Combined simultaneous transcranial and transsphenoidal resection of large-to-giant pituitary adenomas.

BACKGROUND: While large-to-giant pituitary adenomas (PAs) may be safely removed by experienced surgeons through a single route, the procedure is technically challenging. We present the outcome of a simultaneous combined transcranial and transsphenoidal approach and discuss its applications. METHODS: A retrospective review was conducted on 12 consecutive patients. Surgical complications, visual and endocrinological functions, and tumour control were reviewed. RESULTS: There were four men and eight women, with a mean age of 47.6 years. All but one patient had non-functioning PAs. The mean tumour height was 4.1 cm (range: 2.3-5.5). The predominant presenting symptoms were visual field loss in eight patients, headache in three patients and mental confusion in one patient. There was no operative mortality. Post-operative cerebrospinal fluid leakage occurred in one patient. Five of the eight patients who presented with visual field loss achieved full recovery, and three had partial improvement. Two patients developed permanent diabetes insipidus after surgery. Panhypopituitarism occurred in one patient. Gross total removal (GTR) was achieved in five, and subtotal removal (STR) in seven patients. Seven patients received post-operative external irradiation. All patients who had GTR remained tumour-free and all those with STR had stable diseases after a mean follow-up period of 53.1 months (range: 14.1-92.1). CONCLUSION: The simultaneous 'above and below' approach is a safe and effective surgical strategy for large-to-giant PAs, particularly when expertise in endoscopic transsphenoidal surgery is unavailable. Its use, however, should be limited to a carefully selected group of patients, and tailored to individual user's expertise and experience.

False-negative cerebrospinal fluid cryptococcal antigen test due to small-colony variants of Cryptococcus neoformans meningitis in a patient with cystopleural shunt.

This is the first report of a small-colony variant Cryptococcus neoformans isolated from the cerebrospinal fluid of a patient with cystopleural shunt associated chronic meningitis. Cryptococcal antigen testing of the cerebrospinal fluid and the serum were both negative. The atypical morphology and the false-negative test may lead to delay of diagnosis and treatment.

Outcome analysis of patients with craniofacial resection: Hong Kong experience.

BACKGROUND: The aim of this study was to evaluate the clinical outcome of patients who underwent craniofacial resection for tumour in the anterior skull base at the University of Hong Kong Medical Centre, Queen Mary Hospital, Hong Kong between January 1993 and June 2003. METHODS: A retrospective review was conducted. The duration of follow up ranged from 1.7 to 119 months (median, 41.8 months). The setting was a tertiary referral centre. Thirty-nine patients, 23 males and 16 females, aged 8-79 years were included. Thirty-four patients had malignant tumour and five patients had benign pathology. The tumour pathology was diversified. Nineteen patients had no treatment before the surgery, and the remaining 20 patients had received surgery, radiotherapy or combined treatment before resection. Patients were given postoperative irradiation and/or chemotherapy depending on the pathology of the tumour and the extent of the disease and clearance at the time of surgery. RESULTS: There was no operative mortality. Complications occurred in 10 patients and among them, three required reoperation. The other complications were managed successfully with conservative measures. The 5-year actuarial disease-free survival for patients with benign and malignant pathology was 100 and 77.6%, respectively. For patients with malignant pathology, 5-year actuarial disease-free survival was 90% when the resection margin was negative at surgery. However, the survival dropped to 53.6% when the resection margin was involved macroscopically. CONCLUSION: Craniofacial resection was an appropriate surgical approach with acceptable morbidity in selected patients with tumour located at the anterior skull base. Complete excision of malignant tumour could achieve 90% 5-year disease-free actuarial survival.

Emergency placement of a self-expandable covered stent for carotid artery injury during trans-sphenoidal surgery.

A patient sustained internal carotid artery (ICA) injury during trans-sphenoidal surgery. Bleeding from the resultant pseudo-aneurysm was not fully controlled by surgical packing. Emergency endovascular deployment over the injured ICA segment of a self-expandable covered-stent ('Symbiot' stent), initially designed for use in coronary saphenous vein-graft, was successful in securing haemostasis.

Chronic subdural haematoma and arachnoid cyst in autosomal dominant polycystic kidney disease (ADPKD).

We present the unusual association between chronic subdural haematoma (CSDH), intracranial arachnoid cyst and autosomal dominant polycystic kidney disease (ADPKD) in a 27-year-old man. CSDH is a documented complication of intracranial arachnoid cyst, the incidence of which is increased in patients with ADPKD. Awareness of this association may lead to earlier diagnosis of ADPKD and treatment of its systemic complications, including renal insufficiency, systemic hypertension and previously unsuspected intracranial saccular aneurysm. Surgery for CSDH associated with intracranial arachnoid cyst may be complicated by over-drainage of cerebrospinal fluid due to communication between the cyst and the cisternal subarachnoid space, as illustrated in the present case, and the development of epidural haemorrhage.

Endoscopic-assisted cranionasal resection of olfactory neuroblastoma.

BACKGROUND: Cranionasal resection was first described in 1997 for the surgical resection of olfactory neuroblastoma. The endoscopic transnasal approach is used in cranionasal resection to replace the more invasive craniofacial resection. It has the advantages of avoiding the facial wound and its associated pain, swelling, and scar. The authors have routinely practiced cranionasal resection since 1996 for resection of all anterior skull base tumors in which the resultant skull base bony defect is limited to the nasal and sinus roof. The aim of this study was to review the results of cranionasal resection for olfactory neuroblastoma. METHODS: The results of cranionasal resection for olfactory neuroblastoma in six patients from 1996 to 2003 were reviewed. RESULTS: The Kadesh stages were 3A, 2B, and 1C. None of the patients had postoperative complications. Postoperative radiotherapy was given only to the patient with Kadesh stage C disease. There were no local recurrences. Two patients died of lung metastasis. CONCLUSIONS: Cranionasal resection is a safe and adequate procedure. Postoperative radiotherapy is not necessary after clear resection of Kadesh A and B tumors.

[Auditory brainstem implantation in patient with bilateral acoustic neuromas].

OBJECTIVE: To restore auditory sensation for patient suffering loss of hearing due to bilateral acoustic neuromas. METHOD: One patient of bilateral acoustic neuromas received auditory brainstem implant (ABI) at the same surgery for resection of the second tumor. The retrosigmoid approach was used for resection of the tumor and to exposure the lateral recess of the fourth ventricle for placement of ABI electrode array. Intraoperative 7th and 9th nerves monitoring and electrically evoked auditory brainstem responses (EABR) were recorded to localize the placement of ABI electrode array. RESULT: Initial ABI switch-on was performed eight weeks after the surgery under close monitoring of vital signs. Auditory sensation was perceived on stimulation of all channels. CONCLUSION: The multichannel ABI could effectively restore auditory sensation for patient deafened by bilateral acoustic neuromas. The accurate location of the cochlear complex during surgery was the critical factor for success of ABI.

Metastatic melanoma of the pituitary gland. Case report.

The authors report on the clinical features and imaging studies in a case of metastatic melanoma of the pituitary gland. Cerebral metastatic melanoma and pituitary metastasis from any source are commonly associated with systemic metastasis, whereas pituitary metastatic melanoma without widespread disease dissemination is distinctly rare. This 46-year-old man presented with diabetes insipidus and anterior pituitary dysfunction 5 years after he underwent resection of a cutaneous malignant melanoma of the neck. Magnetic resonance imaging demonstrated the presence of melanin within a sellar tumor mass. Transsphenoidal resection was performed and histopathological examination of tumor material confirmed metastatic melanoma. Postoperative [18F]fluorodeoxyglucose-positron emission tomography revealed no other focus of hypermetabolism in the patient's body.