Pituitary adenoma consistency affects postoperative hormone function: a retrospective study.

BACKGROUND: Tumor consistency recently emerged as a key factor in surgical planning for pituitary adenomas, but its impact on postoperative endocrine function is still unclear. Our study aimed to evaluate the impact of tumor consistency on the development of postoperative pituitary deficiencies. METHODS: Single-center, retrospective analysis of consecutive pituitary surgeries performed between January 2017 and January 2021 at Policlinico Umberto I in Rome. All patients underwent radiological and biochemical evaluations at baseline, and hormone assessments 3 and 6 months after pituitary surgery. Postoperative MRI studies were used to determine resection rates following surgery. Data on tumor consistency, macroscopic appearance, neurosurgical approach, and intraoperative complications were collected. RESULTS: Fifty patients [24 women, mean age 57 ± 13 years, median tumor volume 4800 mm3 [95% CI 620-8828], were included. Greater tumor volume (χ2 = 14.621, p = 0.006) and male sex (χ2 = 12.178, p < 0.001) were associated with worse preoperative endocrine function. All patients underwent transsphenoidal adenomectomy. Fibrous consistency was observed in 10% of patients and was associated with a Ki-67 greater than 3% (χ2 = 8.154, p = 0.04), greater risk of developing postoperative hormone deficiencies (χ2 = 4.485, p = 0.05, OR = 8.571; 95% CI: 0.876-83.908), and lower resection rates (χ2 = 8.148, p = 0.004; OR 1.385, 95% CI; 1.040-1.844). Similarly, worse resection rates were observed in tumors with suprasellar extension (χ2 = 5.048, p = 0.02; OR = 6.000, 95% CI; 1.129-31.880) and CSI (χ2 = 4.000, p = 0.04; OR = 3.857, 95% CI; 0.997-14.916). CONCLUSIONS: Tumor consistency might provide useful information about postoperative pituitary function, likely due to its impact on surgical procedures. Further prospective studies with larger cohorts are needed to confirm our preliminary findings.

Case report: An epidural cavernous hemangioma mimicking a dumbbell-shaped neuroma.

INTRODUCTION AND IMPORTANCE: Spinal epidural cavernous hemangiomas are a rare occurrence. This particular case is made even more distinctive by the fact that the lesion mimicked a dumbbell-shaped neuroma. Moreover, it had a very unique localization (wholly epidural, at cervical-thoracic -C7-D1- level). The importance of this case is linked not only to its remarkable rarity, but also to the diagnostic avenues explored. The surgery was carried out by Prof. Riccardo Caruso, Head of the Neurosurgical Department of the Military Hospital of Rome and Professor of Neurosurgery of Sapienza University of Rome, assisted by Dr. Luigi Marrocco, Senior Neurosurgeon of the Military Hospital of Rome. Postsurgical recovery was managed by Dr. Venceslao Wierzbicki, Senior Neurosurgeon of the Military Hospital of Rome. CASE PRESENTATION: In 2020, a 71 year-old man, suffering from intense pain in the left scapular region and in the ulnar area of the left forearm, underwent surgery for the removal of a spinal epidural cavernous hemangioma involving the left C7-D1 foramen. Prior to surgery, the lesion had been misdiagnosed as a neuroma by a radiologist. CLINICAL DISCUSSION: In the Literature there are other, rare cases of hemangiomas partly located in the spinal canal, and partly located intra and extra foramen. In the case here presented, differential diagnosis as well as a potential Schwannoma, suggested by the dumbbell shape of the lesion, should have considered also the possibility of a meningioma. Two teams of radiologists examined the images, the radiologists of our team, Dr. Valentina Martines and Dr. Emanuele Piccione, thanks to a close inspection of the features of the lesion, postulated the extra-dural position. Other aspects of the scans were then analyzed to help guide future diagnosis of similar lesions. CONCLUSION: With a spinal tumor affecting the foramen, a close examination of the images allows for accurate presurgical differential diagnosis, differentiating between the more frequent neuroma and other rarer tumors, such as a hemangioma.

Paraneoplastic Neuromyelitis Optica Spectrum Disorder Associated With Lung Adenocarcinoma: A Case Report.

Neuromyelitis Optica spectrum disorder is an inflammatory demyelinating disease affecting the central nervous system (CNS), characterized by triad optic neuritis, transverse myelitis, and area postrema syndrome. Antibodies directed against aquaporin-4 (AQP-4), a water channel expressed on the astrocytic membrane, are supposed to play a pathogenic role and are detected in ~80% of cases. Clinical signs of Neuromyelitis Optica spectrum disorder (NMOSD) in elderly patients should arouse the suspicion of paraneoplastic etiology. In this article, we discussed a case of a 76-year-old woman with a 2-month history of confusion, dysarthria, and progressive bilateral leg weakness. A whole-body CT scan showed a neoformation of 5 cm in diameter in the median lobe infiltrating the mediastinal pleura. The tumor had already spread to both the upper and lower right lobes, parietal pleura, and multiple lymph nodes. Pleural cytology revealed adenocarcinoma cells. The brain MRI documented hyperintense alteration in fluid-attenuated inversion recovery (FLAIR) images, involving the anterior portion of the corpus callosum and the periependymal white matter surrounding the lateral ventricles, with mild contrast enhancement on the same areas and meningeal tissue. T2-weighted spinal cord MRI sequences showed extended signal hyperintensity from bulbo-cervical junction to D7 metamer, mainly interesting the central component and the gray matter. Cerebrospinal fluid analysis revealed no neoplastic cells. Serum AQP-4 immunoglobulin (IgG) antibodies were found. Meanwhile, the patient rapidly developed progressive paraparesis and decreased level of consciousness. High-dose intravenous methylprednisolone therapy was started but her conditions rapidly deteriorated. No other treatment was possible.

Assessing the real benefits of surgery for degenerative lumbar spinal stenosis without instability and spondylolisthesis: a single surgeon experience with a mean 8-year follow-up.

BACKGROUND: The degenerative lumbar spinal stenosis is one of the most commonly treated spinal disorders in older adults; despite its increasing frequency, it is not yet clear what the most effective therapy might be. The aim of this study is to investigate the very long term results of a homogenized cohort of patients suffering from lumbar spinal stenosis: the first subset of patients operated on with laminectomy and the second subset of patients was also advised to undergo laminectomy but never operated on. METHODS: Patients from both subgroups were advised to undergo surgery, according to the same criteria, in the period between 2000 and 2010 and were re-evaluated in the period between January and December 2016. RESULTS: Comparing the two subsets of patients, both suffering from clinically relevant LSS, the first subset returns a statistically significant clinical improvement at follow-up. The rate of excellent results decreases over years. Iatrogenic spinal instability incidence was found to be 3.8% in the present cohort. CONCLUSIONS: Although the improvement of the first postoperative years decreases over time and despite the lack of general consensus, the lack of established shared guidelines and the limitations of this research, the results support the utilisation of surgery for the management of this condition. LEVEL OF EVIDENCE: 3.

Hemispheric Chronic Subdural Hematoma Concealing Subdural Metastases: Terrible Surprise Behind Routine Emergency Department Consultation.

The patient is a 79-year-old male, suffering from advanced metastatic prostate cancer, who developed a progressively worsening ideomotor slowing and was therefore referred to the emergency department of our institution. A plain axial computed tomography (CT) scan revealed a vast hemispheric subdural fluid collection, apparently a subdural hematoma. On closer inspection, and most of all, in hindsight, a tenuously isohyperdense signal irregularity at the frontal aspect of the fluid collection appears. Because of the declined general medical conditions and the paucity of the neurologic impairment, a high-dose, corticosteroid-based conservative strategy was performed. The total body CT scan for the routine oncologic follow-up of the prostate cancer scan fell at 20 days from the first CT of the emergency department. A second contrast-enhanced axial CT scan demonstrated the presence of 2 subdural metastases, presumably the initial pathogenesis of the subdural fluid collection.

Leksell gamma knife radiosurgery for cerebral arteriovenous malformations in pediatric patients.

OBJECTS: The authors report their experience of gamma knife radiosurgery (GKR) in a large series of pediatric cerebral arteriovenous malformations (cAVMs). The advantages, risks and failures of this approach are presented and discussed. METHODS: Gamma knife radiosurgery was performed on 63 children aged < or =16 years. Haemorrhage was the clinical onset in 50 out of 63 cases. The mean pre-GK cAVM volume was 3.8 cm(3). Fifty-eight out of 63 cAVMs were Spetzler-Martin grades I-III. Most lesions (47 out of 63) were in eloquent or deep-seated brain regions. CONCLUSION: Gamma knife radiosurgery-related complications occurred in 2 out of 47 cases with an available follow-up (1 had transient and 1 permanent morbidity). No bleeding occurred during the latency period. In 39 children with >36-month follow-up, complete cAVM occlusion was angiographically documented in 31, with a 3- and 4-year actuarial obliteration rate of 72 and 77% respectively. High rates of complete obliteration and very low frequency of permanent morbidity with no bleeding during the latency period encourage widespread application of GKR in the treatment of pediatric cAVMs.

Selective venous sampling in diagnosing ACTH-dependent hypercortisolism.

PURPOSE: To evaluate the sensitivity of selective sampling from the inferior petrosal sinuses in the differential diagnosis of ACTH-dependent hypercortisolism with non-diagnostic pituitary imaging. MATERIALS AND METHODS: Between 1987 and 2001, 17 patients (14 women and 3 men, aged 18-63 years) with ACTH-dependent hypercortisolism and negative X-ray of the sellar region, underwent simultaneous bilateral sampling from the inferior petrosal sinuses with ACTH measurement, at baseline and after stimulation with CRH (100 micro i.v.). Baseline samplings were also carried out at the level of the infrarenal and suprarenal inferior vena cava, of the adrenal and suprahepatic veins, of the superior vena cava, of the jugular veins, and of a peripheral vein. A central/peripheral gradient >2 at baseline and/or one >3 after stimulation with CRH was considered indicative of the pituitary origin of ACTH. Bilateral femoral venous catheterization was performed in an angiographic room using 5-French introducers after local anaesthesia. Selective catheterization of the inferior petrosal sinuses was achieved with 100 cm-long, steam-bent (45 degrees) 5-French catheters, without lateral holes. RESULTS: Twelve patients exhibited ACTH central/ peripheral gradients indicating the pituitary origin of the hormonal hyperincretion; this was confirmed by surgical exploration of the hypophysis in 10 patients, whereas 2 refused surgery and were therefore "lost". Of the five patients without ACTH central/peripheral gradients, one had an adrenal metastasis from ACTH-secreting lung neoplasia (with ACTH gradient in the blood flowing back from the adrenal gland), one had a hepatic CRHoma (with high levels of CRH in the suprahepatic veins), whereas the origin of the hyperincretion remained indeterminate in three. CONCLUSIONS: Bilateral simultaneous selective sampling from the inferior petrosal sinuses for ACTH measurements proved to be highly sensitive and free of complications in the differential diagnosis of ACTH-dependent forms of hypercortisolism.