COMPARISON OF TRANSCRANIAL AND TRANSSPHENOIDAL APPROACHES IN INTRA AND SUPRASELLAR PITUITARY ADENOMAS - SYSTEMATIC REVIEW.

Context: Pituitary adenomas are benign tumors, usually found in men in their 3rd and 5th decades of life, representing 10-15% of all intracranial tumors. The clinical manifestations include important endocrinological disturbances and visual impairment. Objective: This study aimed to determine the most suitable neurosurgical approach regarding the dimensions, extensions and invasiveness of tumor extensions. Design: This was a systematic review of the literature from 2002-2022, focused on clinical outcome, especially endocrinological state according to the surgical approach. Subjects and Methods: We performed an advanced search on Web of Science and PubMed databases on October 10th, 2022. The literature showed 300 studies in the last 20 years, and after we applied the inclusion and exclusion criteria's, 19 studies were fully read and analyzed. Results: Postoperative complications were reviewed in each surgical approach group, including visual impairment, new endocrinological disturbances, diabetes insipidus and cerebrospinal fluid leakage. Analyze of the endocrinological findings did not determined differences in transcranial groups from transsphenoidal groups. Overall complications were identified in the transcranial cohorts, while cerebrospinal fluid leakage still represent the main problem in transsphenoidal groups. The majority of studies found included extended endoscopic transsphenoidal approach, which shows results of great potential. Conclusions: For the surgical treatment of pituitary adenoma, transsphenoidal procedure with or without extended approaches is preferred, but they're cases when a craniotomy is mandatory for a feasible gross tumor resection. Combined "above and below" simultaneous procedure or a two-staged intervention is recommended for giant pituitary adenoma, to maximize tumor resection and lower the risk of cerebrospinal fluid leakage.

Concomitant completely ossified trigeminal pore and Dorello's canal.

Commonly, the trigeminal and abducens nerve course to the middle cranial fossa, beneath the tentorial border (posterior petroclinoid dural ligament) and, respectively, beneath Grüber's petrosphenoidal ligament, in Dorello's canal. It is hereby reported a rare unilateral association of anatomic variants which was found when the brain computed tomography angiography of a 56-year-old male patient was observed. On the left side, the tentorial border was ossified above the petrous apex, resulting in a tentorial bar 1.96 cm long that transformed the trigeminal pore into a completely ossified one. On that side was also found an ossified petrosphenoidal ligament determining a completely ossified Dorello's canal. On the opposite side a 2.9 mm long clinoid bar extended from the posterior clinoid process to the anterior one. Although these bars are not common in humans they should be documented in computed tomography in cases with associated trigeminal neuralgia and abducens nerve palsy.

Bilateral absence of the transverse sinuses with fenestrated superior sagittal sinus draining through enlarged occipital and marginal sinuses.

The endothelial-lined dural venous sinuses collect blood from the brain, meninges, and calvaria and drain it to the internal jugular veins. The adult drainage pathway of the venous sinuses confluent is commonly via the transverse and sigmoid sinuses to the jugular bulb. The occipital (OS) and marginal (MS) sinuses are well-represented before birth, in most cases. During a retrospective study of the computed tomography angiograms of a 64-year-old female was found a rare combination of variants of the posterior fossa sinuses. The confluence of the dural venous sinuses was rhomboidal and drained superiorly the superior sagittal sinus, and inferiorly a well-represented OS. The transverse sinuses were aplastic, on the right side, and hypoplastic on the opposite side. The OS further drained into the MS which, on each side, emptied into the respective jugular bulb. On each side a condylar vein left the junction of the sigmoid sinus and jugular bulb. Such posterior fossa drainage, exclusively on the OS-MS pathway, should be kept in mind when transections of the venous sinuses are intended during neurosurgical approaches of the foramen magnum. The OS-MS drainage is rather a persisting foetal pattern. The bilateral anatomical exclusion of the transverse sinuses is an added condition to spare the OS and MS.

Craniopharyngiomas in children - experience of consecutive 152 operated cases.

CONTEXT: Craniopharyngiomas (CPH) are benign tumors, rarely encountered in children, representing 5-6% of all intracranial tumors. OBJECTIVE: This study aimed to analyze the surgical management and quality of life in a series of CPH pediatric cases. DESIGN: This was a multicenter study performed over a 25-year period (1994 - 2019) in Bucharest. SUBJECTS AND METHODS: 152 children (0-17 years old) were treated for CPH. Preoperative manifestations were intracranial hypertension, endocrine dysfunction, visual impairment, ataxia, intellectual performance decrease. RESULTS: Considering all surgical approaches used, we advocate for pterional approach to best fit in CPH. We achieved gross-total removal (GTR) in 83 cases (54.4%), near-total resection (NTR) in 13 cases (9%), partial resection (PTR) in 51 cases (33.3%). 5 cases were biopsies (3.2%). Gamma Knife Surgery was performed in 10 cases (6.5%), all recurrences. At 6 months GOS revealed: Good Recovery 70 cases (46.2%), Moderate Disability 62 cases (40.7%), Severe Disability 13 (8.5%), Vegetative State 2 cases (1.3%), Deceased 5 cases (3.2%). Complications were: diabetes insipidus (89.3%); hypopituitarism (66.4%); hypothalamic damage (17.7%); visual deterioration (18.4%). CONCLUSIONS: Surgery remains the main option, but GTR complications prove the necessity for a multidisciplinary approach. Outcome predicting factors are: age, tumor size, hydrocephalus degree, hypothalamic dysfunction.

COMBINED APPROACH FOR LARGE TUMORS OF THE NOSE AND PARANASAL SINUSES--CASE REPORT.

Due to the insidious onset and common symptoms, the diagnostic of sinonasal tumors is late in the evolution. Usually, at that time, the preferred endoscopic approach alone is not recommended, therefore a mixed openendoscopic approach appears to be the best choice in terms of exposure of the tumor and a clear margin resection. The purpose of this case report study is to demonstrate the necessity of careful preoperative assessment and the advantages of combined approach for a complete resection and favorable long-term results.

Surgical treatment of advanced ovarian cancer.

BACKGROUND: The classical treatment for advanced ovarian cancer (OC) consists of a optimal cytoreductive surgery (when the postoperative residual tumor is under 1 cm.), followed by adjuvant chemotherapy based on platinum or paclitaxel derivatives. The 5-year survival rate in case of advanced OC with secondary peritoneal carcinomatosis (PC) is below 25%. The treatment of PC (interpreted as a local-regional disease and not as a systemic disease) is based on an aggressive surgical act (a full or maximal cytoreduction without residual tumor), followed by local chemotherapy or hypertermic intraperitoneal chemotherapy. This is a retrospective study which reassesses the surgical treatment of advanced OC within the period January 2004 - December 2010 in the Center of General Surgery and Liver Transplantation within Fundeni Institute. METHODS: In the period January 2004 - December 2010 in the Center of General Surgery and Liver Transplantation within Fundeni Institute were operated 405 patients with advanced ovarian cancer. In 105 patients (25.9%) intraperitoneal chemotherapy with Cisplatin was performed. RESULTS: Overal survival was calculated for a subsample of 297 patients, for whom it was possible to properly ensure the follow-up, being of 43 months in the patients with intraperitoneal chemotherapy (p = 0.02) and 37 months in the patients without intraperitoneal chemotherapy. CONCLUSIONS: The maximal cytoreduction associating IPCH is an aggressive multidisciplinary therapeutic approach in advanced OC, reserved for difficult cases, considered in the past without solution. In properly selected cases, this shows a clear increase in survival rate.

Clinico-pathological correlations in fatal ischemic stroke. An immunohistochemical study of human brain penumbra.

Ischemic stroke is one of the most frequent pathologies with high invalidating potential and a leading cause of death. The brain tissue adjacent to the central necrotic core, defined as penumbra, was extensively characterized mostly by imaging techniques and in animal models. Our goal was to identify a large panel of molecules in this particular area on human brains harvested at autopsy. Twenty-one patients with ischemic stroke and seven control cases were taken into study. We used immunohistochemistry to characterize necrotic lesions. Metalloproteinases, mostly MMP-9, seem to be involved in brain ischemia, but as a protective and not as a deleterious factor. Apoptotic molecules are not increasingly expressed in stroke compared to control cases. Mast cell enzymes chymase and tryptase are described for the first time in neurons and glia, even with unclear significance. Microglia appears active in stroke and stimulating methods directed to it could be useful. Nitric oxide synthases and cyclooxygenase-2 were also involved in stroke cases but not in control ones. Other factors as VEGF and its receptors, PDGF, b-FGF or TNF-alpha showed no significant expression related to ischemic brain injury. Animal study of penumbra and human tissue findings are distinct and research should be focused on the latter approach in order to find valuable and safe therapeutic methods.

Actual concepts in scaphocephaly : (an experience of 98 cases).

Craniosynostoses are recognized as a group of birth defects that impair the skull structures by early closure of one or more sutures, causing an abnormal cranial shape. Among the "simple" craniosynostoses, (a single closed suture) the most common is scaphocephaly. The 3D CT scan is the most relevant and rapid diagnostic test. The authors present the personal experience of 98 scaphocephaly cases diagnosed and surgically treated in the Neurosurgical Department of "Bagdasar-Arseni" Emergency Hospital during a period of 10 years (2000 - 2009). The procedure of choice was the Stein & Schut (1977) extensive craniotomy that removes the early closed suture. There were no post-operatory death cases and no abnormally closed sutures. The routine use of the craniotome facilitates the lateral osteotomy that allows a normal brain growth and a normal symmetrical skull shape development. The authors advocate for early surgery during the first 6 months of life.

[Preservation of rat liver using prolonged perfusion with a complex solution lacking hemoglobin]. / Conservarea ficatului de sobolan prin perfuzare prelungita cu o solutie complexa lipsita de hemoglobina

The author's aim was to investigate conservation of rat liver by continuous perfusion of the isolated organ in conditions of normal temperature, as well as in hypothermia. A complex solution was used, lacking hemoglobin. Over a period of 5 hours of conservation the authors evaluated the perfusion rate, the concentration of lactate and pyruvate in the conservation medium, while on histological preparations was investigated the formation of fibrin deposits in the intra-hepatic vessels. The results confirmed the positive effects of hypothermia, that is not due exclusively to a limiting of the metabolic necessities of the organ but also to a reduction of the fibrinogenesis and a slowing down of the formation of intra-hepatic microaggregates.

Factors influencing the establishment of the normal values of the respiratory activities of human liver mitochondria.

Some factors that influence the values of respiratory activities of liver mitochondria isolated from surgical biopsy specimens have been studied. By sedimentating of mitochondria at a lower centrifugal force (5,500 g) than usually used for rat liver mitochondria, and washing the mitochondrial pellet twice, the contamination with lysosomes and microsomes was lowered. At 37 degrees C, and in the presence of hexokinase and glucose, the oxygen uptake was greater than at 25 degrees C and in their absence. The respiratory control was good and the respiratory activities were rather stable during the first 3-4 h after isolation. The respiratory activities of mitochondria isolated from patients with duodenal or gastric ulcers, biliary diseases, and subjects with no digestive diseases (all having normal liver) were compared. Differences in oxygen uptake and acceptor control index values with some substrates were noted. The conditions for selection of controls in studies on subcellular fractions of human liver include: absence of any hepatic antecedents; no clinical evidence of liver involvement; no abnormality in routine liver function tests; a histologic aspect free of pathological conditions, and a normal aspect of the tissue during the homogenization and the fractionation procedure (absence of steatosis or fibrosis). These data provide a basis for the standardization of methods in establishing the reference values of mitochondrial activities for the modifications in a variety of diseases.