Transnasal transsphenoidal endoscopic controlled vs sublabial transseptal microsurgical approach for sellar lesions

Objective: this study was designed to evaluate transnasal trans-sphenoidal endoscopic-controlled approach and compare it to the standard sublabial transnasal transseptal trans-sphenoidal microsurgical approach for sellar lesions

Design: prospective study

Materials and Methods: forty patients with sellar lesions were included in this work that was conducted between June 1997 and January 2002. Twenty patients were approached by the classic sublabial transnasal transseptal transsphenoidal microsurgical technique described by Hardy and another group of 20 patients were managed endoscopically Patients were allocated randomly to either group. All patients had clinical, radiological, ophthalmic and endocrine evaluation prior to surgery. Both techniques were compared as regard accessibility, visibility, duration of surgery, completion of lesion resection, morbidity including trauma to nasal skeleton and length of hospitalization and return to work

Results: lesions accessibility, visibility and completion of resection were better with the endoscopic-controlled technique. Mean [SD] operative times were significantly reduced in the endoscopic group vs. the sublabial group: 2.7 [0.7] hours vs. 3.4 [0.9] hours. Hospital stay ranged between 1-3 days for endoscopic group and 4-10 days for the sublabial microsurgical group. There was significant reduction in trauma to nasal skeleton in endoscopic group. There were no major complications in both techniques

Conclusion: the emerging endoscopic-controlled transnasal trans-sphenoidal approach for lesions in the sella is safe and effective alternative to the standard sublabial transnasal transseptal transsphenoidal microsurgical approach. It has the advantage of minimal invasiveness

Early experience in stereotactic radiosurgery of metastatic brain tumours in Egypt

The results of two prospective randomized studies 1, 2 indicate survival advantages for patients with single brain metastases treated with surgery and radiotherapy compared with radiotherapy alone. Radiosurgery - a minimally invasive technique that uses multiple convergent beams to deliver a high dose of radiation to a small volume precisely localized stereotactically - can serve as a surgical alternative. The biological and physical characteristics of metastases [radiographically discrete, small, spherical, non- invasive] render them ideal targets for radiosurgery, with the potential advantages of reduced morbidity, short hospitalization and reduced health care costs. At Mansoura we treated [10] patients with brain metastases, [7] had single lesions and [3] had multiple lesions [up to 5]. The age ranged between 51 and 68ys. The primary lesion was known in [8] cases. Each received a dose of 20 Gy to the tumor edge and a supplementary whole brain dose of 2000 cGy divided over 10 fractions. All patients, except one, tolerated the treatment well and were discharged from hospital within 3 days on average. One case who had five lesions developed hydrocephalus that was shunted, he died a few days later. Nine Patients showed subsequent radiological evidence of tumor shrinkage and central tumor necrosis. The peritumoural edema subsequently subsided and most patients became steroid independent within 3 months of radiosurgery .We acknowledge the small number of cases and short period of follow up that negate any statistical significance. However our limited experience shows that stereotactic radiosurgery is a safe alternative to open surgery, particularly for lesions in deep location, near eloquent cortex and for multiple lesions. Surgical resection would be more advantageous for metastatic lesion of size greater than 35 mm in diameter with significant edema and mass effect, particularly if there is significant mass effect on fourth ventricle

Computed tomography versus magnetic reasonance imaging in diagnosis of congenital cystic intracranial lesions

Twenty one cases of congenital cystic intracranial lesions [having a range of age 24 days to 15 years] were subjected to CT and MRI examinations. The imaging findings were compared with the final diagnosis obtained by clinical data, operation and follow up. The lesions appeared mostly as hypodense nonenhancing masses of CSF density by CT, exerting mass effect according to the size and no surrounding edema. By MRI, they appeared hypointense in T1WI and hyperintense in T2WI. The pathological varieties encountered were; 2 cases of holoprosencephaly, 2 hydranencephaly, one porencephaly, 8 Dandy walker [DW] complex, 7 arachnoid cysts, and one epidermoid tumour. Both CT and MRI can give similar informations concerning the size, shape, rim thickness and other morphologic characteristics of cystic intracranial lesions. Additional data given by MRI are; superior visualization of cerebellar vermis in cases of Dandy Walker complex hence it could be classified into [type A] with absent vermis and [type B] with present vermis in the axial MRI cuts for the fourth ventricular level. MRI is better for detection of infection in an arachnoid cyst by the presence of high signal intensity inside the cyst, It is also able to predict the nature of the contents of the epidermoid cyst whether protein or triglycerides according to its signal intensity in both T[1] and T[2] WI. MRI can detect abnormal signal intensity in the cyst wall of a porencephalic cyst that helps differentiation from arachnoid cysts. Also MRI has a better performance specially in posterior fossa lesions as it is not affected by beam hardening artifact as CT. Other advantages of MRI include lack of ionizing radiation and direct visualization of blood flow, Muliplanar capability and high soft tissue resolution. CT is superior to MRI in the detection of calcification in certain lesions as epidermoid cyst