women, p = .047), had ES in preoperative MR imaging. ES patients had smaller mean tumor diameter (6.3 mm) than non-ES patients (11.2 mm, p = .001). In preoperative MR imaging, occult adenoma was found in three (25%) ES and three (4.5%) non-ES patients (p = .044). Intraoperative cerebrospinal fluid (CSF) leakage was more frequent in the ES patients than in the non-ES patients (58.3 vs. 25.8%, p = .024). This led to an increased rate of sellar floor reconstruction using abdominal fat and/or postoperative lumber drainage in the ES patients (ES: 41.7 vs. non-ES: 16.7%, p = .063). Endocrinological remission after surgery was more frequent in the non-ES patients (72.7%) than in the ES patients (58.3%) (p = .248). Co-existence of acromegaly with ES is not rare, and is associated with occult adenoma, intra/postoperative CSF leakage, and a worse endocrinological outcome after transsphenoidal surgery; although, the underlying mechanism remains unclear.

  12. Pneumocephalus with BiPAP use after transsphenoidal surgery☆,☆☆,★

    Science.gov (United States)

    Kopelovich, Jonathan C.; de la Garza, Gabriel O.; Greenlee, Jeremy D.W.; Graham, Scott M.; Udeh, Chiedozie I.; O'Brien, Erin K.

    2013-01-01

    While the benefits of continuous positive airway pressure (CPAP) or bilevel positive airway pressure (BiPAP) for patients with obstructive sleep apnea are well described, reports in the literature of complications from its use are rare. A patient who received postoperative BiPAP after undergoing transsphenoidal craniopharyngioma resection developed severe pneumocephalus and unplanned intensive care unit admission. Although the pneumocephalus resolved with conservative management over two weeks, we propose caution in the use of CPAP postoperatively in patients undergoing procedures of the head and neck. PMID:22626688

  13. Invasive v non-invasive assessment of the carotid arteries prior to trans-sphenoidal surgery

    International Nuclear Information System (INIS)

    Macpherson, P.; Teasdale, E.; Hadley, D.M.; Teasdale, G.

    1987-01-01

    Imaging studies in 47 patients who were to undergo trans-sphenoidal surgery were analysed with reference to the vascular structures in the parasellar region. The results of cavernous sinography, dynamic contrast enhanced computed tomography (CT) and magnetic resonance imaging (MRI) showed good correlation with each other and with the appearances found at operation. CT and MRI, both non-invasive investigations, are therefore reliable preliminary screening methods for identifying the small proportion of patients on whom other imaging techniques need to be performed. (orig.)

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

    Science.gov (United States)

    Bellut, David; Hlavica, Martin; Schmid, Christoph; Bernays, René L

    2010-10-01

    Acromegaly is a rare disease, usually caused by a growth hormone (GH)-producing pituitary adenoma. If untreated, severe cardiovascular, metabolic, cosmetic, and orthopedic disturbances will result. Surgery is generally recommended as the first-line treatment. Transsphenoidal surgical techniques were recently extended by the introduction of intraoperative MR (iMR) imaging. In the present study, the contribution of ultra-low-field (0.15-T) iMR imaging to tumor resection, complication avoidance, and endocrinological and neurological outcome was analyzed. A series of 39 consecutive transsphenoidal iMR imaging-guided (using the PoleStar N20 device) surgical procedures performed between September 2005 and August 2009 for GH-producing pituitary adenomas was retrospectively analyzed. In addition to the patients' clinical data, the following criteria were evaluated independently: duration of surgery; length of hospital stay; endocrinological parameters; results of neurological examinations; and pre-, post-, and intraoperative MR imaging results. Thirty-seven patients with acromegaly underwent 39 transsphenoidal surgeries for pituitary adenomas. During a median follow-up period of 30 months (range 9-56 months), the remission rate was 73.5% in 34 patients with primary surgery and 20% in 5 cases with previous surgery; overall the remission rate was 66.7%. There were no serious postoperative complications. Detection of tumor remnant on iMR imaging led to a 5.1% increase in remission rate. 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

  15. Symptomatic Cerebral Vasospasm and Delayed Cerebral Ischemia Following Transsphenoidal Resection of a Craniopharyngioma.

    Science.gov (United States)

    Ricarte, Irapuá Ferreira; Funchal, Bruno F; Miranda Alves, Maramélia A; Gomes, Daniela L; Valiente, Raul A; Carvalho, Flávio A; Silva, Gisele S

    2015-09-01

    Vasospasm has been rarely described as a complication associated with craniopharyngioma surgery. Herein we describe a patient who developed symptomatic vasospasm and delayed cerebral ischemia after transsphenoidal surgery for a craniopharyngioma. A 67-year-old woman became drowsy 2 weeks after a transsphenoidal resection of a craniopharyngioma. A head computed tomography (CT) was unremarkable except for postoperative findings. Electroencephalogram and laboratory studies were within the normal limits. A repeated CT scan 48 hours after the initial symptoms showed bilateral infarcts in the territory of the anterior cerebral arteries (ACA). Transcranial Doppler (TCD) showed increased blood flow velocities in both anterior cerebral arteries (169 cm/second in the left ACA and 145 cm/second in the right ACA) and right middle cerebral artery (164 cm/second) compatible with vasospasm. A CT angiography confirmed the findings. She was treated with induced hypertension and her level of consciousness improved. TCD velocities normalized after 2 weeks. Cerebral vasospasm should be considered in the differential diagnosis of patients with altered neurologic status in the postoperative period following a craniopharyngioma resection. Copyright © 2015 National Stroke Association. Published by Elsevier Inc. All rights reserved.

  16. Utility of Early Post-operative High Resolution Volumetric MR Imaging after Transsphenoidal Pituitary Tumor Surgery

    Science.gov (United States)

    Patel, Kunal S.; Kazam, Jacob; Tsiouris, Apostolos J.; Anand, Vijay K.; Schwartz, Theodore H.

    2014-01-01

    Objective Controversy exists over the utility of early post-operative magnetic resonance imaging (MRI) after transsphenoidal pituitary surgery for macroadenomas. We investigate whether valuable information can be derived from current higher resolution scans. Methods Volumetric MRI scans were obtained in the early (30 days) post-operative periods in a series of patients undergoing transsphenoidal pituitary surgery. The volume of the residual tumor, resection cavity, and corresponding visual field tests were recorded at each time point. Statistical analyses of changes in tumor volume and cavity size were calculated using the late MRI as the gold standard. Results 40 patients met the inclusion criteria. Pre-operative tumor volume averaged 8.8 cm3. Early postoperative assessment of average residual tumor volume (1.18 cm3) was quite accurate and did not differ statistically from late post-operative volume (1.23 cm3, p=.64), indicating the utility of early scans to measure residual tumor. Early scans were 100% sensitive and 91% specific for predicting ≥ 98% resection (psurgery and a lack of decrease should alert the surgeon to possible persistent compression of the optic apparatus that may warrant re-operation. PMID:25045791

  17. Postoperative follow-up of pituitary adenomas after trans-sphenoidal resection: MRI and clinical correlation

    Energy Technology Data Exchange (ETDEWEB)

    Rodriguez, O. [Servicio de Radiologia, Hospital de Cruces, Baracaldo (Spain); Mateos, B. [Servicio de Radiologia, Hospital de Cruces, Baracaldo (Spain); Pedraja, R. de la [Servicio de Endocrinologia, Hospital de Cruces, Baracaldo (Spain); Villoria, R. [Servicio de Radiologia, Hospital de Cruces, Baracaldo (Spain); Hernando, J.I. [Servicio de Radiologia, Hospital de Cruces, Baracaldo (Spain); Pastor, A. [Servicio de Radiologia, Hospital de Cruces, Baracaldo (Spain); Pomposo, I. [Servicio de Neurocirugia, Hospital de Cruces, Baracaldo (Spain); Aurrecoechea, J. [Servicio de Neurocirugia, Hospital de Cruces, Baracaldo (Spain)

    1996-11-01

    Our purpose was to correlate the morphological changes seen on MRI studies of the sellar region after trans-sphenoidal resection of pituitary adenomas with clinical and hormonal studies. Between January 1993 and March 1994, 16 patients with a pituitary adenoma (9 macroadenomas and 7 microadenomas) were subjected to trans-sphenoidal resection and included in a prospective study. The protocol consisted of MRI, hormonal and visual studies at the following times: immediately postoperative (1st week), 1st month, 4th month and 1st year after surgery. The evolution of the contents of the sella turcica (tumour remnant, packing material and gland tissue), effects on the infundibulum, optic chiasm, cavernous sinus and sphenoid sinus were correlated with the clinical and hormonal studies. Stabilisation of the postsurgical changes occurred by the 4th month. Tumour remnants were noted in the immediate postoperative period in macroadenomas. Compression of the infundibulum was the only reliable indicator of possible involvement. Optic chiasm compression, defined as close contact between the chiasm and the tumour, was the only morphological finding that indicated visual impairment. There was no standard repneumatisation pattern in the sphenoid sinus, since mucosal changes resembling sinusitis were one of the postsurgical changes. We found MRI not to be useful for follow-up of microadenomas. (orig.). With 4 figs., 4 tabs.

  18. Incidence, risk factors and management of severe post-transsphenoidal epistaxis.

    Science.gov (United States)

    De Los Reyes, Kenneth M; Gross, Bradley A; Frerichs, Kai U; Dunn, Ian F; Lin, Ning; Rincon-Torroella, Jordina; Annino, Donald J; Laws, Edward R

    2015-01-01

    Among the major complications of transsphenoidal surgery, less attention has been given to severe postoperative epistaxis, which can lead to devastating consequences. In this study, we reviewed 551 consecutive patients treated over a 4 year period by the senior author to evaluate the incidence, risk factors, etiology and management of immediate and delayed post-transsphenoidal epistaxis. Eighteen patients (3.3%) developed significant postoperative epistaxis - six immediately and 12 delayed (mean postoperative day 10.8). Fourteen patients harbored macroadenomas (78%) and 11 of 18 (61.1%) had complex nasal/sphenoid anatomy. In the immediate epistaxis group, 33% had acute postoperative hypertension. In the delayed group, one had an anterior ethmoidal pseudoaneurysm, and one had restarted anticoagulation on postoperative day 3. We treated the immediate epistaxis group with bedside nasal packing followed by operative re-exploration if conservative measures were unsuccessful. The delayed group underwent bedside nasal hemostasis; if unsuccessful, angiographic embolization was performed. After definitive treatment, no patients had recurrent epistaxis. Copyright © 2014 Elsevier Ltd. All rights reserved.

  19. MRI Findings of Causalgia of the Lower Extremity Following Transsphenoidal Resection of Pituitary Tumor

    Directory of Open Access Journals (Sweden)

    D. Ryan Ormond

    2012-01-01

    Full Text Available Background. Causalgia is continuing pain, allodynia, or hyperalgesia after nerve injury with edema, changes in skin blood flow, or abnormal sudomotor activity. Here we report a case of lower extremity causalgia following elective transsphenoidal resection of a pituitary tumor in a young man. Clinical Presentation. A 33-year-old man with acromegaly underwent elective sublabial transsphenoidal resection of his pituitary tumor. During the three-hour surgery, the lower limbs were kept in a supine, neutral position with a pillow under the knees. The right thigh was slightly internally rotated with a tape to expose fascia lata, which was harvested to repair the sella. Postoperatively, he developed causalgia in a distal sciatic and common peroneal nerve distribution. Pain was refractory to several interventions. Finally, phenoxybenzamine improved his pain significantly. Conclusions. Malpositioning in the operating room resulted in causalgia in this young man. Phenoxybenzamine improved, and ultimately resolved, his symptoms. Improvement in his pain symptoms correlated with resolution of imaging changes in the distal sciatic and peroneal nerves on the side of injury.

  20. Postoperative follow-up of pituitary adenomas after trans-sphenoidal resection: MRI and clinical correlation

    International Nuclear Information System (INIS)

    Rodriguez, O.; Mateos, B.; Pedraja, R. de la; Villoria, R.; Hernando, J.I.; Pastor, A.; Pomposo, I.; Aurrecoechea, J.

    1996-01-01

    Our purpose was to correlate the morphological changes seen on MRI studies of the sellar region after trans-sphenoidal resection of pituitary adenomas with clinical and hormonal studies. Between January 1993 and March 1994, 16 patients with a pituitary adenoma (9 macroadenomas and 7 microadenomas) were subjected to trans-sphenoidal resection and included in a prospective study. The protocol consisted of MRI, hormonal and visual studies at the following times: immediately postoperative (1st week), 1st month, 4th month and 1st year after surgery. The evolution of the contents of the sella turcica (tumour remnant, packing material and gland tissue), effects on the infundibulum, optic chiasm, cavernous sinus and sphenoid sinus were correlated with the clinical and hormonal studies. Stabilisation of the postsurgical changes occurred by the 4th month. Tumour remnants were noted in the immediate postoperative period in macroadenomas. Compression of the infundibulum was the only reliable indicator of possible involvement. Optic chiasm compression, defined as close contact between the chiasm and the tumour, was the only morphological finding that indicated visual impairment. There was no standard repneumatisation pattern in the sphenoid sinus, since mucosal changes resembling sinusitis were one of the postsurgical changes. We found MRI not to be useful for follow-up of microadenomas. (orig.). With 4 figs., 4 tabs

  1. Trans-sphenoidal treatment of postsurgical cerebrospinal fluid fistula: CT-guided closure

    International Nuclear Information System (INIS)

    Floris, R.; Salvatore, C.; Simonetti, G.

    1998-01-01

    Cerebrospinal fluid (CSF) leakage after trans-sphenoidal surgery is a troublesome complication with a risk of meningitis and pneumocephalus. We suggest CT-guided intrasphenoidal injection of fibrin sealant through a 12-gauge needle as a simple alternative to surgical management of CSF fistulae. We treated eight patients, operated via the trans-sphenoidal route (five pituitary adenomas, three craniopharyngiomas), for a postoperative CSF leak by CT-guided intrasphenoidal injection of fibrin sealant alone in three cases and fibrin sealant and autologous blood in 5. CT was obtained 10 days after the procedure in all cases. In four patients, the CSF leak was closed successfully at the first attempt. The procedure was repeated on the four remaining patients because only a reduction in leakage was obtained at the first attempt. This procedure preserves olfaction and avoids the risk of frontal lobe damage. It could therefore represent the treatment of choice in many cases of anterior cranial fossa postsurgical CSF leaks. (orig.) (orig.)

  2. Low incidence of adrenal insufficiency after transsphenoidal surgery in patients with acromegaly: a long-term follow-up study

    NARCIS (Netherlands)

    Burgers, Anne Marij G.; Kokshoorn, Nieke E.; Pereira, Alberto M.; Roelfsema, Ferdinand; Smit, Johannes W. A.; Biermasz, Nienke R.; Romijn, Johannes A.

    2011-01-01

    The long-term prevalence of adrenal insufficiency after transsphenoidal surgery for GH-secreting pituitary adenomas is unknown. However, recently a single study reported a high prevalence of adrenal insufficiency in acromegalic patients after surgical and/or medical treatment without postoperative

  3. Time Course of Symptomatic Recovery After Endoscopic Transsphenoidal Surgery for Pituitary Adenoma Apoplexy in the Modern Era.

    Science.gov (United States)

    Zaidi, Hasan A; Cote, David J; Burke, William T; Castlen, Joseph P; Bi, Wenya Linda; Laws, Edward R; Dunn, Ian F

    2016-12-01

    Pituitary tumor apoplexy can result from either hemorrhagic or infarctive expansion of pituitary adenomas, and the related mass effect can result in compression of critical neurovascular structures. The time course of recovery of visual field deficits, headaches, ophthalmoparesis, and pituitary dysfunction after endoscopic transsphenoidal surgery has not been well established. Medical records were retrospectively reviewed for all patients who underwent endoscopic transsphenoidal surgery for pituitary tumor apoplexy from April 2008 to November 2014. Of 578 patients who underwent transsphenoidal surgery, pituitary tumor apoplexy was identified in 44 patients (7.6%). Two patients had prior surgery, leaving 42 patients for final analysis. These included infarction-related apoplexy in 7 (14.4%) patients, and hemorrhagic apoplexy in 35 (85.6%) patients. Hemorrhagic adenomas had a larger axial tumor diameter than patients with infarctive adenomas (4.4 ± 4.1 cm vs. 1.8 ± 0.8 cm; P surgery. Endoscopic transsphenoidal surgery can provide durable resolution of symptoms for patients presenting with pituitary tumor apoplexy. Recovery from headaches, visual, and pituitary dysfunction may be more rapid compared with ophthalmoparesis. Copyright © 2016 Elsevier Inc. All rights reserved.

  4. Progressive improvement of impaired visual acuity during the first year after transsphenoidal surgery for non-functioning pituitary macroadenoma

    NARCIS (Netherlands)

    Dekkers, O. M.; de Keizer, R. J. W.; Roelfsema, F.; Vd Klaauw, A. A.; Honkoop, P. J.; van Dulken, H.; Smit, J. W. A.; Romijn, J. A.; Pereira, A. M.

    2007-01-01

    Improvement of visual field defects continues even years after the initial surgical treatment. Because this process of continuing improvement has not been documented for visual acuity, we audited our data to explore the pattern of recovery of visual acuity until 1 year after transsphenoidal surgery

  5. The Prognostic Value of Perioperative Profiles of ACTH and Cortisol for Recurrence after Transsphenoidal Hypophysectomy in Dogs with Corticotroph Adenomas

    NARCIS (Netherlands)

    van Rijn, S J; Hanson, J M; Zierikzee, D; Kooistra, H S; Penning, L C; Tryfonidou, M A; Meij, B P

    2015-01-01

    BACKGROUND: Transsphenoidal hypophysectomy is an effective treatment for dogs with pituitary-dependent hypercortisolism (PDH). However, long-term recurrence of hypercortisolism is a well-recognized problem, indicating the need for reliable prognostic indicators. OBJECTIVES: The aim of this study was

  6. Late Onset of CSF Rhinorrhea in a Postoperative Transsphenoidal Surgery Patient Following Robotic-Assisted Abdominal Hysterectomy

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    Justin T. Dowdy MD

    2014-01-01

    Full Text Available Cerebrospinal fluid (CSF leak is the most commonly encountered perioperative complication in transsphenoidal surgery for pituitary lesions. Direct closure with a combination of autologous fat, local bone, and/or synthetic grafts remains the standard of care for leaks encountered at the time of surgery as well as postoperatively. The development of the vascularized nasoseptal flap as a closure technique has increased the surgeon’s capacity to correct even larger openings in the dura of the sella as well as widely exposed anterior skull base defects. Yet these advances in the technical nuances for management of post-transsphenoidal CSF leak are useless without the ability to recognize a CSF leak by physical examination, clinical history, biochemical testing, or radiographic assessment. Here, we report a case of a patient who developed a CSF leak 28 years after transsphenoidal surgery, precipitated by a robotic-assisted hysterectomy during which increased intra-abdominal pressure and steep Trendelenberg positioning were both factors. Given the remote nature of the patient’s transsphenoidal surgery and relative paucity of data regarding such a complication, the condition went unrecognized for several months. We review the available literature regarding risk and pathophysiology of CSF leak following abdominal surgery and propose the need for increased vigilance in identification of such occurrences with the increasing acceptance and popularity of minimally invasive abdominal and pelvic surgeries as standards in the field.

  7. Endoscopic Endonasal Dacryocystorhinostomy Combined with Canaliculus Repair for the Management of Dacryocystitis with Canalicular Obstruction

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    Yunhai Tu

    2015-01-01

    Full Text Available Purpose. The aim of this study is to propose a simple and efficient combination surgery for the management of dacryocystitis with canalicular obstruction. Methods. A retrospective noncomparative case series of dacryocystitis with canalicular obstruction has been studied. Twelve patients with dacryocystitis and canalicular obstruction underwent a conventional endoscopic endonasal dacryocystorhinostomy (EE-DCR combined with a modified canalicular repair. Postoperative observations included slit lamp, fluorescein dye disappearance test, lacrimal syringing, lacrimal endoscopy, and nasal endoscopy. Results. After 6–18 months of postoperative follow-up, the symptoms of epiphora and mucopurulent discharge disappeared completely in 10 patients, and occasional or intermittent epiphora remained in 2 patients. All of the twelve patients showed an opened intranasal ostium and normal fluorescein dye disappearance test. Patent bicanalicular irrigation was achieved in 9 patients. One patient had a partial and the other two had a complete reobstruction by lacrimal irrigation to their repaired lower canaliculus; however, all of them had a patent lacrimal irrigation to upper canaliculus. The functional success rate for the combination surgery is 83% (10/12, and anatomical success rate is 75% (9/12. Conclusion. EE-DCR combined with modified canalicular repair is a simple and efficient method for the management of dacryocystitis with canalicular obstruction.

  8. Endoscopic endonasal dacryocystorhinostomy combined with stent implantation as treatment for acute dacryocystitis

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    Si-Si Pu

    2017-02-01

    Full Text Available AIM: To discuss the feasibility and clinical efficacy of endoscopic endonasal dacryocystorhinostomy(EN-DCRcombined with stent implantation for treatment of acute dacryocystitis. METHODS: A total of 31 patients(32 eyespresenting with acute dacryocystitis were treated with EN-DCR combined with stent implantation under antibiotic cover from April 2014 to December 2015. These patients were followed up for 3 to 12mo. RESULTS: The medial canthal edema and erythema was gradually reducing within 48h in all patients. The hospitalization time took 2 to 8d(average 3.8±1.6d. Patients underwent removal of stent about 3mo after surgery. Thirty-one eyes showed no symptoms such as lacrimation or pus discharging, and irrigation of lacrimal duct was unobstructed. Irrigation of lacrimal duct was passable in 1 of 32 patients who has a relative narrow ostial. Results in this series, 31 cases were cured,1case improved, the total cure rate was 97%. CONCLUSION: There is no evidence shown that EN-DCR combined with stent implantation can increase the risk of spreading infection through tissue planes, causing septicemia, and exacerbating inflammation. Instead, it has advantages like gradual reduction in inflammatory symptoms, economic benefits of reduced patient stay, maintenance of the orbicularis muscle lacrimal pump and absence of external scar. It is indicated that EN-DCR combined with stent implantation is a safe and feasible surgical procedure for patients with acute dacryocystitis.

  9. Drainage or Packing of the Sella? Transsphenoidal Surgery for Primary Pituitary Abscess: Report of Two Cases

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    Soichi Oya

    2009-01-01

    Full Text Available The detailed surgical procedure of the transsphenoidal surgery for pituitary abscess has scarcely been described previously because it is a very rare clinical entity. The authors reported two cases of primary pituitary abscess. In case 1, the anterior wall of the sella turcica was reconstructed with the vomer bone after irrigating the abscess cavity, but the sella was not packed by fat for fear of the persistent infection by devascularized tissues. This led to the postoperative meningocele, the cerebrospinal fluid leak, and bacterial meningitis despite the successful abscess drainage. In case 2, tight sellar packing and reconstruction of the sellar wall were performed to avoid these postoperative complications, which resulted in complete drainage and uneventful postoperative course. Although accumulation of more cases is obviously needed to establish the definitive surgical technique in pituitary abscess surgery, our experience might suggest that packing of the sella is not impeditive for postoperative sufficient drainage.

  10. MRI image characteristics of materials implanted at sellar region after transsphenoidal resection of pituitary tumours

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    Bladowska, J.; Sasiadek, M.; Bednarek-Tupikowska, G.; Sokolska, V.; Badowski, R.; Moron, K.; Bonicki, W.

    2010-01-01

    Background: Post-surgical evaluation of the pituitary gland in MRI is difficult because of a change in anatomical conditions. It depends also on numerous other factors, including: size and expansion of the tumour before surgery, type of surgical access, quality and volume of implanted materials and time of its resorption. The purpose was to demonstrate the characteristics of the implanted materials on MRI performed after transsphenoidal resection of pituitary tumours and to identify imaging criteria helpful in differential diagnosis of masses within the sellar region. Material/Methods: One hundred and fifty-four patients after transsphenoidal resection of pituitary tumours were included in the study. In general, 469 MRI examinations were performed with a 1.5 T scanner. We obtained T1-weighted sagittal and coronal, enhanced and unenhanced images. In 102 cases, additional T2-weighted coronal, unenhanced images with 1.5 T unit were obtained as well. Results: The implanted materials appeared in 95 patient: fat in 86 and muscle with fascia in 3 patients. We could recognise implanted muscle and fascia in T2-weighted images, because of high signal intensity of the degenerating muscle and the line of low signal representing fascia. The implanted titanium mesh was found in 4 patients. Haemostatic materials were visible only in 2 patients in examinations performed at an early postoperative stage (1 month after the procedure). Conclusions: The knowledge of MRI characteristics of the materials implanted at the sellar region is very important in postoperative diagnosis of pituitary tumours and may help discriminate between tumorous and non-tumorous involvement of the sellar region. Some implanted materials, like fat, could be seen on MRI for as long as 10 years after the operation, others, like haemostatic materials, for only 1 month after surgery. T2-weighted imaging is a useful assessment method of the implanted muscle and fascia for a long time after surgery. (authors)

  11. Quantitative evaluation of headache severity before and after endoscopic transsphenoidal surgery for pituitary adenoma.

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    Wolf, Amparo; Goncalves, Sandy; Salehi, Fateme; Bird, Jeff; Cooper, Paul; Van Uum, Stan; Lee, Donald H; Rotenberg, Brian W; Duggal, Neil

    2016-06-01

    OBJECT The relationship between headaches, pituitary adenomas, and surgical treatment of pituitary adenomas remains unclear. The authors assessed the severity and predictors of self-reported headaches in patients referred for surgery of pituitary adenomas and evaluated the impact of endoscopic transsphenoidal surgery on headache severity and quality of life (QOL). METHODS In this prospective study, 79 patients with pituitary adenomas underwent endoscopic transsphenoidal resection and completed the Headache Impact Test (HIT-6) and the 36-Item Short Form Health Survey (SF-36) QOL questionnaire preoperatively and at 6 weeks and 6 months postoperatively. RESULTS Preoperatively, 49.4% of patients had mild headache severity, 13.9% had moderate severity, 13.9% had substantial severity, and 22.8% had intense severity. Younger age and hormone-producing tumors predisposed greater headache severity, while tumor volume, suprasellar extension, chiasmal compression, and cavernous sinus invasion of the pituitary tumors did not. Preoperative headache severity was found to be significantly associated with reduced scores across all SF-36 QOL dimensions and most significantly associated with mental health. By 6 months postoperatively, headache severity was reduced in a significant proportion of patients. Of the 40 patients with headaches causing an impact on daily living (moderate, substantial, or intense headache), 70% had improvement of at least 1 category on HIT-6 by 6 months postoperatively, while headache worsened in 7.6% of patients. The best predictors of headache response to surgery included younger age, poor preoperative SF-36 mental health score, and hormone-producing microadenoma. CONCLUSIONS The results of this study confirm that surgery can significantly improve headaches in patients with pituitary adenomas by 6 months postoperatively, particularly in younger patients whose preoperative QOL is impacted. A larger multicenter study is underway to evaluate the long

  12. Visual Fields at Presentation and after Trans-sphenoidal Resection of Pituitary Adenomas

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    Renu Dhasmana

    2011-01-01

    Full Text Available Purpose: To evaluate visual field changes in patients with pituitary adenomas following trans-sphenoidal surgery. Methods: Eighteen patients with pituitary adenomas underwent a complete ophthalmic assessment and visual field analysis using the Humphrey Field Analyzer 30-2 program before and after trans-sphenoidal surgical resection at the Himalayan Institute of Medical Sciences over a one year period. Visual acuity, duration of symptoms, optic nerve head changes, pattern of visual field defects, and variables such as mean deviation and visual field index were compared. Results: Thirty-six eyes of 18 patients including 10 male and 8 female subjects with mean age of 35.1±9.9 years and histologically proven pituitary adenoma were included. Mean visual acuity at presentation was 0.29 logMAR which improved to 0.21 logMAR postoperatively (P = 0.305. Of 36 eyes, 24 (66.7% had visual field defects including temporal defects in 12 eyes (33.3%, non-specific defects in 10 eyes (27.8%, and peripheral field constriction in 2 eyes (5.6%. Mean deviation of visual fields at presentation was -14.28 dB which improved to -11.32 dB postoperatively. The visual field index improved from 63.5% to 75% postoperatively. Favorable visual field outcomes were correlated with shorter duration of symptoms and absence of optic nerve head changes at presentation. Conclusion: Visual field defects were present in two thirds of patients at presentation. An overall improvement in vision and visual fields was noted after surgical resection. An inverse correlation was found between the duration of symptoms and postoperative visual field recovery, signifying the importance of early surgical intervention.

  13. Endoscopic vs. microscopic transsphenoidal surgery for Cushing's disease: a systematic review and meta-analysis.

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    Broersen, Leonie H A; Biermasz, Nienke R; van Furth, Wouter R; de Vries, Friso; Verstegen, Marco J T; Dekkers, Olaf M; Pereira, Alberto M

    2018-05-16

    Systematic review and meta-analysis comparing endoscopic and microscopic transsphenoidal surgery for Cushing's disease regarding surgical outcomes (remission, recurrence, and mortality) and complication rates. To stratify the results by tumor size. Nine electronic databases were searched in February 2017 to identify potentially relevant articles. Cohort studies assessing surgical outcomes or complication rates after endoscopic or microscopic transsphenoidal surgery for Cushing's disease were eligible. Pooled proportions were reported including 95% confidence intervals. We included 97 articles with 6695 patients in total (5711 microscopically and 984 endoscopically operated). Overall, remission was achieved in 5177 patients (80%), with no clear difference between both techniques. Recurrence was around 10% and short term mortality surgery (12.9 vs. 4.0%), whereas transient diabetes insipidus occurred less often (11.3 vs. 21.7%). For microadenomas, results were comparable between both techniques. For macroadenomas, the percentage of patients in remission was higher after endoscopic surgery (76.3 vs. 59.9%), and the percentage recurrence lower after endoscopic surgery (1.5 vs. 17.0%). Endoscopic surgery for patients with Cushing's disease reaches comparable results for microadenomas, and probably better results for macroadenomas than microscopic surgery. This is present despite the presumed learning curve of the newer endoscopic technique, although confounding cannot be excluded. Based on this study, endoscopic surgery may thus be considered the current standard of care. Microscopic surgery can be used based on neurosurgeon's preference. Endocrinologists and neurosurgeons in pituitary centers performing the microscopic technique should at least consider referring Cushing's disease patients with a macroadenoma.

  14. Randomized, double-blinded, placebo-controlled trial comparing two multimodal opioid-minimizing pain management regimens following transsphenoidal surgery.

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    Shepherd, Deborah M; Jahnke, Heidi; White, William L; Little, Andrew S

    2018-02-01

    OBJECTIVE Pain control is an important clinical consideration and quality-of-care metric. No studies have examined postoperative pain control following transsphenoidal surgery for pituitary lesions. The study goals were to 1) report postoperative pain scores following transsphenoidal surgery, 2) determine if multimodal opioid-minimizing pain regimens yielded satisfactory postoperative pain control, and 3) determine if intravenous (IV) ibuprofen improved postoperative pain scores and reduced opioid use compared with placebo. METHODS This study was a single-center, randomized, double-blinded, placebo-controlled intervention trial involving adult patients with planned transsphenoidal surgery for pituitary tumors randomized into 2 groups. Group 1 patients were treated with scheduled IV ibuprofen, scheduled oral acetaminophen, and rescue opioids. Group 2 patients were treated with IV placebo, scheduled oral acetaminophen, and rescue opioids. The primary end point was patient pain scores (visual analog scale [VAS], rated 0-10) for 48 hours after surgery. The secondary end point was opioid use as estimated by oral morphine equivalents (OMEs). RESULTS Of 136 patients screened, 62 were enrolled (28 in Group 1, 34 in Group 2). The study was terminated early because the primary and secondary end points were reached. Baseline characteristics between groups were well matched except for age (Group 1, 59.3 ± 14.4 years; Group 2, 49.8 ± 16.2 years; p = 0.02). Mean VAS pain scores were significantly different, with a 43% reduction in Group 1 (1.7 ± 2.2) compared with Group 2 (3.0 ± 2.8; p transsphenoidal surgery. IV ibuprofen resulted in significantly improved pain scores and significantly decreased opioid use compared with placebo. Postoperative multimodal pain management, including a nonsteroidal antiinflammatory medication, should be considered after surgery to improve patient comfort and to limit opioid use. Clinical trial registration no.: NCT02351700 (clinicaltrials

  15. Late Onset of CSF Rhinorrhea in a Postoperative Transsphenoidal Surgery Patient Following Robotic-Assisted Abdominal Hysterectomy

    OpenAIRE

    Dowdy, Justin T.; Moody, Marcus W.; Cifarelli, Christopher P.

    2014-01-01

    Cerebrospinal fluid (CSF) leak is the most commonly encountered perioperative complication in transsphenoidal surgery for pituitary lesions. Direct closure with a combination of autologous fat, local bone, and/or synthetic grafts remains the standard of care for leaks encountered at the time of surgery as well as postoperatively. The development of the vascularized nasoseptal flap as a closure technique has increased the surgeon’s capacity to correct even larger openings in the dura of the se...

  16. Endoscopic management of Atypical sellar cavernous hemangioma: A case report and review of the literature

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    A.M. Al-Sharydah

    2018-01-01

    Conclusion: Seller cavernous hemangioma (SCH is an extremely rare lesion that can be misdiagnosed. It is characterized by clinico-radiological features similar to those of other lesions such as pituitary macroadenoma and should be included in the differential diagnosis. The endoscopic endonasal transsphenoidal (EET approach with subtotal/total resection appears to be a feasible option for debulking, with less surgical complications. Nonetheless, combining stereotactic radiosurgery will reduce postsurgical morbidities.

  17. Effect of repeated transsphenoidal surgery in recurrent or residual pituitary adenomas: A systematic review and meta-analysis

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    Heringer, Lindolfo Carlos; de Oliveira, Matheus Fernandes; Rotta, José Marcus; Botelho, Ricardo Vieira

    2016-01-01

    Background: Recurrent or residual pituitary adenomas previously treated by transsphenoidal surgery are not uncommon. There are no strongly established guidelines to perform treatment of such cases. The objective of this study is to elucidate the effect of transsphenoidal reoperation in residual or recurrent pituitary adenomas. Methods: We made a systematic review of the literature to elucidate this effect through electronic search in MEDLINE/PubMed and Cochrane Central database. PRISMA statement was used as a basis for this systematic review and analysis of the risk of bias was made according to the Grading of Recommendations, Assessment, Development and Evaluation recommendations. Results: In this review, fifteen studies were finally pooled analyzed. Although remission rates (RRs) and follow-up periods varied widely, from 149 patients with growth hormone-secreting tumors the mean RR was 44.5%, from 273 patients with adrenocorticotropic hormone-secreting tumors the mean RR was 55.5% and among 173 patients with nonsecreting tumors, RR was 76.1%. There was significant higher RR in nonsecreting tumors. Mean follow-up was 32.1 months. No difference was found between microscopic and endoscopic techniques. Conclusions: A second transsphenoidal surgery is accompanied by a chance of remission in approximately half of cases with secreting tumors. In nonsecreting ones, success is higher. PMID:26958420

  18. Incidence, Etiology and Outcomes of Hyponatremia after Transsphenoidal Surgery: Experience with 344 Consecutive Patients at a Single Tertiary Center

    Science.gov (United States)

    Barber, Sean M.; Liebelt, Brandon D.; Baskin, David S.

    2014-01-01

    Hyponatremia is often seen after transsphenoidal surgery and is a source of considerable economic burden and patient-related morbidity and mortality. We performed a retrospective review of 344 patients who underwent transsphenoidal surgery at our institution between 2006 and 2012. Postoperative hyponatremia was seen in 18.0% of patients at a mean of 3.9 days postoperatively. Hyponatremia was most commonly mild (51.6%) and clinically asymptomatic (93.8%). SIADH was the primary cause of hyponatremia in the majority of cases (n = 44, 71.0%), followed by cerebral salt wasting (n = 15, 24.2%) and desmopressin over-administration (n = 3, 4.8%). The incidence of postoperative hyponatremia was significantly higher in patients with cardiac, renal and/or thyroid disease (p = 0.0034, Objective Risk (OR) = 2.60) and in female patients (p = 0.011, OR = 2.18) or patients undergoing post-operative cerebrospinal fluid drainage (p = 0.0006). Treatment with hypertonic saline (OR = −2.4, p = 0.10) and sodium chloride tablets (OR = −1.57, p = 0.45) was associated with a non-significant trend toward faster resolution of hyponatremia. The use of fluid restriction and diuretics should be de-emphasized in the treatment of post-transsphenoidal hyponatremia, as they have not been shown to significantly alter the time-course to the restoration of sodium balance. PMID:26237599

  19. Incidence, Etiology and Outcomes of Hyponatremia after Transsphenoidal Surgery: Experience with 344 Consecutive Patients at a Single Tertiary Center

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    Sean M. Barber

    2014-10-01

    Full Text Available Hyponatremia is often seen after transsphenoidal surgery and is a source of considerable economic burden and patient-related morbidity and mortality. We performed a retrospective review of 344 patients who underwent transsphenoidal surgery at our institution between 2006 and 2012. Postoperative hyponatremia was seen in 18.0% of patients at a mean of 3.9 days postoperatively. Hyponatremia was most commonly mild (51.6% and clinically asymptomatic (93.8%. SIADH was the primary cause of hyponatremia in the majority of cases (n = 44, 71.0%, followed by cerebral salt wasting (n = 15, 24.2% and desmopressin over-administration (n = 3, 4.8%. The incidence of postoperative hyponatremia was significantly higher in patients with cardiac, renal and/or thyroid disease (p = 0.0034, Objective Risk (OR = 2.60 and in female patients (p = 0.011, OR = 2.18 or patients undergoing post-operative cerebrospinal fluid drainage (p = 0.0006. Treatment with hypertonic saline (OR = −2.4, p = 0.10 and sodium chloride tablets (OR = −1.57, p = 0.45 was associated with a non-significant trend toward faster resolution of hyponatremia. The use of fluid restriction and diuretics should be de-emphasized in the treatment of post-transsphenoidal hyponatremia, as they have not been shown to significantly alter the time-course to the restoration of sodium balance.

  20. Patient satisfaction following endoscopic endonasal dacryocystorhinostomy: a quality of life study.

    Science.gov (United States)

    Jutley, G; Karim, R; Joharatnam, N; Latif, S; Lynch, T; Olver, J M

    2013-09-01

    To assess the subjective success and quality of life of adult patients post endoscopic endonasal dacryocystorhinostomy (EE-DCR) for acquired nasolacrimal duct obstruction. Retrospective, questionnaire study performed at least 6 months post EE-DCR. Hundred and ten of the 282 consecutive patients who underwent EE-DCR. A standardised questionnaire (Glasgow Benefit Inventory, GBI) was used to analyse the quality of life. The questionnaire examines four parameters, providing total, subscale, social, and physical scores. We aimed to assess patient experience following EE-DCR surgery. Total GBI scores range from -100 to +100, the former reflecting maximal negative benefit and corresponding to subjective worsening of tearing and impact on quality of life. Any positive score reflects a satisfactory surgical outcome and +100 represents maximal positive benefit. A score of zero is no perceived benefit. The average age was 62 years, 63% were female. In three of the parameters measured, there was a subjective improvement post surgery: subscale score 22.16 (95% CI: 15.23-29.09), total score 15.04 (95% CI: 9.74-20.35), and social support score 4.67 (95% CI: 0.93-8.42). Physical health scored -4.47 (95% CI: -10.25 to 1.32). Secondary analyses demonstrate no statistical significance with respect to outcome whether a trainee or consultant performed the procedure. Younger patients (under split median of 63.5) had a better total score 19.04 (95% CI: 11.35-27.74) than those older than 63.5 years (11.04, 95% CI: 3.61-18.47). This study shows that EE-DCR gave patients improvement in quality of life, proven by a validated questionnaire. The mean total score of 15.04 found in our study compares with the 18.7 recorded by Feretis et al in 2009. Results were irrespective of the grade of surgeon, similar to the findings of Fayers et al for functional successes. This study supports the use of EE-DCR for the improvement of quality of life in adult patients.

  1. Comparison of external dacryocystorhinostomy and 5-fluorouracil augmented endonasal laser dacryocystorhinostomy. A Retrospective review

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    Watts Patrick

    2001-01-01

    Full Text Available Purpose: To compare the success rates of external dacryocystorhinostomy (EXT-DCR with 5-fluorouracil (5-FU augmented endonasal laser dacryocystorhinostomy (ENL-DCR and to record the complications associated with 5-FU augmented ENL-DCR Materials and Methods: This was a retrospective non-randomised study. Forty-one patients with primary acquired nasolacrimal duct obstruction underwent an EXT-DCR (19 patients or an ENL-DCR (22 patients over a 3-year period. A Holmium YAG laser (Ho:YAG was used in the latter group of patients. Silicone tubes intubated in all patients were removed at three months. 5-FU was applied intraoperatively at the site of the ostium in the ENL-DCR patients. The median follow-up was 12 months (range 3-24 months for the ENL-DCR group and 22 months (range 6-28 months for the EXT-DCR group. The patency of the lacrimal system and the severity of epiphora were assessed at a final-review. Results: The median age of the EXT-DCR group was 77 years (range 53-87 and that of the ENL-DCR group was 71 years (range 23 to 84. There were 12 female patients in the former group and 19 in the latter. The percentage of success in the EXT-DCR group was 94.7% (95% confidence interval (CI = 75.4-99.1 = , and 63.6% in the ENL-DCR group (95% CI= 43.0-80.3. The confidence interval for the difference of 31.1% was 5.6-52.2. There was a statistically significant difference between the two groups, p=0.024 (Fisher exact test. Conclusions: These data suggest that EXT-DCR provides better results than 5-FU augmented ENL-DCR. However, ENL-DCR is the procedure of choice in certain circumstances such as in elderly, frail or medically unfit patients. Our results of 5-FU augmented ENL-DCR compare favourably with other published series.

  2. Pontine encephalocele and abnormalities of the posterior fossa following transclival endoscopic endonasal surgery.

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    Koutourousiou, Maria; Filho, Francisco Vaz Guimaraes; Costacou, Tina; Fernandez-Miranda, Juan C; Wang, Eric W; Snyderman, Carl H; Rothfus, William E; Gardner, Paul A

    2014-08-01

    Transclival endoscopic endonasal surgery (EES) has recently been used for the treatment of posterior fossa tumors. The optimal method of reconstruction of large clival defects following EES has not been established. A morphometric analysis of the posterior fossa was performed in patients who underwent transclival EES to compare those with observed postoperative anatomical changes (study group) to 50 normal individuals (anatomical control group) and 41 matched transclival cases with preserved posterior fossa anatomy (case-control group) using the same parameters. Given the absence of clival bone following transclival EES, the authors used the line between the anterior commissure and the basion as an equivalent to the clival plane to evaluate the location of the pons. Four parameters were studied and compared in the two populations: the pontine location/displacement, the maximum anteroposterior (AP) diameter of the pons, the maximum AP diameter of the fourth ventricle, and the cervicomedullary angle (CMA). All measurements were performed on midsagittal 3-month postoperative MR images in the study group. Among 103 posterior fossa tumors treated with transclival EES, 14 cases (13.6%) with postoperative posterior fossa anatomy changes were identified. The most significant change was anterior displacement of the pons (transclival pontine encephalocele) compared with the normal location in the anatomical control group (p 50% of the clivus) and dura. Nine (64.3%) of the 14 patients were overweight (body mass index [BMI] > 25 kg/m(2)). An association between BMI and the degree of pontine encephalocele was observed, but did not reach statistical significance. The use of a fat graft as part of the reconstruction technique following transclival EES with dural opening was the single significant factor that prevented pontine displacement (p = 0.02), associated with 91% lower odds of pontine encephalocele (OR = 0.09, 95% CI 0.01-0.77). The effect of fat graft reconstruction was

  3. [Clinical observation on controlling antihypertension with the general anesthesia of TEAS and anesthetics in endoscopic endonasal surgery].

    Science.gov (United States)

    Zhao, Wensheng; Zhao Xian; Li, Jinjin; Fang, Jianqiao

    2015-12-01

    To study whether the dose of controlling antihypertensive drug is reduced by transcutaneous electrical acupoint stimulation (TEAS) and the anesthetics, as well as the control of blood pressure (BP) and heart rate (HR) in endoscopic endonasal surgery with general anesthesia. Sixty patients for selective endoscopic endonasal surgery with general anesthetics and controlling antihypertension involved were selected and randomized into a TEAS group, a sham-TEAS group, 30 cases in each one. The electric pads were attached to bilateral Hegu (LI 4), Zusanli (ST 36), Sanyinjiao (SP 6) and Quchi (LI 11), stimulated with Hans-200 apparatus, 3 to 5 mA, 2 Hz/100 Hz in the TEAS group based on the patients' response to comfort. No electric stimulation was applied to the sham-TEAS group. The general anesthesia started after 30 min intervention and lasted till the end of surgery. The BP and HR were observed and recorded at the end of monitoring in operation room, 10 min after tranquilization (T0), 30 min after intervention (Tj, after induction~of general anestiesa (T2), 30 min after surgery start (T3), 60 min after surgery start (T4) and 30 min after extubation (T5). The doses of vecuronium bromide, propofol and nitroglycerin were recorded statistically in surgery, as well as the operative bleeding volume, the operative time, the resuscitation time and the visual analogue scale (VAS) score after resuscitation. Compared with that at T0, the mean arterial pressure (MAP) at T2, T3, T4 and T5 in the TEAS group and at T3 and T4 in the sham-TEAS group was all reduced, indicating the significant difference (all P 0.05). HR was different at T2 to Ts in the sham-TEAS group statistically (all P 0.05). The general anesthesia with TEAS and anesthetics involved for controlling antihypertension contributes to the control of BP and HR in the patients in endoscopic endonasal surgery. The impacts are not obvious on the doses of antihypertensive drug, the general anesthetics, the operative bleeding

  4. A Case of Pseudoaneurysm of the Internal Carotid Artery Following Endoscopic Endonasal Pituitary Surgery: Endovascular Treatment with Flow-Diverting Stent Implantation

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    Ali Karadag

    2017-10-01

    Full Text Available Internal carotid artery (ICA pseudoaneurysm is a rare complication of endoscopic endonasal surgery occurring in 0.4–1.1% of cases. Pseudoaneurysms can subsequently result in other complications, such as subarachnoid hemorrhage, epistaxis, and caroticocavernous fistula with resultant death or permanent neurologic deficit. In this case, we illustrate endovascular treatment with a flow-diverting stent for an ICA pseudoaneurysm after endoscopic endonasal surgery for a pituitary adenoma in a 56-year-old male. Surgery was complicated by excessive intraoperative bleeding and emergent CT angiography confirmed an iatrogenic pseudoaneurysm on the anteromedial surface of the ICA. The pseudoaneurysm was treated endovascularly with flow-diverting stent implantation only. Follow-up CT angiography after three months demonstrated occlusion of the pseudoaneurysm.

  5. The dynamics of post-operative plasma ACTH values following transsphenoidal surgery for Cushing's disease.

    Science.gov (United States)

    Srinivasan, Lakshmi; Laws, Edward R; Dodd, Robert L; Monita, Monique M; Tannenbaum, Christyn E; Kirkeby, Kjersti M; Chu, Olivia S; Harsh, Griffith R; Katznelson, Laurence

    2011-12-01

    Rapid assessment of adrenal function is critical following transsphenoidal surgery (TSS) for Cushing's disease (CD) in order to determine surgical efficacy. We hypothesize that there may be a role for ACTH measurement as a rapid indicator of adrenal function. Following surgery for CD, glucocorticoids were withheld and paired plasma ACTH and serum cortisol levels were measured every 6 h. Post-operative hypocortisolemia was defined as serum cortisol surgeries: nine subjects attained hypocortisolemia. Plasma ACTH levels decreased more in subjects with hypocortisolemia (0.9 pg/ml/hr, P = 0.0028) versus those with persistent disease (0 0.2 pg/ml/hr, P = 0.26) within the first 48 h after surgery. In contrast to subjects with persistent disease, all subjects with hypocortisolemia achieved a plasma ACTH <20 pg/ml by 19 h (range 1-19 h). Four of the nine subjects with hypocortisolemia achieved plasma ACTH <20 pg/ml by 13 h and the remaining five subjects by 19 h. Hypocortisolemia occurred between 3-36 h following achievement of a plasma ACTH <20 pg/ml. In CD, a reduction in postoperative plasma ACTH levels differentiates subjects with surgical remission versus subjects with persistent disease. The utility of plasma ACTH measurements in the postoperative management of CD remains to be determined.

  6. Dexamethasone PONV prophylaxis alters the hypothalamic-pituitary-adrenal axis after transsphenoidal pituitary surgery.

    Science.gov (United States)

    Burkhardt, Till; Rotermund, Roman; Schmidt, Nils-Ole; Kiefmann, Rainer; Flitsch, Jörg

    2014-07-01

    Postoperative nausea and vomiting (PONV) is common after general anesthesia and are reported by approximately 20% to 25% of all patients and up to 39% of patients undergoing neurosurgical procedures. The most common standard prophylaxis is a single application of 4 mg of dexamethasone before initiating anesthesia. Dexamethasone is known to suppress adreno-corticotroph hormone and cortisol levels. The objective was to find out whether this prophylaxis has an effect on the postoperative levels of cortisol in patients undergoing transsphenoidal pituitary surgery, and therefore simulates pituitary deficiency. A retrospective analysis of the files of 136 consecutive patients who were operated during a course of 6 months were included. Nineteen patients with a known history of PONV received a standard dose of 4 mg of dexamethasone perioperatively. Blood tests were drawn at the first postoperative day and were compared with blood tests of patients who had no history of PONV and therefore received no prophylaxis. Patients who were treated with a dexamethasone PONV prophylaxis showed no significant changes in cortisol levels; preoperative median of 93 μg/L (range, 39 to 427) and a postoperative median of 87 μg/L (range, 10 to 733; P=0.798) opposed to patients who did not receive such treatment; preoperative cortisol 114 μg/L (range, 10 to 387) and postoperative levels of 273 μg/L (range, 10 to 1352; Ptranssphenoidal surgery, the probability that dexamethasone PONV prophylaxis suppresses postoperative cortisol levels should be considered.

  7. Results of repeated transsphenoidal surgery in Cushing's disease. Long-term follow-up.

    Science.gov (United States)

    Valderrábano, Pablo; Aller, Javier; García-Valdecasas, Leopoldo; García-Uría, José; Martín, Laura; Palacios, Nuria; Estrada, Javier

    2014-04-01

    Transsphenoidal surgery (TSS) is the treatment of choice for Cushing's disease (CD). However, the best treatment option when hypercortisolism persists or recurs remains unknown. The aim of this study was to analyze the short and long-term outcome of repeat TSS in this situation and to search for response predictors. Data from 26 patients with persistent (n=11) or recurrent (n=15) hypercortisolism who underwent repeat surgery by a single neurosurgeon between 1982 and 2009 were retrospectively analyzed. Remission was defined as normalization of urinary free cortisol (UFC) levels, and recurrence as presence of elevated UFC levels after having achieved remission. The following potential outcome predictors were analyzed: adrenal status (persistence or recurrence) after initial TSS, tumor identification in imaging tests, degree of hypercortisolism before repeat TSS, same/different surgeon in both TSS, and time to repeat surgery. Immediate postoperative remission was achieved in 12 patients (46.2%). Five of the 10 patients with available follow-up data relapsed after surgery (median time to recurrence, 13 months). New hormone deficiencies were seen in seven patients (37%), and two patients had cerebrospinal fluid leakage. No other major complications occurred. None of the preoperative factors analyzed was predictive of surgical outcome. When compared to initial surgery, repeat TSS for CD is associated to a lower remission rate and a higher risk of recurrence and complications. Further studies are needed to define outcome predictors. Copyright © 2013 SEEN. Published by Elsevier Espana. All rights reserved.

  8. Risk of post-operative pneumocephalus in patients with obstructive sleep apnea undergoing transsphenoidal surgery.

    Science.gov (United States)

    White-Dzuro, Gabrielle A; Maynard, Ken; Zuckerman, Scott L; Weaver, Kyle D; Russell, Paul T; Clavenna, Matthew J; Chambless, Lola B

    2016-07-01

    Patients undergoing transsphenoidal surgery (TSS) have an anterior skull base defect that limits the use of positive pressure ventilation post-operatively. Obstructive sleep apnea (OSA) can be seen in these patients and is treated with continuous positive airway pressure (CPAP). In our study we documented the incidence of pre-existing OSA and reported the incidence of diagnosed pneumocephalus and its relationship to OSA. A retrospective review was conducted from a surgical outcomes database. Electronic medical records were reviewed, with an emphasis on diagnosis of OSA and documented symptomatic pneumocephalus. A total of 324 patients underwent 349 TSS for sellar mass resection. The average body mass index of the study cohort was 32.5kg/m(2). Sixty-nine patients (21%) had documented OSA. Only 25 out of 69 (36%) had a documented post-operative CPAP plan. Out of all 349 procedures, there were two incidents of pneumocephalus diagnosed. Neither of the patients had pre-existing OSA. One in five patients in our study had pre-existing OSA. Most patients returned to CPAP use within several weeks of TSS for resection of a sellar mass. Neither of the patients with pneumocephalus had pre-existing OSA and none of the patients with early re-initiation of CPAP developed this complication. This study provides preliminary evidence that resuming CPAP early in the post-operative period might be less dangerous than previously assumed. Copyright © 2016 Elsevier Ltd. All rights reserved.

  9. [Predictors of long-term remission after transsphenoidal surgery in Cushing's disease].

    Science.gov (United States)

    Abellán Galiana, Pablo; Fajardo Montañana, Carmen; Riesgo Suárez, Pedro Antonio; Gómez Vela, José; Escrivá, Carlos Meseguer; Lillo, Vicente Rovira

    2013-10-01

    There is no consensus on the remission criteria for Cushing's disease or on the definition of disease recurrence after transsphenoidal surgery, and comparison of the different published series is therefore difficult. A long-term recurrence rate of Cushing's disease ranging from 2%-25% has been reported. Predictors of long-term remission reported include: 1) adenoma-related factors (aggressiveness, size, preoperative identification in MRI), 2) surgery-related factors, mainly neurosurgeon experience, 3) clinical factors, of which dependence on and duration of glucocorticoid treatment are most important, and 4) biochemical factors. Among the latter, low postoperative cortisol levels, less than 2 mcg/dL predict for disease remission. However, even when undetectable plasma cortisol levels are present, long-term recurrence may still occur and lifetime follow-up is required. We report the preliminary results of the first 20 patients with Cushing's disease operated on at our hospital using nadir cortisol levels less than 2 mcg/dl as remission criterion. Copyright © 2012 SEEN. Published by Elsevier Espana. All rights reserved.

  10. Xanthomatous Hypophysitis Presenting with Diabetes Insipidus Completely Cured Through Transsphenoidal Surgery: Case Report and Literature Review.

    Science.gov (United States)

    Lin, Wei; Gao, Lu; Guo, Xiaopeng; Wang, Wenze; Xing, Bing

    2017-08-01

    Xanthomatous hypophysitis (XH) is extremely rare. Only 27 cases have been reported in the literature. No XH patient presenting with diabetes insipidus (DI) has been completely cured through surgery. Here, we describe the first XH case of a DI patient whose pituitary function was normalized postoperatively, without hormone replacement therapy. A 41-year-old woman suffered from polydipsia, DI, headache, and breast discharge. Laboratory investigation revealed hyperprolactinemia. Pituitary magnetic resonance imaging showed a 2.0-cm × 1.4-cm × 1.6-cm lesion that demonstrated heterogeneous intensity on T1-weighted imaging and peripheral ring enhancement following contrast; the lesion was totally removed through transsphenoidal surgery. Histopathologic and immunohistochemical examinations confirmed the diagnosis of XH. At the 4- and 15-month follow-up visits, all pituitary-related hormones were normal, and the patient was not taking medication. A repeat pituitary magnetic resonance imaging showed no evidence of recurrence. To the best of our knowledge, this case is the first documented occurrence of XH with DI completely cured through surgery. If XH is suspected, total surgical resection of the lesion is recommended and normal pituitary tissue should be carefully protected intraoperatively. Copyright © 2017 Elsevier Inc. All rights reserved.

  11. The impact of transsphenoidal surgery on neurocognitive function: A systematic review.

    Science.gov (United States)

    Alsumali, Adnan; Cote, David J; Regestein, Quentin R; Crocker, Erin; Alzarea, Abdulaziz; Zaidi, Hasan A; Bi, Wenya Linda; Dawood, Hassan Y; Broekman, Marike L; van Zandvoort, Martine J E; Mekary, Rania A; Smith, Timothy R

    2017-08-01

    Cognitive impairment following transsphenoidal surgery (TSS) among patients with pituitary tumors has been intermittently reported and is not well established. We performed a systematic review to summarize the impact of TSS on cognitive function. We conducted a systematic search of the literature using the PubMed, Cochrane, and Embase databases through October 2014. Studies were selected if they reported cognitive status after surgery and included at least 10 adult patients with pituitary tumors undergoing either endoscopic or microscopic TSS. After removing 69 duplicates, 758 articles were identified, of which 24 were selected for full text review after screening titles and abstracts. After reviewing full texts, nine studies with a combined total of 682 patients were included in the final analysis. Eight studies were cross-sectional and one was longitudinal. These studies used a wide variety of neurocognitive tests to assess memory, attention and executive function post-operatively. Of the eight studies, six reported impairments in verbal and non-verbal memory post-operatively, while others found no association related to memory, and some reported an improvement in episodic, verbal, or logical memory. While four studies found an impaired association between TSS and attention or executive function, another four studies did not. The current literature on cognitive impairments after TSS is limited and inconsistent. This review demonstrates that patients undergoing TSS may experience a variety of effects on executive function and memory post-operatively, but changes in verbal memory are most common. Copyright © 2017 Elsevier Ltd. All rights reserved.

  12. Significant Improvement in Chronic Persistent Headaches Caused by Small Rathke Cleft Cysts After Transsphenoidal Surgery.

    Science.gov (United States)

    Fukui, Issei; Hayashi, Yasuhiko; Kita, Daisuke; Sasagawa, Yasuo; Oishi, Masahiro; Tachibana, Osamu; Nakada, Mitsutoshi

    2017-03-01

    Rathke cleft cysts (RCC) usually are asymptomatic and can be observed via the use of conservative methods. Some patients with RCCs, however, have severe headaches even if they are small enough to be confined to the sella, and these small RCCs seldom have been discussed. This study presents an investigation into clinical characteristics of small RCCs associated with severe headaches, demonstrating efficacy and safety of endoscopic transsphenoidal surgery (ETSS) to relieve headaches. In this study, 13 patients with small RCCs (maximum diameter HIT-6) score was calculated both pre- and postoperatively to evaluate headache severity. All patients complained of severe headaches, which disturbed their daily life. Most headaches were nonpulsating and localized in the frontal area. Characteristically, 6 patients (46%) experienced severe headaches with sudden onset that continued chronically. HIT-6 score was 64 on average, meaning headaches affected daily life severely. After surgical decompression of the cyst, headache in all of the patients improved dramatically and HIT-6 score decreased significantly to 37, suggesting that headaches were diminished. No newly developed deficiencies of the anterior pituitary lobe function were detected. Postoperative occurrence of diabetes insipidus was found in 2 patients, both of which were transient. No recurring cysts were found. Severe headaches can develop from small RCCs. In the present study, ETSS was performed on such patients effectively and safely to relieve their headaches. Copyright © 2017 Elsevier Inc. All rights reserved.

  13. Gamma radiosurgery combined with trans-sphenoidal surgery for pituitary tumor involved to the cavernous sinus

    International Nuclear Information System (INIS)

    Ikeda, Hidetoshi; Yoshimoto, Takashi; Shirokura, Hidefumi.

    1995-01-01

    Ten patients (2 males and 8 females with an average age of 39 years) were treated with combined trans-sphenoidal surgery and gamma radiosurgery for pituitary tumor involved to the cavernous sinus. A Follow-up period ranged from 7 to 29 months, with a mean of 21 months. Therapeutic effects were assessed using magnetic resonance imaging (MRI) every 3 months, endocrine examination, optical examination for visual field, and auditory test. Pituitary tumor after radiosurgery was shown as hypointensity on T1-weighted images and hyperintensity on T2-weighted images. Tumor response could be classified on MRI into (1) a remarkably decreased tumor in size with increased contrast enhancement (n=6), (2) a remarkably decreased tumor in size with unchanged contrast enhancement (n=one), (3) a slightly decreased tumor in size with increased spotted contrast enhancement (n=2), and (4) unchanged tumor in size with decreased contrast enhancement (n=one). Of 6 Type 1 patients, 5 had growth hormone production. Growth hormone production tended to be associated with favorable response to radiosurgery. In 3 patients who showed endocrinologically favorable response (such as increased growth hormone in blood and somatomedin C value), complete regression of tumor was achieved at a 20-month follow-up period. Radiosurgery also seemed to be useful for treating hormone active tumors. (N.K.)

  14. Lumbar Drains Decrease the Risk of Postoperative Cerebrospinal Fluid Leak Following Endonasal Endoscopic Surgery for Suprasellar Meningiomas in Patients With High Body Mass Index.

    Science.gov (United States)

    Cohen, Salomon; Jones, Samuel H; Dhandapani, Sivashanmugam; Negm, Hazem M; Anand, Vijay K; Schwartz, Theodore H

    2018-01-01

    Postoperative cerebrospinal fluid (CSF) leak is a persistent, albeit much less prominent, complication following endonasal endoscopic surgery. The pathology with highest risk is suprasellar meningiomas. A postoperative lumbar drain (LD) is used to decrease the risk of CSF leak but is not universally accepted. To compare the rates of postoperative CSF leak between patients with and without LD who underwent endonasal endoscopic surgical resection of suprasellar meningiomas. A consecutive series of newly diagnosed suprasellar meningiomas was drawn from a prospectively acquired database of endonasal endoscopic surgeries at our institution. An intraoperative, preresection LD was placed and left open at 5 cc/h for ∼48 h. In a subset of patients, the LD could not be placed. Rates of postoperative CSF leak were compared between patients with and without an LD. Twenty-five patients underwent endonasal endoscopic surgical resection of suprasellar meningiomas. An LD could not be placed in 2 patients. There were 2 postoperative CSF leaks (8%), both of which occurred in the patients who did not have an LD (P = .0033). The average body mass index (BMI) of the patients in whom the LD could not be placed was 39.1 kg/m2, compared with 27.6 kg/m2 for those in whom the LD could be placed (P = .009). In the subgroup of obese patients (BMI > 30 kg/m2), LD placement was protective against postoperative CSF leak (P = .022). The inability to place an LD in patients with obesity is a risk factor for postoperative CSF leak. An LD may be useful to prevent postoperative CSF leak, particularly in patients with elevated BMI. Copyright © 2017 by the Congress of Neurological Surgeons

  15. Multiport Combined Endoscopic Approach to Nonembolized Juvenile Nasopharyngeal Angiofibroma with Parapharyngeal Extension: An Emerging Concept

    Directory of Open Access Journals (Sweden)

    Tiruchy Narayanan Janakiram

    2016-01-01

    Full Text Available Background. Surgical approaches to the parapharyngeal space (PPS are challenging by virtue of deep location and neurovascular content. Juvenile Nasopharyngeal Angiofibroma (JNA is a formidable hypervascular tumor that involves multiple compartments with increase in size. In tumors with extension to parapharyngeal space, the endonasal approach was observed to be inadequate. Combined Endoscopic Endonasal Approaches and Endoscopic Transoral Surgery (EEA-ETOS approach has provided a customized alternative of multicorridor approach to access JNA for its safe and efficient resection. Methods. The study demonstrates a case series of patients of JNA with prestyloid parapharyngeal space extension operated by endoscopic endonasal and endoscopic transoral approach for tumor excision. Results. The multiport EEA-ETOS approach was used to provide wide exposure to access JNA in parapharyngeal space. No major complications were observed. No conversion to external approach was required. Postoperative morbidity was low and postoperative scans showed no residual tumor. A one-year follow-up was maintained and there was no evidence of disease recurrence. Conclusion. Although preliminary, our experience demonstrates safety and efficacy of multiport approach in providing access to multiple compartments, facilitating total excision of JNA in selected cases.

  16. Reconstruction of the sellar floor using a silicone plate in transsphenoidal surgery and its postoperative appearance on magnetic resonance images

    International Nuclear Information System (INIS)

    Kabuto, Masanori; Kubota, Toshihiko; Kobayashi, Hidenori; Sato, Kazufumi; Ishii, Hisao; Nakagawa, Takao; Arai, Ryowa; Kitai, Ryuhei; Tuchida, Akira

    1993-01-01

    The reconstruction of the sellar floor using a silicone plate in transsphenoidal surgery and its postoperative appearance on magnetic resonance (MR) images are described. Thirty-eight patients with pituitary adenoma and four with Rathke's cleft cyst underwent this operation and postoperative MR imaging over a 4-year period. A fitting silicone plate for closing of the sellar floor window could be easily made from a large silicone block at the operation. The postoperative position of the silicone plate could be clearly detected by MR imaging as a very low intensity plate on both T1- and T2-weighted sagittal images. (author)

  17. Detection of recurrent Cushing's disease: proposal for standardized patient monitoring following transsphenoidal surgery.

    Science.gov (United States)

    Ayala, Alejandro; Manzano, Alex J

    2014-09-01

    Transsphenoidal surgery (TSS) is first-line treatment for Cushing's disease (CD), a devastating disorder of hypercortisolism resulting from overproduction of adrenocorticotropic hormone by a pituitary adenoma. Surgical success rates vary widely and disease may recur years after remission is achieved. Recognizing CD recurrence can be challenging; although there is general acceptance among endocrinologists that patients need lifelong follow-up, there are currently no standardized monitoring guidelines. To begin addressing this need we created a novel, systematic algorithm by integrating information from literature on relapse rates in surgically-treated CD patients and our own clinical experiences. Reported recurrence rates range from 3 to 47 % (mean time to recurrence 16-49 months), emphasizing the need for careful post-surgical patient monitoring. We recommend that patients with post-operative serum cortisol surgery) be monitored semiannually for 3 years and annually thereafter. Patients with post-operative cortisol between 2 and 5 µg/dL may experience persistent or subclinical CD and should be evaluated every 2-3 months until biochemical control is achieved or additional treatment is initiated. Post-operative cortisol >5 µg/dL often signifies persistent disease and second-line treatment (e.g., immediate repeat pituitary surgery, radiotherapy, and/or medical therapy) may be considered. This follow-up algorithm aims to (a) enable early diagnosis and treatment of recurrent CD, thereby minimizing the detrimental effects of hypercortisolism, and (b) begin addressing the need for standardized guidelines for vigilant monitoring of CD patients treated by TSS, as demonstrated by the reported rates of recurrence.

  18. Usefulness of Intraoperative Monitoring of Visual Evoked Potentials in Transsphenoidal Surgery

    Science.gov (United States)

    KAMIO, Yoshinobu; SAKAI, Naoto; SAMESHIMA, Tetsuro; TAKAHASHI, Goro; KOIZUMI, Shinichiro; SUGIYAMA, Kenji; NAMBA, Hiroki

    2014-01-01

    Postoperative visual outcome is a major concern in transsphenoidal surgery (TSS). Intraoperative visual evoked potential (VEP) monitoring has been reported to have little usefulness in predicting postoperative visual outcome. To re-evaluate its usefulness, we adapted a high-power light-stimulating device with electroretinography (ERG) to ascertain retinal light stimulation. Intraoperative VEP monitoring was conducted in TSSs in 33 consecutive patients with sellar and parasellar tumors under total venous anesthesia. The detectability rates of N75, P100, and N135 were 94.0%, 85.0%, and 79.0%, respectively. The mean latencies and amplitudes of N75, P100, and N135 were 76.8 ± 6.4 msec and 4.6 ± 1.8 μV, 98.0 ± 8.6 msec and 5.0 ± 3.4 μV, and 122.1 ± 16.3 msec and 5.7 ± 2.8 μV, respectively. The amplitude was defined as the voltage difference from N75 to P100 or P100 to N135. The criterion for amplitude changes was defined as a > 50% increase or 50% decrease in amplitude compared to the control level. The surgeon was immediately alerted when the VEP changed beyond these thresholds, and the surgical manipulations were stopped until the VEP recovered. Among the 28 cases with evaluable VEP recordings, the VEP amplitudes were stable in 23 cases and transiently decreased in 4 cases. In these 4 cases, no postoperative vision deterioration was observed. One patient, whose VEP amplitude decreased without subsequent recovery, developed vision deterioration. Intraoperative VEP monitoring with ERG to ascertain retinal light stimulation by the new stimulus device was reliable and feasible in preserving visual function in patients undergoing TSS. PMID:25070017

  19. Endoscopic Transsphenoidal Salvage Surgery for Symptomatic Residual Cystic Craniopharyngioma after Radiotherapy.

    Science.gov (United States)

    Emanuelli, Enzo; Frasson, Giuliana; Cazzador, Diego; Borsetto, Daniele; Denaro, Luca

    2018-04-01

    Objectives  Ideal treatment of craniopharyngiomas is still controversial. Radiotherapy (RT) is considered effective for recurrences or after subtotal tumor removal (STR). About 40 to 50% of patients may experience tumor cyst expansion soon after RT; in these cases, the role of salvage surgery is debated. Design  Operative video. Setting  Tertiary care center. Participants  An 11-year-old boy diagnosed with persistent craniopharyngioma. In 2015, the patient underwent right frontotemporal craniotomy for STR at another center, complicated by panhypopituitarism. Two years later, fractionated 54-Gy RT was performed on growing residual tumor. After 3 months, he was admitted to our hospital due to persistent malaise, vomiting, pulsating headache, and epistaxis. Ophthalmologic evaluation evidenced left homonymous hemianopsia. Results  A contrast-enhanced magnetic resonance imaging (MRI) showed a 27-mm cystic component enlarging from the cranial end of the persistent craniopharyngioma lesion, extending into the third ventricle. Biventricular hydrocephalus and brain midline shift to the right were present. Compared with the early post-RT MRI, the cystic component of the tumor demonstrated growth. The patient underwent external ventricular drainage placement for emergent treatment of hydrocephalus and endoscopic transsphenoidal surgery. After cystic content drainage, the lesion was completely removed with its capsule. A "gasket seal" technique was performed for skull base reconstruction, with autologous fascia lata, septal bone, and mucoperiosteum from inferior turbinate. Histologic examination confirmed the craniopharyngioma diagnosis. Postoperative MRI showed resolution of the hydrocephalus and complete tumor removal. Conclusion  Although shrinkage of cystic components of craniopharyngioma residuals may occur within 5 to 6 months after RT, salvage surgery is indicated in symptomatic patients. The link to the video can be found at https://youtu.be/4x6Qe76bf60 .

  20. Outcomes of Primary Transsphenoidal Surgery in Cushing Disease: Experience of a Tertiary Center.

    Science.gov (United States)

    Keskin, Fatma Ela; Ozkaya, Hande Mefkure; Bolayirli, Murat; Erden, Secil; Kadioglu, Pınar; Tanriover, Necmettin; Gazioglu, Nurperi

    2017-10-01

    To report the initial and long-term remission rates and related factors, secondary treatments, and outcomes of a series of patients with Cushing disease (CD). We included 147 consecutive adult patients with CD who underwent primary transsphenoidal surgery (TSS) between 1998 and 2014 in this study. Eighty-two were followed up in the Cerrahpasa Medical Faculty Endocrinology and Metabolism outpatient clinic. Patients were requested to attend a long-term remission assessment; 55 could be contacted, and data for the remaining 27 patients' last visit to the outpatient clinics were reviewed for early and late remission. Six patients were excluded from the study. Magnetic resonance imaging (MRI) findings and pathologic results including mitosis, Ki-67 levels, and P53 in immunostaining of all patients were evaluated. Data of 82 patients with CD with an average age of 36 years [interquartile range: 29-47] were analyzed with a mean follow-up of 7.5 years [interquartile range: 5-10]. Overall initial remission rates were 72.3% after TSS. Among the 82 patients, 16 patients had Gamma Knife radiosurgery and 7 patients underwent adrenalectomy. After these additional treatments, the long-term remission rate was found as 69.7%. The highest remission rates were with microadenomas. Recurrence was most frequently seen in patients without tumor evidence on MRI. Patients with high Ki-67 levels had higher recurrence rates in long-term follow-up (P = 0.02). Life-long follow-up for patients with CD seems essential. Undetectable tumors on MRI before TSS and high Ki-67 immunopositivity were found as risk factors for tumor recurrence. Copyright © 2017 Elsevier Inc. All rights reserved.

  1. Folate receptor overexpression can be visualized in real time during pituitary adenoma endoscopic transsphenoidal surgery with near-infrared imaging.

    Science.gov (United States)

    Lee, John Y K; Cho, Steve S; Zeh, Ryan; Pierce, John T; Martinez-Lage, Maria; Adappa, Nithin D; Palmer, James N; Newman, Jason G; Learned, Kim O; White, Caitlin; Kharlip, Julia; Snyder, Peter; Low, Philip S; Singhal, Sunil; Grady, M Sean

    2017-08-25

    OBJECTIVE Pituitary adenomas account for approximately 10% of intracranial tumors and have an estimated prevalence of 15%-20% in the general US population. Resection is the primary treatment for pituitary adenomas, and the transsphenoidal approach remains the most common. The greatest challenge with pituitary adenomas is that 20% of patients develop tumor recurrence. Current approaches to reduce recurrence, such as intraoperative MRI, are costly, associated with high false-positive rates, and not recommended. Pituitary adenomas are known to overexpress folate receptor alpha (FRα), and it was hypothesized that OTL38, a folate analog conjugated to a near-infrared (NIR) fluorescent dye, could provide real-time intraoperative visual contrast of the tumor versus the surrounding nonneoplastic tissues. The preliminary results of this novel clinical trial are presented. METHODS Nineteen adult patients who presented with pituitary adenoma were enrolled. Patients were infused with OTL38 2-4 hours prior to surgery. A 4-mm endoscope with both visible and NIR light capabilities was used to visualize the pituitary adenoma and its margins in real time during surgery. The signal-to-background ratio (SBR) was recorded for each tumor and surrounding tissues at various endoscope-to-sella distances. Immunohistochemical analysis was performed to assess the FRα expression levels in all specimens and classify patients as having either high or low FRα expression. RESULTS Data from 15 patients (4 with null cell adenomas, 1 clinically silent gonadotroph, 1 totally silent somatotroph, 5 with a corticotroph, 3 with somatotrophs, and 1 somatocorticotroph) were analyzed in this preliminary analysis. Four patients were excluded for technical considerations. Intraoperative NIR imaging delineated the main tumors in all 15 patients with an average SBR of 1.9 ± 0.70. The FRα expression level of the adenomas and endoscope-to-sella distance had statistically significant impacts on the fluorescent

  2. Endoscopic transnasal approach for removing pituitary tumors

    Directory of Open Access Journals (Sweden)

    Mirian Cabral Moreira de Castro

    2014-05-01

    Full Text Available To describe a series of 129 consecutive patients submitted to the resection of pituitary tumors using the endoscopic transsphenoidal approach in a public medical center. Method: Retrospective analysis based on the records of patients submitted to the resection of a pituitary tumor through the endoscopic transsphenoidal approach between 2004 and 2009. Results: One hundred and twenty-nine records were analyzed. The tumor was non-secreting in 96 (74.42% and secreting in 33 patients (22.58%. Out of the secretory tumors, the most prevalent was the growth hormone producer (7.65%, followed by the prolactinoma, (6.98%. Eleven patients developed cerebral spinal fluid (CSF fistulas, and four of them developed meningitis. One patient died due to intracerebral hemorrhage in the postoperative period. Conclusion: The endoscopic transsphenoidal approach to sellar tumors proved to be safe when the majority of the tumors were non-secreting. The most frequent complication was CSF. This technique can be done even in a public hospital with financial limits, since the health professionals are integrated.

  3. Outcome of endoscopic transsphenoidal surgery in combination with somatostatin analogues in patients with growth hormone producing pituitary adenoma.

    Science.gov (United States)

    Zhou, Tao; Wang, Fuyu; Meng, Xianghui; Ba, Jianmin; Wei, Shaobo; Xu, Bainan

    2014-11-01

    To determine the efficacy of endoscopic surgery in combination with long-acting somatostatin analogues (SSAs) in treating patients with growth hormone (GH)-secreting pituitary tumor. We performed retrospective analysis of 133 patients with GH producing pituitary adenoma who underwent pure endoscopic transsphenoidal surgery in our center from January 2007 to July 2012. Patients were followed up for a range of 3-48 months. The radiological remission, biochemical remission and complication were evaluated. A total of 110 (82.7%) patients achieved radiological complete resection, 11 (8.2%) subtotal resection, and 12 (9.0%) partial resection. Eighty-eight (66.2%) patients showed nadir GH level less than 1 ng/mL after oral glucose administration. No mortality or severe disability was observed during follow up. Preoperative long-acting SSA successfully improved left ventricle ejection fraction (LVEF) and blood glucose in three patients who subsequently underwent success operation. Long-acting SSA (20 mg every 30 days) achieved biochemical remission in 19 out 23 (82.6%) patients who showed persistent high GH level after surgery. Endoscopic transsphenoidal surgery can biochemically cure the majority of GH producing pituitary adenoma. Post-operative use of SSA can improve biochemical remission.

  4. The Influence of Pituitary Size on Outcome After Transsphenoidal Hypophysectomy in a Large Cohort of Dogs with Pituitary-Dependent Hypercortisolism

    NARCIS (Netherlands)

    van Rijn, Sarah; Galac, S.; Tryfonidou, M. A.; Hesselink, J. W.; Penning, L. C.; Kooistra, H. S.; Meij, B. P.

    2016-01-01

    BACKGROUND Transsphenoidal hypophysectomy is one of the treatment strategies in the comprehensive management of dogs with pituitary-dependent hypercortisolism (PDH). OBJECTIVES To describe the influence of pituitary size at time of pituitary gland surgery on long-term outcome. ANIMALS

  5. Pituitary magnetic resonance imaging is not required in the postoperative follow-up of acromegalic patients with long-term biochemical cure after transsphenoidal surgery

    NARCIS (Netherlands)

    Zirkzee, E. J. M.; Corssmit, E. P. M.; Biermasz, N. R.; Brouwer, P. A.; Wiggers-de Bruine, F. T.; Kroft, L. J. M.; van Buchem, M. A.; Roelfsema, F.; Pereira, A. M.; Smit, J. W. A.; Romijn, J. A.

    2004-01-01

    After successful transsphenoidal surgery for acromegaly, life-long follow-up is required, because 10-15% of patients develop recurrence of disease. We assessed whether it is safe to perform postoperative follow-up with only biochemical evaluation in acromegalic patients initially cured by

  6. Cost-Effectiveness Analysis of Microscopic and Endoscopic Transsphenoidal Surgery Versus Medical Therapy in the Management of Microprolactinoma in the United States.

    Science.gov (United States)

    Jethwa, Pinakin R; Patel, Tapan D; Hajart, Aaron F; Eloy, Jean Anderson; Couldwell, William T; Liu, James K

    2016-03-01

    Although prolactinomas are treated effectively with dopamine agonists, some have proposed curative surgical resection for select cases of microprolactinomas to avoid life-long medical therapy. We performed a cost-effectiveness analysis comparing transsphenoidal surgery (either microsurgical or endoscopic) and medical therapy (either bromocriptine or cabergoline) with decision analysis modeling. A 2-armed decision tree was created with TreeAge Pro Suite 2012 to compare upfront transsphenoidal surgery versus medical therapy. The economic perspective was that of the health care third-party payer. On the basis of a literature review, we assigned plausible distributions for costs and utilities to each potential outcome, taking into account medical and surgical costs and complications. Base-case analysis, sensitivity analysis, and Monte Carlo simulations were performed to determine the cost-effectiveness of each strategy at 5-year and 10-year time horizons. In the base-case scenario, microscopic transsphenoidal surgery was the most cost-effective option at 5 years from the time of diagnosis; however, by the 10-year time horizon, endoscopic transsphenoidal surgery became the most cost-effective option. At both time horizons, medical therapy (both bromocriptine and cabergoline) were found to be more costly and less effective than transsphenoidal surgery (i.e., the medical arm was dominated by the surgical arm in this model). Two-way sensitivity analysis demonstrated that endoscopic resection would be the most cost-effective strategy if the cure rate from endoscopic surgery was greater than 90% and the complication rate was less than 1%. Monte Carlo simulation was performed for endoscopic surgery versus microscopic surgery at both time horizons. This analysis produced an incremental cost-effectiveness ratio of $80,235 per quality-adjusted life years at 5 years and $40,737 per quality-adjusted life years at 10 years, implying that with increasing time intervals, endoscopic

  7. Value of Free-Run Electromyographic Monitoring of Extraocular Cranial Nerves during Expanded Endonasal Surgery (EES) of the Skull Base.

    Science.gov (United States)

    Thirumala, Parthasarathy D; Mohanraj, Santhosh Kumar; Habeych, Miguel; Wichman, Kelley; Chang, Yue-Fang; Gardner, Paul; Snyderman, Carl; Crammond, Donald J; Balzer, Jeffrey

    2013-06-01

    Objective To evaluate the value of free-run electromyography (f-EMG) monitoring of extraocular cranial nerves (EOCN) III, IV, and VI during expanded endonasal surgery (EES) of the skull base in reducing iatrogenic cranial nerve (CN) deficits. Design We retrospectively identified 200 patients out of 990 who had at least one EOCN monitored during EES. We further separated patients into groups according to the specific CN monitored. In each CN group, we classified patients who had significant (SG) f-EMG activity as Group I and those who did not as Group II. Results A total of 696 EOCNs were monitored. The number of muscles supplied by EOCNs that had SG f-EMG activity was 88, including CN III = 46, CN IV = 21, and CN VI = 21. There were two deficits involving CN VI in patients who had SG f-EMG activity during surgery. There were 14 deficits observed, including CN III = 3, CN IV = 2, and CN VI = 9 in patients who did not have SG f-EMG activity during surgery. Conclusions f-EMG monitoring of EOCN during EES can be useful in identifying the location of the nerve. It seems to have limited value in predicting postoperative neurological deficits. Future studies to evaluate the EMG of EOCN during EES need to be done with both f-EMG and triggered EMG.

  8. Multimodal Navigation in Endoscopic Transsphenoidal Resection of Pituitary Tumors Using Image-Based Vascular and Cranial Nerve Segmentation: A Prospective Validation Study.

    Science.gov (United States)

    Dolati, Parviz; Eichberg, Daniel; Golby, Alexandra; Zamani, Amir; Laws, Edward

    2016-11-01

    Transsphenoidal surgery (TSS) is the most common approach for the treatment of pituitary tumors. However, misdirection, vascular damage, intraoperative cerebrospinal fluid leakage, and optic nerve injuries are all well-known complications, and the risk of adverse events is more likely in less-experienced hands. This prospective study was conducted to validate the accuracy of image-based segmentation coupled with neuronavigation in localizing neurovascular structures during TSS. Twenty-five patients with a pituitary tumor underwent preoperative 3-T magnetic resonance imaging (MRI), and MRI images loaded into the navigation platform were used for segmentation and preoperative planning. After patient registration and subsequent surgical exposure, each segmented neural or vascular element was validated by manual placement of the navigation probe or Doppler probe on or as close as possible to the target. Preoperative segmentation of the internal carotid artery and cavernous sinus matched with the intraoperative endoscopic and micro-Doppler findings in all cases. Excellent correspondence between image-based segmentation and the endoscopic view was also evident at the surface of the tumor and at the tumor-normal gland interfaces. Image guidance assisted the surgeons in localizing the optic nerve and chiasm in 64% of cases. The mean accuracy of the measurements was 1.20 ± 0.21 mm. Image-based preoperative vascular and neural element segmentation, especially with 3-dimensional reconstruction, is highly informative preoperatively and potentially could assist less-experienced neurosurgeons in preventing vascular and neural injury during TSS. In addition, the accuracy found in this study is comparable to previously reported neuronavigation measurements. This preliminary study is encouraging for future prospective intraoperative validation with larger numbers of patients. Copyright © 2016 Elsevier Inc. All rights reserved.

  9. Risks and Benefits of Endoscopic Transsphenoidal Surgery for Nonfunctioning Pituitary Adenomas in Patients of the Ninth Decade.

    Science.gov (United States)

    Chinezu, Rares; Fomekong, Franklin; Lasolle, Héllène; Trouillas, Jacqueline; Vasiljevic, Alexandre; Raverot, Gerald; Jouanneau, Emmanuel

    2017-10-01

    The population older than 80 years of age (very elderly) is increasing, and the management of these patients with pituitary surgery is controversial. To determine the prevalence of pituitary tumors in elderly patients and to determine the safety of endoscopic transsphenoidal pituitary surgery for nonfunctioning pituitary adenomas in patients aged older than 80 years. This retrospective study included elderly (65-75 years old) and very elderly consecutive patients operated between 2007 and 2015 for nonfunctioning pituitary adenomas. Tumor characteristics, comorbidities, pre- and postoperative visual and endocrinologic status, and postoperative complications were compared. Of the total 623 operated patients, 307 had nonfunctioning pituitary adenomas. Twenty-three percent (n = 143) of all patients were aged older than 65 years, whereas 2.56% (n = 16) were aged older than 80 years. Gonadotroph and nonimmunoreactive tumors occurred in 81% of patients aged older than 65 years. The study groups were Group A, comprising 15 patients aged older than 80 years, and Group B, comprising 49 patients aged 65-75 years. No presurgical statistical differences were noted between the 2 groups. Complete tumor resection was achieved in 53.3% of Group A and 73.5% of Group B. Postsurgical visual status improved significantly in Group A than in Group B (P = 0.0012). No deaths occurred, and no group differences were noted in the postoperative complications. Age exceeding 80 years is not by itself a predictor of worse clinical outcome of endoscopic transsphenoidal pituitary surgery for nonfunctioning adenomas. Emphasis should be placed on visual pathway decompression for the quality of life in very old people. Copyright © 2017 Elsevier Inc. All rights reserved.

  10. Therapeutic outcomes of transsphenoidal surgery in pediatric patients with craniopharyngiomas: a single-center study.

    Science.gov (United States)

    Yamada, Shozo; Fukuhara, Noriaki; Yamaguchi-Okada, Mitsuo; Nishioka, Hiroshi; Takeshita, Akira; Takeuchi, Yasuhiro; Inoshita, Naoko; Ito, Junko

    2018-03-30

    OBJECTIVE The aim of this study was to analyze the outcomes of transsphenoidal surgery (TSS) in a single-center clinical series of pediatric craniopharyngioma patients treated with gross-total resection (GTR). METHODS The authors retrospectively reviewed the surgical outcomes for 65 consecutive patients with childhood craniopharyngiomas (28 girls and 37 boys, mean age 9.6 years) treated with TSS (45 primary and 20 repeat surgeries) between 1990 and 2015. Tumors were classified as subdiaphragmatic or supradiaphragmatic. Demographic and clinical characteristics, including extent of resection, complications, incidence of recurrence, pre- and postoperative visual disturbance, pituitary function, and incidence of diabetes insipidus (DI), as well as new-onset obesity, were analyzed and compared between the primary surgery and repeat surgery groups. RESULTS Of the 45 patients in the primary surgery group, 26 (58%) had subdiaphragmatic tumors and 19 had supradiaphragmatic tumors. Of the 20 patients in the repeat surgery group, 9 (45%) had subdiaphragmatic tumors and 11 had supradiaphragmatic tumors. The only statistically significant difference between the 2 surgical groups was in tumor size; tumors were larger (mean maximum diameter 30 mm) in the primary surgery group than in the repeat surgery group (25 mm) (p = 0.008). GTR was accomplished in 59 (91%) of the 65 cases; the GTR rate was higher in the primary surgery group than in the repeat surgery group (98% vs 75%, p = 0.009). Among the patients who underwent GTR, 12% experienced tumor recurrence, with a median follow-up of 7.8 years, and recurrence tended to occur less frequently in primary than in repeat surgery patients (7% vs 27%, p = 0.06). Of the 45 primary surgery patients, 80% had deteriorated pituitary function and 83% developed DI, whereas 100% of the repeat surgery patients developed these conditions. Among patients with preoperative visual disturbance, vision improved in 62% but worsened in 11%. Visual

  11. Simultaneous occurrence of subarachnoid hemorrhage and epistaxis due to ruptured petrous internal carotid artery aneurysm. Association with transsphenoidal surgery and radiation therapy. Case report

    International Nuclear Information System (INIS)

    Endo, Hidenori; Fujimura, Miki; Inoue, Takashi; Matsumoto, Yasushi; Ogawa, Yoshikazu; Kawagishi, Jun; Jokura, Hidefumi; Shimizu, Hiroaki; Tominaga, Teiji

    2011-01-01

    A 62-year-old woman presented with simultaneous subarachnoid hemorrhage (SAH) and massive epistaxis. The patient had been treated for pituitary prolactinoma by two transsphenoidal surgeries, gamma knife radiosurgery, and conventional radiation therapy since age 43 years. Cerebral angiography showed left petrous internal carotid artery (ICA) aneurysm with slight stenosis on the adjacent left petrous ICA. She underwent superficial temporal artery-middle cerebral artery (STA-MCA) double anastomosis with endovascular internal trapping without complication the day after onset. Postoperative course was uneventful; the patient did not develop symptomatic vasospasm, recurrent epistaxis, or cerebrospinal fluid rhinorrhea. Postoperative angiography demonstrated complete disappearance of the aneurysm with patent STA-MCA anastomosis. The patient was discharged 2 months after surgery without neurological deficit. The present case is extremely rare with simultaneous onset of SAH and epistaxis caused by ruptured petrous ICA aneurysm. The transsphenoidal surgeries and radiation therapies might have been critical in the formation of the petrous ICA aneurysm. (author)

  12. Design and Validation of an Open-Source, Partial Task Trainer for Endonasal Neuro-Endoscopic Skills Development: Indian Experience.

    Science.gov (United States)

    Singh, Ramandeep; Baby, Britty; Damodaran, Natesan; Srivastav, Vinkle; Suri, Ashish; Banerjee, Subhashis; Kumar, Subodh; Kalra, Prem; Prasad, Sanjiva; Paul, Kolin; Anand, Sneh; Kumar, Sanjeev; Dhiman, Varun; Ben-Israel, David; Kapoor, Kulwant Singh

    2016-02-01

    Box trainers are ideal simulators, given they are inexpensive, accessible, and use appropriate fidelity. The development and validation of an open-source, partial task simulator that teaches the fundamental skills necessary for endonasal skull-base neuro-endoscopic surgery. We defined the Neuro-Endo-Trainer (NET) SkullBase-Task-GraspPickPlace with an activity area by analyzing the computed tomography scans of 15 adult patients with sellar suprasellar parasellar tumors. Four groups of participants (Group E, n = 4: expert neuroendoscopists; Group N, n =19: novice neurosurgeons; Group R, n = 11: neurosurgery residents with multiple iterations; and Group T, n = 27: neurosurgery residents with single iteration) performed grasp, pick, and place tasks using NET and were graded on task completion time and skills assessment scale score. Group E had lower task completion times and greater skills assessment scale scores than both Group N and R (P ≤ 0.03, 0.001). The performance of Groups N and R was found to be equivalent; in self-assessing neuro-endoscopic skill, the participants in these groups were found to have equally low pretraining scores (4/10) with significant improvement shown after NET simulation (6, 7 respectively). Angled scopes resulted in decreased scores with tilted plates compared with straight plates (30° P ≤ 0.04, 45° P ≤ 0.001). With tilted plates, decreased scores were observed when we compared the 0° with 45° endoscope (right, P ≤ 0.008; left, P ≤ 0.002). The NET, a face and construct valid open-source partial task neuroendoscopic trainer, was designed. Presimulation novice neurosurgeons and neurosurgical residents were described as having insufficient skills and preparation to practice neuro-endoscopy. Plate tilt and endoscope angle were shown to be important factors in participant performance. The NET was found to be a useful partial-task trainer for skill building in neuro-endoscopy. Copyright © 2016 Elsevier Inc. All rights reserved.

  13. Multimodal Navigation in Endoscopic Transsphenoidal Resection of Pituitary Tumors using Image-based Vascular and Cranial Nerve Segmentation: A Prospective Validation Study

    Science.gov (United States)

    Dolati, Parviz; Eichberg, Daniel; Golby, Alexandra; Zamani, Amir; Laws, Edward

    2016-01-01

    Introduction Transsphenoidal surgery (TSS) is a well-known approach for the treatment of pituitary tumors. However, lateral misdirection and vascular damage, intraoperative CSF leakage, and optic nerve and vascular injuries are all well-known complications, and the risk of adverse events is more likely in less experienced hands. This prospective study was conducted to validate the accuracy of image-based segmentation in localization of neurovascular structures during TSS. Methods Twenty-five patients with pituitary tumors underwent preoperative 3TMRI, which included thin-sectioned 3D space T2, 3D Time of Flight and MPRAGE sequences. Images were reviewed by an expert independent neuroradiologist. Imaging sequences were loaded in BrainLab iPlanNet (16/25 cases) or Stryker (9/25 cases) image guidance platforms for segmentation and pre-operative planning. After patient registration into the neuronavigation system and subsequent surgical exposure, each segmented neural or vascular element was validated by manual placement of the navigation probe on or as close as possible to the target. The audible pulsations of the bilateral ICA were confirmed using a micro-Doppler probe. Results Pre-operative segmentation of the ICA and cavernous sinus matched with the intra-operative endoscopic and micro-Doppler findings in all cases (Dice Similarity Coefficient =1). This information reassured the surgeons with regard to the lateral extent of bone removal at the sellar floor and the limits of lateral exploration. Excellent correspondence between image-based segmentation and the endoscopic view was also evident at the surface of the tumor and at the tumor-normal gland interfaces. This assisted in preventing unnecessary removal of the normal pituitary gland. Image-guidance assisted the surgeons in localizing the optic nerve and chiasm in 64% of the cases and the diaphragma sella in 52% of cases, which helped to determine the limits of upward exploration and to decrease the risk of CSF

  14. Early versus late Gamma Knife radiosurgery following transsphenoidal surgery for nonfunctioning pituitary macroadenomas: a multicenter matched-cohort study.

    Science.gov (United States)

    Pomeraniec, I Jonathan; Kano, Hideyuki; Xu, Zhiyuan; Nguyen, Brandon; Siddiqui, Zaid A; Silva, Danilo; Sharma, Mayur; Radwan, Hesham; Cohen, Jonathan A; Dallapiazza, Robert F; Iorio-Morin, Christian; Wolf, Amparo; Jane, John A; Grills, Inga S; Mathieu, David; Kondziolka, Douglas; Lee, Cheng-Chia; Wu, Chih-Chun; Cifarelli, Christopher P; Chytka, Tomas; Barnett, Gene H; Lunsford, L Dade; Sheehan, Jason P

    2017-10-27

    OBJECTIVE Gamma Knife radiosurgery (GKRS) is frequently used to treat residual or recurrent nonfunctioning pituitary macroadenomas. There is no consensus as to whether GKRS should be used early after surgery or if radiosurgery should be withheld until there is evidence of imaging-defined progression of tumor. Given the high incidence of adenoma progression after subtotal resection over time, the present study intended to evaluate the effect of timing of radiosurgery on outcome. METHODS This is a multicenter retrospective review of patients with nonfunctioning pituitary macroadenomas who underwent transsphenoidal surgery followed by GKRS from 1987 to 2015 at 9 institutions affiliated with the International Gamma Knife Research Foundation. Patients were matched by adenoma and radiosurgical parameters and stratified based on the interval between last resection and radiosurgery. Operative results, imaging data, and clinical outcomes were compared across groups following early (≤ 6 months after resection) or late (> 6 months after resection) radiosurgery. RESULTS After matching, 222 patients met the authors' study criteria (from an initial collection of 496 patients) and were grouped based on early (n = 111) or late (n = 111) GKRS following transsphenoidal surgery. There was a greater risk of tumor progression after GKRS (p = 0.013) and residual tumor (p = 0.038) in the late radiosurgical group over a median imaging follow-up period of 68.5 months. No significant difference in the occurrence of post-GKRS endocrinopathy was observed (p = 0.68). Thirty percent of patients without endocrinopathy in the early cohort developed new endocrinopathies during the follow-up period versus 27% in the late cohort (p = 0.84). Fourteen percent of the patients in the early group and 25% of the patients in the late group experienced the resolution of endocrine dysfunction after original presentation (p = 0.32). CONCLUSIONS In this study, early GKRS was associated with a lower risk of

  15. Endoscopic graduated multiangle, multicorridor resection of juvenile nasopharyngeal angiofibroma: an individualized, tailored, multicorridor skull base approach.

    Science.gov (United States)

    Liu, James K; Husain, Qasim; Kanumuri, Vivek; Khan, Mohemmed N; Mendelson, Zachary S; Eloy, Jean Anderson

    2016-05-01

    OBJECT Juvenile nasopharyngeal angiofibromas (JNAs) are formidable tumors because of their hypervascularity and difficult location in the skull base. Traditional transfacial procedures do not always afford optimal visualization and illumination, resulting in significant morbidity and poor cosmesis. The advent of endoscopic procedures has allowed for resection of JNAs with greater surgical freedom and decreased incidence of facial deformity and scarring. METHODS This report describes a graduated multiangle, multicorridor, endoscopic approach to JNAs that is illustrated in 4 patients, each with a different tumor location and extent. Four different surgical corridors in varying combinations were used to resect JNAs, based on tumor size and location, including an ipsilateral endonasal approach (uninostril); a contralateral, transseptal approach (binostril); a sublabial, transmaxillary Caldwell-Luc approach; and an orbitozygomatic, extradural, transcavernous, infratemporal fossa approach (transcranial). One patient underwent resection via an ipsilateral endonasal uninostril approach (Corridor 1) only. One patient underwent a binostril approach that included an additional contralateral transseptal approach (Corridors 1 and 2). One patient underwent a binostril approach with an additional sublabial Caldwell-Luc approach for lateral extension in the infratemporal fossa (Corridors 1-3). One patient underwent a combined transcranial and endoscopic endonasal/sublabial Caldwell-Luc approach (Corridors 1-4) for an extensive JNA involving both the lateral infratemporal fossa and cavernous sinus. RESULTS A graduated multiangle, multicorridor approach was used in a stepwise fashion to allow for maximal surgical exposure and maneuverability for resection of JNAs. Gross-total resection was achieved in all 4 patients. One patient had a postoperative CSF leak that was successfully repaired endoscopically. One patient had a delayed local recurrence that was successfully resected

  16. Cirugía transnasal transesfenoidal endoscópica en afecciones de región selar Endoscopic transsphenoidal transnasal surgery in affections of the sellar region

    Directory of Open Access Journals (Sweden)

    Justo Luis González González

    2005-08-01

    aleatorizados y controlados, en busca de información más consistente en relación con el valor real de la técnica, a estas alturas del desarrollo de la cirugía hipofisaria.For a great number of pitituary tumors surgery is the first-line treatment and the microsurgical transsphenoidal approach is the most used. At present, it is performed by microscopic and endoscopic way. Recently, the endoscopic transnasal approach has emerged as an option under development that could predominate in a near future. The aim of the present paper was to evaluate by analyzing the results if it was possible to perform in our setting the endoscopic transsphenoidal transnasal approach for the lesions of the sellar region with surgical results similar at least to those obtained with the traditional microsurgical method. A limited strictly controlled and prospective cohort research of 10 patients selected according to the inclusion criteria that underwent transnasal endoscopic surgery between August 2002 and August 2003 at the Neurosurgery service of “Hermanos Ameijeiras” Hospital, was conducted. 6 cases with hypophyseal macroadenomas were operated on (3 GH-releasing, 1 PRL-secreting and 2 non-releasing hypophyseal macroadenomas. The other 4 were diagnosed LCR fistula through the sellar floor. Total exeresis of the tumor was performed in 5 of the 6 macroadenomas, whereas subtotal exeresis was attained in the other one. Rhinorrhea disappeared in 2 patients with LCR fistula and it was maintained in the other 2. Of the complications observed in 30 % of the cases, only in one (10 %, they were beyond the transoperative. It was concluded that the results obtained by using the endoscopic transnasal method make the procedure in our setting safe enough to justify its implementation and to carry out further randomized and controlled studies searching for more consistent information in relation to the real value of the technique at this level of development of the hypophyseal surgery.

  17. Endoscopic Endonasal Anterior Skull Base Surgery: A Systematic Review of Complications During the Past 65 Years.

    Science.gov (United States)

    Borg, Anouk; Kirkman, Matthew A; Choi, David

    2016-11-01

    Endoscopic skull base surgery is becoming more popular as an approach to the anterior skull base for tumors and cerebrospinal fluid (CSF) fistulae. It offers the advantages of better cosmesis and improved quality of life after surgery. We reviewed the complication rates reported in the literature. A literature search was performed in the electronic database Ovid MEDLINE (1950 to August 25, 2015) with the search item "([Anterior] AND Skull base surgery) AND endoscopic." We identified 82 relevant studies that included 7460 cases. An average overall complication rate of 17.1% (range 0%-68.0%) and a mortality rate of 0.4% (0%-10.0%) were demonstrated in a total of 82 studies that included 7460 cases. The average CSF leak rate for all studies was 8.9% (0%-40.0%) with meningiomas and clival lesions having the greatest CSF leak rates. The most frequent benign pathology encountered was pituitary adenomas (n = 3720, 49.8% of all cases) and the most frequent malignant tumor was esthesioneuroblastoma (n = 120, 1.6% of all cases). Studies that included only CSF fistula repairs had a lower average total complication rate (12.9%) but a greater rate of meningitis compared with studies that reported mixed pathology (2.4% vs. 1.3%). A trend towards a lower total complication rate with increasing study size was observed. The endoscopic approach is an increasingly accepted technique for anterior skull base tumor surgery and is associated with acceptable complication rates. Increasing experience with this technique can decrease rates of complications. Copyright © 2016 Elsevier Inc. All rights reserved.

  18. Toward Shorter Hospitalization After Endoscopic Transsphenoidal Pituitary Surgery: Day-by-Day Analysis of Early Postoperative Complications and Interventions.

    Science.gov (United States)

    Shimanskaya, Viktoria E; Wagenmakers, Margreet A E M; Bartels, Ronald H M A; Boogaarts, Hieronymus D; Grotenhuis, J André; Hermus, Ad R M M; van de Ven, Annenienke C; van Lindert, Erik J

    2018-03-01

    It is unclear which patients have the greatest risk of developing complications in the first days after endoscopic transsphenoidal pituitary surgery (ETS) and how long patients should stay hospitalized after surgery. The objective of this study is to identify which patients are at risk for early postoperative medical and surgical reinterventions to optimize the length of hospitalization. The medical records of 146 patients who underwent ETS for a pituitary adenoma between January 2013 and July 2016 were reviewed retrospectively. Data were collected on baseline patient-related characteristics, characteristics of the pituitary adenoma, perioperative complications and interventions, and postoperative outcomes. Patients who underwent additional interventions on days 2, 3, and 4 after ETS were identified as cases, and patients who did not have any interventions after day 1 postoperatively were identified as controls. Diabetes mellitus (odds ratio [OR], 4.279; 95% confidence interval [CI], 1.149-15.933; P = 0.03), incomplete adenoma resection (OR, 2.840; 95% CI, 1.228-6.568; P = 0.02) and increased morning sodium concentration on day 2 after surgery (OR, 5.211; 95% CI, 2.158-12.579; P surgery have an increased chance on reinterventions. In addition, patients without any interventions on day 1 and 2 are at low risk for later reinterventions. These patients could be suitable candidates for early hospital discharge. Copyright © 2018 Elsevier Inc. All rights reserved.

  19. Ranking of MR tomography after transsphenoidal resection of the pituitary. Retrospective comparison between endocrinology, surgery and MRT

    International Nuclear Information System (INIS)

    Siewert, B.; Kaiser, W.A.; Hochstetter, A.; Solymosi, L.; Bootsveld, K.

    1994-01-01

    Postoperative magnetic resonance images of 40 patients after transsphenoidal surgery for pituitary adenoma were evaluated retrospectively. The signal intensities of packing material and residual tumour were analysed. T 1 -weighted spin-echo sequences were obtained in coronal and sagittal views with and without intravenous injection of contrast media. Residual tumour demonstrated homogeneous or inhomogeneous signal intensity on the native scan with homogeneous or inhomogeneous enhancement. Packing material demonstrated a homogeneous signal intensity on the images obtained without injection of contrast media with a peripheral enhancement or alternate layers of low and intermediate signal intensity with alternate enhancement after injection of contrast media. In 5 of 54 examinations different results were found in MRI, endocrinology and surgery (two false negative and one false positive MRI in correlation with endocrinology; two residual tumours on MRI where surgery was supposed to be complete). Application of intravenous contrast media facilitates the interpretation of postoperative examination of the pituitary gland as well as comparison with preoperative examinations and the knowledge of the intraoperative procedure. (orig.) [de

  20. Endoscopic endonasal anatomy of superior orbital fissure and orbital apex regions: critical considerations for clinical applications.

    Science.gov (United States)

    Dallan, Iacopo; Castelnuovo, Paolo; de Notaris, Matteo; Sellari-Franceschini, Stefano; Lenzi, Riccardo; Turri-Zanoni, Mario; Battaglia, Paolo; Prats-Galino, Alberto

    2013-05-01

    The superior orbital fissure is a critical three-dimensional space connecting the middle cranial fossa and the orbit. From an endoscopic viewpoint, only the medial aspect has a clinical significance. It presents a critical relationship with the lateral sellar compartment, the pterygopalatine fossa and the middle cranial fossa. The connective tissue layers and neural and vascular structures of this region are described. The role of Muller's muscle is confirmed, and the utility of the maxillary and optic strut is outlined. Muller's muscle extends for the whole length of the inferior orbital fissure, passes over the maxillary strut and enters the superior orbital fissure, representing a critical surgical landmark. Dividing the tendon between the medial and inferior rectus muscle allows the identification of the main trunk of the oculomotor nerve, and a little laterally, it is usually possible to visualize the first part of the ophthalmic artery. Based on a better knowledge of anatomy, we trust that this area could be readily addressed in clinical situations requiring an extended approach in proximity of the orbital apex.

  1. The effects of dexmedetomidine and magnesium sulphate in adult patients undergoing endoscopic transnasal transsphenoidal resection of pituitary adenoma: A double-blind randomised study

    Directory of Open Access Journals (Sweden)

    Rabie Soliman

    2017-01-01

    Full Text Available Background and Aim: Transnasal transsphenoidal resection of pituitary tumours is associated with blood loss and wide fluctuations in haemodynamic parameters. The aim of the present study was to compare the effect of dexmedetomidine and magnesium sulphate during the transsphenoidal resection of pituitary tumours. Methods: The study was a double-blind, randomised study and included 152 patients classified randomly into two groups: Group D: Dexmedetomidine was given as a loading dose 1 μg/kg over 10 min before induction followed by an infusion at 0.5 μg/kg/h during the surgery. Group M: Magnesium sulphate was given as loading dose of 50 mg/kg over 10 min followed by an infusion at 15 mg/kg/h during the surgery. The systolic, diastolic and mean arterial blood pressures, in addition to the amount of blood loss were measured at specific timepoints. Data were described in terms of mean ± standard deviation, median, frequencies, 95% confidence of interval of mean and percentages. Results: Mean bleeding score was lower in Group D than Group M (1.36 ± 0.48 vs. 3.05 ± 0.65, respectively; P = 0.002. Mean blood loss was lower in Group D (157.43 ± 48.79 ml vs.299.47 ± 77.28 ml in Group M; P < 0.001Heart rate, mean arterial pressure, fentanyl requirements, end-tidal sevoflurane concentration, and extubation and emergence times were lower, while incidence of bradycardia and hypotension were higher in Group D. Conclusions: During transsphenoidal pituitary resection, dexmedetomidine, compared to magnesium, is associated with lower blood loss and better operating conditions but with more hypotension and bradycardia

  2. Reasons and results of endoscopic surgery for prolactinomas: 142 surgical cases.

    Science.gov (United States)

    Akin, Safak; Isikay, Ilkay; Soylemezoglu, Figen; Yucel, Taskin; Gurlek, Alper; Berker, Mustafa

    2016-05-01

    We report herein a retrospective analysis of the results of 142 consecutive prolactinoma cases operated upon using an endoscopic endonasal trans-sphenoidal approach over a period of 6 years. Medical records of 142 cases were analysed with respect to indications for surgery, duration of hospital stay, early remission rates, failures and recurrence rates during a median follow-up of 36 months. On the basis of magnetic resonance imaging (MRI) data, 19 patients (13.4 %) had microadenoma, 113 (79.6 %) had macroadenoma, and the remaining 10 (7.0 %) had giant adenomas. Cavernous sinus invasion was identified in 25 patients by MRI and confirmed during surgery. Atypical adenoma was diagnosed in 16 patients. Sparsely granulated prolactin adenoma was identified in 99 patients (69.7 %). Our results demonstrate that male sex and higher preoperative prolactin levels are independent factors predicting persistent disease. The post-surgical complications are as follows: 2.8 % patients had meningitis, 2.1 % patients had postoperative cerebrospinal fluid leak and 2.1 % patients had panhypopituitarism. At the end of follow-up, 74.6 % patients went into remission. During follow-up period, five patients who had initial remission developed recurrence. Our series together with literature data suggest that an endoscopic endonasal trans-sphenoidal approach in the treatment of proloctinomas has a favourable rate of remission. According to the findings of this study, endoscopic endonasal trans-sphenoidal surgery might be an appropriate therapy choice for patients with prolactinoma who could not have been managed with recommended therapeutic modalities.

  3. Primary clival mucocele: case report.

    Science.gov (United States)

    Fujimoto, Yasunori; Harada, Yu; Toyota, Shingo; Wakayama, Akatsuki; So, Hiroyuki; Yoshimine, Toshiki

    2011-01-01

    A 40-year-old man presented with a history of diplopia due to left abducens nerve palsy persisting for a few days. Neuroimaging examinations revealed a cystic mass in the clivus and erosion of its posterior wall. Drainage of the lesion was accomplished through a small bone defect in the anterior wall of the clivus using the endoscopic endonasal transsphenoidal approach. This procedure improved the symptoms of the patient. Intraoperative and histological findings led to a diagnosis of mucocele. A mucocele localized only in the clivus is uncommon and the pathogenesis may be closely related to pneumatization of the clivus.

  4. Comparison between endoscopic and microscopic approaches for surgery of pituitary tumours.

    Science.gov (United States)

    Khan, Inamullah; Shamim, Muhammad Shahzad

    2017-11-01

    Surgical techniques for resection of pituitary tumours have come a long way since it was first introduced in late 18th century. Nowadays, most pituitary surgeries are performed through trans-nasal trans-sphenoidal approach either using a microscope, or an endoscope. Herein the authors review the literature and compare these two instruments with regards to their outcomes when used for resection of pituitary tumours. .

  5. Dynamics of postoperative serum cortisol after transsphenoidal surgery for Cushing's disease: implications for immediate reoperation and remission.

    Science.gov (United States)

    Mayberg, Marc; Reintjes, Stephen; Patel, Anika; Moloney, Kelley; Mercado, Jennifer; Carlson, Alex; Scanlan, James; Broyles, Frances

    2017-12-22

    OBJECTIVE Successful transsphenoidal surgery for adrenocorticotropin hormone (ACTH)-producing pituitary tumors is associated with subnormal postoperative serum cortisol levels, which may guide decisions regarding immediate reoperation. However, little is known about the detailed temporal course of changes in serum cortisol in the immediate postoperative period, and the relationship of postoperative cortisol dynamics to remission and late recurrence. METHODS A single-center retrospective cohort analysis was performed for all patients undergoing pituitary surgery from 2007 through 2015. Standardized diagnostic and treatment algorithms were applied to all patients with potential Cushing's disease (CD), including microsurgical transsphenoidal adenomectomy (TSA) by a single surgeon. All patients had serum cortisol levels drawn at 6-hour intervals for 72 hours after surgery, and were offered reoperation within 3 days for normal or supranormal postoperative cortisol levels. Primary outcomes were 6-month remission and late recurrence; secondary outcomes were persistent postoperative hypocortisolism and surgical morbidity. Discriminatory levels of postoperative serum cortisol for predicting remission were calculated at various intervals after surgery using receiver operating characteristic (ROC) curves. RESULTS Among 89 patients diagnosed with CD, 81 underwent initial TSA for a potentially curable lesion; 23 patients (25.8%) underwent an immediate second TSA. For the entire cohort, 6-month remission was achieved in 77.8% and late recurrences occurred in 9.5%, at a mean of 43.5 months. Compared with patients with a single surgery, those with an immediate second TSA had similar rates of remission (78.3% vs 77.6%) and late recurrence (5.6% vs 11.1%). The rate of hypocortisolism for patients with 2 surgeries (12/23, 52.2%) was significantly greater than that for patients with single surgeries (13/58, 22.4%; p surgery protocol. The temporal course of postoperative serum cortisol

  6. Demographic study of pituitary adenomas undergone trans-sphenoidal surgery in Loghman Hakim Hospital, Tehran, Iran 2001–2013

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    Farahnaz Bidari Zerehpoosh

    2015-01-01

    Full Text Available Background: Pituitary adenomas (PAs are abnormal benign tumors that develop in the pituitary gland. This study aimed to assess the prevalence of different types of PAs with an indication for trans-sphenoidal surgery in a well-defined population referred to Loghman Hakim Hospital during 2001–2013. Subjects and Methods: In this retrospective study, the prevalence rate and symptoms associated with pituitary mass and hormone excess in operated patients were investigated. The diagnosis was verified after retrieval of clinical, hormonal, radiological, and pathological data. Demographic data were collected in all cases. Descriptive analysis, t-test, one-way analysis of variance and Fischer exacts test were used. Results: A total of 278 patients with PAs who underwent surgical interventions were evaluated. Most of the patients were aged 40–50 years with an average of 41 ± 14. The most prominent complaint was pressure effect, which was detected in 153 cases (55.2%. At the second place, hormonal disorders were observed in 125 cases (44.8%. Type of pituitary tumors were: Prolactinomas (29.1%, growth hormone (GH-producing tumors (25%, nonfunctioning PAs (28.4%, adrenocorticotropic hormone (ACTH-producing tumors (2.1%, thyroid stimulating hormone (TSH-producing tumors (0.7%, GH/prolactin (13.6%, GH/ACTH (0.3%, and TSH/ACTH (0.3%. Fifty-seven patients presented with recurrent adenomas. Pituitary apoplexy was found in 11 patients. One case of Sheehan syndrome was recorded among these. The correlations between clinical symptoms and patients, age and sex were not significant. Conclusion: The overview of demographic characteristics in Iranian patients with PAs with surgical indication has been discussed in the present investigation. The prevalence of different types of PAs and the most common clinical symptoms have been demonstrated.

  7. Delayed Occurrence of Diabetes Insipidus After Transsphenoidal Surgery with Radiologic Evaluation of the Pituitary Stalk on Magnetic Resonance Imaging.

    Science.gov (United States)

    Hayashi, Yasuhiko; Aida, Yasuhiro; Sasagawa, Yasuo; Oishi, Masahiro; Kita, Daisuke; Tachibana, Osamu; Ueda, Fumiaki; Nakada, Mitsutoshi

    2018-02-01

    Diabetes insipidus (DI) is a major complication of transsphenoidal surgery (TSS). DI usually occurs within a couple of days after TSS. Delayed occurrence of postoperative DI is rarely observed and its developing mechanisms remain unknown. Six patients were identified as having postoperative delayed DI, which was defined as DI that first occurred 2 or more weeks after TSS. They consisted of 1 male and 5 females, and their mean age was 38.3 years (range, 10-76 years). Five patients were histologically diagnosed with Rathke cleft cyst (RCC), and one had RCC coexisting with prolactin-secreting adenoma. Sequential T1-weighted magnetic resonance imaging was evaluated for hyperintensity (HI) in the pituitary stalk and the posterior lobe, indicating the location of antidiuretic hormone. No patients had any DI before TSS. Delayed DI occurred 2 weeks to 3 months after TSS and persisted for 2 weeks to 5 months. T1-weighted magnetic resonance imaging showed that the HI in the posterior lobe became faint but did not disappear after DI occurrence, and their intensities increased with recovery from DI. In contrast, the HI in the pituitary stalk was found faintly preoperatively and turned clear postoperatively and decreased with recovery from DI. The morphologic patterns were dependent on DI duration. In the delayed occurrence of DI, it was suggested that preoperative antidiuretic hormone transport was mildly congested yet not completely blocked when DI manifested postoperatively. Gradual spreading of inflammation to the infundibulum after RCC removal was considered as 1 possible mechanism of this delayed DI development. Copyright © 2017 Elsevier Inc. All rights reserved.

  8. The recovery of the hypothalamo-pituitary-adrenal axis after transsphenoidal operation in three patients with Cushing's disease

    International Nuclear Information System (INIS)

    Lamberts, S.W.J.; Klijn, J.G.M.; Jong, F.H. de; Birkenhager, J.C.

    1981-01-01

    The recovery of the hypothalamo-pituitary-adrenal axis after selective transsphenoidal adenomectomy was studied in 3 patients with Cushing's disease by measuring basal plasma ACTH and cortisol concentrations, cortisol secretion rate, the diurnal rhythm of cortisol, and the reaction of cortisol to lysine vasopressin (LVP), of compound S to metyrapone and of cortisol and growth hormone to an insulin-induced hypoglycaemia. The third patient had been treated previously by external pituitary irradiation. In 2 patients basal plasma ACTH levels returned within normal values before plasma cortisol, but no supra-physiological plasma concentrations of ACTH were seen as has been observed after withdrawal of exogenous glucocorticoids. With regard to the different stimulation tests: at first the normal reaction of plasma cortisol to LVP returned after 3 months, at the same time as the restoration of growth hormone secretion in response to hypoglycaemia. A normalization of the reaction to metyrapone was seen thereafter while finally the reaction of cortisol to an insulin-induced hypoglycaemia and the diurnal rhythm of plasma cortisol returned 15 to 18 months after operation in the first patient and after 12 months in the second patient. Selective adenomectomy had also been carried out in the third patient, as evidenced by normal TSH, LH and FSH secretion. Hypocortisolism, and a deficient ACTH and growth hormone secretion in response to the stimuli mentioned, however, did not normalize up till 22 months after operation. The restoration of the hypothalamo-pituitary-adrenal axis after selective pituitary adenomectomy in Cushing's disease was prevented in this patient by prior external pituitary irradiation. (author)

  9. Primary Endoscopic Transnasal Transsphenoidal Surgery for Magnetic Resonance Image-Positive Cushing Disease: Outcomes of a Series over 14 Years.

    Science.gov (United States)

    Kuo, Chao-Hung; Yen, Yu-Shu; Wu, Jau-Ching; Chen, Yu-Chun; Huang, Wen-Cheng; Cheng, Henrich

    2015-09-01

    There are scant data of endoscopic transsphenoidal surgery (ETS) with adjuvant therapies of Cushing disease (CD). To report the remission rate, secondary management, and outcomes of a series of CD patients. Patients with CD with magnetic resonance imaging (MRI)-positive adenoma who underwent ETS as the first and primary treatment were included. The diagnostic criteria were a combination of 24-hour urine-free cortisol, elevated serum cortisol levels, or other tests (e.g., inferior petrosal sinus sampling). All clinical and laboratory evaluations and radiological examinations were reviewed. Forty consecutive CD patients, with an average age of 41.0 years, were analyzed with a mean follow-up of 40.2 ± 29.6 months. These included 22 patients with microadenoma and 18 with macroadenoma, including 9 cavernous invasions. The overall remission rate of CD after ETS was 72.5% throughout the entire follow-up. Patients with microadenoma or noninvasive macroadenoma had a higher remission rate than those who had macroadenoma with cavernous sinus invasion (81.8% or 77.8% vs. 44.4%, P = 0.02). After ETS, the patients who had adrenocorticotropic hormone-positive adenoma had a higher remission rate than those who had not (76.5% vs. 50%, P = 0.03). In the 11 patients who had persistent/recurrent CD after the first ETS, 1 underwent secondary ETS, 8 received gamma-knife radiosurgery (GKRS), and 2 underwent both. At the study end point, two (5%) of these CD patients had persistent CD and were under the medication of ketoconazole. For MRI-positive CD patients, primary (i.e., the first) ETS yielded an overall remission rate of 72.5%. Adjuvant therapies, including secondary ETS, GKRS, or both, yielded an ultimate remission rate of 95%. Copyright © 2015 Elsevier Inc. All rights reserved.

  10. The utility of high-resolution intraoperative MRI in endoscopic transsphenoidal surgery for pituitary macroadenomas: early experience in the Advanced Multimodality Image Guided Operating suite

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    Zaidi, Hasan A.; De Los Reyes, Kenneth; Barkhoudarian, Garni; Litvack, Zachary N.; Bi, Wenya Linda; Rincon-Torroella, Jordina; Mukundan, Srinivasan; Dunn, Ian F.; Laws, Edward R.

    2016-01-01

    Objective Endoscopic skull base surgery has become increasingly popular among the skull base surgery community, with improved illumination and angled visualization potentially improving tumor resection rates. Intraoperative MRI (iMRI) is used to detect residual disease during the course of the resection. This study is an investigation of the utility of 3-T iMRI in combination with transnasal endoscopy with regard to gross-total resection (GTR) of pituitary macroadenomas. Methods The authors retrospectively reviewed all endoscopic transsphenoidal operations performed in the Advanced Multimodality Image Guided Operating (AMIGO) suite from November 2011 to December 2014. Inclusion criteria were patients harboring presumed pituitary macroadenomas with optic nerve or chiasmal compression and visual loss, operated on by a single surgeon. Results Of the 27 patients who underwent transsphenoidal resection in the AMIGO suite, 20 patients met the inclusion criteria. The endoscope alone, without the use of iMRI, would have correctly predicted 13 (65%) of 20 cases. Gross-total resection was achieved in 12 patients (60%) prior to MRI. Intraoperative MRI helped convert 1 STR and 4 NTRs to GTRs, increasing the number of GTRs from 12 (60%) to 16 (80%). Conclusions Despite advances in visualization provided by the endoscope, the incidence of residual disease can potentially place the patient at risk for additional surgery. The authors found that iMRI can be useful in detecting unexpected residual tumor. The cost-effectiveness of this tool is yet to be determined. PMID:26926058

  11. Endoscopic Transnasal Approach for Cholesterol Granuloma of the Petrous Apex

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    Mohammad Samadian

    2015-01-01

    Full Text Available Cholesterol granulomas are rare round or ovoid cysts. They contain cholesterol crystals surrounded by foreign bodies of giant cells and are characterized by chronic inflammation. Large cholesterol granuloma can compress surrounding tissue especially cranial nerves. There are several types of surgery for the resection of cholesterol granuloma. We describe 4 cases of cholesterol granuloma operated on via transnasal endoscopic approach. In this report, we describe radiologic and pathologic features of this lesion and explain the advantages and disadvantages of transsphenoidal endoscopic approach for these rare lesions.

  12. Evolution of Technique in Endoscopic Transsphenoidal Surgery for Pituitary Adenoma: A Single Institution Experience from 220 Procedures.

    Science.gov (United States)

    Hansasuta, Ake; Pokanan, Siriwut; Punyawai, Pritsana; Mahattanakul, Wattana

    2018-01-01

    Introduction Endoscopic transsphenoidal surgery (ETSS) for pituitary adenoma (PA) has been a recent shift from the traditional microscopic technique. Although some literature demonstrated superiority of ETSS over the microscopic method and some evaluated mono- vs. binostril access within the ETSS, none had explored the potential influence of dedicated instrument, as this procedure had evolved, on patients' outcomes when compared to traditional microscopic tools. Objective To investigate our own clinical and radiographic outcomes of ETSS for PA with its technical evolution over time as well as a significance of, having vs. lacking, the special endoscopic tools. Methods Included patients underwent ETSS for PA performed by the first author (AH). Prospectively recorded patients' data concerning pre-, intra- and postoperative clinical and radiographic assessments were subject to analysis. The three groups of differently evolving ETSS techniques, beginning with mononostril (MN) to binostril ETSS with standard microsurgical instruments (BN1) and, lastly, binostril ETSS with specially-designed endoscopic tools (BN2), were examined for their impact on the intra- and, short- and long-term, postoperative results. Also, the survival after ETSS for PA, as defined by the need for reintervention in each technical group, was appraised. Results From January 2006 to 2012, there were 47, 101 and 72 ETSS, from 183 patients, in the MN, BN1 and BN2 cohorts, respectively. Significant preoperative findings were greater proportion of patients with prior surgery (p=0.01) and tumors with parasellar extension (p=0.02) in the binostril (BN1&2) than the MN group. Substantially shorter operative time and less amount of blood loss were evident as our technique had evolved (psurgery, Knosp grade, and firm tumor while BN1, BN2 and percentages of anteroposterior dimension PA removal had positive effect on longer survival. Conclusion The evolution of technique for ETSS for PA from MN to BN2 has shown

  13. Comparison of sinonasal quality of life and health status in patients undergoing microscopic and endoscopic transsphenoidal surgery for pituitary lesions: a prospective cohort study.

    Science.gov (United States)

    Little, Andrew S; Kelly, Daniel F; Milligan, John; Griffiths, Chester; Prevedello, Daniel M; Carrau, Ricardo L; Rosseau, Gail; Barkhoudarian, Garni; Jahnke, Heidi; Chaloner, Charlene; Jelinek, Kathryn L; Chapple, Kristina; White, William L

    2015-09-01

    Despite the widespread adoption of endoscopic transsphenoidal surgery for pituitary adenomas, the sinonasal quality of life (QOL) and health status in patients who have undergone this technique have not been compared with these findings in patients who have undergone the traditional direct uninostril microsurgical technique. In this study, the authors compared the sinonasal QOL and patient-reported health status after use of these 2 surgical techniques. The study design was a nonblinded prospective cohort study. Adult patients with sellar pathology and planned transsphenoidal surgery were screened at 4 pituitary centers in the US between October 2011 and August 2013. The primary end point of the study was postoperative patient-reported sinonasal QOL as measured by the Anterior Skull Base Nasal Inventory-12 (ASK Nasal-12). Supplementary end points included patient-reported health status estimated by the 8-Item Short Form Health Survey (SF-8) and EuroQol (EQ)-5D-5L instruments, and sinonasal complications. Patients were followed for 6 months after surgery. A total of 301 patients were screened and 235 were enrolled in the study. Of these, 218 were analyzed (111 microsurgery patients, 107 endoscopic surgery patients). Demographic and tumor characteristics were similar between groups (p ≥ 0.12 for all comparisons). The most common complication in both groups was sinusitis (7% in the microsurgery group, 13% in the endoscopic surgery group; p = 0.15). Patients treated with the endoscopic technique were more likely to have postoperative nasal debridements (p surgery, but then returned to baseline at 3 months. At 3 months after surgery, patients treated with endoscopy reported statistically better sinonasal QOL compared with patients treated using the microscopic technique (p = 0.02), but there were no significant differences at any of the other postoperative time points. This is the first multicenter study to examine the effect of the transsphenoidal surgical technique

  14. Basilar expansion of the human sphenoidal sinus: an integrated anatomical and computerized tomography study

    International Nuclear Information System (INIS)

    Haetinger, Rainer G.; Navarro, Joao A.C.; Liberti, Edson A.

    2006-01-01

    Basilar expansion of the sphenoidal sinus (BESS) was studied in order to demonstrate its critical relevance in endoscopic or microscopic endonasal surgical interventions, including access to the sphenoidal sinus itself or in transsphenoidal pituitary approaches. Direct evaluation of anatomical specimens (25 dry skulls and 25 formalin-fixed hemi heads) and the use of computerized tomography (CT) (50 dry skulls and 750 patients) showed a high BESS frequency (69%). The authors considered BESS to be critical when the posterior wall of the clivus was 2-mm thick and found a high incidence of this important anatomical variation (44%). This study also evaluated the relationship between the sinonasal septa, the clivus, and the internal carotid arteries, and a considerable regularity in the location of these structures was seen. The septa were anatomically related to the internal carotid arteries in 55% and to the clivus in 33% of the cases. In conclusion, the high frequency of critical BESS here described is relevant to endoscopic or microscopic endonasal surgical interventions, including access to the sphenoidal sinus itself or in transsphenoidal pituitary approaches. (orig.)

  15. The Posterior Transpetrosal Approach in a Case of Large Retrochiasmatic Craniopharyngioma: Operative Video and Technical Nuances.

    Science.gov (United States)

    Labidi, Moujahed; Watanabe, Kentaro; Loit, Marie-Pier; Hanakita, Shunya; Froelich, Sébastien

    2018-02-01

    Objectives  To discuss the use of the posterior petrosal approach for the resection of a retrochiasmatic craniopharyngioma. Design  Operative video. Results  In this case video, the authors discuss the surgical management of a large craniopharyngioma, presenting with mass effect on the third ventricle and optic apparatus. A first surgical stage, through an endoscopic endonasal transtubercular approach, allowed satisfactory decompression of the optic chiasma and nerves in preparation for adjuvant therapy. However, accelerated growth of the tumor, with renewed visual deficits and mass effect on the hypothalamus and third ventricle, warranted a supplementary resection. A posterior transpetrosal 1 2 (also called "retrolabyrinthine transtentorial") was performed to obtain a better exposure of the tumor and the surrounding anatomy (floor and walls of the third ventricle, perforating vessels, optic nerves, etc.) 3 . Nuances of technique and surgical pearls related to the posterior transpetrosal are discussed and illustrated in this operative video, including the posterior mobilization of the transverse-sigmoid sinuses junction, preservation of the venous anatomy during the tentorial incision, identification and preservation of the floor of the third ventricle during tumor resection, and a careful multilayer closure. Conclusion  Retrochiasmatic craniopharyngiomas are difficult to reach tumors that often require skull base approaches, either endoscopic endonasal or transcranial. The posterior transpetrosal approach is an important part of the surgical armamentarium to safely resect these complex tumors. The link to the video can be found at: https://youtu.be/2MyGLJ_v1kI .

  16. Clinical and histologic studies of olfactory outcomes after nasoseptal flap harvesting.

    Science.gov (United States)

    Kim, Sang-Wook; Park, Kyung Bum; Khalmuratova, Roza; Lee, Hong-Kyoung; Jeon, Sea-Yuong; Kim, Dae Woo

    2013-07-01

    Since the introduction of an endonasal endoscopic approach in transsphenoidal pituitary surgery, reports of perioperative olfactory changes have presented conflicting results. We examined the incidence of olfactory loss in cases of endoscopic transsphenoidal pituitary surgery with skull base repair using the nasoseptal flap (NSF) and the effects of monopolar electrocautery commonly used in designing the NSF. Case-control study. Fifteen patients who underwent endoscopic transsphenoidal pituitary surgery with skull base reconstruction using the NSF were divided into cold knife (n = 8) and electrocautery (n = 7) groups according to the device used in the superior incision of the NSF. Patients were followed regularly to monitor the need for dressing or adhesiolysis around the olfactory cleft. All subjects received olfactory tests before and 6 months after surgery. Septal mucosa specimens obtained during posterior septectomy were incised with different devices, and the degree of mucosal damage was evaluated. One patient in the electrocautery group demonstrated olfactory dysfunction postoperatively, but the other 14 patients showed no decrease in olfaction. In histologic analyses, 55.8% and 76.9% of the mucosal surface showed total epithelial loss when the mucosa was cut with cutting- and coagulation-mode electrocautery, respectively. In contrast, only 20% of the mucosal surface exhibited total epithelial loss when the mucosa was cut with a cold knife (P knife in making superior incision may reduce tissue damage with better olfactory outcomes. Copyright © 2013 The American Laryngological, Rhinological and Otological Society, Inc.

  17. Characterization of transsphenoidal complications in patients with acromegaly: an analysis of inpatient data in the United States from 2002 to 2010.

    Science.gov (United States)

    Raikundalia, Milap D; Pines, Morgan J; Svider, Peter F; Baredes, Soly; Folbe, Adam J; Liu, James K; Eloy, Jean Anderson

    2015-05-01

    Transsphenoidal surgery (TSS) is a common procedure for a variety of pituitary lesions. This procedure can be associated with complications related to the surgery or specific pathology. In this study, we evaluate inpatient postoperative complications among patients who underwent TSS for growth hormone adenomas using a nationally representative database, and compare patient characteristics and complications to patients who underwent TSS for other benign pituitary neoplasms. Analysis of the Nationwide Inpatient Sample revealed 13,070 TSS patients (including 892 with acromegaly) between 2002 and 2010. Complication rates, outcomes, patient demographics, hospital stay, and total charges were evaluated among TSS patients with and without acromegaly. There was an increase in TSS performed in both cohorts from 2002 to 2010. Acromegaly patients were younger, had shorter hospital stays, and incurred fewer charges. Acromegaly patients had a lower occurrence of postoperative urinary/renal complications (0.2% vs 1.1%), thromboembolic events (0% vs 0.4%), fluid/electrolyte abnormalities (5.7% vs 9.1%), and iatrogenic hypopituitarism (0.3% vs 1.1%) compared to other TSS patients (all p < 0.05). After adjusting for age, acromegalic patients maintained a statistically lower occurrence of fluid/electrolyte abnormalities (p = 0.007). Cerebrospinal fluid leak occurrence in acromegaly patients was 2.6% vs 1.7% in non-acromegaly patients, a result that did not reach significance (p = 0.054). Upon comparison of inpatient hospitalizations for patients undergoing TSS for growth hormone adenomas and other benign pituitary neoplasms, acromegaly patients had a significantly lower occurrence of postoperative fluid/electrolyte abnormalities. Acromegaly patients had shorter hospitalizations and subsequently fewer total charges. © 2015 ARS-AAOA, LLC.

  18. Long-term outcomes of tissue-based ACTH-antibody assay-guided transsphenoidal resection of pituitary adenomas in Cushing disease.

    Science.gov (United States)

    Erfe, J Mark; Perry, Avital; McClaskey, John; Inzucchi, Silvio E; James, Whitney Sheen; Eid, Tore; Bronen, Richard A; Mahajan, Amit; Huttner, Anita; Santos, Florecita; Spencer, Dennis

    2017-10-13

    OBJECTIVE Cushing disease is caused by a pituitary micro- or macroadenoma that hypersecretes adrenocorticotropic hormone (ACTH), resulting in hypercortisolemia. For decades, transsphenoidal resection (TSR) has been an efficacious treatment but with certain limitations, namely precise tumor localization and complete excision. The authors evaluated the novel use of a double-antibody sandwich assay for the real-time quantitation of ACTH in resected pituitary specimens with the goals of augmenting pathological diagnosis and ultimately improving long-term patient outcome. METHODS This study involved a retrospective review of records and an analysis of assay values, pathology slides, and MRI studies of patients with Cushing disease who had undergone TSR in the period from 2009 to 2014 and had at least 1 year of follow-up in coordination with an endocrinologist. In the operating room, biopsy specimens from the patients had been analyzed for tissue ACTH concentration. Additional samples were simultaneously sent for frozen-section pathological analysis. The ACTH assay performance was compared against pathology assessments of surgical tumor samples using receiver operating characteristic (ROC) analysis and against pre- and postoperative MRI studies. RESULTS Fourteen patients underwent TSR with guidance by ACTH-antibody assay and pathological assessment of 127 biopsy samples and were followed up for an average of 3 years. The ACTH threshold for discriminating adenomatous from normal tissue was 290,000 pg/mg of tissue, based on jointly maximized sensitivity (95.0%) and specificity (71.3%). Lateralization discordance between preoperative MRI studies and surgical visualization was noted in 3 patients, confirming the impression that MRI alone may not achieve optimal localization. A majority of the patients (85.7%) attained long-term disease remission based on urinary free cortisol levels, plasma cortisol levels, and long-term corticosteroid therapy. Comparisons of patient

  19. Prediction of postoperative diabetes insipidus using morphological hyperintensity patterns in the pituitary stalk on magnetic resonance imaging after transsphenoidal surgery for sellar tumors.

    Science.gov (United States)

    Hayashi, Yasuhiko; Kita, Daisuke; Watanabe, Takuya; Fukui, Issei; Sasagawa, Yasuo; Oishi, Masahiro; Tachibana, Osamu; Ueda, Fumiaki; Nakada, Mitsutoshi

    2016-12-01

    Diabetes insipidus (DI) remains a complication of transsphenoidal surgery (TSS) for sellar and parasellar tumors. Antidiuretic hormone (ADH) appears as hyper intensity (HI) in the pituitary stalk and the posterior lobe of the pituitary gland on T1-weighted magnetic resonance (MR) imaging. Its disappearance from the posterior lobe occurs with DI, indicating a lack of ADH. The appearance of HI in the pituitary stalk indicates disturbances in ADH transport. This retrospective study included 172 patients undergoing TSS for sellar tumors at our institute from 2006 to 2014. Sequential T1-weighted MR images without enhancement were evaluated for HI in the pituitary stalk and the posterior lobe to assess the localization of ADH before and at intervals after TSS. DI was assessed pre- and postoperatively. HI in the pituitary stalk showed the following morphology: (1) ovoid in the distal end of the pituitary stalk (group A), (2) linear in the distal part of the pituitary stalk (group B), (3) linear in the whole pituitary stalk (group C). Preoperative DI occurred in 6 patients (3.5 %) with no HI observed in the posterior lobe. Postoperative DI was transient in 82 patients (47.7 %), and permanent in 11 (6.4 %). One week after surgery, HI was absent in the posterior lobe in 74 patients (43.0 %), and present in the pituitary stalk in 99 patients (57.6 %); both were significantly correlated with postoperative DI (p < 0.001). The absence of HI in the posterior lobe (A, 48.9 %; B, 68.3 %; C, 92.3 %), persistence of DI (A, 3.7 days; B, 45.9 days; C, 20.5 months), and duration until HI recovery in the posterior lobe (A, 3.6 months; B, 6.8 months; C, 22.9 months) were greatest in group C, followed by group B, and then group A. Fourteen group A patients did not have postoperative DI despite having HI in the pituitary stalk and the posterior lobe. Four group C patients developed permanent DI with persistence HI in the pituitary stalk. HI in the pituitary stalk and its

  20. Limits of the endoscopic transnasal transtubercular approach.

    Science.gov (United States)

    Gellner, Verena; Tomazic, Peter V

    2018-06-01

    The endoscopic transnasal trans-sphenoidal transtubercular approach has become a standard alternative approach to neurosurgical transcranial routes for lesions of the anterior skull base in particular pathologies of the anterior tubercle, sphenoid plane, and midline lesions up to the interpeduncular cistern. For both the endoscopic and the transcranial approach indications must strictly be evaluated and tailored to the patients' morphology and condition. The purpose of this review was to evaluate the evidence in literature of the limitations of the endoscopic transtubercular approach. A PubMed/Medline search was conducted in January 2018 entering following keywords. Upon initial screening 7 papers were included in this review. There are several other papers describing the endoscopic transtubercular approach (ETTA). We tried to list the limitation factors according to the actual existing literature as cited. The main limiting factors are laterally extending lesions in relation to the optic canal and vascular encasement and/or unfavorable tumor tissue consistency. The ETTA is considered as a high level transnasal endoscopic extended skull base approach and requires excellent training, skills and experience.

  1. Cerebrospinal fluid fistula after endoscopic transsphenoidal surgery: experience in a spanish center Fístula liquórica após cirurgia transesfenoidal endoscópica: experiência de um centro espanhol

    Directory of Open Access Journals (Sweden)

    Alicia Del Carmen Becerra Romero

    2010-06-01

    Full Text Available BACKGROUND: Postoperative cerebrospinal fluid (CSF fistula is the most serious complication after transsphenoidal surgery. OBJECTIVE: To analyze the incidence of CSF fistula after endoscopic transsphenoidal surgery for tumor removal in sellar region; to discuss associated factors and methods used for sellar closure. METHOD: Retrospective study of 67 patients (73 surgeries operated via transsphenoidal endoscopy at Hospital Vall D'Hebron and Hospital Clinic of the Universidad de Barcelona, Spain. The data collected included: age, sex, hospitalization stay, suprasellar extension of the lesion, type of tumor, evidence of intraoperative CSF fistula, complications of postoperative CSF fistula, previous surgery and radiotherapy. RESULTS: Six patients (8.2% had postoperative CSF fistula, and their average hospitalization was 5 days longer with resulting complications: two of whom had pneumoencephalus and two with meningitis. No association was found between the data collected and postoperative CSF fistula. CONCLUSION: The rate of CSF fistula after endoscopic transsphenoidal surgery from the present study is contained within the literature. Unlike other reports, no association between the variables and postoperative CSF fistula was found in this report.A fístula liquórica pós-operatória é a complicação mais séria após cirurgia transesfenoidal. OBJETIVO: Analisar a incidência de fístula liquórica após cirurgia endoscópica transesfenoidal para remoção de tumores selares, discutir fatores associados e método utilizado para fechamento selar. MÉTODO: Estudo retrospectivo de 67 pacientes (73 cirurgias operados via endoscopia transesfenoidal no Hospital Vall D'Hebron e Hospital Clínic da Universidad de Barcelona, Espanha. Os dados coletados foram: idade, sexo, dias de internação, extensão supra-selar da lesão, tipo de tumor, evidência de fístula liquórica intra-operatória, complicações da fístula liquórica p

  2. Pituitary apoplexy in a teenager--case report.

    Science.gov (United States)

    Chao, Chen-Cheng; Lin, Chun-Ju

    2014-06-01

    Pituitary apoplexy is a rare clinical emergency which results from hemorrhage or infarction in the pituitary gland. We present a 14-year-old girl with pituitary apoplexy and review the literature. Our patient experienced blurred vision, nausea, and headache. Her best-corrected visual acuity was 20/200 and 20/20. Confrontation test visual field testing revealed bitemporal hemianopsia. Brain imaging demonstrated a suprasellar mass. The microscopic endonasal transsphenoidal approach only found 5-10 mL brownish fluid-like material. Pathology confirmed no malignancy. Pituitary apoplexy was diagnosed. Her nausea and headache gradually improved. Six months after operation, her best-corrected visual acuity had improved to 20/30 and 20/20. Although pituitary apoplexy is rare in pediatric patients, prompt evaluation including detailed ophthalmic examination, biochemical evaluation, endocrine workup, and image study are very important. Copyright © 2014 Elsevier Inc. All rights reserved.

  3. A combination of modified transnasal endoscopic maxillectomy via transnasal prelacrimal recess approach with or without radiotherapy for selected sinonasal malignancies.

    Science.gov (United States)

    He, Shuangba; Bakst, Richard L; Guo, Tao; Sun, Jingwu

    2015-10-01

    An external approach for resection of sinonasal tumors is associated with increased morbidity. Therefore, we employed a modified transnasal endoscopic maxillectomy combined with pre and/or postoperative radiotherapy for early stage maxillary carcinomas. It aims to evaluate our early experience with endoscopic resection of selected malignant sinonasal tumors. The medical and radiology records of patients who underwent endonasal endoscopic resection of malignant sinonasal tumors between 2008 and 2012 were retrospectively reviewed. Ten cases of selected malignant tumor were performed to resect by modified transnasal endoscopic maxillectomy. All the patients were without evidence of disease at a mean follow-up of 26.8 months. No major complications were recorded. The mean hospitalization stay was 6.6 days. In very carefully selected cases of malignant tumors, modified transnasal endoscopic maxillectomy is acceptable. The postoperative complication rate is low, cosmetic outcome is excellent and patients do not require a long hospitalization.

  4. Simultaneous above and below approach to giant pituitary adenomas: surgical strategies and long-term follow-up

    Science.gov (United States)

    D’Ambrosio, Anthony L.; Grobelny, Bartosz T.; Freda, Pamela U.; Wardlaw, Sharon; Bruce, Jeffrey N.

    2012-01-01

    Introduction Giant pituitary adenomas of excessive size, fibrous consistency or unfavorable geometric configuration may be unresectable through conventional operative approaches. We present our select case series for operative resection and long-term follow-up for these unusual tumors, employing both a staged procedure and a combined transsphenoidal-transcranial above and below approach. Method A retrospective chart review was performed on patients operated via the staged, and combined approaches by the senior author (J.N·B.). Pre-operative characteristics and postoperative outcomes were reviewed. A detailed description of the operative technique and perioperative management is provided. Results Between 1993 and 1996, two patients harboring giant pituitary adenomas underwent an intentionally staged resection, and between 1997 and 2006, nine patients harboring giant pituitary adenomas underwent surgery via a single-stage above and below approach. Nine patients (82%) presented with non-secreting adenomas and two patients (18%) presented with prolactinomas refractory to medical management. Gross total resection was achieved in six patients (55%), near total resection in 1 (9%), and subtotal removal in 4 (36%). Seven patients (64%) experienced visual improvement postoperatively and no major complications occurred. Long-term follow-up averaged 51.6 months. Panhypopituitarism was observed in four patients, partial hypopituitarism in four, persistent DI in two, and persistent SIADH in one. Conclusions The addition of a transcranial component to the transsphenoidal approach offers additional visualization of critical neurovascular structures during giant pituitary adenoma resection. Complications rates are similar to other series in which complex pituitary adenomas are resected by other means. The above and below approach is both safe and effective and the immediate and long-term advantages of a single-stage approach justify its utility in this select group of patients

  5. [Informed Treatment Consent and Refusal in Advanced Endonasal Surgery: The Ethical Dilemma of Olfaction Sacrifice in Surgery for Chronic Rhinosinusitis with Polyposis].

    Science.gov (United States)

    Subtil, João; Araújo, João Pedro; Saraiva, José; Santos, Alberto; Vera-Cruz, Paulo; Paço, João; Pais, Diogo

    2015-01-01

    Olfaction is frequently affected in chronic rhino-sinusitis with polyposis and has been recognised to have important impact on quality of life. Surgical resolution on cases of maximal medical therapy failure is an option to relieve symptoms, with debates as to how extensive surgery should be. A more radical approach will achieve better disease control with less relapse, but can also compromise olfaction. This decision about a more radical surgical approach should be shared with the patient. Thorough informed consent regarding disease control and hyposmia should be taken. Literature review and consultation with a board of experts. We propose some elements to be included in the informed consent discussion, in order to broadly address the surgical limitations regarding anosmia as a frequent complaint, as well as the different options and their associated consequences. Radical surgery decision making should be shared with the patient and the informed consent should be as thorough as possible regarding disease control and hyposmia resolution.

  6. The Pedicled Buccal Fat Pad: Anatomical Study of the New Flap for Skull Base Defect Reconstruction After Endoscopic Endonasal Transpterygoid Surgery

    Science.gov (United States)

    Golbin, Denis A.; Lasunin, Nikolay V.; Cherekaev, Vasily A.; Polev, Georgiy A.

    2016-01-01

    Objectives To evaluate the efficacy and safety of using a buccal fat pad for endoscopic skull base defect reconstruction. Design Descriptive anatomical study with an illustrative case presentation. Setting Anatomical study was performed on 12 fresh human cadaver specimens with injected arteries (24 sides). Internal carotid artery was exposed in the coronal plane via the endoscopic transpterygoid approach. The pedicled buccal fat pad was used for reconstruction. Participants: 12 human cadaver head specimens; one patient operated using the proposed technique. Main outcome measures: Proximity of the buccal fat pad flap to the defect, compliance of the flap, comfort and safety of harvesting procedure, and compatibility with the Hadad–Bassagasteguy nasoseptal flap. Results: Harvesting procedure was performed using anterior transmaxillary corridor. The pedicled buccal fat pad flap can be used to pack the sphenoid sinus or cover the internal carotid artery from cavernous to upper parapharyngeal segment. Conclusion The buccal fat pad can be safely harvested through the same approach without external incisions and is compliant enough to conform to the skull base defect. The proposed pedicled flap can replace free abdominal fat in central skull base reconstruction. The volume of the buccal fat pad allows obliteration of the sphenoid sinus or upper parapharyngeal space. PMID:28180047

  7. Quality of Life and Work Capacity Are Unrelated to Approach or Complications After Pituitary Surgery.

    Science.gov (United States)

    Uvelius, Erik; Castelo, Nazia; Kahlon, Babar; Svensson, Christer; Cervin, Anders; Höglund, Peter; Valdemarsson, Stig; Siesjö, Peter

    2017-12-01

    Endoscopic pituitary surgery has shown favorable clinical outcomes. Less is known about the impact of surgical approaches on health-related quality of life (HRQoL) and work capacity. The present study was undertaken to compare transsphenoidal microscope-assisted surgery with endoscopic transsphenoidal surgery regarding preoperative and surgical factors for the final outcome of HRQoL and work capacity. In a retrospective study of patients operated on for pituitary adenoma, outcome was compared between those operated on before and after transition with endoscopic surgery at our department. Data were gathered via patient questionnaires and patients' files. After exclusions, 235 patients were included (99 microsurgical and 136 endoscopic). Frequency of complications was similar but tumor size was significantly larger in the endoscopic group. Complications did not affect HRQoL or work capacity. HRQoL was not affected by surgical technique but showed an overall trend toward lower values compared with the general population. Sick leave, return to work frequency, and permanent sick leave were not affected by surgical technique. Female gender was a factor for lower ratings in all outcome variables. Surgical technique does not influence HRQoL or work capacity in this long-term follow-up although both are decreased compared with the general population. We conclude that fully endoscopic pituitary surgery, despite including larger tumors, bears the same risk for complications as microsurgery. In addition, females have a greater risk for decrease in HRQoL and work ability. This factor should be taken into account when informing patients and appreciating expectations of treatment. Copyright © 2017 Elsevier Inc. All rights reserved.

  8. Laparoscopic adrenalectomy: Gaining experience by graded approach

    Directory of Open Access Journals (Sweden)

    Dalvi Abhay

    2006-01-01

    Full Text Available INTRODUCTION: Laparoscopic adrenalectomy (LA has become a gold standard in management of most of the adrenal disorders. Though report on the first laparoscopic adrenalectomy dates back to 1992, there is no series of LA reported from India. Starting Feb 2001, a graded approach to LA was undertaken in our center. Till March 2006, a total of 34 laparoscopic adrenalectomies were performed with success. MATERIALS AND METHODS: The endocrinology department primarily evaluated all patients. Patients were divided into Group A - unilateral LA and Group B - bilateral LA (BLA. The indications in Group A were pheochromocytoma (n=7, Conn′s syndrome (n=3, Cushing′s adenoma (n=2, incidentaloma (n=2; and in Group B, Cushing′s disease (CD following failed trans-sphenoid pituitary surgery (n = 8; ectopic ACTH- producing Cushing′s syndrome (n=1 and congenital adrenal hyperplasia (CAH (n=1. The lateral transabdominal route was used. RESULTS: The age group varied from 12-54 years, with mean age of 28.21 years. Average duration of surgery in Group A was 166.43 min (40-270 min and 190 min (150- 310 min in Group B. Average blood loss was 136.93 cc (20-400 cc in Group A and 92.5 cc (40-260 cc in Group B. There was one conversion in each group. Mean duration of surgical stay was 1.8 days (1-3 days in Group A and 2.6 days (2-4 days in Group B. All the patients in both groups were cured of their illness. Three patients in Group B developed Nelson′s syndrome. The mean follow up was of 24.16 months (4-61 months. CONCLUSION: LA though technically demanding, is feasible and safe. Graded approach to LA is the key to success.

  9. Frontobasal Midline Meningiomas: Is It Right To Shed Doubt on the Transcranial Approaches? Updates and Review of the Literature.

    Science.gov (United States)

    Ruggeri, Andrea Gennaro; Cappelletti, Martina; Fazzolari, Benedetta; Marotta, Nicola; Delfini, Roberto

    2016-04-01

    Traditionally, the surgical removal of tuberculum sellae meningioma (TSM) and olfactory groove meningioma (OGM) requires transcranial approaches and microsurgical techniques, but in the last decade endoscopic expanded endonasal approaches have been introduced: transcribriform for OGMs and transtuberculum-transplanum for TSM. A comparative analysis of the literature concerning the two types of surgical treatment of OGMs and TSM is, however, difficult. We conducted a literature search using the PubMed database to compare data for endoscopic and microsurgical techniques in the literature. We also conducted a retrospective analysis of selected cases from our series presenting favorable characteristics for an endoscopic approach, based on the criteria of operability of these lesions as generally accepted in the literature, and we compared the results obtained in these patients with those in the endoscopic literature. We believe that making the sample more homogeneous, the difference between microsurgical technique and endoscopic technique is no longer so striking. A greater radical removal rate, a reduced incidence of cerebrospinal fluid fistula and, especially, the possibility of removing lesions of any size are advantages of transcranial surgery; a higher percentage of improvement in visual outcome and a lower risk of a worsening of a pre-existing deficit or onset of a new deficit are advantages of the endoscopic technique. At present, the microsurgical technique is still the gold standard for the removal of the anterior cranial fossa meningiomas of all sizes, and the endoscopic technique remains a second option in certain cases. Copyright © 2016 Elsevier Inc. All rights reserved.

  10. The use of intraoperative computed tomography navigation in pituitary surgery promises a better intraoperative orientation in special cases

    Directory of Open Access Journals (Sweden)

    Stefan Linsler

    2016-01-01

    Full Text Available Objective: The safety of endoscopic skull base surgery can be enhanced by accurate navigation in preoperative computed tomography (CT and magnetic resonance imaging (MRI. Here, we report our initial experience of real-time intraoperative CT-guided navigation surgery for pituitary tumors in childhood. Materials and Methods: We report the case of a 15-year-old girl with a huge growth hormone-secreting pituitary adenoma with supra- and perisellar extension. Furthermore, the skull base was infiltrated. In this case, we performed an endonasal transsphenoidal approach for debulking the adenoma and for chiasma decompression. We used an MRI neuronavigation (Medtronic Stealth Air System which was registered via intraoperative CT scan (Siemens CT Somatom. Preexisting MRI studies (navigation protocol were fused with the intraoperative CT scans to enable three-dimensional navigation based on MR and CT imaging data. Intraoperatively, we did a further CT scan for resection control. Results: The intraoperative accuracy of the neuronavigation was excellent. There was an adjustment of <1 mm. The navigation was very helpful for orientation on the destroyed skull base in the sphenoid sinus. After opening the sellar region and tumor debulking, we did a CT scan for resection control because the extent of resection was not credible evaluable in this huge infiltrating adenoma. Thereby, we were able to demonstrate a sufficient decompression of the chiasma and complete resection of the medial part of the adenoma in the intraoperative CT images. Conclusions: The use of intraoperative CT/MRI-guided neuronavigation for transsphenoidal surgery is a time-effective, safe, and technically beneficial technique for special cases.

  11. Endoscopic Transseptal Approach with Posterior Nasal Spine Removal: A Wide Surgical Corridor to the Craniovertebral Junction and Odontoid: Technical Note and Case Series.

    Science.gov (United States)

    Rossini, Zefferino; Milani, Davide; Nicolosi, Federico; Costa, Francesco; Lasio, Giovanni Battista; D'Angelo, Vincenzo Antonio; Fornari, Maurizio; Colombo, Giovanni

    2018-02-01

    The transnasal approach to lesions involving the craniovertebral junction represents a technical challenge because of limited inferior exposure. The endoscopic transseptal approach (EtsA) with posterior nasal spine (PNS) removal is described. This technique can create a wide exposure of the craniovertebral junction, thereby increasing the caudal exposure. On patients undergoing anterior craniovertebral junction decompression, we calculated the degree of exposure on the sagittal plan through a paraseptal route, an EtsA without and with PNS removal. The horizontal exposure and working area with the latter approach were also evaluated. Five patients underwent the transnasal procedure. The age of patients ranged from 34-71 years. All patients harbored basilar impression. The mean postoperative Nurick grade (1, 8) was improved versus the average preoperative grade (3). The average follow-up duration was 16 months. All patients underwent occipitocervical fixation. The mean vertical distances, from the clinoid recess to the inferior most limit with the paraseptal approach, EtsA without and with PNS removal were 38.52, 44.12, and 51.16 mm, respectively. The difference between our approach and a standard paraseptal route was statistically significant (P = 0.041; P< 0.05). The mean horizontal distances were 31.68 mm (mononostril entry) and 35.37 mm (binostril entry). The mean working area was 1795.53 mm 2 . Endoscopic endonasal approaches to the craniovertebral junction are increasing, but the downward extension on the anterior cervical spine represents a limit. Therefore, many surgeons prefer transoral or transcervical approaches. The EtsA with PNS removal allows for a more caudal exposure than the standard paraseptal approach, with reduced nasal trauma. Copyright © 2017 Elsevier Inc. All rights reserved.

  12. Design of a multifiber light delivery system for photoacoustic-guided surgery

    Science.gov (United States)

    Eddins, Blackberrie; Bell, Muyinatu A. Lediju

    2017-04-01

    This work explores light delivery optimization for photoacoustic-guided minimally invasive surgeries, such as the endonasal transsphenoidal approach. Monte Carlo simulations were employed to study three-dimensional light propagation in tissue, comprising one or two 4-mm diameter arteries located 3 mm below bone, an absorbing metallic drill contacting the bone surface, and a single light source placed next to the 2.4-mm diameter drill shaft with a 2.9-mm diameter spherical drill tip. The optimal fiber distance from the drill shaft was determined from the maximum normalized fluence to the underlying artery. Using this optimal fiber-to-drill shaft distance, Zemax simulations were employed to propagate Gaussian beams through one or more 600 micron-core diameter optical fibers for detection on the bone surface. When the number of equally spaced fibers surrounding the drill increased, a single merged optical profile formed with seven or more fibers, determined by thresholding the resulting light profile images at 1/e times the maximum intensity. We used these simulations to inform design requirements, build a one to seven multifiber light delivery prototype to surround a surgical drill, and demonstrate its ability to simultaneously visualize the tool tip and blood vessel targets in the absence and presence of bone. The results and methodology are generalizable to multiple interventional photoacoustic applications.

  13. Pituitary Apoplexy due to the Diagnostic Test in a Cushing"s Disease Patient.

    Science.gov (United States)

    Kuzu, Fatih; Unal, Mustafa; Gul, Sanser; Bayraktaroglu, Taner

    2018-01-01

    Pituitary apoplexy is a medical condition that needs urgent diagnosis and treatment. It may occur spontaneously or may be precipitated by a variety of reasons including dynamic endocrine tests. Although pituitary apoplexy is usually seen in nonfunctional pituitary adenoma, it can also be seen in ACTH secreting macroadenomas. ACTH secreting adenomas present usually as microadenomas and in these patients apoplexy is rarely seen. In this paper we present a 30-year-old male patient with a history of Cushing"s disease who suffered from pituitary apoplexy after the 1 mg dexamethasone suppression test. He underwent endoscopic endonasal transsphenoidal surgery and his symptoms and signs were significantly improved.

  14. Behandling af invert papillom med endonasal endoskopisk sinuskirurgi

    DEFF Research Database (Denmark)

    Andersen, Pia Juul; Kjeldsen, Anette Drøhse; Pedersen, Arne Toft

    2002-01-01

    INTRODUCTION: Inverted papilloma is a benign sinonasal tumour and has a marked tendency to recur after surgical excision. The tumour may be associated with malignancy and during growth it may destroy surrounding tissue. The treatment is either lateral rhinotomy or endoscopic sinus surgery. The aim...... of the study was to describe the course of all patients treated with endoscopic sinus surgery at the ENT Department at Vejle County Hospital during the period 1 January to 31 December 1999. MATERIAL AND METHODS: Twenty-eight journals of patients diagnosed with inverted nasal papillomas were reviewed...... with carcinoma. We did not see any serious side effects to the treatment. DISCUSSION: Endoscopic sinus surgery in combination with Caldwell-Luc can be recommended as an alternative treatment to lateral rhinotomy in patients with inverted papillomas. Preoperative staging with CT or MR-scanning, experienced...

  15. Coblation-assisted endonasal endoscopic resection of juvenile nasopharyngeal angiofibroma.

    Science.gov (United States)

    Ye, L; Zhou, X; Li, J; Jin, J

    2011-09-01

    Juvenile nasopharyngeal angiofibroma may be successfully resected using endoscopic techniques. However, the use of coblation technology for such resection has not been described. This study aimed to document cases of Fisch class I juvenile nasopharyngeal angiofibroma with limited nasopharyngeal and nasal cavity extension, which were completely resected using an endoscopic coblation technique. We retrospectively studied 23 patients with juvenile nasopharyngeal angiofibroma who underwent resection with either traditional endoscopic instruments (n = 12) or coblation (n = 11). Intra-operative blood loss and overall operative time were recorded. The mean tumour resection time for coblation and traditional endoscopic instruments was 87 and 136 minutes, respectively (t = 9.962, p angiofibroma (Fisch class I), with good surgical margins and minimal blood loss.

  16. Skull base tumor model.

    Science.gov (United States)

    Gragnaniello, Cristian; Nader, Remi; van Doormaal, Tristan; Kamel, Mahmoud; Voormolen, Eduard H J; Lasio, Giovanni; Aboud, Emad; Regli, Luca; Tulleken, Cornelius A F; Al-Mefty, Ossama

    2010-11-01

    Resident duty-hours restrictions have now been instituted in many countries worldwide. Shortened training times and increased public scrutiny of surgical competency have led to a move away from the traditional apprenticeship model of training. The development of educational models for brain anatomy is a fascinating innovation allowing neurosurgeons to train without the need to practice on real patients and it may be a solution to achieve competency within a shortened training period. The authors describe the use of Stratathane resin ST-504 polymer (SRSP), which is inserted at different intracranial locations to closely mimic meningiomas and other pathological entities of the skull base, in a cadaveric model, for use in neurosurgical training. Silicone-injected and pressurized cadaveric heads were used for studying the SRSP model. The SRSP presents unique intrinsic metamorphic characteristics: liquid at first, it expands and foams when injected into the desired area of the brain, forming a solid tumorlike structure. The authors injected SRSP via different passages that did not influence routes used for the surgical approach for resection of the simulated lesion. For example, SRSP injection routes included endonasal transsphenoidal or transoral approaches if lesions were to be removed through standard skull base approach, or, alternatively, SRSP was injected via a cranial approach if the removal was planned to be via the transsphenoidal or transoral route. The model was set in place in 3 countries (US, Italy, and The Netherlands), and a pool of 13 physicians from 4 different institutions (all surgeons and surgeons in training) participated in evaluating it and provided feedback. All 13 evaluating physicians had overall positive impressions of the model. The overall score on 9 components evaluated--including comparison between the tumor model and real tumor cases, perioperative requirements, general impression, and applicability--was 88% (100% being the best possible

  17. Pedagogical approaches

    DEFF Research Database (Denmark)

    Lund Larsen, Lea

    questions are: How (much) and what do teachers learn from experience? And how do teachers of adults develop their pedagogical approach? I examine the field of adult learners from the teachers’ perspective. Firstly, I identify some of the commonly described characteristics of adults as learners...... in formal settings, but in most teaching settings, the teachers act alone and develop their pedagogical approaches/- teaching strategies with no synchronous sparring from a colleague. Adult learners have particular needs and characteristics that their teachers must be able to address (cf. Knowles...

  18. Capability approach

    DEFF Research Database (Denmark)

    Jensen, Niels Rosendal; Kjeldsen, Christian Christrup

    Lærebogen er den første samlede danske præsentation af den af Amartya Sen og Martha Nussbaum udviklede Capability Approach. Bogen indeholder en præsentation og diskussion af Sen og Nussbaums teoretiske platform. I bogen indgår eksempler fra såvel uddannelse/uddannelsespolitik, pædagogik og omsorg....

  19. Endoscopic trans-sphenoidal drainage of petrous apex cholesterol ...

    African Journals Online (AJOL)

    conditions and prescribing in sport. • It presents ... management. • It features new as well as existing drugs, indexed by both trade and generic ... the professional compilation and editing by a team from the Division of Clinical. Pharmacology ...

  20. Transsphenoidal hypophysectomy in beagle dogs: evaluation of a microsurgical technique

    Energy Technology Data Exchange (ETDEWEB)

    Meij, B. P. [Utrecht University, Utrecht (Netherlands); Voorhout, G.; Ingh, T.S.G.A.M. van den; Hazewinkel, H. A.W.; Verlaat, J.W. van ' t

    1997-07-15

    Objective-Assessment of a microsurgical technique for transsphenoidalhypophysectomy in dogs. Study Design-Prospective study using physicalexamination, pituitary function testing, computed tomography (CT), and histological examination at autopsy. Animals or Sample Population-Eight laboratory beagle dogs. Methods-Pituitary function was assessed before and at 10 weeks after hypophysectomy by combined administration of four releasing hormones (anterior pituitary), administration of haloperidol (pars intermedia), and infusion of hypertonic saline (posterior pituitary). Results-CT imaging enabled accurate preoperative localization of the pituitary. Appropriate positioning and surgical technique facilitated exposure of the pituitary and its extraction without hemorrhage. Postoperative recovery was generally uncomplicated. None of the eight dogs had somatotropic. gonadotropic, lactotropic, melanotropic, or posterior pituitary responses to stimulation at 10 weeks after hypophysectomy. Four dogs (ACTH nonresponders) also had no corticotropicresponse and four (ACTH responders) bad small but significant responses in the combined anterior pituitary function test. Adrenocortical atrophy was more pronounced in the ACTH nonresponders than in the responders. No residual pituitary tissue was found along the ventral hypothalamic diencephalon but nests of pituitary cells were found embedded infibrous tissue in the sella turcica. Conclusions-The surgical technique proved to be safe and effective. Microscopic nests of pituitary cells in the sella turcica may be responsible for residual corticotropic response to hypophysiotropic stimulation after hypophysectomy. Clinical Relevance-The surgical technique may be used in the treatment of dogs with pituitary-dependent hyperadrenocorticism. The corticotropic response is the most sensitive criterion in assessing completeness of hypophysectomy in dogs. (C) Copyright 1997 by The American College of Veterinary Surgeons.

  1. Transsphenoidal hypophysectomy in beagle dogs: evaluation of a microsurgical technique

    International Nuclear Information System (INIS)

    Meij, B.P.; Voorhout, G.; Ingh, T.S.G.A.M. van den; Hazewinkel, H.A.W.; Verlaat, J.W. van 't

    1997-01-01

    Objective-Assessment of a microsurgical technique for transsphenoidalhypophysectomy in dogs. Study Design-Prospective study using physicalexamination, pituitary function testing, computed tomography (CT), and histological examination at autopsy. Animals or Sample Population-Eight laboratory beagle dogs. Methods-Pituitary function was assessed before and at 10 weeks after hypophysectomy by combined administration of four releasing hormones (anterior pituitary), administration of haloperidol (pars intermedia), and infusion of hypertonic saline (posterior pituitary). Results-CT imaging enabled accurate preoperative localization of the pituitary. Appropriate positioning and surgical technique facilitated exposure of the pituitary and its extraction without hemorrhage. Postoperative recovery was generally uncomplicated. None of the eight dogs had somatotropic. gonadotropic, lactotropic, melanotropic, or posterior pituitary responses to stimulation at 10 weeks after hypophysectomy. Four dogs (ACTH nonresponders) also had no corticotropicresponse and four (ACTH responders) bad small but significant responses in the combined anterior pituitary function test. Adrenocortical atrophy was more pronounced in the ACTH nonresponders than in the responders. No residual pituitary tissue was found along the ventral hypothalamic diencephalon but nests of pituitary cells were found embedded infibrous tissue in the sella turcica. Conclusions-The surgical technique proved to be safe and effective. Microscopic nests of pituitary cells in the sella turcica may be responsible for residual corticotropic response to hypophysiotropic stimulation after hypophysectomy. Clinical Relevance-The surgical technique may be used in the treatment of dogs with pituitary-dependent hyperadrenocorticism. The corticotropic response is the most sensitive criterion in assessing completeness of hypophysectomy in dogs. (C) Copyright 1997 by The American College of Veterinary Surgeons

  2. Perioperative lumbar drain utilization in transsphenoidal pituitary resection.

    Science.gov (United States)

    Alharbi, Shatha; Harsh, Griffith; Ajlan, Abdulrazag

    2018-01-01

    To evaluate lumbar drain (LD) efficacy in transnasal resection of pituitary macroadenomas in preventing postoperative cerebrospinal fluid (CSF) leak, technique safety, and effect on length of hospital stay. We conducted a retrospective data review of pituitary tumor patients in our institution who underwent surgery between December 2006 and January 2013. All patients were operated on for complete surgical resection of pituitary macroadenoma tumors. Patients were divided into 2 groups: group 1 received a preoperative drain, while LD was not preoperatively inserted in group 2. In cases of tumors with suprasellar extension with anticipation of high-flow leak, LD was inserted after the patient was intubated and in a lateral position. Lumbar drain was used for 48 hours, and the drain was removed if no leak was observed postoperatively. In documented postoperative CSF leak patients with no preoperative drain, the leak was treated by LD trial prior to surgical reconstruction. Cases in which leak occurred 6 months postoperatively were excluded. Our study population consisted of 186 patients, 99 women (53%) and 87 men (47%), with a mean age of 50.3+/-16.1 years. Complications occurred in 7 patients (13.7%) in group 1 versus 21 (15.5%) in group 2 (p=0.72). Postoperative CSF leak was observed in 1 patient (1.9%) in group 1 and 7 (5%) in group 2 (Fisher exact test=0.3). Length of hospital stay was a mean of 4.7+/-1.9 days in group 1 and a mean of 2.7+/-2.4 days in group 2 (pLD insertion is generally considered safe with a low risk of complications, it increases the length of hospitalization. Minor complications include headaches and patient discomfort.

  3. Narrative approaches

    DEFF Research Database (Denmark)

    Stelter, Reinhard

    2012-01-01

    Narrative coaching is representative of the new wave – or third generation – of coaching practice . The theory and practice of narrative coaching takes into account the social and cultural conditions of late modern society, and must be seen as intertwined with them. Some initial conceptualizations...... of narrative coaching were developed by David Drake (2006, 2007, 2008, 2009) in the USA and Australia, by Ho Law in the UK (Law, 2007a + b; Law & Stelter, 2009) and by Reinhard Stelter (2007, 2009, 2012, in preparation; Stelter & Law, 2010) in Denmark. In the following chapter the aim is to present coaching...... as a narrative-collaborative practice, an approach that is based on phenomenology, social constructionism and narrative theory. Seeing narrative coaching as a collaborative practice also leads to reflecting on the relationship between coach and coachee(s) in a new way, where both parts contribute to the dialogue...

  4. Oriented Approach

    Directory of Open Access Journals (Sweden)

    Seyed Mohammad Moghimi

    2013-12-01

    Full Text Available Promoting productivity is one of the goals of usinginformation technology in organizations. The purpose of this research isexamining the impact of IT on organizational productivity andrecognizing its mechanisms based on process-oriented approach. For thisend, by reviewing the literature of the subject a number of impacts of ITon organizational processes were identified. Then, through interviewswith IT experts, seven main factors were selected and presented in aconceptual model. This model was tested through a questionnaire in 148industrial companies. Data analysis shows that impact of IT onproductivity can be included in the eight major categories: Increasing ofthe Automation, Tracking, Communication, Improvement, Flexibility,Analytic, Coordination and Monitoring in organizational processes.Finally, to improve the impact of information technology onorganizational productivity, some suggestions are presented.

  5. Delayed Onset of Isolated Unilateral Oculomotor Nerve Palsy Caused by Post-Traumatic Pituitary Apoplexy: A Case Report

    Directory of Open Access Journals (Sweden)

    Tomoki Ishigaki

    2017-09-01

    Full Text Available Post-traumatic pituitary apoplexy is uncommon, most of which present with a sudden onset of severe headache and visual impairments associated with a dumbbell-shaped pituitary tumor. We experienced an unusual case of post-traumatic pituitary apoplexy with atypical clinical features. A 66-year-old man presented with mild cerebral contusion and an incidentally diagnosed intrasellar tumor after a fall accident with no loss of consciousness. The patients denied any symptoms before the accident. After 4 days, the left oculomotor nerve palsy developed and deteriorated associated with no severe headache. Repeated neuroimages suggested that pituitary apoplexy had occurred at admission and showed that the tumor compressed the left cavernous sinus. The patient underwent endonasal transsphenoidal surgery at 6 days after head injury, and the mass reduction improved the oculomotor nerve palsy completely within the following 14 days. The pathologic diagnosis was nonfunctioning pituitary adenoma with hemorrhage and necrosis.

  6. Thyrotropin-secreting pituitary tumor presenting with congestive heart failure and good response to dopaminergic agonist cabergoline

    Directory of Open Access Journals (Sweden)

    Yu-Hsi Kao

    2013-11-01

    Full Text Available Hyperthyroidism is an important inducing factor in patients with atrial fibrillation, and may trigger heart failure. Thyrotropin (thyroid stimulating hormone, TSH-secreting pituitary tumors are rare causes of hyperthyroidism. Here, we report a 66-year-old man with a pituitary TSH-secreting tumor who presented with hyperthyroidism and congestive heart failure. Endonasal trans-sphenoidal pituitary adenomectomy was performed. After the operation, the symptoms of hyperthyroidism and congestive heart failure were relieved, associated with normalization of thyroid function tests. Unfortunately, hand tremor and progressively elevated free T4 and TSH concentrations recurred 5 months after surgery. A dopaminergic agonist, cabergoline was administered and euthyroidism was restored for at least 11 months.

  7. Life Span Developmental Approach

    OpenAIRE

    Ali Eryilmaz

    2011-01-01

    The Life Span Developmental Approach examines development of individuals which occurs from birth to death. Life span developmental approach is a multi-disciplinary approach related with disciplines like psychology, psychiatry, sociology, anthropology and geriatrics that indicates the fact that development is not completed in adulthood, it continues during the life course. Development is a complex process that consists of dying and death. This approach carefully investigates the development of...

  8. Persistent CSF Rhinorrhoea, Pneumocephalus, and Recurrent Meningitis Following Misdiagnosis of Olfactory Neuroblastoma

    Directory of Open Access Journals (Sweden)

    Neil Barua

    2010-01-01

    Full Text Available A 41-year-old female patient was admitted with streptococcal meningitis on a background of 5-month history of CSF rhinorrhoea. Imaging revealed an extensive skull base lesion involving the sphenoid and ethmoid sinuses, the pituitary fossa with suprasellar extension and bony destruction. Histological examination of an endonasal transethmoidal biopsy suggested a diagnosis of olfactory neuroblastoma. A profuse CSF leak occurred and the patient developed coliform meningitis. A second endonasal endoscopic biopsy was undertaken which demonstrated the tumour to be a prolactinoma. Following endonasal repair of the CSF leak and lumbar drainage, she developed profound pneumocephalus. The patient underwent three further unsuccessful CSF leak repairs. Definitive control of the CSF leak was finally achieved through a transcranial approach with prolonged lumbar drainage. This case illustrates some of the potentially devastating complications which can occur as a consequence of complex skull base lesions. A multidisciplinary approach may be required to successfully manage such cases.

  9. The sustainable livelihoods approach

    DEFF Research Database (Denmark)

    Oelofse, Myles; Jensen, Henning Høgh

    2008-01-01

    food chain has on producers and their families, an analysis was conducted of the use of the Sustainable Livelihoods Approach (SLA). The SLA provides a holistic and integrative approach which researchers can use as the overriding frame for their research. The application of the approach is recommended...

  10. Cirurgia endoscópica transnasal da região selar: estudo dos primeiros 100 casos Transnasal endoscopic surgery of the sellar region: study of the first 100 cases

    Directory of Open Access Journals (Sweden)

    Jackson Gondim

    2003-09-01

    custos hospitalares. As desvantagens são a diminuição da profundidade de campo, a necessidade de constante controle do endoscópio e a necessidade de maior experiência com as técnicas de endoscopia.An endoscopic endonasal transsphenoidal approach to the sella was performed in 100 consecutive patients, with a follow up from 3 to 55 months: 57 females and 43 males, age ranging from 14 and 70 years. 76 cases pituitary adenomas: 22 were acromegaly (7 microadenomas and 15 macroadenomas; 21 null cell adenomas (3 microadenomas and 18 macroadenomas; 19 Cushing disease (11 microadenomas and 8 macroadenomas, 10 prolactinomas (6 microadenomas and 4 macroadenomas, and 4 LH adenomas (4 macroadenomas. In this serie, remission was achieved in 44.8% for macroadenomas, 60% for acromegaly, 27.7% for null cell adenoma, 50% for Cushing disease, 50% for prolactinomas and 50% for LH adenomas, and 81.4% for microadenomas 85% for acromegaly, 100% for null cell adenoma, 81.8% for Cushing disease, 66% for prolactinoma. We had also four craniopharyngiomas, four sphenoidal mucocele, three sphenoidal aspergillus, one Rathke cyst, one hypophysitis, one cavernous aneurysm, one encefalocele, one intrasellar meningioma, one intrasellar tuberculoma and a sphenoid fibrous dysplasia. In this series we also had six fistulas of the anterior base that were completely cured. We had a mortality of 2, one null cell giant adenoma in a 57 years old man and another patient, 38 years old, with a giant craniopharyngioma. The morbidity was: two cured meningitis, three cured fistulas, and two permanent diabetes insipidus. Endoscopic endonasal transsphenoidal surgery in this series resulted with comparable surgical outcomes to conventional microscopic transsphenoidal surgery. The advantages of this technique have been represented by an easier access to the lesion, better visualisation and increased illumination of the surgical sites, microdissection of the tumor with maximum preservation of the pituitary function

  11. Alternative Auditing Approaches

    Energy Technology Data Exchange (ETDEWEB)

    Kandt, Alicen J [National Renewable Energy Laboratory (NREL), Golden, CO (United States)

    2017-09-15

    This presentation for the 2017 Energy Exchange in Tampa, Florida, offers information about advanced auditing technologies and techniques including alternative auditing approaches and considerations and caveats.

  12. Evaluating six soft approaches

    DEFF Research Database (Denmark)

    Sørensen, Lene; Vidal, Rene Victor Valqui

    2006-01-01

    ’s interactive planning principles to be supported by soft approaches in carrying out the principles in action. These six soft approaches are suitable for supporting various steps of the strategy development and planning process. These are the SWOT analysis, the Future Workshop, the Scenario methodology......, Strategic Option Development and Analysis, Strategic Choice Approach and Soft Systems Methodology. Evaluations of each methodology are carried out using a conceptual framework in which the organisation, the result, the process and the technology of the specific approach are taken into consideration. Using...

  13. Evaluating Six Soft Approaches

    DEFF Research Database (Denmark)

    Sørensen, Lene Tolstrup; Valqui Vidal, René Victor

    2008-01-01

    's interactive planning principles to be supported by soft approaches in carrying out the principles in action. These six soft approaches are suitable forsupporting various steps of the strategy development and planning process. These are the SWOT analysis, the Future Workshop, the Scenario methodology......, Strategic Option Development and Analysis, Strategic Choice Approach and Soft Systems Methodology. Evaluations of each methodology are carried out using a conceptual framework in which the organisation, the result, the process and the technology of the specific approach are taken into consideration. Using...

  14. Evaluating six soft approaches

    DEFF Research Database (Denmark)

    Sørensen, Lene Tolstrup; Vidal, Rene Victor Valqui

    2008-01-01

    's interactive planning principles to be supported by soft approaches in carrying out the principles in action. These six soft approaches are suitable forsupporting various steps of the strategy development and planning process. These are the SWOT analysis, the Future Workshop, the Scenario methodology......, Strategic Option Development and Analysis, Strategic Choice Approach and Soft Systems Methodology. Evaluations of each methodology are carried out using a conceptual framework in which the organisation, the result, the process and the technology of the specific approach are taken into consideration. Using...

  15. Stuttering-Psycholinguistic Approach

    Science.gov (United States)

    Hategan, Carolina Bodea; Anca, Maria; Prihoi, Lacramioara

    2012-01-01

    This research promotes psycholinguistic paradigm, it focusing in delimitating several specific particularities in stuttering pathology. Structural approach, on language sides proves both the recurrent aspects found within specialized national and international literature and the psycholinguistic approaches dependence on the features of the…

  16. Approaches to understand culture

    DEFF Research Database (Denmark)

    Rasmussen, Lauge Baungaard; Rauner, Felix

    1996-01-01

    Different approaches to understand the concept ofculture are presented and evaluated. The author'sconcept of culture is defined. Different aspectsof the concept are discussed.......Different approaches to understand the concept ofculture are presented and evaluated. The author'sconcept of culture is defined. Different aspectsof the concept are discussed....

  17. Flipped Classroom Approach

    Science.gov (United States)

    Ozdamli, Fezile; Asiksoy, Gulsum

    2016-01-01

    Flipped classroom is an active, student-centered approach that was formed to increase the quality of period within class. Generally this approach whose applications are done mostly in Physical Sciences, also attracts the attention of educators and researchers in different disciplines recently. Flipped classroom learning which wide-spreads rapidly…

  18. The Geodynamic Approach

    DEFF Research Database (Denmark)

    Steenfelt, Jørgen S.; Ibsen, Lars Bo

    1996-01-01

    The Danish National lecture: The Geodynamic approach - problem or possibility? - mirrors the authors involvement in projects and research focusing on the impact of the geodynamic approach. The lecture discusses the why and how of some of the geotechnical anomalies and the differences in traditional...

  19. Life Span Developmental Approach

    Directory of Open Access Journals (Sweden)

    Ali Eryilmaz

    2011-03-01

    Full Text Available The Life Span Developmental Approach examines development of individuals which occurs from birth to death. Life span developmental approach is a multi-disciplinary approach related with disciplines like psychology, psychiatry, sociology, anthropology and geriatrics that indicates the fact that development is not completed in adulthood, it continues during the life course. Development is a complex process that consists of dying and death. This approach carefully investigates the development of individuals with respect to developmental stages. This developmental approach suggests that scientific disciplines should not explain developmental facts only with age changes. Along with aging, cognitive, biological, and socioemotional development throughout life should also be considered to provide a reasonable and acceptable context, guideposts, and reasonable expectations for the person. There are three important subjects whom life span developmental approach deals with. These are nature vs nurture, continuity vs discontinuity, and change vs stability. Researchers using life span developmental approach gather and produce knowledge on these three most important domains of individual development with their unique scientific methodology.

  20. Otoplasty: A graduated approach.

    Science.gov (United States)

    Foda, H M

    1999-01-01

    Numerous otoplastic techniques have been described for the correction of protruding ears. Technique selection in otoplasty should be done only after careful analysis of the abnormal anatomy responsible for the protruding ear deformity. A graduated surgical approach is presented which is designed to address all contributing factors to the presenting auricular deformity. The approach starts with the more conservative cartilage-sparing suturing techniques, then proceeds to incorporate other more aggressive cartilage weakening maneuvers. Applying this approach resulted in better long-term results with less postoperative lateralization than that encountered on using the cartilage-sparing techniques alone.

  1. Introducing Systems Approaches

    Science.gov (United States)

    Reynolds, Martin; Holwell, Sue

    Systems Approaches to Managing Change brings together five systems approaches to managing complex issues, each having a proven track record of over 25 years. The five approaches are: System Dynamics (SD) developed originally in the late 1950s by Jay Forrester Viable Systems Model (VSM) developed originally in the late 1960s by Stafford Beer Strategic Options Development and Analysis (SODA: with cognitive mapping) developed originally in the 1970s by Colin Eden Soft Systems Methodology (SSM) developed originally in the 1970s by Peter Checkland Critical Systems Heuristics (CSH) developed originally in the late 1970s by Werner Ulrich

  2. Flipped Classroom Approach

    Directory of Open Access Journals (Sweden)

    Fezile Ozdamli

    2016-07-01

    Full Text Available Flipped classroom is an active, student-centered approach that was formed to increase the quality of period within class. Generally this approach whose applications are done mostly in Physical Sciences, also attracts the attention of educators and researchers in different disciplines recently. Flipped classroom learning which wide-spreads rapidly in the world, is not well recognized in our country. That is why the aim of study is to attract attention to its potential in education field and provide to make it recognize more by educators and researchers. With this aim, in the study what flipped classroom approach is, flipped classroom technology models, its advantages and limitations were explained.

  3. Multidisciplinary Approaches to Allergies

    NARCIS (Netherlands)

    Gao Zhongshan,; Shen, Hua-Hao; Zheng, M.; Frewer, L.J.; Gilissen, L.J.W.J.

    2012-01-01

    Allergy is an immunological disease caused by multiple factors and characterized by variability, specificity and complexity. "Multidisciplinary Approaches to Allergies" covers diverse aspects ranging from basic molecular mechanisms to societal issues within the framework of multidisciplinary

  4. Behavioral based safety approaches

    International Nuclear Information System (INIS)

    Maria Michael Raj, I.

    2009-01-01

    Approach towards the establishment of positive safety culture at Heavy Water Plant, Tuticorin includes the adoption of several important methodologies focused on human behavior and culminates with achievement of Total Safety Culture where Quality and Productivity are integrated with Safety

  5. The transformativity approach

    DEFF Research Database (Denmark)

    Holm, Isak Winkel; Lauta, Kristian Cedervall

    2017-01-01

    During the last five to ten years, a considerable body of research has begun to explore how disasters, real and imagined, trigger social transformations. Even if the contributions to this this research stems from a multitude of academic disciplines, we argue in the article, they constitute...... an identifiable and promising approach for future disaster research. We suggest naming it the transformativity approach. Whereas the vulnerability approach explores the social causation of disasters, the transformativity approach reverses the direction of the gaze and investigates the social transformation...... brought about by disasters. Put simply, the concept of vulnerability is about the upstream causes of disaster and the concept of transformativity about the downstream effects. By discussing three recent contributions (by the historian Greg Bankoff, the legal sociologist Michelle Dauber...

  6. RNA/PNA Approach

    Indian Academy of Sciences (India)

    In this approach we want to develop structural analogue of the leader that might have higher affinity towards the Phosphoprotein, but would impair the dimerization process and viral leader RNA binding.

  7. a Capability approach

    African Journals Online (AJOL)

    efforts towards gender equality in education as a means of achieving social justice. ... should mean that a lot of capability approach-oriented commentators are ... processes, their forms of exercising power, and their rules, unwritten cultures, ...

  8. A Theoretical Approach

    African Journals Online (AJOL)

    NICO

    L-rhamnose and L-fucose: A Theoretical Approach ... L-ramnose and L-fucose, by means of the Monte Carlo conformational search method. The energy of the conformers ..... which indicates an increased probability for the occurrence of.

  9. Approach To Absolute Zero

    Indian Academy of Sciences (India)

    more and more difficult to remove heat as one approaches absolute zero. This is the ... A new and active branch of engineering ... This temperature is called the critical temperature, Te' For sulfur dioxide the critical ..... adsorbent charcoal.

  10. Revitalizing the setting approach

    DEFF Research Database (Denmark)

    Bloch, Paul; Toft, Ulla; Reinbach, Helene Christine

    2014-01-01

    BackgroundThe concept of health promotion rests on aspirations aiming at enabling people to increase control over and improve their health. Health promotion action is facilitated in settings such as schools, homes and work places. As a contribution to the promotion of healthy lifestyles, we have ...... approach is based on ecological and whole-systems thinking, and stipulates important principles and values of integration, participation, empowerment, context and knowledge-based development....... further developed the setting approach in an effort to harmonise it with contemporary realities (and complexities) of health promotion and public health action. The paper introduces a modified concept, the supersetting approach, which builds on the optimised use of diverse and valuable resources embedded...... in local community settings and on the strengths of social interaction and local ownership as drivers of change processes. Interventions based on a supersetting approach are first and foremost characterised by being integrated, but also participatory, empowering, context-sensitive and knowledge...

  11. Flipped Classroom Approach

    OpenAIRE

    Fezile Ozdamli; Gulsum Asiksoy

    2016-01-01

    Flipped classroom is an active, student-centered approach that was formed to increase the quality of period within class. Generally this approach whose applications are done mostly in Physical Sciences, also attracts the attention of educators and researchers in different disciplines recently. Flipped classroom learning which wide-spreads rapidly in the world, is not well recognized in our country. That is why the aim of study is to attract attention to its potential in education field and pr...

  12. STUTTERING-PSYCHOLINGUISTIC APPROACH

    OpenAIRE

    Maria Anca; Carolina Bodea Haţegan; Lăcrămioara Prihoi

    2012-01-01

    This research promotes psycholinguistic paradigm, it focusing in delimitating several specific particularities in stuttering pathology. Structural approach, on language sides proves both the recurrent aspects found within specialized national and international literature and the psycholinguistic approaches dependence on the features of the linguistic material. Thus, the conclusions of this research study offer the possibility of promoting cross-cultural and cross-linguistic researches, with t...

  13. An approach to measurement

    International Nuclear Information System (INIS)

    Gudder, S.P.

    1984-01-01

    A new approach to measurement theory is presented. The definition of measurement is motivated by direct laboratory procedures as they are carried out in practice. The theory is developed within the quantum logic framework. The work clarifies an important problem in the quantum logic approach; namely, where the Hilbert space comes from. The relationship between measurements and observables is considered, and a Hilbert space embedding theorem is presented. Charge systems are also discussed. (author)

  14. The Knowledge Governance Approach

    DEFF Research Database (Denmark)

    Foss, Nicolai J.

    with diverse capabilities of handling these transactions. Various open research issues that a knowledge governance approach may illuminate are sketched. Although knowledge governance draws clear inspiration from organizational economics and `rational' organization theory, it recognizes that knowledge......An attempt is made to characterize a `knowledge governance approach' as a distinctive, emerging field that cuts across the fields of knowledge management, organisation studies, strategy and human resource management. Knowledge governance is taken up with how the deployment of administrative...

  15. Theoretical Approaches to Coping

    Directory of Open Access Journals (Sweden)

    Sofia Zyga

    2013-01-01

    Full Text Available Introduction: Dealing with stress requires conscious effort, it cannot be perceived as equal to individual's spontaneous reactions. The intentional management of stress must not be confused withdefense mechanisms. Coping differs from adjustment in that the latter is more general, has a broader meaning and includes diverse ways of facing a difficulty.Aim: An exploration of the definition of the term "coping", the function of the coping process as well as its differentiation from other similar meanings through a literature review.Methodology: Three theoretical approaches of coping are introduced; the psychoanalytic approach; approaching by characteristics; and the Lazarus and Folkman interactive model.Results: The strategic methods of the coping approaches are described and the article ends with a review of the approaches including the functioning of the stress-coping process , the classificationtypes of coping strategies in stress-inducing situations and with a criticism of coping approaches.Conclusions: The comparison of coping in different situations is difficult, if not impossible. The coping process is a slow process, so an individual may select one method of coping under one set ofcircumstances and a different strategy at some other time. Such selection of strategies takes place as the situation changes.

  16. Successful endoscopic endonasal repair of nasal meningoencephalocele in a 21-day-old neonate

    OpenAIRE

    Mohindra, Satyawati; Mohindra, Sandeep; Patro, Sourabha Kumar

    2015-01-01

    Introduction: Indications of surgical intervention in congenital nasal meningoencephaloceles includes presence of cerebro spinal fluid rhinorrhea having a risk of causing meningitis, episodes of prior meningitis and bilateral nasal obstruction causing respiratory difficulty in these obligate nasal breathers. Many authors would like to wait till the patient attains the age of 2 to 3 years for repair of the defect due to surgical feasibility. However, early intervention prevents further episode...

  17. EVALUATING THE EFFICACY OF PRESERVING THE MUCOSAL FLAP IN ENDONASAL DCR

    Directory of Open Access Journals (Sweden)

    Koteswar

    2015-11-01

    Full Text Available INTRODUCTION Endoscopic DCR is routinely performed by otolaryngologists for the treatment of chronic dacryocystitis. However, postoperative stenosis and failure rates are common. OBJECTIVE The objective of our study is to evaluate the role of preserving the mucosal flap in maintaining the patency of neo ostium. The surgical technique involved the creation of nasal mucosal and large posterior lacrimal flaps at the medial lacrimal sac wall and the two flaps were placed in close apposition. Success was defined as complete resolution of epiphora and a patent lacrimal system, evaluated by lacrimal irrigation and endoscopy followed upto 1 year postoperatively. MATERIALS AND METHODS A prosective study was conducted in 60 patients and followed for a duration of 1 year in ENT department,KMC,Guntur RESULTS In our study, Symptomatic and anatomic success was seen in 59 out of 60 operations that is 98% success in syringing patency was seen with this technique, which is comparable to external DCR and better than other endoscopic techniques. CONCLUSION Mucosal flap preservation appears to be the single most important innovation in endoscopic DCR surgery, which makes it comfortable for both the surgeon and patient, apart from providing a 98% success rate in our study.

  18. National long-lasting effect of endonasal endoscopic sphenopalatine artery clipping for epistaxis

    DEFF Research Database (Denmark)

    Ludvigsen Gede, Lisbeth; Aanaes, Kasper; Collatz, Helle

    2013-01-01

    We consider sphenopalatine artery ligation to be a safe and effective treatment of posterior epistaxis as the long-term need for revision surgery and the complication rates are low. Surgery should be considered earlier in the treatment of posterior epistaxis....

  19. Robot-assisted endoscope guidance versus manual endoscope guidance in functional endonasal sinus surgery (FESS).

    Science.gov (United States)

    Eichhorn, Klaus Wolfgang; Westphal, Ralf; Rilk, Markus; Last, Carsten; Bootz, Friedrich; Wahl, Friedrich; Jakob, Mark; Send, Thorsten

    2017-10-01

    Having one hand occupied with the endoscope is the major disadvantage for the surgeon when it comes to functional endoscopic sinus surgery (FESS). Only the other hand is free to use the surgical instruments. Tiredness or frequent instrument changes can thus lead to shaky endoscopic images. We collected the pose data (position and orientation) of the rigid 0° endoscope and all the instruments used in 16 FESS procedures with manual endoscope guidance as well as robot-assisted endoscope guidance. In combination with the DICOM CT data, we tracked the endoscope poses and workspaces using self-developed tracking markers. All surgeries were performed once with the robot and once with the surgeon holding the endoscope. Looking at the durations required, we observed a decrease in the operating time because one surgeon doing all the procedures and so a learning curve occurred what we expected. The visual inspection of the specimens showed no damages to any of the structures outside the paranasal sinuses. Robot-assisted endoscope guidance in sinus surgery is possible. Further CT data, however, are desirable for the surgical analysis of a tracker-based navigation within the anatomic borders. Our marker-based tracking of the endoscope as well as the instruments makes an automated endoscope guidance feasible. On the subjective side, we see that RASS brings a relief for the surgeon.

  20. Sinonasal metallic foreign body penetration of the anterior cranial fossa

    Directory of Open Access Journals (Sweden)

    Madeleine B. Samuelson

    2017-03-01

    Conclusion: Intracranial metallic foreign bodies may have significant potential morbidity. Recent advances in endonasal techniques for anterior skull base access may enhance outcomes through reduced morbidity and mortality, improved speed and precision, shorter hospital stays, and lower post-operative pain [1,2,4]. Technical nuances of these approaches and medical decision-making in the context of various neurosurgical considerations are discussed.

  1. Approaching a Postcolonial Arctic

    DEFF Research Database (Denmark)

    Jensen, Lars

    2016-01-01

    This article explores different postcolonially configured approaches to the Arctic. It begins by considering the Arctic as a region, an entity, and how the customary political science informed approaches are delimited by their focus on understanding the Arctic as a region at the service...... of the contemporary neoliberal order. It moves on to explore how different parts of the Arctic are inscribed in a number of sub-Arctic nation-state binds, focusing mainly on Canada and Denmark. The article argues that the postcolonial can be understood as a prism or a methodology that asks pivotal questions to all...... approaches to the Arctic. Yet the postcolonial itself is characterised by limitations, not least in this context its lack of interest in the Arctic, and its bias towards conventional forms of representation in art. The article points to the need to develop a more integrated critique of colonial and neo...

  2. Life History Approach

    DEFF Research Database (Denmark)

    Olesen, Henning Salling

    2015-01-01

    as in everyday life. Life histories represent lived lives past, present and anticipated future. As such they are interpretations of individuals’ experiences of the way in which societal dynamics take place in the individual body and mind, either by the individual him/herself or by another biographer. The Life...... History approach was developing from interpreting autobiographical and later certain other forms of language interactive material as moments of life history, i.e. it is basically a hermeneutic approach. Talking about a psycho-societal approach indicates the ambition of attacking the dichotomy...... of the social and the psychic, both in the interpretation procedure and in some main theoretical understandings of language, body and mind. My article will present the reflections on the use of life history based methodology in learning and education research as a kind of learning story of research work....

  3. Technical approach document

    International Nuclear Information System (INIS)

    1989-12-01

    The Uranium Mill Tailings Radiation Control Act (UMTRCA) of 1978, Public Law 95-604 (PL95-604), grants the Secretary of Energy the authority and responsibility to perform such actions as are necessary to minimize radiation health hazards and other environmental hazards caused by inactive uranium mill sites. This Technical Approach Document (TAD) describes the general technical approaches and design criteria adopted by the US Department of Energy (DOE) in order to implement remedial action plans (RAPS) and final designs that comply with EPA standards. It does not address the technical approaches necessary for aquifer restoration at processing sites; a guidance document, currently in preparation, will describe aquifer restoration concerns and technical protocols. This document is a second revision to the original document issued in May 1986; the revision has been made in response to changes to the groundwater standards of 40 CFR 192, Subparts A--C, proposed by EPA as draft standards. New sections were added to define the design approaches and designs necessary to comply with the groundwater standards. These new sections are in addition to changes made throughout the document to reflect current procedures, especially in cover design, water resources protection, and alternate site selection; only minor revisions were made to some of the sections. Sections 3.0 is a new section defining the approach taken in the design of disposal cells; Section 4.0 has been revised to include design of vegetated covers; Section 8.0 discusses design approaches necessary for compliance with the groundwater standards; and Section 9.0 is a new section dealing with nonradiological hazardous constituents. 203 refs., 18 figs., 26 tabs

  4. Homogenization approach in engineering

    International Nuclear Information System (INIS)

    Babuska, I.

    1975-10-01

    Homogenization is an approach which studies the macrobehavior of a medium by its microproperties. Problems with a microstructure play an essential role in such fields as mechanics, chemistry, physics, and reactor engineering. Attention is concentrated on a simple specific model problem to illustrate results and problems typical of the homogenization approach. Only the diffusion problem is treated here, but some statements are made about the elasticity of composite materials. The differential equation is solved for linear cases with and without boundaries and for the nonlinear case. 3 figures, 1 table

  5. Thematic curriculum approach

    Directory of Open Access Journals (Sweden)

    Šefer Jasmina P.

    2003-01-01

    Full Text Available Thematic curriculum combines disciplines and media. The process is problem-oriented and the scenario most often follows the logic of exploring or storytelling. Those two approaches to teaching are appropriate because they fit into interdisciplinary and creative open-ended problem solving through play, as insisted upon by thematic curriculum. The matrix, where seven types of abilities intersect with five types of problems according to their degree of openness, defines well the outcomes of teaching. However, it did not prove to be suitable for planning the majority of activities in thematic curriculum, for it follows with difficulty the process of exploring or storytelling i.e. it disrupts the subject matter coherence of thematic curriculum. Therefore, it is suggested that matrix should be used for disciplinary curriculum planning but for that of thematic curriculum only in exclusive cases. The matrix should be used primarily as a framework for evaluating the distribution of various types of abilities and problem situations in teaching. The logic of diverse approaches to teaching reflects itself in the manner of planning and organizing the teaching process. Conceptual, visual-graphic, structural and other aids employed during educational process planning should suit the nature of the approach chosen. On the basis of qualitative investigations of educational process, in the present paper considerations are given to various approaches to teaching development of various drafts for the planning of teaching, and recognition of the logic of storytelling and exploring in thematic curriculum.

  6. Islamic approach in counseling.

    Science.gov (United States)

    Hanin Hamjah, Salasiah; Mat Akhir, Noor Shakirah

    2014-02-01

    A religious approach is one of the matters emphasized in counseling today. Many researchers find that there is a need to apply the religious element in counseling because religion is important in a client's life. The purpose of this research is to identify aspects of the Islamic approach applied in counseling clients by counselors at Pusat Kaunseling Majlis Agama Islam Negeri Sembilan (PKMAINS). In addition, this research also analyses the Islamic approach applied in counseling at PKMAINS with reference to al-Quran and al-Sunnah. This is a qualitative research in the form of case study at PKMAINS. The main method used in this research is interview. The research instrument used is interview protocol. The respondents in this study include 9 counselors who serve in one of the counseling centers in Malaysia. This study also uses questionnaire as an additional instrument, distributed to 36 clients who receive counseling service at the center. The findings of the study show that the Islamic approach applied in counseling at PKMAINS may be categorized into three main aspects: aqidah (faith), ibadah (worship/ultimate devotion and love for God) and akhlaq (moral conduct). Findings also show that the counseling in these aspects is in line with Islamic teachings as contained in al-Quran and al-Sunnah.

  7. A green chemistry approach

    Indian Academy of Sciences (India)

    Administrator

    One-pot synthesis of quinaldine derivatives by using microwave irradiation without any solvent – A green chemistry approach. JAVAD SAFARI*, SAYED HOSSEIN BANITABA and SEPEHR SADEGH SAMIEI. Department of Chemistry, The Faculty of sciences, University of Kashan, Kashan,. P.O. Box 87317-51167, I.R. Iran.

  8. Realistic Approach to Innovation.

    Science.gov (United States)

    Dawson, Garth C.

    Part of the Omaha police in-service training program was devoted to innovative approaches to solving police department problems and improving community relations. The sessions were an attempt to use the brainstorming technique to elicit new solutions to everyday problems faced by the rank-and-file members of the police department. The report…

  9. Salt repository design approach

    International Nuclear Information System (INIS)

    Matthews, S.C.

    1983-01-01

    This paper presents a summary discussion of the approaches that have been and will be taken in design of repository facilities for use with disposal of radioactive wastes in salt formations. Since specific sites have yet to be identified, the discussion is at a general level, supplemented with illustrative examples where appropriate. 5 references, 1 figure

  10. The Capability Approach

    NARCIS (Netherlands)

    I.A.M. Robeyns (Ingrid)

    2011-01-01

    textabstract In its most general description, the capability approach is a flexible and multi-purpose normative framework, rather than a precise theory of well-being, freedom or justice. At its core are two normative claims: first, the claim that the freedom to achieve well-being is of primary

  11. Orion Emergency Mask Approach

    Science.gov (United States)

    Tuan, George C.; Graf, John C.

    2009-01-01

    Emergency mask approach on Orion poses a challenge to the traditional Shuttle or Station approaches. Currently, in the case of a fire or toxic spill event, the crew utilizes open loop oxygen masks that provide the crew with oxygen to breath, but also dumps the exhaled oxygen into the cabin. For Orion, with a small cabin volume, the extra oxygen will exceed the flammability limit within a short period of time, unless a nitrogen purge is also provided. Another approach to a fire or toxic spill event is the use of a filtering emergency masks. These masks utilize some form of chemical beds to scrub the air clean of toxic providing the crew safe breathing air for a period without elevating the oxygen level in the cabin. Using the masks and a form of smoke-eater filter, it may be possible to clean the cabin completely or to a level for safe transition to a space suit to perform a cabin purge. Issues with filters in the past have been the reaction time, breakthroughs, and high breathing resistance. Development in a new form of chemical filters has shown promise to make the filtering approach feasible.

  12. Approach to neonatal sepsis

    Directory of Open Access Journals (Sweden)

    Shankar Narayan

    2015-01-01

    The treatment includes supportive care along with administration of appropriate antibiotics. Adjuvant treatment includes IVIG, GCSF, exchange transfusion and pentoxifylline administration. This paper aims to present an algorithmic approach to neonatal sepsis to expedite the diagnosis along with providing appropriate and adequate treatment.

  13. Approaches to acceptable risk

    International Nuclear Information System (INIS)

    Whipple, C.

    1997-01-01

    Several alternative approaches to address the question open-quotes How safe is safe enough?close quotes are reviewed and an attempt is made to apply the reasoning behind these approaches to the issue of acceptability of radiation exposures received in space. The approaches to the issue of the acceptability of technological risk described here are primarily analytical, and are drawn from examples in the management of environmental health risks. These include risk-based approaches, in which specific quantitative risk targets determine the acceptability of an activity, and cost-benefit and decision analysis, which generally focus on the estimation and evaluation of risks, benefits and costs, in a framework that balances these factors against each other. These analytical methods tend by their quantitative nature to emphasize the magnitude of risks, costs and alternatives, and to downplay other factors, especially those that are not easily expressed in quantitative terms, that affect acceptance or rejection of risk. Such other factors include the issues of risk perceptions and how and by whom risk decisions are made

  14. Health: An Ecosystem Approach

    International Development Research Centre (IDRC) Digital Library (Canada)

    In the early days, the research supported was largely biomedical: vaccines, ... editor of Découvrir magazine in Montréal, who produced the first draft of the book, ...... Their transdisciplinary approach included gender-specific parameters. ..... Over time, some progress was made against malaria, but the war was far from won.

  15. NEW APPROACHES: Toppling trains

    Science.gov (United States)

    Parry, Malcolm

    1998-03-01

    This article explains a novel way of approaching centripetal force: theory is used to predict an orbital period at which a toy train will topple from a circular track. The demonstration has proved useful in A-level, GNVQ and undergraduate Physics and Engineering schemes.

  16. Approach to Absolute Zero

    Indian Academy of Sciences (India)

    Home; Journals; Resonance – Journal of Science Education; Volume 2; Issue 10. Approach to Absolute Zero Below 10 milli-Kelvin. R Srinivasan. Series Article Volume 2 Issue 10 October 1997 pp 8-16. Fulltext. Click here to view fulltext PDF. Permanent link: https://www.ias.ac.in/article/fulltext/reso/002/10/0008-0016 ...

  17. Fuel cycle oriented approach

    International Nuclear Information System (INIS)

    Petit, A.

    1987-01-01

    The term fuel cycle oriented approach is currently used to designate two quite different things: the attempt to consider all or part of a national fuel cycle as one material balance area (MBA) or to consider individual MBAs existing in a state while designing a unique safeguards approach for each and applying the principle of nondiscrimination to fuel cycles as a whole, rather than to individual facilities. The merits of such an approach are acceptability by the industry and comparison with the contemplated establishment of long-term criteria. The following points concern the acceptability by the industry: (1) The main interest of the industry is to keep an open international market and therefore, to have effective and efficient safeguards. (2) The main concerns of the industry regarding international safeguards are economic burden, intrusiveness, and discrimination. Answers to these legitimate concerns, which retain the benefits of a fuel cycle oriented approach, are needed. More specifically, the problem of reimbursing the operator the costs that he has incurred for the safeguards must be considered

  18. Financial Management: An Organic Approach

    Science.gov (United States)

    Laux, Judy

    2013-01-01

    Although textbooks present corporate finance using a topical approach, good financial management requires an organic approach that integrates the various assignments financial managers confront every day. Breaking the tasks into meaningful subcategories, the current article offers one approach.

  19. Ecosystem approach in education

    Science.gov (United States)

    Nabiullin, Iskander

    2017-04-01

    Environmental education is a base for sustainable development. Therefore, in our school we pay great attention to environmental education. Environmental education in our school is based on ecosystem approach. What is an ecosystem approach? Ecosystem is a fundamental concept of ecology. Living organisms and their non-living environments interact with each other as a system, and the biosphere planet functions as a global ecosystem. Therefore, it is necessary for children to understand relationships in ecosystems, and we have to develop systems thinking in our students. Ecosystem approach and systems thinking should help us to solve global environmental problems. How do we implement the ecosystem approach? Students must understand that our biosphere functions as a single ecosystem and even small changes can lead to environmental disasters. Even the disappearance of one plant or animal species can lead to irreversible consequences. So in the classroom we learn the importance of each living organism for the nature. We pay special attention to endangered species, which are listed in the Red Data List. Kids are doing projects about these organisms, make videos, print brochures and newspapers. Fieldwork also plays an important role for ecosystem approach. Every summer, we go out for expeditions to study species of plants and animals listed in the Red Data List of Tatarstan. In class, students often write essays on behalf of any endangered species of plants or animals, this also helps them to understand the importance of each living organism in nature. Each spring we organise a festival of environmental projects among students. Groups of 4-5 students work on a solution of environmental problems, such as water, air or soil pollution, waste recycling, the loss of biodiversity, etc. Participants shoot a clip about their project, print brochures. Furthermore, some of the students participate in national and international scientific Olympiads with their projects. In addition to

  20. Domain Approach: An Alternative Approach in Moral Education

    Science.gov (United States)

    Vengadasalam, Chander; Mamat, Wan Hasmah Wan; Mail, Fauziah; Sudramanian, Munimah

    2014-01-01

    This paper discusses the use of the domain approach in moral education in an upper secondary school in Malaysia. Moral Education needs a creative and an innovative approach. Therefore, a few forms of approaches are used in the teaching-learning of Moral Education. This research describes the use of domain approach which comprises the moral domain…

  1. Rail transport systems approach

    CERN Document Server

    2017-01-01

    This book shows how the systems approach is employed by scientists in various countries to solve specific problems concerning railway transport. In particular, the book describes the experiences of scientists from Romania, Germany, the Czech Republic, the UK, Russia, Ukraine, Lithuania and Poland. For many of these countries there is a problem with the historical differences between the railways. In particular, there are railways with different rail gauges, with different signaling and communication systems, with different energy supplies and, finally, with different political systems, which are reflected in the different approaches to the management of railway economies. The book’s content is divided into two main parts, the first of which provides a systematic analysis of individual means of providing and maintaining rail transport. In turn, the second part addresses infrastructure and management development, with particular attention to security issues. Though primarily written for professionals involved...

  2. Approach to reliability assessment

    International Nuclear Information System (INIS)

    Green, A.E.; Bourne, A.J.

    1975-01-01

    Experience has shown that reliability assessments can play an important role in the early design and subsequent operation of technological systems where reliability is at a premium. The approaches to and techniques for such assessments, which have been outlined in the paper, have been successfully applied in variety of applications ranging from individual equipments to large and complex systems. The general approach involves the logical and systematic establishment of the purpose, performance requirements and reliability criteria of systems. This is followed by an appraisal of likely system achievment based on the understanding of different types of variational behavior. A fundamental reliability model emerges from the correlation between the appropriate Q and H functions for performance requirement and achievement. This model may cover the complete spectrum of performance behavior in all the system dimensions

  3. Thermodynamics an engineering approach

    CERN Document Server

    Cengel, Yunus A

    2014-01-01

    Thermodynamics, An Engineering Approach, eighth edition, covers the basic principles of thermodynamics while presenting a wealth of real-world engineering examples so students get a feel for how thermodynamics is applied in engineering practice. This text helps students develop an intuitive understanding by emphasizing the physics and physical arguments. Cengel and Boles explore the various facets of thermodynamics through careful explanations of concepts and use of numerous practical examples and figures, having students develop necessary skills to bridge the gap between knowledge and the confidence to properly apply their knowledge. McGraw-Hill is proud to offer Connect with the eighth edition of Cengel/Boles, Thermodynamics, An Engineering Approach. This innovative and powerful new system helps your students learn more efficiently and gives you the ability to assign homework problems simply and easily. Problems are graded automatically, and the results are recorded immediately. Track individual stude...

  4. Electronics a systems approach

    CERN Document Server

    Storey, Neil

    2017-01-01

    Electronics plays a central role in our everyday lives. It is at the heart of almost all of today's essential technology, from mobile phones to computers and from cars to power stations. As such, all engineers, scientists and technologists need to have a fundamental understanding of this exciting subject, and for many this will just be the beginning. Now in its sixth edition, Electronics: A Systems Approach provides an outstanding introduction to this fast-moving and important field. Comprehensively revised and updated to cover the latest developments in the world of electronics, the text continues to use Neil Storey's established and well-respected systems approach. It introduces the basic concepts first before progressing to a more advanced analysis, enabling you to contextualise what a system is designed to achieve before tackling the intricacies of designing or analysing its various components with confidence. This book is accompanied by a website which contains over 100 video tutorials to help explain ke...

  5. Transaction based approach

    Science.gov (United States)

    Hunka, Frantisek; Matula, Jiri

    2017-07-01

    Transaction based approach is utilized in some methodologies in business process modeling. Essential parts of these transactions are human beings. The notion of agent or actor role is usually used for them. The paper on a particular example describes possibilities of Design Engineering Methodology for Organizations (DEMO) and Resource-Event-Agent (REA) methodology. Whereas the DEMO methodology can be regarded as a generic methodology having its foundation in the theory of Enterprise Ontology the REA methodology is regarded as the domain specific methodology and has its origin in accountancy systems. The results of these approaches is that the DEMO methodology captures everything that happens in the reality with a good empirical evidence whereas the REA methodology captures only changes connected with economic events. Economic events represent either change of the property rights to economic resource or consumption or production of economic resources. This results from the essence of economic events and their connection to economic resources.

  6. Approaching comparative company law

    OpenAIRE

    Donald, David C.

    2008-01-01

    This paper identifies some common errors that occur in comparative law, offers some guidelines to help avoid such errors, and provides a framework for entering into studies of the company laws of three major jurisdictions. The first section illustrates why a conscious approach to comparative company law is useful. Part I discusses some of the problems that can arise in comparative law and offers a few points of caution that can be useful for practical, theoretical and legislative comparative ...

  7. Approaching Service Innovation Patterns

    OpenAIRE

    Andrea NAGY

    2013-01-01

    The present paper aims at analyzing the types of innovation in the field of services. First, the concept of innovation is defined and second, field literature is reviewed from the perspective of service innovation. The main types of innovation are identified based on several attempts at defining innovation, the most notable being Schumpeter’s. Thus, it is possible to approach concepts such as product and process innovation, incremental and radical innovation. Another aim has been to regard se...

  8. Robust Approaches to Forecasting

    OpenAIRE

    Jennifer Castle; David Hendry; Michael P. Clements

    2014-01-01

    We investigate alternative robust approaches to forecasting, using a new class of robust devices, contrasted with equilibrium correction models. Their forecasting properties are derived facing a range of likely empirical problems at the forecast origin, including measurement errors, implulses, omitted variables, unanticipated location shifts and incorrectly included variables that experience a shift. We derive the resulting forecast biases and error variances, and indicate when the methods ar...

  9. The Branding Management Approaches

    Institute of Scientific and Technical Information of China (English)

    YAKOUBI; Mohamed Lamine

    2014-01-01

    [Abstract]We wil try to present,through the display of the various branding concepts and theories, the different branding management approaches.This wil present the different visions of the discipline depending on the author to try and demonstrate their differences,at first, and their complementarities at last to help the different branding management practitioners (brand managers,marketing managers,advertisers,media-planners……) apprehend the right brand positioning strategy to engage.

  10. Towards a Dual Approach

    DEFF Research Database (Denmark)

    Holli, Anne Maria; Harder, Mette Marie Stæhr

    2016-01-01

    Drawing on insights from state feminism and legislative studies on parliamentary committees, this article develops a dual approach for the comparative analysis of committees on gender equality. Empirically, it compares the standing committees on gender equality in Denmark and Finland, two Nordic...... as measured by legislative outputs and oversight differs, however, in line with differing committee system characteristics: the Finnish committee has more impact on legislative outputs while the Danish committee has more impact on overseeing government....

  11. APPROACHES FOR SUSTAINABLE MANUFACTURING

    Institute of Scientific and Technical Information of China (English)

    G(U)NTHER Seliger; SEBASTIAN Kernbaum; MARCO Zettl

    2007-01-01

    Sustainable development is a holistic approach harmonizing ecological, economical and socio-political needs with respect to the superior objective of enhancing human living standards. Thereby the availability of natural resources and the conservation of the ecosystems have to be considered that future generations have the possibility to meet their own needs. A long-term economical development demands the transition from a source-sink economy to a cycle economy as a result of limited resources, limited environmental capacities to absorb waste and emissions as well as increasing needs of a growing population. A reference model for sustainability in manufacturing is presented and used to illustrate sustainable approaches with respect to management, technology, process and product. Adaptation of products and components is a vital element for supporting efficient reuse of products and components. Consequently adaptation contributes to the ambitious goals of sustainability. Technological enablers for adaptation as modularity, information and communication technology are exemplarily introduced. Moreover, approaches for disseminating knowledge in sustainability are given.

  12. Peritonitis: laparoscopic approach

    Directory of Open Access Journals (Sweden)

    Agresta Ferdinando

    2006-03-01

    Full Text Available Abstract Background Laparoscopy has became as the preferred surgical approach to a number of different diseases because it allows a correct diagnosis and treatment at the same time. In abdominal emergencies, both components of treatment – exploration to identify the causative pathology and performance of an appropriate operation – can often be accomplished via laparoscopy. There is still a debate of peritonitis as a contraindication to this kind of approach. Aim of the present work is to illustrate retrospectively the results of a case-control experience of laparoscopic vs. open surgery for abdominal peritonitis emergencies carried out at our institution. Methods From January 1992 and January 2002 a total of 935 patients (mean age 42.3 ± 17.2 years underwent emergent and/or urgent surgery. Among them, 602 (64.3% were operated on laparoscopically (of whom 112 -18.7% – with peritonitis, according to the presence of a surgical team trained in laparoscopy. Patients with a history of malignancy, more than two previous major abdominal surgeries or massive bowel distension were not treated Laparoscopically. Peritonitis was not considered contraindication to Laparoscopy. Results The conversion rate was 23.2% in patients with peritonitis and was mainly due to the presence of dense intra-abdominal adhesions. Major complications ranged as high as 5.3% with a postoperative mortality of 1.7%. A definitive diagnosis was accomplished in 85.7% (96 pat. of cases, and 90.6% (87 of these patients were treated successfully by Laparoscopy. Conclusion Even if limited by its retrospective feature, the present experience let us to consider the Laparoscopic approach to abdominal peritonitis emergencies a safe and effective as conventional surgery, with a higher diagnostic yield and allows for lesser trauma and a more rapid postoperative recovery. Such features make Laparoscopy a challenging alternative to open surgery in the management algorithm for abdominal

  13. Standardised approach to optimisation

    International Nuclear Information System (INIS)

    Warren-Forward, Helen M.; Beckhaus, Ronald

    2004-01-01

    Optimisation of radiographic images is said to have been obtained if the patient has achieved an acceptable level of dose and the image is of diagnostic value. In the near future, it will probably be recommended that radiographers measure patient doses and compare them to reference levels. The aim of this paper is to describe a standardised approach to optimisation of radiographic examinations in a diagnostic imaging department. A three-step approach is outlined with specific examples for some common examinations (chest, abdomen, pelvis and lumbar spine series). Step One: Patient doses are calculated. Step Two: Doses are compared to existing reference levels and the technique used compared to image quality criteria. Step Three: Appropriate action is taken if doses are above the reference level. Results: Average entrance surface doses for two rooms were as follows AP Abdomen (6.3mGy and 3.4mGy); AP Lumbar Spine (6.4mGy and 4.1mGy) for AP Pelvis (4.8mGy and 2.6mGy) and PA chest (0.19mGy and 0.20mGy). Comparison with the Commission of the European Communities (CEC) recommended techniques identified large differences in the applied potential. The kVp values in this study were significantly lower (by up to lOkVp) than the CEC recommendations. The results of this study have indicated that there is a need to monitor radiation doses received by patients undergoing diagnostic radiography examinations. Not only has the assessment allowed valuable comparison with International Diagnostic Reference Levels and Radiography Good Practice but has demonstrated large variations in mean doses being delivered from different rooms of the same radiology department. Following the simple 3-step approach advocated in this paper should either provide evidence that department are practising the ALARA principle or assist in making suitable changes to current practice. Copyright (2004) Australian Institute of Radiography

  14. Experimental approaches and applications

    CERN Document Server

    Crasemann, Bernd

    1975-01-01

    Atomic Inner-Shell Processes, Volume II: Experimental Approaches and Applications focuses on the physics of atomic inner shells, with emphasis on experimental aspects including the use of radioactive atoms for studies of atomic transition probabilities. Surveys of modern techniques of electron and photon spectrometry are also presented, and selected practical applications of inner-shell processes are outlined. Comprised of six chapters, this volume begins with an overview of the general principles underlying the experimental techniques that make use of radioactive isotopes for inner-sh

  15. Craniopharyngioma - Transnasal Endoscopic Approach

    Directory of Open Access Journals (Sweden)

    Sanjeev Bhagat,

    2011-01-01

    Full Text Available Craniopharyngiomas are slow growing tumours arising from remnants of the craniopharyngeal duct and occupy the sellar region. The patients may remain asymptomatic for long duration or present with headache or visual disturbances. Surgery is the mainstay of the treatment. Traditionally these tumours have been removed by neurosurgeons through the cranial approach but the advent of nasal endoscopes has opened new avenues for ENT surgeons to treat such patients. We hereby present a case of craniopharyngioma who was successfully treated by Trans-nasal Hypophysectomy.

  16. URBAN POLITICS: KEY APPROACHES

    Directory of Open Access Journals (Sweden)

    Ledyaeva Ol'ga Mikhaylovna

    2012-10-01

    Full Text Available Several approaches that underlie urban politics are discussed in the paper. They include neo-liberalism, political economy discourse, elitist/pluralist debates, and postmodernism. The neoliberal approach focuses on the limited role of the state and individual responsibility. The legal framework protects both the rights and responsibilities of individuals and regulates the operation of the market. It is the market that fosters individual choices and provides goods and services by virtue of the processes which are flexible, efficient and transparent. The political economy approaches (regulation theory, public choice theory, neo-Marxism explain urban politics via the analysis of national and international economic processes and changes in contemporary capitalism. Changes in national and international economies determine what solutions are possible. The discourse has been influenced by the debate on globalization of capital and labour markets. Modern elitism and neopluralism are represented by theories of "growth machines" and "urban regimes". The former focuses on bargaining alliances between political and business leaders in order to manage the urban system and to promote its growth. The latter develops neopluralist explanations of power within local communities with an emphasis on the fragmented nature of the government where local authorities lack comprehensive governing powers. Postmodernism views the city as the site of the crisis of late capitalism which leads to segregation of neighbourhoods onto prosperous areas and ghettoes. In contrast to the modern city, the postmodern city is not defined by its industrial base; rather, it is determined by its consumerist environment of malls and museums, characterized by revivalist architecture. At the same time, the suburban shopping mall and a motorway network make nonsense of the idea of the city as a unique and well-defined space. These and other approaches encompass a wide spectrum of possibilities

  17. New Encrypted Steganography Approach

    Directory of Open Access Journals (Sweden)

    Saba Mohammed Husain‎

    2017-12-01

    Full Text Available The proposed research Provides an approach for hiding an encrypted text in side a digital image. Where the text is encrypted in a complex manner used method of PlayFair to encrypt clear text and to increase security put lettering ciphertext on the geometric shape clockwise and then we write the ciphertext output in the form of lines, taken new ciphertext and converted to Ascii code and then to binary and hidden text in bits least importance in the picture. The results were good by PNSR scale

  18. The Capability Approach

    OpenAIRE

    Robeyns, Ingrid

    2011-01-01

    textabstract In its most general description, the capability approach is a flexible and multi-purpose normative framework, rather than a precise theory of well-being, freedom or justice. At its core are two normative claims: first, the claim that the freedom to achieve well-being is of primary moral importance, and second, that freedom to achieve well-being is to be understood in terms of people’s capabilities, that is, their real opportunities to do and be what they have reason to value. Thi...

  19. The collaboratory approach

    International Nuclear Information System (INIS)

    Peskin, A.M.

    1997-01-01

    A open-quotes collaboratoryclose quotes has been defined as a center without walls, in which researchers can perform their work without regard to geographical location. To an increasing degree, engineering design and development is also taking the form of far-flung collaborations among divisions of a plant, subcontractors, university consultants and customers. It has long been recognized that quality engineering education presents the student with an environment that duplicates as much as possible that which the graduate will encounter in industry. To that end, it is important that engineering schools begin to introduce the collaboratory approach in its preparation, and even use it in delivery of subject matter to students

  20. Diagnostic Approach to Myelopathies

    International Nuclear Information System (INIS)

    Granados Sanchez, Ana Maria; Garcia Posada, Lina Maria; Ortega Toscano, Cesar Andres; Lopez Lopez, Alejandra

    2011-01-01

    Myelopathy is a broad term that refers to spinal cord involvement of multiple etiologies. Spinal cord diseases often have devastating consequences, ranging from quadriplegia and paraplegia to severe sensory deficits due to its confinement in a very small area. Many of these diseases are potentially reversible if they are recognized on time, hence the importance of recognizing the significance of magnetic resonance imaging when approaching a multifactorial disease considered as one of the most critical neurological emergencies, where prognosis depends on an early and accurate diagnosis.

  1. HEDR modeling approach

    International Nuclear Information System (INIS)

    Shipler, D.B.; Napier, B.A.

    1992-07-01

    This report details the conceptual approaches to be used in calculating radiation doses to individuals throughout the various periods of operations at the Hanford Site. The report considers the major environmental transport pathways--atmospheric, surface water, and ground water--and projects and appropriate modeling technique for each. The modeling sequence chosen for each pathway depends on the available data on doses, the degree of confidence justified by such existing data, and the level of sophistication deemed appropriate for the particular pathway and time period being considered

  2. The collaboratory approach

    Energy Technology Data Exchange (ETDEWEB)

    Peskin, A.M.

    1997-04-01

    A {open_quotes}collaboratory{close_quotes} has been defined as a center without walls, in which researchers can perform their work without regard to geographical location. To an increasing degree, engineering design and development is also taking the form of far-flung collaborations among divisions of a plant, subcontractors, university consultants and customers. It has long been recognized that quality engineering education presents the student with an environment that duplicates as much as possible that which the graduate will encounter in industry. To that end, it is important that engineering schools begin to introduce the collaboratory approach in its preparation, and even use it in delivery of subject matter to students.

  3. Pharmacogenetics approach to therapeutics.

    Science.gov (United States)

    Koo, Seok Hwee; Lee, Edmund Jon Deoon

    2006-01-01

    1. Pharmacogenetics refers to the study of genetically controlled variations in drug response. Functional variants caused by single nucleotide polymorphisms (SNPs) in genes encoding drug-metabolising enzymes, transporters, ion channels and drug receptors have been known to be associated with interindividual and interethnic variation in drug response. Genetic variations in these genes play a role in influencing the efficacy and toxicity of medications. 2. Rapid, precise and cost-effective high-throughput technological platforms are essential for performing large-scale mutational analysis of genetic markers involved in the aetiology of variable responses to drug therapy. 3. The application of a pharmacogenetics approach to therapeutics in general clinical practice is still far from being achieved today owing to various constraints, such as limited accessibility of technology, inadequate knowledge, ambiguity of the role of variants and ethical concerns. 4. Drug actions are determined by the interplay of several genes encoding different proteins involved in various biochemical pathways. With rapidly emerging SNP discovery technological platforms and widespread knowledge on the role of SNPs in disease susceptibility and variability in drug response, the pharmacogenetics approach to therapeutics is anticipated to take off in the not-too-distant future. This will present profound clinical, economic and social implications for health care.

  4. Proteomic approach to nanotoxicity.

    Science.gov (United States)

    Matysiak, Magdalena; Kapka-Skrzypczak, Lucyna; Brzóska, Kamil; Gutleb, Arno C; Kruszewski, Marcin

    2016-03-30

    In recent years a large number of engineered nanomaterials (NMs) have been developed with promising technical benefits for consumers and medical appliances. In addition to already known potentially advantageous biological properties (antibiotic, antifungal and antiviral activity) of NMs, many new medical applications of NMs are foreseen, such as drug carriers, contrast agents, radiopharmaceuticals and many others. However, there is increasing concern about potential environmental and health effects due to NMs exposure. An increasing body of evidence suggests that NMs may trigger undesirable hazardous interactions with biological systems with potential to generate harmful effects. In this review we summarized a current state of knowledge on the proteomics approaches to nanotoxicity, including protein corona formation, in vitro and in vivo effects of exposure to NMs on proteome of different classes of organisms, from bacteria and plants to mammals. The effects of NMs on the proteome of environmentally relevant organisms are also described. Despite the benefit that development of nanotechnology may bring to the society, there are still major gaps of knowledge on the influence of nanomaterials on human health and the environment. Thus, it seems necessary to conduct further interdisciplinary research to fill the knowledge gaps in NM toxicity, using more holistic approaches than offered by conventional biological techniques. “OMICS” techniques will certainly help researchers in this field. In this paper we summarized the current stage of knowledge of the effects of nanoparticles on the proteome of different organisms, including those commonly used as an environmentally relevant indicator organisms.

  5. Endoscopic approach to achalasia

    Science.gov (United States)

    Müller, Michaela; Eckardt, Alexander J; Wehrmann, Till

    2013-01-01

    Achalasia is a primary esophageal motor disorder. The etiology is still unknown and therefore all treatment options are strictly palliative with the intention to weaken the lower esophageal sphincter (LES). Current established endoscopic therapeutic options include pneumatic dilation (PD) or botulinum toxin injection. Both treatment approaches have an excellent symptomatic short term effect, and lead to a reduction of LES pressure. However, the long term success of botulinum toxin (BT) injection is poor with symptom recurrence in more than 50% of the patients after 12 mo and in nearly 100% of the patients after 24 mo, which commonly requires repeat injections. In contrast, after a single PD 40%-60% of the patients remain asymptomatic for ≥ 10 years. Repeated on demand PD might become necessary and long term remission can be achieved with this approach in up to 90% of these patients. The main positive predictors for a symptomatic response to PD are an age > 40 years, a LES-pressure reduction to 40 years, was nearly equivalent to surgery. A new promising technique might be peroral endoscopic myotomy, although long term results are needed and practicability as well as safety issues must be considered. Treatment with a temporary self expanding stent has been reported with favorable outcomes, but the data are all from one study group and must be confirmed by others before definite recommendations can be made. In addition to its use as a therapeutic tool, endoscopy also plays an important role in the diagnosis and surveillance of patients with achalasia. PMID:23951393

  6. Interstage Flammability Analysis Approach

    Science.gov (United States)

    Little, Jeffrey K.; Eppard, William M.

    2011-01-01

    The Interstage of the Ares I launch platform houses several key components which are on standby during First Stage operation: the Reaction Control System (ReCS), the Upper Stage (US) Thrust Vector Control (TVC) and the J-2X with the Main Propulsion System (MPS) propellant feed system. Therefore potentially dangerous leaks of propellants could develop. The Interstage leaks analysis addresses the concerns of localized mixing of hydrogen and oxygen gases to produce deflagration zones in the Interstage of the Ares I launch vehicle during First Stage operation. This report details the approach taken to accomplish the analysis. Specified leakage profiles and actual flammability results are not presented due to proprietary and security restrictions. The interior volume formed by the Interstage walls, bounding interfaces with the Upper and First Stages, and surrounding the J2-X engine was modeled using Loci-CHEM to assess the potential for flammable gas mixtures to develop during First Stage operations. The transient analysis included a derived flammability indicator based on mixture ratios to maintain achievable simulation times. Validation of results was based on a comparison to Interstage pressure profiles outlined in prior NASA studies. The approach proved useful in the bounding of flammability risk in supporting program hazard reviews.

  7. Ethnographic Approaches in Primatology.

    Science.gov (United States)

    Dore, Kerry M; Radford, Lucy; Alexander, Sherrie; Waters, Siân

    2018-01-01

    The shared evolutionary histories and anatomical similarities between humans and non-human primates create dynamic interconnections between these alloprimates. In this foreword to Folia Primatologica's special issue on "Ethnographic Approaches in Primatology," we review the ethnographic method and existing literature at the intersection of primatology and ethnography. We summarize, compare and contrast the 5 contributions to this special issue to highlight why the human-non-human primate interface is a compelling area to investigate via ethnographic approaches and to encourage increased incorporation of ethnography into the discipline of primatology. Ethnography is a valuable and increasingly popular tool with its use no longer limited to anthropological practitioners investigating traditional, non-Western peoples. Scholars from many disciplines now use ethnographic methods to investigate all members of our globalised world, including non-humans. As our closest living relatives, non-human primates (hereafter "primates") are compelling subjects and thus appear in a range of contexts within ethnographic investigations. The goal of this special issue is to highlight the trajectory of research at the intersection of primatology and ethnography and to illustrate the importance of ethnographic methods for the advancement of primatology as a discipline. © 2018 S. Karger AG, Basel.

  8. Approaches for Stereo Matching

    Directory of Open Access Journals (Sweden)

    Takouhi Ozanian

    1995-04-01

    Full Text Available This review focuses on the last decade's development of the computational stereopsis for recovering three-dimensional information. The main components of the stereo analysis are exposed: image acquisition and camera modeling, feature selection, feature matching and disparity interpretation. A brief survey is given of the well known feature selection approaches and the estimation parameters for this selection are mentioned. The difficulties in identifying correspondent locations in the two images are explained. Methods as to how effectively to constrain the search for correct solution of the correspondence problem are discussed, as are strategies for the whole matching process. Reasons for the occurrence of matching errors are considered. Some recently proposed approaches, employing new ideas in the modeling of stereo matching in terms of energy minimization, are described. Acknowledging the importance of computation time for real-time applications, special attention is paid to parallelism as a way to achieve the required level of performance. The development of trinocular stereo analysis as an alternative to the conventional binocular one, is described. Finally a classification based on the test images for verification of the stereo matching algorithms, is supplied.

  9. Technical approach document

    International Nuclear Information System (INIS)

    1988-04-01

    This document describes the general technical approaches and design criteria adopted by the US Department of Energy (DOE) in order to implement Remedial Action Plans (RAPs) and final designs that comply with EPS standards. This document is a revision to the original document. Major revisions were made to the sections in riprap selection and sizing, and ground-water; only minor revisions were made to the remainder of the document. The US Nuclear Regulatory Commission (NRC) has prepared a Standard Review Plan (NRC-SRP) which describes factors to be considered by the NRC in approving the RAP. Sections 3.0, 4.0, 5.0, and 7.0 of this document are arranged under the same headings as those used in the NRC-SRP. This approach is adopted in order to facilitate joint use of the documents. Section 2.0 (not included in the NRC-SRP) discusses design considerations; Section 3.0 describes surface-water hydrology and erosion control; Section 4.0 describes geotechnical aspects of pile design; Section 5.0 discusses the Alternate Site Selection Process; Section 6.0 deals with radiological issues (in particular, the design of the radon barrier); Section 7.0 discusses protection of groundwater resources; and Section 8.0 discusses site design criteria for the RAC

  10. Fournier's gangrene current approaches.

    Science.gov (United States)

    Ozkan, Omer F; Koksal, Neset; Altinli, Ediz; Celik, Atilla; Uzun, Mehmet A; Cıkman, Oztekin; Akbas, Alpaslan; Ergun, Ersin; Kiraz, Hasan A; Karaayvaz, Muammer

    2016-10-01

    Fournier's gangrene is a rare but highly mortal infectious disease characterised by fulminant necrotising fasciitis involving the genital and perineal regions. The objective of this study is to analyse the demographics, clinical feature and treatment approaches as well as outcomes of Fournier's gangrene. Data were collected retrospectively from medical records and operative notes. Patient data were analysed by demographics, aetiological factors, clinical features, treatment approaches and outcomes. Twelve patients (five female and seven male) were enrolled in this study. The most common aetiology was perianal abscess (41·6%). Wound cultures showed a mixture of microorganisms in six (50%) patients. For faecal diversion, while colostomy was performed in six cases (50%), Flexi-Seal was used in two cases (16·6%). In four patients (33·4%), no faecal diversion was performed. Negative pressure wound therapy (NPWT) system was effective in the last four patients (33·4%). The mean hospitalisation period in patients who used NPWT was 18 days, while it was 20 days in the others. NPWT in Fournier's gangrene is a safe dressing method. It promotes granulation formation. Flexi-Seal faecal management is an alternative method to colostomy and provides protection from its associated complications. The combination of two devices (Flexi-Seal and NPWT) is an effective and comfortable method in the management of Fournier's gangrene in appropriate patients. © 2014 The Authors. International Wound Journal © 2014 Medicalhelplines.com Inc and John Wiley & Sons Ltd.

  11. Breakfast: a multidisciplinary approach.

    Science.gov (United States)

    Affinita, Antonio; Catalani, Loredana; Cecchetto, Giovanna; De Lorenzo, Gianfranco; Dilillo, Dario; Donegani, Giorgio; Fransos, Lucia; Lucidi, Fabio; Mameli, Chiara; Manna, Elisa; Marconi, Paolo; Mele, Giuseppe; Minestroni, Laura; Montanari, Massimo; Morcellini, Mario; Rovera, Giuseppe; Rotilio, Giuseppe; Sachet, Marco; Zuccotti, Gian Vincenzo

    2013-07-10

    The role of breakfast as an essential part of an healthy diet has been only recently promoted even if breakfast practices were known since the Middle Age. The growing scientific evidences on this topic are extremely sector-based nevertheless breakfast could be regarded from different point of views and from different expertises. This approach, that take into account history, sociology, anthropology, medicine, psychology and pedagogy, is useful to better understand the value of this meal in our culture. The aim of this paper was to analyse breakfast-related issues based on a multidisciplinary approach with input by specialists from different fields of learning. Breakfast is now recommended as part of a diet because it is associated with healthier macro- and micronutrient intakes, body mass index and lifestyle. Moreover recent studies showed that breakfast improves cognitive function, intuitive perception and academic performance. Research demonstrates the importance of providing breakfast not only to children but in adults and elderly too. Although the important role breakfast plays in maintaining the health, epidemiological data from industrialised countries reveal that many individuals either eat a nutritionally unhealthy breakfast or skip it completely. The historical, bio-psychological and educational value of breakfast in our culture is extremely important and should be recognized and stressed by the scientific community. Efforts should be done to promote this practice for the individual health and well-being.

  12. Systemic approaches to biodegradation.

    Science.gov (United States)

    Trigo, Almudena; Valencia, Alfonso; Cases, Ildefonso

    2009-01-01

    Biodegradation, the ability of microorganisms to remove complex chemicals from the environment, is a multifaceted process in which many biotic and abiotic factors are implicated. The recent accumulation of knowledge about the biochemistry and genetics of the biodegradation process, and its categorization and formalization in structured databases, has recently opened the door to systems biology approaches, where the interactions of the involved parts are the main subject of study, and the system is analysed as a whole. The global analysis of the biodegradation metabolic network is beginning to produce knowledge about its structure, behaviour and evolution, such as its free-scale structure or its intrinsic robustness. Moreover, these approaches are also developing into useful tools such as predictors for compounds' degradability or the assisted design of artificial pathways. However, it is the environmental application of high-throughput technologies from the genomics, metagenomics, proteomics and metabolomics that harbours the most promising opportunities to understand the biodegradation process, and at the same time poses tremendous challenges from the data management and data mining point of view.

  13. Advanced intelligence and mechanism approach

    Institute of Scientific and Technical Information of China (English)

    ZHONG Yixin

    2007-01-01

    Advanced intelligence will feature the intelligence research in next 50 years.An understanding of the concept of advanced intelligence as well as its importance will be provided first,and detailed analysis on an approach,the mechanism approach.suitable to the advanced intelligence research will then be flolowed.And the mutual relationship among mechanism approach,traditional approaches existed in artificial intelligence research,and the cognitive informatics will be discussed.It is interesting to discover that mechanism approach is a good one to the Advanced Intelligence research and a tmified form of the existed approaches to artificial intelligence.

  14. Proteomics - new analytical approaches

    International Nuclear Information System (INIS)

    Hancock, W.S.

    2001-01-01

    Full text: Recent developments in the sequencing of the human genome have indicated that the number of coding gene sequences may be as few as 30,000. It is clear, however, that the complexity of the human species is dependent on the much greater diversity of the corresponding protein complement. Estimates of the diversity (discrete protein species) of the human proteome range from 200,000 to 300,000 at the lower end to 2,000,000 to 3,000,000 at the high end. In addition, proteomics (the study of the protein complement to the genome) has been subdivided into two main approaches. Global proteomics refers to a high throughput examination of the full protein set present in a cell under a given environmental condition. Focused proteomics refers to a more detailed study of a restricted set of proteins that are related to a specified biochemical pathway or subcellular structure. While many of the advances in proteomics will be based on the sequencing of the human genome, de novo characterization of protein microheterogeneity (glycosylation, phosphorylation and sulfation as well as the incorporation of lipid components) will be required in disease studies. To characterize these modifications it is necessary to digest the protein mixture with an enzyme to produce the corresponding mixture of peptides. In a process analogous to sequencing of the genome, shot-gun sequencing of the proteome is based on the characterization of the key fragments produced by such a digest. Thus, a glycopeptide and hence a specific glycosylation motif will be identified by a unique mass and then a diagnostic MS/MS spectrum. Mass spectrometry will be the preferred detector in these applications because of the unparalleled information content provided by one or more dimensions of mass measurement. In addition, highly efficient separation processes are an absolute requirement for advanced proteomic studies. For example, a combination of the orthogonal approaches, HPLC and HPCE, can be very powerful

  15. Stochastic approach to microphysics

    Energy Technology Data Exchange (ETDEWEB)

    Aron, J.C.

    1987-01-01

    The presently widespread idea of ''vacuum population'', together with the quantum concept of vacuum fluctuations leads to assume a random level below that of matter. This stochastic approach starts by a reminder of the author's previous work, first on the relation of diffusion laws with the foundations of microphysics, and then on hadron spectrum. Following the latter, a random quark model is advanced; it gives to quark pairs properties similar to those of a harmonic oscillator or an elastic string, imagined as an explanation to their asymptotic freedom and their confinement. The stochastic study of such interactions as electron-nucleon, jets in e/sup +/e/sup -/ collisions, or pp -> ..pi../sup 0/ + X, gives form factors closely consistent with experiment. The conclusion is an epistemological comment (complementarity between stochastic and quantum domains, E.P.R. paradox, etc...).

  16. Mouthsticks - A Participatory Approach.

    Science.gov (United States)

    Ernst, Waltraud; Nussbaum, Gerhard; Berger, Veronika M; Major, Zoltan

    2017-01-01

    Mouthsticks are quite an old kind of assistive technology (AT) but nevertheless they are up to now the Swiss army knives among AT. Unfortunately the popularity of mouthsticks massively decreased during the 1990s with the result that knowledge about how to produce good mouthsticks got lost and that there are hardly any adaptable mouthsticks available on the market. This paper discusses the development of a personalized mouthstick with the involvement of end users - people with severe physical disabilities - and occupational therapists as experts of everyday use. A participatory approach was chosen. The results of the analysis of a standardized questionnaire, group discussions and a collaborative workshop with IT-designers, polymer engineers, end users, occupational therapists and gender and diversity researchers are presented and discussed. This proved the necessity of the development of a personalized mouthstick.

  17. Globalization - Different approaches

    Directory of Open Access Journals (Sweden)

    Viorica Puscaciu

    2014-11-01

    Full Text Available In this paper we investigate the different approaches of the globalization phenomenon. Despite the geographical distancesm, the link between people are ever more strong on different ways and plans: from technology between political, economical, cultural world events, and many other aspects. So, the link between globalization and democracy, and its impact on the most important social and economic matters. We also surprise the impact of the internet revolution and its corolar e-commerce, and its consequences, sometimes unpredictible ones. Another annalysed problem is that of the governments trying, and sometimes succeeding to controll the money, products, peole and their ideas that freely move inside the national frontiers, thus going to slower or to stop the progress. Nevertheless, this global interraction between people also create phenomena of insecurity on different ways: terrorism, traffic of arms, drugs, economical aggresions causing the environment, and other inconvenient facts and situations.

  18. Engineering students' sustainability approaches

    Science.gov (United States)

    Haase, S.

    2014-05-01

    Sustainability issues are increasingly important in engineering work all over the world. This article explores systematic differences in self-assessed competencies, interests, importance, engagement and practices of newly enrolled engineering students in Denmark in relation to environmental and non-environmental sustainability issues. The empirical base of the article is a nation-wide, web-based survey sent to all newly enrolled engineering students in Denmark commencing their education in the fall term 2010. The response rate was 46%. The survey focused on a variety of different aspects of what can be conceived as sustainability. By means of cluster analysis, three engineering student approaches to sustainability are identified and described. The article provides knowledge on the different prerequisites of engineering students in relation to the role of sustainability in engineering. This information is important input to educators trying to target new engineering students and contribute to the provision of engineers equipped to meet sustainability challenges.

  19. Cognitive approaches to emotions.

    Science.gov (United States)

    Oatley, Keith; Johnson-Laird, P N

    2014-03-01

    Cognitive approaches offer clear links between how emotions are thought about in everyday life and how they are investigated psychologically. Cognitive researchers have focused on how emotions are caused when events or other people affect concerns and on how emotions influence processes such as reasoning, memory, and attention. Three representative cognitive theories of emotion continue to develop productively: the action-readiness theory, the core-affect theory, and the communicative theory. Some principles are common to them and divergences can be resolved by future research. Recent explanations have included how emotions structure social relationships, how they function in psychological illnesses, and how they are central to music and fiction. Copyright © 2013 Elsevier Ltd. All rights reserved.

  20. Radiolab - three different approaches

    DEFF Research Database (Denmark)

    Lønstrup, Ansa

    2012-01-01

    , who methodologically operates within tree levels of investigation: 1) the syntax, 2) the semantic and 3) the ontology level. Accordingly, this analysis is conducted, as if the sound object was performed by a vocal ensemble oscillating ‘between a musical and a speech act’. Torben Sangild’s paper......Radiolab – three different approaches The three papers in this ‘suite’ have a special background and context. At the 2010 conference SoundActs in Aarhus the three panellists were each given the task to provide a paper with an analysis of the same sound object, thus exhibiting and contrasting...... via his own repeated listening process – as a scholarly-analytical analysis of the subjectiv act of creating meaning. He draws on presumptions and prejudices, demonstrating the impossibility of a purely structural listening. The analysis relates these hermeneutical reflections to formal musicological...

  1. Slurry pipeline design approach

    Energy Technology Data Exchange (ETDEWEB)

    Betinol, Roy; Navarro R, Luis [Brass Chile S.A., Santiago (Chile)

    2009-12-19

    Compared to other engineering technologies, the design of a commercial long distance Slurry Pipeline design is a relatively new engineering concept which gained more recognition in the mid 1960 's. Slurry pipeline was first introduced to reduce cost in transporting coal to power generating units. Since then this technology has caught-up worldwide to transport other minerals such as limestone, copper, zinc and iron. In South America, the use of pipeline is commonly practiced in the transport of Copper (Chile, Peru and Argentina), Iron (Chile and Brazil), Zinc (Peru) and Bauxite (Brazil). As more mining operations expand and new mine facilities are opened, the design of the long distance slurry pipeline will continuously present a commercially viable option. The intent of this paper is to present the design process and discuss any new techniques and approach used today to ensure a better, safer and economical slurry pipeline. (author)

  2. Bioengineering a conceptual approach

    CERN Document Server

    Pavlovic, Mirjana

    2015-01-01

    This book explores critical principles and new concepts in bioengineering, integrating the biological, physical and chemical laws and principles that provide a foundation for the field. Both biological and engineering perspectives are included, with key topics such as the physical-chemical properties of cells, tissues and organs; principles of molecules; composition and interplay in physiological scenarios; and the complex physiological functions of heart, neuronal cells, muscle cells and tissues. Chapters evaluate the emerging fields of nanotechnology, drug delivery concepts, biomaterials, and regenerative therapy. The leading individuals and events are introduced along with their critical research. Bioengineering: A Conceptual Approach is a valuable resource for professionals or researchers interested in understanding the central elements of bioengineering. Advanced-level students in biomedical engineering and computer science will also find this book valuable as a secondary textbook or reference.

  3. Integration a functional approach

    CERN Document Server

    Bichteler, Klaus

    1998-01-01

    This book covers Lebesgue integration and its generalizations from Daniell's point of view, modified by the use of seminorms. Integrating functions rather than measuring sets is posited as the main purpose of measure theory. From this point of view Lebesgue's integral can be had as a rather straightforward, even simplistic, extension of Riemann's integral; and its aims, definitions, and procedures can be motivated at an elementary level. The notion of measurability, for example, is suggested by Littlewood's observations rather than being conveyed authoritatively through definitions of (sigma)-algebras and good-cut-conditions, the latter of which are hard to justify and thus appear mysterious, even nettlesome, to the beginner. The approach taken provides the additional benefit of cutting the labor in half. The use of seminorms, ubiquitous in modern analysis, speeds things up even further. The book is intended for the reader who has some experience with proofs, a beginning graduate student for example. It might...

  4. [Psychosomatic approach to encopresis].

    Science.gov (United States)

    Boige, N; Missonnier, S; Bellaïche, M; Foucaud, P

    1999-12-01

    Encopresis most often results from functional constipation and a behaviour disorder characterised by retention of faeces. Rarely it is a passive or active expulsion of normal faeces. It indicates a failure in the education of sphincter control, often with a preferential development of autoerotic versus relational investments. A depressive component is frequent. We propose a bidisciplinary approach with a somatic and psychological evaluation of the encopretic child from the first visit. The physical examination assesses constipation and stercoral stasis. Associated psychopathological symptoms or a pathogenic psychosocial situation must be sought. The therapeutic means must be directed towards the different etiologic features. Explanations of the physiopathology of the symptom and discussion with the child and the parents on the origin of the dysfunction must be accomplished first. A medical treatment of the constipation is generally indicated. Psychotherapy is initiated according to the background and associated psychopathological symptoms.

  5. Microscopic approach to polaritons

    DEFF Research Database (Denmark)

    Skettrup, Torben

    1981-01-01

    contrary to experimental experience. In order to remove this absurdity the semiclassical approach must be abandoned and the electromagnetic field quantized. A simple microscopic polariton model is then derived. From this the wave function for the interacting exciton-photon complex is obtained...... of light of the crystal. The introduction of damping smears out the excitonic spectra. The wave function of the polariton, however, turns out to be very independent of damping up to large damping values. Finally, this simplified microscopic polariton model is compared with the exact solutions obtained...... for the macroscopic polariton model by Hopfield. It is seen that standing photon and exciton waves must be included in an exact microscopic polariton model. However, it is concluded that for practical purposes, only the propagating waves are of importance and the simple microscopic polariton wave function derived...

  6. Investigational Approaches for Mesothelioma

    International Nuclear Information System (INIS)

    Surmont, Veerle F.; Thiel, Eric R. E. van; Vermaelen, Karim; Meerbeeck, Jan P. van

    2011-01-01

    Malignant pleural mesothelioma (MPM) is a rare, aggressive tumor with a poor prognosis. In view of the poor survival benefit from first-line chemotherapy and the lack of subsequent effective treatment options, there is a strong need for the development of more effective treatment approaches for patients with MPM. This review will provide a comprehensive state of the art of new investigational approaches for mesothelioma. In an introductory section, the etiology, epidemiology, natural history, and standard of care treatment for MPM will be discussed. This review provide an update of the major clinical trials that impact mesothelioma treatment, discuss the impact of novel therapeutics, and provide perspective on where the clinical research in mesothelioma is moving. The evidence was collected by a systematic analysis of the literature (2000–2011) using the databases Medline (National Library of Medicine, USA), Embase (Elsevier, Netherlands),