Prolactin Secreting Pituitary Microadenoma: Results of Transsphenoidal Surgery After Medical Therapy With Dopamine Agonist.

Medical therapy with dopamine agonist is very effective in controlling prolactin serum levels and it usually represents the first therapeutic choice for prolactin secreting pituitary adenomas. However, many patients present increase of prolactinemia after withdrawal of medical therapy which consequently should be taken for long time; other present intolerance to medical therapy; women with pregnancy need to withdraw dopamine agonists with consequent potential related problems: in these patients transsphenoidal surgery can be requested. The presented study concerns the efficacy of transsphenoidal surgery in patients affected by microprolactinoma after treatment with medical therapy for different periods of time. Different postsurgical results were achieved in 2 groups of 24 (group 1) and 25 (group 2) patients affected by microprolactinoma who had taken medical therapy for a period of time respectively longer or shorter than 1 year. In summary, the authors observed in group 1 a rate of hormonal remission of 33.3% and an overall prolactinemia improvement with possibility of medical therapy withdrawal in 49.9% of patients. In group 2, the authors observed a rate of hormonal remission of 84% and an overall rate of improvement with no necessity of medical therapy of 92%. Therefore, the authors' experience showed that the surgical option for the therapy of microprolactinomas should be indicated within 1 year from the beginning of medical therapy with dopamine agonist, to achieve a high rate of hormonal remission and possibility to withdraw medical therapy. The authors' protocol for microprolactinoma treatment is presented.

Anterior Microsurgical Approach to Ventral Lower Cervical Spine Meningiomas: Indications, Surgical Technique and Long Term Outcome.

Ventral lower cervical spinal meningiomas with posterior displacement of the spinal cord are rare and anterior approach has been rarely reported in the literature. The authors present their experience about eight patients operated through anterior microsurgical approach. Exposure of meningiomas was achieved through one or two corpectomies, according to meningioma extension. Tumour removal was performed thanks to the aid of a dedicated ultrasonic aspirator, and intraoperative evoked potentials were employed. Particular care was taken with the materials adopted for reconstruction of the anterior dural plane, to avoid postoperative cerebrospinal fluid leak. Vertebral fusion and stabilization were achieved by tantalum cage or titanium graft in case of one or two corpectomies respectively; anterior titanium plate fixed with screws was applied in all patients. Extent of tumour removal was related to the presence of a conserved arachnoidal plane between the tumour and the spinal cord: total removal was achieved in 2 patients, while gross total removal in the other six ones. Postoperative neurological outcome, which was favourable in all patients, was related mostly to preoperative neurologic status. No recurrence after total removal and no remnant growth after gross total removal occurred during an average follow-up period of 6, 7 years.

Spinal intramedullary arachnoid cyst: case report and literature review.

BACKGROUND CONTEXT: Intramedullary arachnoid cysts are extremely rare; only 14 cases have been reported in the literature so far. PURPOSE: We report on the case of a 31-year-old woman who presented with back pain and progressive paraparesis secondary to a dorsal intramedullary arachnoid cyst detected on magnetic resonance imaging (MRI): the surgical planning and clinico-radiological outcome are discussed along with a review of the relevant literature. STUDY DESIGN: Case report and literature review. PATIENT SAMPLE: One patient affected by intramedullary arachnoid cyst. OUTCOME MEASURES: Magnetic resonance imaging and pathological findings from operative specimens were used to confirm the diagnosis. METHODS: A 31-year-old woman presented with a 7-year history of back pain that had worsened 3 months before admission to our department; for this reason, the patient had undergone a spinal MRI revealing the presence of a 1-cm cystic intramedullary lesion at the level T11-T12, with no contrast enhancement. After 2 months, the patient presented with a worsening of clinical symptoms complaining of severe back pain radiating to the lower extremities associated with a progressive paraparesis, urinary incontinence, and abdominal pain. Referred to our department, at the time of admission the patient was bedridden because of the impossibility of maintaining a standing position. The patient underwent a T11-T12 laminectomy with fenestration of the cyst. RESULTS: She experienced an immediate relief of pain symptoms, and by the seventh postoperative day she was able to stand without help and walk a few meters with assistance. By the sixth postoperative month, the patient had significantly improved, having gained the ability to walk alone without assistance with complete resolution of the bladder dysfunctions, with no cyst recurrence after approximately 2 years of follow-up. CONCLUSIONS: Intramedullary arachnoid cysts should be considered in the differential diagnosis for intramedullary cystic lesions. A particular consideration deserves their occurrence in asymptomatic patients, who should be adequately informed on the possible natural evolution: when symptomatic, surgical therapy should be promptly offered, considering that a postoperative complete recovery is usually observed, regardless of the surgical technique.

Transsphenoidal removal of huge pituitary adenomas with marked suprasellar extension: results with modified surgical technique.

OBJECTIVE: A modified transsphenoidal technique to remove huge pituitary adenomas with marked suprasellar extension (4.5-8 cm of maximum diameter) is presented. METHODS: The technique allowed to avoid the occurrence of a precocious descent of the suprasellar cisternal plane into the sellar plane during tumour removal and its related consequences (incomplete tumour removal, occurrence of cerebrospinal fluid leak, prolonged time of postoperative stay in hospital). Technique is performed opening at the beginning only the lateral parts of peritumoral dura mater, leaving the central part of the dura mater in support of the central part of tumour and suprasellar cisternal plane. After removal of lateral parts of the tumour, the central part of peritumoral dura mater is opened and the central intra- and supra-sellar parts of the tumour are removed. RESULTS: Total removal was accomplished in 64% and 45% in groups two and one respectively. Intraoperative CSF leak occurred in 2.4% and 22.5% respectively in groups two and one. Postoperative CSF fistula did not occur in group two, while it occurred in 7.4% of patients of group one. Average time of postoperative stay in hospital was 4.3 and 8.2 days in groups two and one respectively. CONCLUSION: The presented modified transsphenoidal microsurgical technique for removal of huge pituitary adenomas allowed to achieve better results than patients operated by standard transsphenoidal surgery.

Fibrous dysplasia of the clivus with a second T8 bone lesion: case report.

BACKGROUND: We present a rare case of a probably poliostotic fibrous dysplasia of the clivus in a young woman with a clival and vertebral involvement. We also compare our case with data reported in tables that include all cases of clival fibrous dysplasia present in literature. CASE DESCRIPTION: Thirty-year-old women presented with headache. We reviewed radiological and clinical literature before surgery. It was possible to perform a preoperative diagnosis of fibrous dysplasia of the clivus so it was possible to adopt a minimally invasive surgical approach on the clivus. The diagnosis of fibrous dysplasia of the clivus was confirmed after the operation. As the patient was asymptomatic, we did not operate on the vertebral lesion which was stable after 1 year. CONCLUSION: We draw the conclusion that it is possible to obtain a correct preoperative diagnosis of fibrous dysplasia based on magnetic resonance imaging and computed tomographic scans; this makes it possible to avoid major surgical operations. The reported case is particularly interesting because apart from the clival fibrous dysplasia, a vertebral involvement of the same type can be assumed; this association has never been reported in literature.

Axial loading MRI of the lumbar spine.

BACKGROUND: The aim of our study was to evaluate the incoming interrelations between chronic low back pain and biomechanical changes of the lumbar spine, using an MRI-compatible axial-loading device mimicking the standing position. MATERIALS AND METHODS: Fifty consecutive patients (28 males and 22 females), with both chronic low pack pain and recurrent painful blockages, were selected and studied using a 1.5 T Gyroscan Intera Philips MRI unit (Philips, Best, Holland) and a dedicated axial loading apparatus (MIKAI manufacturing, Genoa, Italy). RESULTS: After loading, no significant modifications occurred in ten patients (20%), a spinal stenosis was seen in 18 patients (45%), an increase in the discal protrusions or hernias was detected in 8 patients (20%) and a significant accentuation of the spondylolisthesis was observed in 6 patients (15%). CONCLUSION: Axial loading MRI provides valuable information for specific non-invasive or operative management of low back pain.

Syringomyelia associated with hydrocephalus and Blake's pouch cyst: case report.

STUDY DESIGN: This is a case report of a 37-year-old woman who sought treatment for a large syringomyelic cavitation extending from C3 to the entire medulla, a tetraventricular hydrocephalus, and a cystic cavitation in the posterior cranial fossa communicating with the fourth ventricle (Blake's pouch cyst). The patient underwent a decompressive craniectomy, a C1 laminectomy, and the opening of the cysts to enable communication with the subarachnoid spaces. After an initial period of symptom remission, reassured by the magnetic resonance images indicating a reduction of the syringomyelia, the patient's neurologic conditions deteriorated because of further dilation of the ventricular cavities, which was resolved by the insertion of a ventriculoperitoneal shunt. OBJECTIVE: To suggest the treatment of choice in a patient with syringomyelia and hydrocephalus caused by Blake's pouch cyst. SUMMARY OF BACKGROUND DATA: Blake's pouch cyst is an entity often poorly understood, deriving from nonperforation of the primitive foramen of Magendie, causing a precarious equilibrium of the cerebrospinal fluid flow resulting from a defect in communication between the fourth ventricle and the encephalic and spinal subarachnoid spaces. Authors report the association of Blake's pouch cyst with cervicodorsal syringomyelia and tetraventricular hydrocephalus. METHODS: A case of syringomyelia associated with hydrocephalus and Blake's pouch cyst is described. RESULTS: Symptoms of syringomyelia and hydrocephalus disappeared only after positioning of a ventriculoperitoneal shunt. CONCLUSIONS: The treatment of choice for a case of syringomyelia associated with Blake's pouch cyst and hydrocephalus is the application of a ventriculoperitoneal shunt or, even better, an endoscopic third ventriculostomy.

Intrasphenoidal encephalocele associated with cerebrospinal fluid fistula and subdural hematomas: technical case report.

OBJECTIVE AND IMPORTANCE: Intrasphenoidal encephalocele is a rare clinical entity that is often complicated by rhinorrhea, recurrent meningitis, and headache, but in no case has the association of rhinorrhea with subdural hematomas been described. A surgical procedure to stop persistent cerebrospinal fluid leakage is reported. CLINICAL PRESENTATION: A 59-year-old man sought care for intractable rhinoliquorrhea of 6 months' duration. Cranial computed tomographic and magnetic resonance imaging scans revealed a basal posterior frontal bony defect and an evocative image suggesting intrasphenoidal encephalocele. INTERVENTION: A transnasal transsphenoidal surgical procedure was performed; the encephalocele was removed, and the sphenoid sinus was filled with an inflatable pouch made of synthetic dura mater containing abdominal fat. Postoperative reduction of the rhinoliquorrhea, but not its total disappearance, was observed. Total disappearance was achieved only after endonasal, transmucosal inflation of the pouch with human fibrin glue. One of the subdural hematomas disappeared spontaneously, and the other was treated by a surgical procedure. CONCLUSION: The possible role of the presented technique in the treatment of cerebrospinal fluid leakage is discussed.

Calcifying pseudo-tumor of the spine: description of a case and review of the literature.

A case of calcifying pseudo-tumor of the thoracic spine, a rare lesion with tumor-like behavior and a probable inflammatory-reactive origin, is described. The clinical-pathological and neuro-radiological aspects of this lesion are discussed in relation to surgical treatment. In accordance with the other cases reported in the literature, the case observed confirmed the benign behavior of the lesion and the effectiveness of surgical treatment for achieving complete resolution of clinical symptoms without any recurrences, even when removal is only subtotal.