Surgical Tacties for Large Sellar and Parasellar Tumors

We analyzed 56 operations in 45 patients with sellar and parasellar tumors from March, 1990 to May, 1995, to evaluate the determining factors in selecting the surgical approaches for large and giant sellar and suprasellar tumors, based on clinical, endocrinological and radiological findings. The definition of "large" is when the longest diameter of the tumor is more than 20mm on radiographic studies and the term "small" is applied to tumor of diameter below 19mm. The results were as follows: 1) Number of the patients with small tumor was 14(31.1%) and all of them were treated with single stage transsphenoidal approach, and 42 operations were performed in 31(68.9%) patients with large tumors. 2) The approaches for large tumors were: transsphenoidal approach in 32 cases: pterional approach 5 cases: subfrontal interhemispheric approach 4 cases; and subfrontal paramedian approach 1 case. 3) The rate of complete removal for large and giant tumors in the first operation was 29.0%; in second operation, 72.7%; overall the rate was 54.8%. 4) Complications were; transient type diabetes insipidus in 24 cases; meningitis 2 cases; hypothalamic injury 3 cases; CSF rhinorrhea 1 case; and cerebral infarction 1 case; and death 1 case. 5) There was significant relationship between the size of the tumor and tumor types(p0.05) but not wih destruction of the sellar floor(p0.05). 7) In case of incomplete removal with first transsphenoidal approach, a second operation seems to be helpful. 8) In second stage transcranial approach following first transsphenoidal approach, it is easier to remove the tumor due to the decreased tumor size and thus, a reduced need for marked brain retraction. From our findings, we suggest guidelines in choosing the surgical approach for sellar and parasellar tumors as follows: 1) Many of the tumors in the sellae and suprasellar area can be removed successfully by transsphenoidal approach. 2) Taranssphenoidal approach can be repeated safely in stage O, A, B and C, if the diaphragm sella remains intact. 3) Tanscranial approach is recommended primarily in stage D & E, if intrasellar portion of the tumor is not significant or opening of the diaphragm sella is narrow. 4) Transsphenoidal approach followed by transcranial approach is adequate in stage D & E, if significant amount of the tumor remaining in the sella or sellar floor is severely destructed(Grage III, IV).

Factors Related to Clinical Vasospasm after Aneurysmal Subarachnoid Hemorrhage

Authors analysed a series of 175 patients with aneurysmal subarachnoid hemorrhage(SAH) who have undergone the treatment for subarachnoid hemorrhage from July, 1990 to May, 1994 to assess the clinical factors related to clinical vasospasm. This investigation revealed following conclusions. 1) The severity of subarachnoid hemorrhage as seen on computed tomography seemed to be correlated with the appearance of clinical vasospasm. Patients with severe SAH on initial CT scan were at higher risk or clinical vasospasm. 2) Patients with history of hypertension had more significant clinical vasospasm than did normotensive patients after aneurysmal SAH. 3) Aneurysms of the anterior communicating artery were showen to have the highest incidence of clinical vasospasm. 4) Patients with moderate to severe diffuse vasospasm on cerebral angiography had more significant clinical vasospasm than patients with no or local vasospasm. These conclusions suggest that clinical vasospasm after aneurysmal SAH are related to the followi ng predictable factors;amount of blood on the initial CT scan;angiographic vasspasm;history of hypertension and location of aneurysm. Proper management of these factors may diminish the incidence and severity of clinical vasospasm and reduce the morbidity and mortality rate.