Management of Tumors Involving the Cavernous Sinus: Experience of 10 Cases

OBJECTIVE: The authors present the complications after resection of the tumors involving the cavernous sinus and the efficacy and role of the adjuvant therapy in the management of the residual or recurrent tumors invading the cavernous sinus. METHODS: From March 1998 to May 2002, ten patients with cavernous sinus tumors were treated in our hospital. The tumors limited to the outer wall of cavernous sinus were excluded in this study. Pathological diagnoses were meningiomas in seven and pituitary adenomas in three patients. RESULTS: Tumors of the extracavernous portion were removed totally except for two cases. Cavernous sinus was opened in seven patients, among which subtotal removal was achieved in four, and partial removal in three patients. In the remaining three patients, the cavernous sinus was neither opened nor exposed. All patients with intracavernous exploration were complicated by ptosis and extraocular muscles paralysis. Radiotherapy was administered to 6 cases. At present, there is no tumor progression except for one patient with malignant meningioma. CONCLUSION: In patients with large tumors involving the cavernous sinus, especially invading the cavernous internal carotid artery, we recommend subtotal or partial resection of the tumor followed by radiation therapy to prevent permanent postoperative sequele.

The Role of ATP on Reactive Oxygen Species Generation and Cellular Proliferation in BV-2 Cells / 대한소아신경학회지

PURPOSE: Adenosine triphosphate (ATP) evokes several cellular responses in microglia including propagation. However, the role of the purinoceptor on ROS generation in microglia is unclear. In order to determine the action of the purinoceptor in microglia, the effects of ATP on ROS generation and cellular proliferation in BV-2 murine microglial cells were evaluated. An additional aim of this study was to investigate signal transduction pathways using several inhibitors. METHODS: The [Ca2+] was measured using Ca2+ sensitive indicator, Fura-2/AM. ROS production was observed by fluorescence-confocal microscope and cell proliferation was evaluated by counting cell number. RESULTS: ATP increased the intracellular calcium levels ([Ca2+]i) in BV-2 cells in a dose-dependent manner. This increase was attenuated by pretreatment with a calcium chelator (EGTA) and a phospholipase C (PLC) inhibitor (U-73122) while the protein tyrosine kinase (PTK) inhibitor (genistein) had no inhibitory effects. To identify the effects of the nucleotides, ROS generation was observed in the nucleotide-stimulated BV-2 cells. The treatment with 100 M ATP induced ROS generation, but 100 M adenosine and 100 M UTP did not. To investigate the signal transduction pathway in ATP-induced ROS generation, several inhibitors were pretreated before adding ATP. ATP- induced ROS production was blocked by pretreatment with either 0.5 mM EGTA or 10 M U73122 while 40 M genistein had an inhibitory effect on ATP action. Correspondingly, 40 M KN62 (CaM kinase II inhibitor), 1 M sphingosine (protein kinase C inhibitor), 1 nM DPI (NADPH oxidase inhibitor) and 50 M mepacrine (phospholipase A2 inhibitor) could suppress ATP-induced ROS generation. The effects of ATP on cell proliferation was observed 3 days after ATP treatment and its peak velocity after 4 days. NF-kB activation was observed after the cells were incubated with 0.1 mM ATP. The maximal level of NF-kB activation was obtained with 0.3 mM ATP while higher concentrations were less effective. CONCLUSION: Overall, we conclude that ATP in BV-2 cells induces ROS generation and cell propagation. The signal transduction pathways including calcium, CaM kinase II, PLC, protein kinase C, phospholipase A2 and NADPH oxidase are involved in ATP-induced ROS generation.

Intraoperative Aneurysmal Rupture and Management

OBJECTIVE: The rupture of an aneurysm during operation is an event that can be considered grave. The authors present the retrospective analysis of 10 cases of intraoperative rupture in 145 consecutive aneurysm procedure. METHODS: Of 10 cases of intraoperative rupture, two cases were ruptured at predissection period, six cases during dissection and two cases during clip application. RESULTS: The causes of intraoperative aneurysm rupture in our 10 cases were forceful and blunt dissection(4 cases), excessive brain retraction(2 cases), poor exposure of aneurysm neck(1 case), poor clip application(1 case), excessive removal of aneurysmal intracerebral hematoma(1 case), unknown(1 case that was ruptured during anesthesia or craniotomy). Methods of management of nine intraoperative rupture except one of rupture during craniotomy were temporary clipping to the parent artery(3 cases), tentative aneurysm clipping(2 cases), temponade with cottonid and suction(2 cases), and induced hypotension(2 cases). The final outcome of 10 cases of intraoperative aneurysmal rupture was good in 5, fair in 1, poor in 1 and dead in 2 cases. Especially cases that were ruptured during predissection period and case that were managed with induced hypotension were poor result. CONCLUSION: The use of meticulous microsurgical technique with sharp dissection around the aneurysm, a systematic contingency plan for dealing with sudden hemorrhage and the judicious use of temporary clips should serve to minimize the adverse effect of intraoperative rupture on overall management morbidity and mortality.

Surgical Management of Suprasellar Meningioma

OBJECTIVE: Suprasellar meningioma have in general been difficult lesions to treat because of their vicinity to the optic apparatus and major vessels, and high vascularity. This study was performed to analyze clinical outcome of patients with histopathologically identified suprasellar meningioma. METHOD: Between 1989 and 1998, 37 patients(30 women, 7 men: average 47.5years) with histopathologically identified meningiomas originating from the suprasellar region underwent surgical tumor removal in our institution. The medical records and clinical data of these patients are retrospectively analyzed. RESULT: The tumor size ranged from 2.1cm to 6.5cm(average 5.1cm) in diameter. The tumors have been approached basically through the pterional and bifrontal routes. Skull base technique was also applied in large or complicated cases. Total resection rates and overall outcome including visual function was better in patients with tumor of less then 3cm. A considerable increase of mortality, morbidity and failure of visual improvement were seen in case of the tumors size of 3cm or more. CONCLUSION: Early diagnosis and treatment were important factors in the successful management of these suprasellar meningioma. In large complicated cases encasing major vessels or invading cavernous sinus or anterior skull base, surgeons need to operate with extreme caution and piecemeal removal of the tumor without injuring optic apparatus and major vessels utilizing skull base technique.