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).

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.

Periventricular hydatid cyst.

Periventricular localization of hydatid cyst is very rarely seen. A 5-year-old boy with periventricular hydatid cyst is presented. He had right hemiparesis and focal seizures. Computerized tomographic scan showed a hydatid cyst in the left periventricular area. Hydatid cyst was successfully removed. The postoperative course was uneventful.

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.

Huge colloid cyst of the third ventricle associated with calcification in the cyst wall.

Giant or huge colloid cysts of the third ventricle up to of more than 3 cm in diameter are extremely rare. The patient presented with symptoms of increased intracranial pressure, including headache, vomiting, and papilledema. Computerized tomographic (CT) scan revealed a hypodense, huge colloid cyst of the third ventricle associated with calcification in the cyst wall. Both hypodensity and calcification are uncommon roentgenological findings for colloid cysts of the third ventricle. The patient was operated on by the transcortical/transventricular approach and the colloid cyst was completely excised.

Giant cholesterol cyst of the petrous bone: a case report.

The giant cholesterol cyst (GCC) is a benign lesion that gradually enlarges and causes progressive bone erosion and serious neurologic deficits of the cranial nerves within the temporal bone and jugular foramen. We report here a lesion located behind the petrous bone and describe the diagnostic evaluation, pathology, and surgical management.

Tension pneumocephalus after transsphenoidal surgery: two case reports.

In this paper, a brief information on factors taking role in intracranial air formation and tension pneumocephalus because of two cases epidural air formation and tension pneumocephalus following transsphenoidal operation is presented. Two cases were treated conservatively.

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.

Choroid plexus carcinoma of the lateral ventricle. Report of a case in an adult.

Choroid plexus carcinoma is a rare neoplasm and occurs more frequently in children than in adults. Most of these neoplasms in adults arise in the fourth ventricle. A 22-year-old male with choroid plexus carcinoma presenting in the lateral ventricle is reported. The patient was treated by radiotherapy after surgical removal of the tumour. Modern management possibilities and its limitations are discussed.

Pituitary abscesses. Report of three cases.

Three cases of pituitary abscess are presented. In spite of improvements in radiological evaluation, preoperative diagnosis of pituitary abscess is quite difficult and definite preoperative diagnosis is rare in the literature. In our three cases, diagnosis was made postoperatively. Pituitary abscesses are associated with high mortality and morbidity. When first suspected, prompt antibiotic therapy should be considered. Early operative drainage seems to be an important factor in decreasing this high mortality and morbidity.

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.

Encephalo-myo synangiosis (EMS) in the vertebrobasilar occlusive disease. Case reports.

Two cases of vertebro-basilar insufficiency treated with infratentorial (IT) Encephalo-Myo-Synangiosis (EMS) using the pedicled occipitalis muscle flap, are presented. IT EMS was carried out for revascularization of the vertebro-basilar system. None of these cases has suffered from either carotid or vertebro-basilar insufficiency during seven years follow-up period. As far as we know this is the first report of successful IT EMS for vertebro-basilar insufficiency.

Vertebral arteriovenous fistula caused by angiography catheter: case report.

A case of vertebral arteriovenous fistula (VAF) caused by an angiographic catheter during coronary angiography in a 30-year-old female is presented. The patient complained about a roaring noise in her left ear. Preoperative and postoperative angiographic verification of the lesion is presented. The patient was treated by a direct surgical trapping of the vertebral artery (VA) proximal and distal to the fistula.

The use of Nd:YAG laser in pituitary surgery and evaluation of visual function by visual evoked potential (VEP).

Surgery of pituitary tumors has been improved by microneurosurgical methods. However, despite improvements in surgical results, pituitary tumors still continue to represent a problem and, therefore, prompt a search for new surgical techniques. Since Nd:YAG laser energy penetrates the target tissue more deeply than other instruments, its use in the para- and suprasellar region should be considered. It is well known that Visual Evoked Potential (VEP) is a sensitive and objective method for the valuation of compressive or destructive lesions in or around the optic nerve. Visual function correlates with the latency and amplitude of P100 wave in VEP. We used the Nd:YAG laser in 50 transsphenoidal operations of pituitary adenomas. Postoperative effects of the laser on visual function was evaluated by conventional neurophthalmological tests as well as VEP and was compared with preoperative values. Following surgery using Nd:YAG laser, both conventional neurophthalmological tests and VEP values improved due to decompression of optic nerves by tumor removal. In this study, we also examined anterior lobe functions and found that Nd:YAG laser does not affect these functions. Our study shows that Nd:YAG laser has no harmful effects and seems to be very helpful especially for surgery for invading hormone-active adenomas.

Pseudotumor cerebri with familial Mediterranean fever.

Pseudotumor cerebri (PC) is a condition that occurs predominantly in obese women, and long lists of putative causes and associations have been reported. We describe here the case of a woman in whom PC coexisted with familial Mediterranean fever (FMF). A review of the literature revealed no report of an association of these two conditions.

Diagnosis and treatment of intraspinal lipomas.

In this article a 32-case series of intraspinal lipoma localized to the lumbosacral region is presented. All of the patients underwent surgery. Recent reports in the literature indicate that although these lesions show advanced and progressive neurological deficits, very good results can be achieved with surgical treatment. The advantages of computed tomography in diagnosis and the importance of early surgical intervention and postoperative rehabilitation are emphasized.

Craniopharyngioma of the posterior fossa.

A case of craniopharyngioma originating in the very unusual location of the posterior fossa is presented. The patient, a 23-year-old man, was operated on at another hospital when he was 3 years old for craniopharyngioma in the suprasellar area. There was no complaint for several years after this initial operation. Three months before he was admitted to our hospital, he had complaints of headache, vomiting, nausea, and ataxia. A computed tomographic scan revealed a mass with a cyst and calcifications in the posterior fossa. The tumor was removed totally.

A case of intracranial chordoma associated with pituitary adenoma.

We report a patient who had pituitary adenoma and parasellar chordoma coincidentally, with neither irradiation nor a history of head injury. Preoperative computed tomographic (CT) scan had shown an intrasellar mass that infiltrated into the right cavernous sinus. Histopathologically the intrasellar mass was diagnosed as pituitary adenoma and the other mass as chordoma. We present clinical, radiological and histopathological findings, and discuss previously reported cases with multiple intracranial tumours.