Targeted sequencing of cancer-related genes reveals a recurrent TOP2A variant which affects DNA binding and coincides with global transcriptional changes in glioblastoma.

High-grade gliomas are aggressive, deadly primary brain tumors. Median survival of patients with glioblastoma (GBM, WHO grade 4) is 14 months and <10% of patients survive 2 years. Despite improved surgical strategies and forceful radiotherapy and chemotherapy, the prognosis of GBM patients is poor and did not improve over decades. We performed targeted next-generation sequencing with a custom panel of 664 cancer- and epigenetics-related genes, and searched for somatic and germline variants in 180 gliomas of different WHO grades. Herein, we focus on 135 GBM IDH-wild type samples. In parallel, mRNA sequencing was accomplished to detect transcriptomic abnormalities. We present the genomic alterations in high-grade gliomas and the associated transcriptomic patterns. Computational analyses and biochemical assays showed the influence of TOP2A variants on enzyme activities. In 4/135 IDH-wild type GBMs we found a novel, recurrent mutation in the TOP2A gene encoding topoisomerase 2A (allele frequency [AF] = 0.03, 4/135 samples). Biochemical assays with recombinant, wild type (WT) and variant proteins demonstrated stronger DNA binding and relaxation activity of the variant protein. GBM patients carrying the altered TOP2A had shorter overall survival (median OS 150 vs 500 days, P = .0018). In the GBMs with the TOP2A variant we found transcriptomic alterations consistent with splicing dysregulation. luA novel, recurrent TOP2A mutation, which was found exclusively in four GBMs, results in the TOP2A E948Q variant with altered DNA binding and relaxation activities. The deleterious TOP2A mutation resulting in transcription deregulation in GBMs may contribute to disease pathology.

Surgical treatment of symptomatic pineal cysts without hydrocephalus-meta-analysis of the published literature.

BACKGROUND: To examine published data and assess evidence relating to safety and efficacy of surgical management of symptomatic pineal cysts without hydrocephalus (nhSPC), we performed a systematic review of the literature and meta-analysis. METHODS: Following the PRISMA guidelines, we searched Pubmed and SCOPUS for all reports with the query 'Pineal Cyst' AND 'Surgery' as of March 2021, without constraints on study design, publication year or status (PROSPERO_CRD:42,021,242,517). Assessment of 1537 hits identified 26 reports that met inclusion and exclusion criteria. RESULTS: All 26 input studies were either case reports or single-centre retrospective cohorts. The majority of outcome data were derived from routine physician-recorded notes. A total of 294 patients with surgically managed nhSPC were identified. Demographics: Mean age was 29 (range: 4-63) with 77% females. Mean cyst size was 15 mm (5-35). Supracerebellar-infratentorial approach was adopted in 90% of cases, occipital-transtentorial in 9%, and was not reported in 1%. Most patients were managed by cyst resection (96%), and the remainder by fenestration. Mean post-operative follow-up was 35 months (0-228). PRESENTATION: Headache was the commonest symptom (87%), followed by visual (54%), nausea/vomit (34%) and vertigo/dizziness (31%). Other symptoms included focal neurology (25%), sleep disturbance (17%), cognitive impairment (16%), loss of consciousness (11%), gait disturbance (11%), fatigue (10%), 'psychiatric' (2%) and seizures (1%). Mean number of symptoms reported at presentation was 3 (0-9). OUTCOMES: Improvement rate was 93% (to minimise reporting bias only consecutive cases from cohort studies were considered, N = 280) and was independent of presentation. Predictors of better outcomes were large cyst size (OR = 5.76; 95% CI: 1.74-19.02) and resection over fenestration (OR = 12.64; 3.07-52.01). Age predicted worse outcomes (OR = 0.95; 0.91-0.99). Overall complication rate was 17% and this was independent of any patient characteristics. Complications with long-term consequences occurred in 10 cases (3.6%): visual disturbance (3), chronic incisional pain (2), sensory disturbance (1), fatigue (1), cervicalgia (1), cerebellar stroke (1) and mortality due to myocardial infarction (1). CONCLUSIONS: Although the results support the role of surgery in the management of nhSPCs, they have to be interpreted with a great deal of caution as the current evidence is limited, consisting only of case reports and retrospective surgical series. Inherent to such studies are inhomogeneity and incompleteness of data, selection bias and bias related to assessment of outcome carried out by the treating surgeon in the majority of cases. Prospective studies with patient-reported and objective outcome assessment are needed to provide higher level of evidence.

Double pituitary adenomas in a large surgical series.

PURPOSE: To explore the incidence of double pituitary adenomas in a tertiary center for pituitary surgery and asses their clinical, imaging and histopathological features. METHODS: The medical records of the patients operated on for pituitary tumors at the Department of Neurosurgery of Military Institute of Medicine in Warsaw, Poland between the years 2003 and 2018 were retrospectively analyzed. Among the 3270 treated patients, the diagnosis of double pituitary adenoma was established in 22 patients. Clinical, laboratory, detailed histopathological and diagnostics imaging data were collected and analyzed. RESULTS: There were 21 cases of synchronous and one case of asynchronous double pituitary adenoma. The main clinical finding was acromegaly (12/22) followed by Cushing's disease (3/22). The diagnosis of synchronous double pituitary adenoma was suspected in the preoperative MRI in 11 patients. In the remaining patients the diagnosis of contiguous double pituitary adenoma was confirmed in the histopathological examination. There was no predilection for gender and the mean observation time was 74.2 months. In one case of Cushing's disease the occurrence of double pituitary adenoma led to the initial failure of achieving hormonal remission. One patient presented with double pituitary adenomas as a manifestation of Carney complex. CONCLUSIONS: Double pituitary adenoma is a rare entity that can pose a significant challenge especially in the setting of Cushing's disease. Careful inspection of preoperative MRI and diagnostic work-up before transsphenoidal surgery and thorough histopathological microscopic examinations with immunohistochemical staining for all pituitary hormones is essential for establishing the diagnosis of double pituitary adenoma.

Are type I dural arteriovenous fistulas safe? Single-centre experience of endovascular treatment of dural arteriovenous fistulas.

INTRODUCTION: There are mixed reports on the incidence of intracranial haemorrhage in patients with dural arteriovenous fistulas. We assessed new proposed risk factors (i.a. number of outflows and outflow diameter) of intracerebral haemorrhage due to intracranial dural arteriovenous fistula and presented our personal experience in endovascular treatment of dural arteriovenous fistulas. MATERIAL AND METHODS: The patient database from January 2006 and December 2016 was reviewed, and 25 patients with 28 dural arteriovenous fistulas were identified. RESULTS: 50% of patients presented with intracerebral haemorrhage. Multiple dural fistulas occurred in 12% of patients. Spearman's rank correlation coefficient revealed that there was a strong association between Cognard classification type and time needed to treat (r = 0.59, p < 0.05), as well as the volume of contrast used (r = 0.77, p < 0.05). Infratentorial (r = 0.53, p < 0.05) and right-sided (r = 0.66, p < 0.05) localisation were more challenging to treat. Bleeding was associated with poorer clinical outcome (r = 0.48, p < 0.05). No significant differences were found between the non-haemorrhagic group and the haemorrhagic group regarding the number of outflows (p = 0.459) and largest outflow diameter (p = 0.298). Clinical evaluation at follow-up was as follows: 56% of patients were asymptomatic, 24% had non-significant disability, maintaining independency, 16% had moderate disability, and 8% died - one in the course of intracerebral haemorrhage and one due to other sustained injuries. There were no reported embolisation-related complications. CONCLUSIONS: To conclude, regardless of presentation, both symptomatic and asymptomatic dural arteriovenous fistulas deserve clinical attention, structured evaluation, and follow-up. Type I fistulas were associated with haemorrhage in 1/3 of all cases. Overall our results indicate that the risk of haemorrhage and dire consequences is multifactorial.

Surgical treatment of pineal cysts in non-hydrocephalic and neurologically intact patients: selection of surgical candidates and clinical outcome.

PURPOSE: Management of patients presenting for various nonspecific complaints without clear neurological abnormalities and with normal ventricular size remains highly controversial. We intended to share our rationale for surgical treatment of patients who show symptoms of transient increase of intracranial pressure owing to the presence of the cyst. MATERIALS AND METHODS: We have retrospectively analyzed 28 cases of patients who presented without Parinaud syndrome nor ventricular enlargement and underwent pineal cyst removal in our centre between 2007 and 2015. We analyzed patients' age, sex, symptoms, preoperative cyst size, perioperative course, treatment outcome and neurologic status at discharge and at follow-up visits 4 and 12 months afterwards. RESULTS: Main complaints included paroxysmal headaches, nausea, vomiting, visual disturbances, syncope and transient depression of consciousness. Mean age of patients was 31 years (17-55); there were 24 females and 4 males. Mean cyst diameter was 17 mm (10-26). Decision about surgical treament was based on signs of transient increases of intracranial pressure. All patients underwent complete cyst excision via midline suboccipital craniotomy and infratentorial supracerebellar route. Short-lasting perioperative neurological signs (notably upgaze palsy) were noted in 22 cases and uniformly resolved within the observation period of 12 months. CONCLUSION: Abnormal neurological findings and ventricular enlargement are not indispensable to justify surgical treatment of pineal cysts. Judicious selection of surgical candidates based predominantly on clinical grounds can lead to excellent operative results.

Subtemporal Approach for Gross Total Resection of Retrochiasmatic Craniopharyngiomas: Our Experience on 30 Cases.

BACKGROUND: Surgical treatment of retrochiasmatic craniopharyngiomas is associated with higher rates of complications, mortality, failure of complete removal, and recurrence compared with craniopharyngiomas located elsewhere. These tumors lie behind the optic chiasm and when large can extend upward into the third ventricle and downward along the brain stem, making their adequate exposure challenging. Most of the proposed techniques either use a translamina terminalis route or require wide bony exposures. In this study, we assessed the feasibility of a subtemporal approach for achieving gross total resection of retrochiasmatic craniopharyngiomas. METHODS: Thirty patients with retrochiasmatic craniopharyngioma underwent surgery via a subtemporal approach. The technique and surgical and preoperative and postoperative endocrinologic outcomes are described in detail. RESULTS: Gross total resection was achieved in all cases. The average tumor volume was 7.59 mL. The average postsurgical observation time was 73.8 months. During this time, 3 recurrences were observed (10.7%). The perioperative mortality was 6.6%. The pituitary stalk was preserved in 13 cases. Partial preservation of the pituitary stalk did not offer any advantage in terms of pituitary function. No postoperative vision worsening or new fixed neurologic deficits were observed. Among the 22 patients with preoperative vision impairment, 18 reported a significant improvement. The most common abnormalities within the temporal lobe on the side of the exposure seen on control magnetic resonance imaging were mild temporal horn enlargement (13 cases) and T2 hyperintensity (7 cases). CONCLUSIONS: A subtemporal approach can be an attractive alternative approach to accessing retrochiasmatic craniopharyngiomas. Outcomes are comparable to those associated with other widely used and time-consuming exposures.

Outcome Assessment After Surgical Treatment of Tuberculum Sellae Meningiomas- A Preliminary Report.

AIM: To evaluate the endocrinological and ophthalmological results of the tuberculum sellae meningioma surgery. MATRRIAL and METHODS: A total of 18 patients diagnosed with tuberculum sellae meningioma received surgical treatment at Neurosurgery Clinic at Military Medical Institute in Warsaw from January 2010 to July 2012. This analyzed group of patients included 15 females and 3 males at a mean age of 50.5 years (ranging from 30 to 73; SD ± 13.4). In the pre-operative and post-operative periods, all patients underwent magnetic resonance imaging of the head according to a uniform protocol, eye examinations with assessment of visual acuity and field of vision, as well as endocrine tests to evaluate the hypothalamic-pituitary axis (including urine specific gravity and osmolality as well as blood cortisol, TSH, fT3, and fT4 levels). All patients underwent surgical treatment of the tumor via unilateral subfrontal craniotomy, achieving macroscopically complete tumor removal (Simpson grade II resection). RESULTS: The use of the unilateral subfrontal approach helped improve vision in 88% of the treated patients. Endocrine tests revealed no hypothalamic-pituitary axis dysfunction. The most commonly diagnosed meningiomas of the area were meningothelial (77%) and transitional (12%) meningiomas. CONCLUSION: Surgical treatment of tuberculum sellae meningiomas via the unilateral subfrontal approach is a safe technique with no significant complications. Visual improvement was observed in 88% of the patients who had received this treatment. There were no hormonal disturbances in patients operated via the subfrontal approach either prior to or after the procedure, which suggests that surgical treatment of tuberculum sellae meningiomas has no effect on pituitary endocrine function.

[Treatment methods of atypical gunshot wounds to the head--case reports]. / Sposoby leczenia nietypowych obrazen postrzalowych glowy--opisy przypadków.

Due to a high mortality rate, headshot injuries pose serious diagnostic and clinical problems. In this work, we wanted to describe four atypical headshot injuries. The first patient with a headshot injury using a nail gun mishap; the second one after a headshot injury, as a result of attempted murder (the bullet came to a parasagittal halt in the left parietal area); the third victim, after a suicide attempt (the bullet was removed from clivus area, below the pituitary gland); in the case of the fourth patient, after shooting himself with a self-constructed weapon in the chin, the metal body was surgically removed - a bearing pellet from the corpus callosum. Males dominate among victims of headshot injuries. Alcohol is one of the elements that facilitate suicidal behaviour. Anti-spasm, antibacterial, anti-tetanus prophylaxes are incredibly important. In some cases, the metallic body does not have to be removed from the brain. Pulmonary embolism can be a cause of death after 7 days from injury.

Papillary tumor of the pineal region. Report of two cases and literature review.

Papillary tumor of the pineal region (PTPR) was introduced to the WHO classification in 2007. This rare tumor of little known natural history and unpredictable behavior was described in fewer than 100 cases. Its optimal treatment is not established yet. We report another two cases of PTPR in whom tumors were totally removed via supracerebellar infratentorial approach and both were treated with radiotherapy. In a 37-year-old man the operation was delayed 6 years after the first tumor diagnosis and subsequent shunt placement. He has no complaints 10 years after the onset of the disease. A 45-year-old woman has no complaints 24 months after surgery. Our experience and the data from literature indicate that a total tumor removal is the major prognostic factor.

Skull base secretory meningioma. Value of histological and immunohistochemical findings for peritumoral brain edema formation.

Meningiomas are very common neurosurgical problem. Their histological appearance, different size and localization, adherence to vital neural and vascular structures or extensive peritumoral brain edema (PTBE), especially in deep seated tumors, may lead to severe, life-threatening complications. We report a case of tuberculum sellae meningioma (TSM). A 48-year old female presented with 7-month history of blurred vision and progressive visual impairment. Intracranial tumor was confirmed by magnetic resonance imaging (MRI). After ophtalmological and endocrinological evaluation, the patient underwent surgical removal of the tumor. She immediately recovered from her visual disturbances and no tumor recurrences were seen during follow-up. Pathological diagnosis showed a meningioma of the secretory subtype (MS). We discuss the role of immunohistochemical staining in the diagnosis and the role of different factors in the PTBE formation. Selection of surgical route to the TSM is discussed, as well. Review of the literature is presented.

Spontaneous regression of non-functioning pituitary adenoma due to pituitary apoplexy following anticoagulation treatment - a case report and review of the literature.

Pituitary apoplexy (PA) is a rare, potentially life-threatening medical condition due to acute ischaemia or haemorrhage of the pituitary gland. The main clinical features are: abrupt onset of severe headache, nausea, vomiting, deteriorating level of consciousness, visual impairment and/or endocrine deficiency. Correct and prompt diagnosis is essential for effective therapy, but there are no randomised studies or strict recommendations defining treatment modalities. We present the case of a 59 year-old woman with pituitary tumour apoplexy, presenting with severe headache, vomiting and visual field deterioration. The patient was treated conservatively because of her refusal of surgery and was followed-up for five years. In the course of treatment, recovery of the visual field defects, as well as right sixth cranial nerve paresis, was observed. Repeated magnetic resonance imaging (MRI) revealed regression of the tumour without signs of its re-growth. We discuss therapeutic modalities with particular emphasis on morbidity and review the literature relating to the management of pituitary tumour apoplexy.

Identification of mutations in the NF2 gene in Polish patients with neurofibromatosis type 2.

Point mutation and loss of heterozygosity (LOH) analyses were performed in 12 Polish patients with a classic symptom of NF2 - bilateral vestibular schwannomas (BVS). In 5 patients (41.7%), germline mutations were found in the NF2 gene: 2 previously reported substitutions (c.592C>T and c.52C>T) and 3 novel mutations (c.1001_1002insG, c.1029_1030insCC, c.774_778dupGAATG). In addition, LOH analysis of 30 tumour samples from 10 patients revealed a molecular basis of NF2 in 3 patients (25%) that did not have any germline mutation. The molecular defects in sporadic cases of NF2 are still being discussed.

[Reconstruction of the sellar floor in transsphenoidal surgery: our experience of 818 patients]. / Rekonstrukcja dna siodla tureckiego po przezklinowej operacji guzów przysadki: doswiadczenia na podstawie 818 przeprowadzonych operacji.

BACKGROUND AND PURPOSE: Transsphenoidal microsurgery (TSS) is the method of choice for resection of most pituitary tumors. Postoperative cerebrospinal fluid rhinorrhea is one of the most frequent complications of TSS. Its incidence ranges from 1.3 to 9.6%. Failure to close a cerebrospinal fistula can result in life-threatening complications e. g. meningitis or tension pneumocephalus. Therefore sellar closure has to be done properly certainly and has to be watertight. The aim of the study was to evaluate the results of reconstruction of the skull base after TSS with autologous material (fascia lata and fat or muscle). MATERIAL AND METHODS: Our operative experience of reconstruction of the sellar floor during transsphenoidal surgery is described. We report the well known method of the sellar closure using autologous tissue (fascia lata and fat or muscle). We did not use other materials e.g., fibrin glue, titanium mesh etc. This technique has been performed in 316 patients. RESULTS: The postoperative cerebrospinal fluid leakage occurred in 7 patients. Four of them underwent early reoperation. Three others were treated successfully with lumbar drainage. In another patient, a cerebrospinal fistula occurred during chronic pharmacotherapy of the giant PRL-secreting adenoma. Transsphenoidal reconstruction of the skull base according to the described method was performed in that case. Lethal meningitis occurred in one patient in our group. CONCLUSION: In our opinion the described method of reconstruction of the sellar floor is easy, safe and very effective.

[Intrasellar arachnoid cyst. A case report and review of the literature]. / Sródsiodlowa torbiel pajeczynówki. Opis przypadku i przeglad pismiennictwa.

Intrasellar arachnoid cyst (IAC) is a very rare pathological lesion occurring in 5 of 1000 autopsy cases, and constitutes 9% of all arachnoid cysts. As a space-occupying mass, IAC may cause headaches, visual disturbances, hypopituitarism, precocious puberty, and the "bobble-head doll" syndrome. The pathogenesis of IAC remains controversial. Magnetic resonance imaging (MRI) is the neurodiagnostic tool of choice to evaluate IAC. The authors presented a 38 year-old woman suffering from severe chronic headaches, dysmenorrhea, and visual disturbance. MRI revealed an intrasellar cystic lesion that had compressed the optic chiasma. Preoperative endocrinological assessment revealed hyperprolactinemia and hypogonadotropic hypogonadism. The patient underwent transsphenoidal surgery. The cyst membrane was opened and clear, serous fluid was evacuated. The postoperative course was complicated by CSF leakage, which was corrected by an autologous fat graft placement. Visual field defects improved immediately after surgery but a transient panhypopituitarism and diabetes insipidus occurred. Postoperative MRI revealed no recurrence of the lesion during the four-year follow-up.

[Transsphenoidal surgery of secretory and invasive pituitary adenomas (somatotropinoma or corticotropinoma)--own experiences]. / Zastosowanie dostepu przezklinowego w leczeniu operacyjnym czynnych hormonalnie (wydzielajacych GH lub ACTH) inwazyjnych guzów przysadki mózgowej--doswiadczenia wlasne.

UNLABELLED: Invasive pituitary adenomas with extension to the cavernous sinus are rare and comprise 6-10% of all pituitary tumors. Their effective surgical treatment is very difficult. Cavernous sinus invasion increases the morbidity and mortality associated with surgical procedures. Prolonged medical treatment and radiotherapy are an alternative to the surgery. PURPOSE: Efficiency of the extended transnasal transsphenoidal approach in the treatment of the invasive pituitary adenomas with extension to the cavernous sinus. MATERIAL AND METHOD: During the past two years (from January 2000 to December 2001) authors carried out 24 surgical operation in the medial compartment of the cavernous sinus (extended transnasal transsphenoidal approach). Our experience is based on the analysis of 24 patients (19 patients with GH-secreting tumors and 5 patients with ACTH-secreting adenomas--2 with Cushing disease and 3 with Nelson's syndrome) with invasive macroadenomas expanding to the cavernous sinus. Mean age was 46.21 years (range 28-68, SD +/-9.54 years) in our group. Mean serum GH level was 43.95 microg/l (range 9-170 microg/l, SD +/-39.68 microg/l) and mean serum ACTH level in the group of Nelson's syndrome was 1180 pg/ml (range 790-1780 pg/ml, SD +/-527.35 pg/ml). Parasellar extension of the tumor was measured according to Knosp's scale. There were 16 patients in stage III and 9 patients in stage IV. RESULTS: Total surgical removal of invasive GH-secreting adenoma (according cure criteria: basal serum GH level below 2.5 microg/l, OGTT<1 microg/l, normal sex and age-related IGF-I level) we achieved in 6 patients. Basal serum GH level was below 5 microg/l (postoperative mean serum IGF-I level was significantly lower but abnormal) in the next five patients. Remission (normalization of 24-hour urine-free cortisol (UFC) and its metabolites) was achieved in one patient with Cushing disease. Out of 3 patients with Nelson's syndrome two were cured. Their postoperative serum ACTH level was below 80 pg/ml. There were no mortality and no deterioration of cranial and optic nerves. CSF leakage occurred in one patient and was treated surgically. Deterioration of pituitary function and diabetes insipidus occurred in one patient. CONCLUSION: Extended transnasal transsphenoidal approach is the safe surgical procedure in the treatment of invasive GH or ACTH-secreting pituitary adenomas. The overall morbidity rate of this surgical intervention is rare. We suppose the extended transnasal transsphenoidal approach is an alternative for prolonged medical treatment and radiotherapy.

[Own experience in surgical treatment of the pineal region and midbrain tumors via the infratentorial approach]. / Wlasne doswiadczenia w leczeniu chirurgicznym guzów okolicy szyszynki i sródmózgowia z zastosowaniem dostepu podnamiotowego.

Nine cases of tumours located in the pineal and midbrain region in adults operated on between November 1998 and July 2002 in Dept. of Neurosurgery, Central Military Hospital in Warsaw are reported. The patients (2 men and 7 women) were aged from 27 and 69 years (mean age 43.6 years). Their main initial symptoms were caused by hydrocephalus. The histopathological examination revealed anaplastic pinealoma in 2 cases, and pineocytoma, pineal cyst, mesencephalic glial cyst, protoplasmatic astrocytoma, epidermoid cyst, unclear glial scar, and papillary ependymoma in single cases. Five patients had been treated, usually elsewhere, with shunt implantation prior to the surgery. Occipito-suboccipital osteoplastic craniotomy was performed in each case and tumours were totally removed microsurgically via the infratentorial epicerebellar approach. In one case a part of the glial periaqueductal tumour was resected additionally via the fourth ventricle and aqueduct in one stage. Postoperative haematomas in the third and fourth ventricle were found in 2 cases. Main complaints after the surgery included transient diplopia. All the patients improved significantly and resumed their previous life activities. Follow-up ranged from 3 to 44 months. Three patients with pineal tumours and one with a small postoperative ependymoma recurrence were irradiated after the surgery. One patient had been irradiated prior to surgery. Very good results of the surgical treatment of tumours in this area suggest that such patients should be referred earlier to one stage surgical management, as the procedure is easier to perform and shunt implantation may be avoided.

[Preliminary evaluation of risk and effectiveness of early choline alphoscerate treatment in craniocerebral injury]. / Wstepna ocena ryzyka oraz skutecznosci wczesnego wlaczenia alfosceranu choliny w leczeniu urazów czaszkowo-mózgowych.

UNLABELLED: Pharmacological treatment of craniocerebral injuries (CCI) to a large extent involves correction of metabolic disturbances resulting from primary and secondary mechanisms of trauma. Choline alphoscerate (CA), a substrate of phosphatydylocholine and a carrier of choline, plays a major role in phospholipidic transformation of the neuronal cell wall. OBJECTIVE: To goal of the study was to evaluate the risk and efficacy of early CA treatment in patients with CCI. MATERIAL: Twenty three CCI patients were treated with CA in the years 2001-2002. In 8 cases an acute subdural haematoma with multiple hemorrhagic foci was diagnosed. Six patients were diagnosed with cerebral contusion with multiple hemorrhagic foci, while 9 patients suffered from concussion of the brain. The patients' condition was assessed at admission using the adult trauma score (ATS)--11 patients scored 8 points on the ATS, 4 patients scored 9, and 8 patients scored 11 points. METHODS: The inclusion criterion was the patient's clinical status at admission in the range 8-11 ATS points. CA was administered according to the following schedule: 1.0 g/d i.m. for 14 days, then 0.8 g/d orally for the next 28 days. AC (Gliatilin) produced by Italfarmaco was used in the study. The cost of this CA treatment was estimated by the producer at PLN 424. RESULTS: After three months of the treatment an improvement was noted in 96% of the patients. Fourteen patients were independent and professionally active, another five were independent, but did not work, while three patients required permanent care. One patient died because of pneumonia. No complications due to the CA treatment were observed in the group studied. CONCLUSIONS: Early treatment with CA is safe and as a component of complex pharmacotherapy has a beneficial effect on the treatment outcome in CCI patients.

[Surgical treatment of invasive pituitary adenomas (somatotropinoma or corticotropinoma)]. / Leczenie operacyjne czynnych hormonalnie (wydzielajacych GH lub ACTH) inwazyjnych gruczolaków przysadki mózgowej.

AIM OF THE STUDY: To evaluate efficiency of the transcranial epidural approach in the treatment of invasive GH- or ACTH-secreting pituitary adenomas with extension to the cavernous sinus. MATERIAL AND METHODS: During the past two years (from January 2000 to December 2001) 14 patients with invasive GH- or ACTH-secreting pituitary adenomas extending to the cavernous sinus were operated on using the transcranial epidural approach. Our experience is based on an analysis of 12 patients with GH-secreting tumors and 2 patients with ACTH-secreting adenomas. The patients' mean age was 45.36 years (range 28-66, SD +/- 10.26 years). Parasellar extension of the tumor was measured using the Knosp scale--in all the cases there was an extension to the cavernous sinus, in stage III (4 patients) or stage IV (10 patients). RESULTS: In none of the cases a total surgical removal of the invasive GH-secreting adenoma was attained (according the following cure criteria: basal serum GH level below 2.5 micrograms/l, OGTT < 1 microgram/l, normal sex- and age-related IGF-I level). In four patients the surgery resulted in a reduction of the basal serum GH level to below 5 micrograms/l (their postoperative mean serum IGF-I level was 530 micrograms/l--significantly lower, but still abnormal, p < 0.05). In a single case of a female patient the basal serum GH level was below 10 micrograms/l, while in other 7 patients the GH level remained above 10 micrograms/l. Remission (normalization of 24-hour urine-free cortisol (UFC) and its metabolites) was achieved in one patient with the Cushing disease. There were no complications involving case fatality. A transient deterioration of the third cranial nerve function observed in one patient disappeared within 3 months from the surgery. There was no deterioration of pituitary function and no cases of diabetes insipidus in our group. CONCLUSION: Transcranial epidural approach is an alternative to radiotherapy and/or prolonged medication in the treatment of invasive GH- or ACTH-secreting pituitary adenomas.