Endovascular and surgical treatment of unruptured cerebral aneurysms: comparison of risks.

Unruptured cerebral aneurysms are commonly treated by surgical clipping, but endovascular coil embolization is increasingly employed as an alternative. In a blinded review of unruptured aneurysms treated at our institution since 1990, we identified patients whose aneurysms were judged to be treatable by both neurosurgeons and neurointerventional radiologists. A change in Rankin Scale score of 2 or more from hospital admission to discharge, indicating a new moderate disability or worse, was predefined as the primary outcome measure. Long-term follow-up was obtained by mailed questionnaire and telephone interview. Length of stay and hospital charges were totaled for all hospitalizations, including follow-up. Sixty-eight patients treated surgically and 62 patients treated with endovascular coil embolization were considered candidates for either procedure on blinded review, and overall anticipated procedure risk was rated as identical. A larger proportion of patients in the surgical group developed a change in Rankin Scale score of 2 or more (25% of surgical patients vs 8% of endovascular patients). Total length of stay was longer (mean days: 7.7 for surgical patients vs 5.0 for endovascular patients) and hospital charges were greater (mean, $38,000 for surgical patients vs $33,400 for endovascular patients) for the surgical patients. At follow-up, an average of 3.9 years after the procedure, surgical patients were more likely to report persistent new symptoms or disability since treatment (34% of surgical patients vs 8% of endovascular patients) and a longer period for recovery to normal (50% returning to normal in 1 year for surgery and in 27 days for coil embolization). Coil embolization of unruptured cerebral aneurysms seems to be associated with significantly fewer complications than surgical clipping. More long-term data on aneurysm rupture rates are required to confirm efficacy.

Transsphenoidal microsurgical therapy of prolactinomas: initial outcomes and long-term results.

OBJECTIVE: Prolactinomas are frequently treated primarily with dopamine agonists; however, these agents have disadvantages and require life-long therapy. We therefore reassessed transsphenoidal microsurgery as an alternative therapy. METHODS: We reviewed the data for 121 female patients treated surgically for prolactinomas between 1976 and 1979 (Group 1) and 98 patients treated between 1988 and 1992 (Group 2). RESULTS: Of 219 women, 92% with preoperative prolactin (PRL) values of < or = 100 ng/ml and 91% with intrasellar microadenomas experienced initial remission; 80 to 88% of patients with intrasellar macroadenomas or macroadenomas showing moderate suprasellar extension or focal sphenoid sinus invasion experienced remission. Women with PRL values of > 200 ng/ml and those with larger and more invasive adenomas experienced poorer outcomes (37-41% remission). Lower preoperative PRL values and adenoma stage were the best predictors of initial surgical outcomes. At the most recent evaluations, 89% of women who experienced initial remission continued to experience clinical remission; 85% exhibited normal PRL values, and 5% demonstrated mild, asymptomatic, recurrent hyperprolactinemia (PRL values of < 34 ng/ml). In Group 1, 84% of patients continued to experience remission (82% with normal PRL values) after a median follow-up period of 15.6 years. In Group 2, 97% of patients continued to experience remission (88% with normal PRL values) after a median follow-up period of 3.2 years. Lower postoperative PRL values were the best predictors of long-term remission. CONCLUSION: Transsphenoidal microsurgery is an effective alternative to long-term medical therapy for selected patients with prolactinomas. Successful outcomes and long-term remission were achieved in patients with microadenomas and noninvasive macroadenomas.

Transsphenoidal microsurgery for growth hormone-secreting pituitary adenomas: initial outcome and long-term results.

Treatment of acromegaly has long been recognized as necessary to relieve symptoms, halt progression of deformities, and decompress the sella turcica. More recently, treatment strategies have focused on decreasing GH levels to a point at which mortality rates normalize, thereby redefining previous concepts of a cure. No surgical series to date has investigated the long-term effect of treatment on mortality rates. We retrospectively reviewed 254 consecutive patients with acromegaly who underwent transsphenoidal microsurgery of GH-secreting adenomas between 1974-1992. Seventy-six percent of these patients had basal GH levels <5 ng/mL within 30 days of surgery, and 24% had persistent disease. Multivariate analysis revealed that higher stage, grade, and preoperative GH levels were all predictive of persistence (P < 0.01). Long-term follow-up was obtained on 129 of the patients in initial remission. Of these, 9 (7%) had disease recurrence and 120 remained in remission. The incidence of major postoperative complications was 8% (2% permanent diabetes insipidus, 2% cerebrospinal fluid leaks requiring surgery, 2% meningitis, and 2% hypopituitarism), with no mortality. In contrast to the 2.4- to 4.8-fold increased mortality among untreated acromegalics, the mortality rate among patients with posttherapy GH levels <5 ng/mL was equivalent to that of age- and sex-matched controls. Aggressive therapy to normalize GH levels should therefore be instituted at diagnosis.