Cholesterol granulomas of the petrous apex; endonasal endoscopic approach.

OBJECTIVE: Cholesterol granulomas are benign lesions that sometimes occur on the petrous apex (PA). We report our experience using an endoscopic endonasal approach to remove PA cholesterol granulomas. MATERIAL AND METHODS: A retrospective patient chart analysis was conducted at a tertiary care university hospital. RESULTS: Four patients (3 females, 1 male) were included in this study. Patients' ages ranged from 27 to 78 years. Computed tomography (CT) and magnetic resonance imaging (MRI) for diagnosis and computer-assisted navigation were performed. The most common symptom was abducens nerve palsy. The largest granuloma measured 5 x 2 cm and was located on the left side. An endoscopic endonasal approach was chosen and navigation was applied (3/4 patients) to identify the optimal area for opening the granuloma. No complications occurred, and patients were free from recurrence during the follow-up period. CONCLUSION: The endoscopic endonasal approach to PA cholesterol granulomas is feasible and safe. Intra-operative navigation is recommended to identify the position of the internal carotid artery and determine the safest area for opening the granuloma without damaging the artery. Another advantage of this approach is an easier follow-up through diagnostic nasal endoscopy.

Primary paraganglioma simulating pituitary macroadenoma: a case report and review of the literature.

A 76-year-old woman presented with an intrasellar and suprasellar mass which caused deterioration of visual acuity and bitemporal visual field defects. Transsphenoidal and transcranial partial resection revealed a primary chemodectoma. This tumour is very rare in the sellar area, where there are normally no paraganglionic cells. We review the literature and discuss possible mechanisms for the development of this tumour.

Treatment options and time course for intramedullary spinal cord metastasis. Report of three cases and review of the literature.

Surgical treatment of intrameduallary spinal cord metastases (ISCM) has become increasingly effective in recent years. The advent of new imaging techniques combined with an enhanced understanding of the natural history of these tumors has improved the effectiveness of the available treatment options. The authors present three new cases of ISCM successfully treated with surgery. A review of 129 cases found in the literature is also discussed. Characteristic symptomology and presentation are reviewed with an eye toward improving diagnostic methodology. The natural history of ISCM is divided into three phases. Surgical intervention should be used early in phase 2.

Plasma levels of parathyroid hormone-related peptide are elevated in hyperprolactinemia and correlated to bone density status.

Osteopenia is an important clinical manifestation of hyperprolactinemia. Bone loss in these patients has mainly been attributed to concomitant deficiency of gonadal hormones rather than to hyperprolactinemia per se. Parathyroid hormone-related peptide (PTHrP) is expressed in human mammary tissue, and elevated circulating PTHrP levels as well as concomitant hypercalcemia have been described during lactation. We sought to determine circulating PTHrP levels in patients with long-standing hyperprolactinemia and whether PTHrP may exert possible systemic effects on bone and mineral metabolism. We studied 45 patients (30 women and 15 men) with persisting hyperprolactinemia 6 +/- 4 years (mean +/- SD) after trans-sphenoidal surgery for prolactin-producing pituitary adenomas. PTHrP levels in 117 healthy controls were 10.6 +/- 7.3 pmol-eq/l (mean +/- SD). In hyperprolactinemic patients, plasma PTHrP was elevated to 30.3 +/- 13.4 pmol-eq/l (p < 0.001, n = 45), and in patients with humoral hypercalcemia of malignancy PTHrP levels were 52.9 +/- 29.6 (p < 0.001 to controls and hyperprolactinemic patients). Fifty-three percent of hyperprolactinemic patients (n = 24) had clearly elevated PTHrP levels (> 2 SD). Retrospective immunocytochemical studies of the removed pituitary adenomas from 19 patients generally showed a higher degree of immunoreactivity for PTHrP (1-34) in all but one case when compared with normal pituitary tissue. Patients with elevated circulating PTHrP levels showed in most instances strong immunoreactivity to PTHrP in 70-100% of tumor cells.(ABSTRACT TRUNCATED AT 250 WORDS)

Fibrin tissue adhesive sealant for the prevention of CSF leakage following transsphenoidal microsurgery.

Fibrin glue (Beriplast, Behring or Tissucol, Immuno) was used for 126 sublabial transseptal transsphenoidal operations in 119 patients from April 1981 to March 1987 in a variety of sellar pathologies together with septal bone and spongycel to seal the sellar floor and the anterior wall of the sphenoid sinus. The incidence of postoperative rhinorrhea was 1.6%. A review of the literature revealed an incidence of 1.5%-9.6% with the use of autologous tissue for sellar packing such as fat or muscle; fibrin glue combined with autologous grafts led to postoperative rhinorrhea in 1%-4.4%. The present results support the view that sellar and sphenoidal sealing with fibrin glue instead of muscle or fat tissue does not raise the incidence of postoperative rhinorrhea.

Surgical treatment of cerebrovascular occlusive disease. A follow-up study.

This prospective open study of 124 patients [80% with completed stroke (CS), 16% with TIAS, 4% with PRIND] consecutively admitted between 1976 and 1981 investigates the rates of reinfarction after surgical treatment (extra-intracranial arterial bypass, EIAB and/or carotid thrombendarterectomy, TEA). 34% of patients had unilateral carotid stenosis, 26% unilateral internal carotid artery occlusion, 17% had occlusion of one and stenosis of the contralateral internal carotid artery, 14% bilateral carotid stenosis. Combined surgical morbidity and mortality was 5% after 158 operations in 124 patients; 7 of the 8 complications occurred in patients with CS. Of the 120 survivors in the immediate postoperative period, after a mean follow-up period of 5.7 years ranging from 3-8 years, an infarct occurred in 5.8%, i.e., 1% per year; 3 of them occurred ipsilaterally, 2 contralaterally to the first infarct, two remained unknown. Among all 99 patients with CS, the reinfarction rate was 5% (1% per year); in CS patients with a minimal follow-up of 5 years, the annual reinfarction rate was 2%. Of fifty-three patients with completed stroke after EIAB with a mean follow-up of 4.6 years, 3.8% suffered reinfarction (0.8% per year). Among 26 patients with CS and unilateral carotid occlusion after a mean follow-up of 4.7 years, the reinfarction rate was 3.9% (0.8% per year). Among 46 patients with carotid occlusion with or without further stenotic or occlusive lesions, the reinfarction rate was 2.2%.(ABSTRACT TRUNCATED AT 250 WORDS)

[Hypophyseal apoplexy, an urgent indication for surgery]. / Die Hypophysenapoplexie, eine dringliche Operationsindikation.

Pituitary apoplexy with acute visual loss has to be considered as emergency operative indication. 3 cases presenting headache, rapid visual deterioration and ophthalmoplegia were operated upon from a transphenoidal approach. Immediate operative decompression proved to resolve the acutely evolved symptoms in all 3 cases.

The first 100 transsphenoidally operated pituitary adenomas in a non-specialised centre: surgical results and tumour-recurrence.

From 118 transsphenoidally operated patients, 100 had a pituitary adenoma; 33 prolactinomas, 20 HGH-producing, 2 ACTH-producing and 45 inactive adenomas. The first transsphenoidal operation did not cause any mortality; after reoperation for suspected recurrence on follow-up, 2 patients died; thus, the global management mortality was 1.8%. As surgical complications, diabetes insipidus occurred in 5%, hypopituitarism in 4%. Age at operation was significantly higher in female patients with micro- than with macroprolactinomas, and also markedly higher in men than in women with prolactinomas. Preoperative serum prolactin levels were related to tumour size and age and demonstrated an important prognostic factor of postoperative cure. The prognosis of preoperative visual field defects was dependent on preoperative duration. During a follow-up period of 1-6.3 years, 7 patients were reoperated for recurrence of their tumour after intervals of 2-4.5 years; 6 of these patients had had inactive macroadenomas, 1 an ACTH-producing macroadenoma. In 3 of these patients, radiation therapy had been performed. The highest recurrence-rate (19%) among 100 patients was found in patients with inactive macroadenomas with a follow-up of more than 2 years.

[Jugulotympanic paraganglioma]. / Jugulo-tympanisches Paragangliom.

A case is described of a jugulotympanic paraganglioma in a 64-year-old woman with extentions down the jugular vein to the clavicle and penetration of the cerebellar fossa. The symptoms, differential diagnosis, therapy and prognosis are discussed on the basis of this case report and compared with the literature. The importance of radiological investigation (e.g. selective angiography and computed tomography) in respect to diagnosis and determination of tumour size is emphasized. The diagnostic value of the immunohistochemical detection of neuron-specific enolase, a neuroendocrine cell marker and S-100 protein is stressed. The most favourable therapy, depending on tumour extension, seems to comprise preoperative embolisation, radical resection and postoperative radiotherapy.

Predicting lethal outcome after severe head injury -- a computer-assisted analysis of neurological symptoms and laboratory values.

A total number of 58 parameters (laboratory values, neurological symptoms, and vegetative parameters) were evaluated in 150 patients during the first seven days after severe head injury. The patients were divided into two groups, "survivors" and "non-survivors". Eight easily evaluable routine parameters with the most significant differences between the two groups of patients were used for statistical evaluation of a "no survival chance score". These highly indicative parameters are serum osmolarity and urea, blood glucose, total bilirubin, motor reaction to stimuli, body temperature, respiratory activity, and pupil reaction. A "low survival chance limit" was evaluated from each of these parameters by computer analysis. None of the patients in the series survived when three or more of these eight parameters had climbed beyond the limit. So far, the system is able to predict "no survival chances" in 50.8% of the non-survivors some six days prior to death; 80% of these predictions could be made by the fourth day after injury.

The operative approach to lipomas of the corpus callosum.

Survey on the incidence, pathology and the surgical attempts undertaken so far in lipomas of corpus callosum. Report of a case of radical removal with the aid of CO2-Laser beam followed by complete recovery in a 21-year-old woman.

[Growth hormone determination in a combined adenohypophyseal stimulation test (author's transl)]. / Die Wachstumshormonbestimmung mit einem kombinierten Stimulationstest der Adenohypophyse.

The authors sought the simplest but still reliable method for evaluation of the functional reserve of the anterior lobe of the pituitary gland. The proposed test is stimulation of those various functions by injection of insulin, gonadotropin releasing hormone (LH-RH = GnRH) and thyrotropin releasing hormone (TRH). The test fulfils the clinical requirements. Furthermore it forms a valuable first step for the classification of more scientific problems.