The neurosurgical management of prolactinomas.

BACKGROUND: The objective was to discuss the neurosurgical management of the prolactinomas. METHODS: Five-hundred-fifty patients suffering from prolactinoma were treated with trans-sphenoidal and transcranial approach. The diagnosis of prolactinoma was based on various degree of high level prolactinemia, galactorrhea, gonodal disturbance, neurological examination and radiological findings. In all cases the adenoma was histologically verified. The patients were investigated according to the anatomo-radiological classification of Hardy and Vesina, and the range of preoperative PRL basal levels. RESULTS: Follow-up was ascertained in 81% of patients who were followed for a mean of 7.2 year (1-10 year). While the total removal percentage was 98% in the group with microprolactinoma, this ratio dropped to 63.9% for macroadenomas and 23.5% for giant adenomas. Early improvement of prolactin level ratio was 81.6% in microprolactinomas, 28.3 in macroadenomas and 11.7% in giant adenomas. Hormonal cure was 64.3% in microadenomas, 6.7% in macroadenomas and 0% in giant adenomas. The ratio of hormonal cure was decreasing in patients with high prolactin levels. In the follow-up recurrence of prolactinomas occurred in 39% of the patients. CONCLUSIONS: Medical treatment is the first step in prolactin secreting adenomas. Trans-sphenoidal microsurgery became popular in treatment of prolactinomas because of low operative morbidity and mortality. Patients with recurrence should be evaluated for second step treatment (surgery, bromocriptine, or radiotherapy).

Serum immunoglobulins in brain tumours and lumbar disc diseases.

Changes of serum immunoglobulin (Ig) concentrations may occur in both brain tumours and lumbar disc diseases (LDD). The purpose of this study was to investigate the changes of pre- and post-operative serum Ig levels in brain tumours and LDDs. Serum IgG, IgA and IgM levels were measured in 127 patients with brain tumour, 100 patients with LDD and 20 healthy subjects without neurological disease. Increases in one or more of the pre-operative serum Ig levels were observed in the patients with both brain tumours and LDDs compared with controls. However pre-operative serum IgG level was highly increased in all brain tumour types and LDDs (p<0.001). Serum IgA levels and IgM levels in the post-operative stage were significantly decreased in patients with acoustic neurinoma (p<0.01, p<0.001, respectively). Post-operative serum IgG, IgA and IgM levels were significantly decreased (p<0.001) in patients with meningioma. Post-operative serum IgG and IgM levels were significantly decreased (p<0.001) in patients with glioma. Patients with LDD showed a significantly decline in post-operative serum IgA and IgM levels (p<0.001). We think that decline in post-operative serum Ig levels may be of prognostic value in the patients with brain tumours and LDDs.

Tumours of the lateral ventricle. A retrospective review of 112 cases operated upon 1970-1997.

Between the years 1970 and 1997, 112 patients with tumors of the lateral ventricle were operated on at the University of Ankara, School of Medicine, Department of Neurosurgery. Seventy-one patients (63.4%) were male and 41 patients (36.6%) female. Headache (35.7%), nausea and vomiting (22.3%) were the most common presenting complaints. Papilloedema (42.9%), motor and sensory loss (25%) were the most common findings at neurological examination. Complete tumor removal was accomplished in 38.4% of the patients. Histopathologically, the most commonly seen types of the tumor were ependymoma (25%) and astrocytoma (21.4%). Among the various approach, the anterior transcortical (53.6%) and the posterior transcortical (16%) were the most commonly used. Eleven patients were reoperated for tumor recurrence. After surgery, radiation therapy was also performed on fourty-two patients. The morbidity and mortality rates were considerably higher before 1976 when the use of microneurosurgical techniques was introduced. After this, our morbidity and mortality rates decreased dramatically. The overall surgical mortality rate was 7.1% before 1976; during the last 10 years (n:46), it was 6.5%. In this report, our choice of operative approaches and the results will be discussed.

Osteochondroma of the upper cervical spine. A case report.

STUDY DESIGN: A report of a patient with osteochondroma of the upper cervical spine causing radiculopathy. OBJECTIVES: The surgical treatment of this patient involved the complete removal of tumor and compression of neural structures. SUMMARY OF BACKGROUND DATA: Osteochondromas affect mostly the long bones. Involvement of spine by solitary osteochondromas is rare condition. The present report represents a case of spinal osteochondroma causing neurologic symptoms. METHODS: Cervical osteochondromas, best evaluated with routine magnetic resonance imaging and noncontrast computed tomography scans, rarely contribute to cervical nerve root compression. RESULTS: The patient's symptoms gradually resolved after gross total tumor removal. CONCLUSIONS: Symptomatic spinal osteochondromas are rare occurrences in an individual surgeon's experience. Computed tomography or magnetic resonance imaging are the imaging procedures of choice. In the majority of patients with myelopathy or radiculopathy, surgery results in complete relief of symptoms as demonstrated in this case.

Colloid cyst of the third ventricle. Evaluation of 28 cases of colloid cyst of the third ventricle operated on by transcortical transventricular (25 cases) and transcallosal/transventricular (3 cases) approaches.

The clinical and x-ray features of 28 cases of colloid cyst of the third ventricle are described. Colloid cyst is one of the most favourable space-occupying lesions of the brain for successful surgical removal, because an exact pre-operative diagnosis is possible. The surgical approach for colloid cyst of the third ventricle is discussed and the frequency of postoperative seizure is reviewed in 28 cases and compared with the literature.

Tentorial meningiomas.

We report our experience with and long-term results of 37 patients with tentorial meningiomas who underwent surgery between 1972 and 1993. The average age was 43 years, and the mean duration of symptoms was 36 months. Headache (83.8%) and extremity or gait ataxia (35.1%) were the most common complaints. On neurological examination, signs of elevated intracranial pressure and cerebellar deficits (51.4%) were the most common findings, followed by third nerve involvement (35.1%). Computed tomography, angiography, and, in recent years, magnetic resonance imaging were used as diagnostic tools and for planning the surgical procedure. According to the primary site of attachment, the tentorial meningiomas were divided into three subgroups: medial, lateral, and falcotentorial. The lateral and medial tumors, with mainly supratentorial development, were approached from above by using a temporal, temporooccipital, or parietooccipital craniotomy. For tumors developing mainly in the posterior cranial fossa, suboccipital craniectomy was performed. In six patients who showed medial tentorial and petrous apex attachment, a combined subtemporal transpetrosal and retromastoid approach was performed. In 31 patients, the tumors were totally removed, and, in 6 patients, only subtotal excision could be done. Seven patients had postoperative complications, but only one of them died of severe brain edema. Our mortality rate was 2.7%. In this article, appropriate preoperative studies, surgical techniques, and surgical results are discussed.

An intramedullary dermoid cyst abscess due to Brucella abortus biotype 3 at T11-L2 spinal levels.

A 17-year-old boy was admitted to hospital with a history of backache, weakness of the lower extremities and fever. While the diagnosis of brucellosis was made his clinical course worsened. Acute medulla spinalis mass effect and signs of meningitis predominated. It was shown that he had a dermoid cyst infected with Brucella abortus biotype 3 which was the same strain growing in his blood cultures.

Medulloblastomas.

81 patients with biopsy proven medulloblastoma with a mean age of 11.4 years were reviewed. Total removal of the tumour was accomplished in 18 cases (22.2%), subtotal removal in 55 cases (67.9%) and biopsy alone in 8 cases (9.9%). 34 patients (27.5%) had a recurrence of the tumour and 8 patients underwent a second posterior fossa exploration at the time of recurrence. In patients with total resection, five-year survival was 27.7%. With partial resection, five-year survival decreased to 14.5%. In patients with radiotherapy chemotherapy, 21.4% survived 5 years after treatment but this rate decreased to 18.4% in patients treated with radiotherapy only. The surgical mortality rate was 12.3%.

Meningiomas of the tuberculum sella.

A series of 88 consecutive patients operated on for tuberculum sellae meningioma at the Neurosurgery Department of the University of Ankara Medical School was reviewed. Visual impairment was the most common initial complaint. All but 9 patients had visual symptoms. All patients underwent craniotomy, with an operating microscope being used in 62 cases. Use of the operating microscope appeared to increase the total removal rate while lowering the mortality. In our series visual function improved in 53.5%, was unchanged in 27.5%, and worsened in 19% of the patients.

Effectiveness of radiofrequency thermocoagulation in recurrent trigeminal neuralgia after previous retrogasserian rhizotomy.

Between 1974 and 1984, 428 trigeminal neuralgia cases were treated by controlled radiofrequency thermocoagulation (RFTC). 29 had recurrent trigeminal neuralgia after intracranial surgery. 26 of the 29 patients were treated by retrogasserian rhizotomy and 3 by posterior fossa exploration. Among the 26 recurrent trigeminal neuralgia following retrogasserian rhizotomy, RFTC was effective in 23 cases (88.5%), and in 3 cases (11.5%) RFTC was effective for a short period. Repeated RFTC was unable to control the pain attacks which were later relieved by posterior fossa exploration and root section. Of the 3 recurrent trigeminal neuralgia following posterior fossa exploration, RFTC was effective in 2 cases (66.6%).

Symptomatology, evaluation and treatment of aquaductal stenosis.

Thirty-three surgical treated cases of aquaductal stenosis are presented. Beside the classical clinical representation of the disease, the symptomatology caused by anterior and posterior herniation of dilated third ventricle is discussed. The impotence in one male patient which is caused by anterior herniation was proved by means of NPT (Nocturnal Penile Tumescence) recording. In one patient bilateral partial deafness and Parinaud syndrome which was caused by posterior herniation was cured by third ventriculostomy. In the surgical treatment of aquaductal stenosis, the effectiveness of various surgical procedures are presented and the superiority of third ventriculostomy by microtechnique is emphasised.

Spontaneous migration of an intracranial bullet to the cervical spinal canal causing Lhermitte's sign. Case report.

A case is presented of a woman who was shot in the left occipital area with a .32 caliber automatic pistol. She was neurologically intact on admission, and skull x-ray films revealed the bullet in the right suboccipital area. On the 2nd day of the admission she developed Lhermitte's sign. Repeat films showed that the bullet had migrated to the C-4 vertebral level. The bullet was subsequently removed via a total laminectomy at C3-4.