[Therapeutic strategy for intrasellar cystic lesions].

OBJECTIVE: To make a clear distinction of intrasellar cystic lesions: craniopharyngioma (CR), Rathke's cleft cyst (RCC), cystic pituitary adenoma (PA) and intrasellar arachnoid cyst (AC). METHODS: A total of 72 adult patients underwent transsphenoidal approach for the removal of intrasellar cystic lesions. The authors conducted a study to (1) investigate preoperative clinical, biochemical and radiographic features of patients with CR, RCC, PA and AC; (2) identify clinicopathological features of independently predicting recurrence in CR, PA and RCC in adults. These adult patients included CR (n = 10), RCC (n = 27), cystic PA (n = 32) and 1 patient with AC (n = 1). RESULTS: The CR patients presented with hypopituitarism in 80% of cases. According to the biochemical criteria, the percentage of patients with a slight prolactin increase happened in PA (55.6%) and RCC (44.4%). Cystic PA had post-contrasting enhancement in cyst wall because of tumor tissue. Calcification detectable on computed tomographic scanning was present in 70% of CR patients. It was a significantly greater proportion compared to other diseases. Typical RCC was located between anterior and posterior pituitary and the contents in RCC were variable. Mass effects vanished post-operatively in all kinds of lesions. Long-term hormone replacement therapy was administered more in CR patients (60%) and diabetes insipidus than other lesions. One PA patient and 2 CR patients had recurrence during a follow-up of 12 - 52 months (mean: 34). RCC and AC had no recurrence. CONCLUSION: Craniopharyngioma, Rathke's cleft cyst, cystic pituitary adenoma and intrasellar arachnoid cyst are a spectrum of diseases with different therapeutic strategies. An accurate diagnosis of these lesions is essential so as to determine the type of treatment to improve outcome.

[Preservation of pituitary stalk in the microsurgery of giant pituitary adenoma and its significance].

OBJECTIVE: To investigate and elucidate how to preserve the pituitary stalk in the microsurgery of giant pituitary adenoma (GPA) and its clinical significance. METHODS: 45 GPA patients, 23 males and 22 female; aged 40.8, including 12 cases of invasive pituitary adenoma (IPA) underwent craniotomy based on the respective preoperative neuroradiological imaging characteristics. The anatomical relationship between the pituitary stalk and tumor was recorded. The methods to protect the pituitary stalk were summarized. RESULTS: Total tumor excision was achieved in 25 patients (55.5%), near-total resection was done in 12 (26.7%), and subtotal resection in 8 (17.8%). During the surgical proceeding, the pituitary stalk was distinguished from the tumor and preserved well in all 33 cases with non-invasive giant pituitary adenoma. On the contrary, in the 12 cases of invasive giant pituitary adenoma (IPA) the pituitary stalk was visualized in only 7 cases. In the patients with visualized pituitary stalks 4 pituitary stalks were not identified very well. In most cases (91%) the pituitary stalks were located laterally (on the left or right side) or supero-posterior to the tumor, only a few were located anteriorly. In all 12 IPA patients 2 cases of postoperative hemorrhage occurred associated with remnant tumor and immediate hematoma evacuation was performed, however, one patient died due to hypothalamus injury. CONCLUSION: Pituitary stalk has various anatomical relationships to the entity of GPA; most are located lateral or supero-posterior to the tumor. However, the relationship between the stalk and tumor is not clear in IPA. Identifying and preserving the pituitary stalk well during surgical manipulation will be beneficial to get an excellent outcome.

[Anatomic research of the subtemporal transpetrosalridge approach].

OBJECTIVE: Subtemporal transpetrosal ridge approach (STA) was introduced to remove the petroclival meningiomas with the simple, safe and minimal invasive character. It is suggested to replace the combined approach to reduce the morbidity and mortality. METHODS: Surgical anatomic study was done on 10 adult cadaver heads fixed in 10% formalin and 10 dry skulls. Ten cadaver heads were examined by bone-window CT scan pre and post-operation. The relationships of important anatomic structures and positions were measured and photographed. RESULTS: For the STA, the important structures include Vein of Labbe, petrous bone and brain stem ventral space. The important data include the drilling space of the petrous ridge. CONCLUSIONS: STA is an original approach to remove petroclival meningiomas. By drilling the petrous ridge, it allows the resecion of the tumor simple, safe and minimal invasive. It is suggested to replace the combined approach with STA to diminish the morbidity and mortality.

Posterior petrous meningiomas: 82 cases.

OBJECT: The aim of this study was to discuss posterior petrous meningiomas--their classification, clinical manifestations, surgical treatments, and patient outcomes. METHODS: A retrospective analysis was performed in 82 patients with posterior petrous meningiomas for microsurgery. According to the anatomical relationship with the posterior surface of the petrous bone and with special reference to the internal auditory canal (IAC), posterior petrous meningiomas were classified into three types: Type I, located laterally to the IAC (28 cases); Type II, located medially to the IAC, which might extend to the cavernous sinus and clivus (32 cases); and Type III, extensively attached to the posterior surface of the petrous bone, which might envelop the seventh and eighth cranial nerves (22 cases). Sixty-eight (83%) of 82 cases involved total resection. The rate of anatomical preservation of facial nerve was 97.5%, whereas the functional preservation rate was 81%. The rate of hearing preservation was 67%. All Type I tumors were completely resected, and the rate of anatomical preservation of facial nerve was 100% and functional preservation was 93%. Regarding Type II lesions, 75% of 32 cases involved total resection; the rate of anatomical preservation of facial nerve was 97% and functional preservation was 75%. For Type III lesions, 73% of 22 cases were totally resected. The rate of anatomical preservation of facial nerve in patients with this tumor type was 95%, whereas functional preservation was 73%. CONCLUSIONS: Clinical manifestations and surgical prognoses are different among the various types of posterior petrous meningiomas. It is more difficult for Types II and III tumors to be resected radically than Type I lesions, and postoperative functional outcomes are significantly worse accordingly. The primary principles in dealing with this disease entity include preservation of vital vascular and central nervous system structures and total resection of the tumor as much as possible.

[The diagnosis and microsurgical treatment of solid cerebellar hemangioreticuloma].

OBJECTIVE: To study the clinical features, neuroimaging presentations, diagnosis and differential diagnosis, and operative warning events of the solid cerebellar hemangioblastoma. METHODS: The clinical data of 48 patients with solid cerebellar haemangioreticuloma were retrospectively analysed. Preoperative examinations included CT and MRI in all patients, DSA in 20, preoperative embolization of feeding arteries of tumor in 16, a preoperative ventriculoperitoneal shunt was placed in 5 cases. The lesion distribution of 48 patients was as follows: 14 lesions were situated in the left hemisphere of cerebellum with an extent into the cerebellopontine angle in 2 cases, 12 in right hemisphere of cerebellum, 8 in superior vermis, 7 in inferior vermis, 6 in left subtentorium, 1 in left cerebellar tonsil. RESULTS: The tumors of 48 patients were totally removed. One patient occurred normal perfusion pressure breakthrough during surgery, and gastrointestinal hemorrhage on the second day after operation. Other patients all were intra- and postoperatively uneventful. Except for autoinfusion, no patients transfused heterogenous blood. There were no operative mortality and serious complications in this series. CONCLUSIONS: The solid cerebellar hemangioblastoma was benign neoplasm. Abiding by properly operative techniques, the optimal results can be obtained.

[Microsurgical treatment of cranial-cervical type giant ependymoma within the fourth ventricle in adult patients].

OBJECTIVE: To study the neuroimaging characteristics, microsurgical treatment and prognosis of cranial-cervical type giant ependymoma within the fourth ventricle in adult patients. METHODS: The clinical data of 22 patients with cranial-cervical type giant ependymoma within the fourth ventricle were retrospectively analyzed. The suboccipital and C(1-3) posterior midline approach were performed in all patients. RESULTS: The tumor of all patients not only occupied the cavity of the fourth ventricle but also protruded into the cervical canal through the foramen of Magendie and extended to the cervical 2 or cervical 3 level. The tumor was totally removed in 20 patients, and subtotally removed in 2. Six patients received radiotherapy postoperatively. The time of mean follow-up of all patients was 5.5 years. One patient underwent a second operation 5 years after the first surgical procedure in other hospital due to tumor recurrence. The 5-year survival rate was 100%. All patients recovered their normal life or work. CONCLUSION: Cranial-cervical type giant ependymoma within the fourth ventricle in adult patients has a good prognosis. The surgery with postoperative adjuvant radiotherapy can obtain a optimal results.