The use of 1.5 T magnetic resonance imaging for therapeutic decisions in patients with cardiac implantable electronic devices and significant neurological, neurosurgical and neuro-oncology diagnostic indications.

UNLABELLED: Between September 2009 and May 2014 the classification of 36 patients with cardiac implantable electronic devices (CIEDs) in terms of the feasibility of MRI scanning due to strong clinical indications was carried out. Finally MRI examinations were performed in 20 patients, of whom 27 studies were conducted and a total number of 35 anatomical regions were scanned. Neurological, neurosurgical and neuro-oncology indications for MRI were reported in 19 patients (95%) in whom 26 MRI studies (96.3%) were performed, and 34 anatomical regions (97.1%) were scanned. One patient had indications for MRI in the field of cardiology. Medical information obtained from 27 MRI studies allowed decisions to be made regarding the treatment in all patients. After 8 studies (29.6%), patients were classified into 9 different neurosurgical procedures. In the case of the remaining 19 studies (70.4%), there were no indications for surgical treatment and the decisions to implement conservative treatment were made. There were no complications related to the implanted CIEDs observed: neither immediate nor in the follow-up.

Interesting coincidence of atypical TSH-secreting pituitary adenoma and chronic lymphocytic leukemia.

Thyrotropin-secreting adenomas (TSH-oma) are very rare pituitary tumours. They are macroadenomas usually presenting with signs and symptoms of hyperthyroidism, and mass effects. They can co-secrete other hormones such as growth hormone or prolactin. Different malignancies, including haematological ones, are reported in patients with pituitary diseases. Chronic lymphocytic leukemia (CLL) occurs mostly in older patients, more often in males. CLL is associated with increased risk of second malignancies such as other blood neoplasms, skin and solid tumours. We present a successful neurosurgical outcome in a patient with an interesting coincidence of atypical TSH-oma and asymptomatic CLL.

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.

Double, synchronous pituitary adenomas causing acromegaly and Cushing's disease. A case report and review of literature.

Double pituitary adenomas are very rare and present up to 1 % of pituitary adenomas in unselected autopsy series and up to 2 % in large surgical series. We report a case of a 47-year-old man presented slight clinical features of acromegaly with 2 years duration. Endocrine evaluation confirmed active acromegaly and revealed adrenocorticotropin hormone-dependent hypercortisolemia. Preoperative magnetic resonance imaging of the pituitary demonstrated clearly separated double microadenomas with different intensity. The patient underwent transsphenoidal surgery and both tumors were completely removed and were fixed separately. The histological and ultrastructural examination confirmed coincidence of the double, clearly separated pituitary adenomas in one gland. Postoperative function of the hypothalamo-hypophyseal axis was normalized. We conclude from this case and a literature review that double endocrinologically active pituitary adenomas leading to acromegaly and Cushing's disease may occur. Additionally, a review of the literature regarding multiple pituitary adenomas has also been performed.

The impact of transsphenoidal surgery on glucose homeostasis and insulin resistance in acromegaly.

BACKGROUND AND PURPOSE: Impaired glucose tolerance and overt diabetes mellitus are frequently associated with acro-megaly. The aim of this study was to find out whether these alterations could be reversed after transsphenoidal surgery. MATERIAL AND METHODS: Two hundred and thirty-nine acromegalic patients were studied before and 6-12 months after transsphenoidal surgery. Diagnosis of active acromegaly was established on the basis of widely recognized criteria. In each patient, glucose and insulin concentrations were assessed during the 75 γ oral glucose tolerance test (OGTT). To estimate insulin resistance, we used homeostasis model assessment (HOMA-IR) and the quantitative insulin sensitivity check index (QUICKI). RESULTS: At the moment of diagnosis, diabetes mellitus was present in 25% of the acromegalic patients. After surgery, the pre-valence of diabetes mellitus normalized to the level present in the general Polish population. We found a statistically significant reduction after surgery in plasma glucose levels both fasting (89.45 ± 13.92 mg/dL vs. 99.12 ± 17.33 mg/dL, p < 0.001) and during OGTT. Similarly, a prominent reduction in insulin secretion was found after surgery compared to the moment of diagnosis (15.44 ± 8.80 mIU/mL vs. 23.40 ± 10.24 mIU/mL, p < 0.001). After transsphenoidal surgery, there was a significant reduction in HOMA-IR (3.08 vs. 6.76, p < 0.0001) and a significant increase in QUICKI (0.32 vs. 0.29, p < 0.001). There were no statistically significant differences after surgery in fasting glucose and insulin levels between patients with controlled and in-adequately controlled disease. CONCLUSIONS: We conclude that in acromegalic patients glucose homeostasis alterations and insulin sensitivity can be normalized after transsphenoidal surgery, even if strict biochemical cure criteria are not fulfilled.

An image-guided, noninvasive method of cannulation of the foramen ovale for awake, percutaneous radiofrequency rhizotomy.

The authors describe a simple and low-cost technique for image-guided cannulation of the foramen ovale during treatment of medically refractory trigeminal neuralgia using percutaneous radiofrequency rhizotomy. Computed tomography-guided neuronavigation and the noninvasive ear, nose, and throat Small Active Frame system were applied for visualization of cannulation of the foramen ovale in the awake patient. Use of invasive head-clamp fixation was unnecessary. Three patients were treated using this technique in which the foramen ovale was reached using a single tract. No adverse effects of this technique were reported. The potential benefits and disadvantages of this method are presented.

Obsessive-compulsive disorder secondary to a right parietal lobe haemorrhage: a case report.

This case report presents a 39-year-old previously healthy man, who presented with typical obsessive-compulsive disorder and neurological symptoms and was found to have a right parietal lobe haemorrhage. His psychiatric and neurological recovery was associated with a complete radiological resolution. This report is consistent with recent imaging studies implicating the parietal lobe in the pathogenesis of obsessive-compulsive disorder and adds haemorrhage to the list of organic cerebral lesions causally associated with this disorder.

A follow-up of 130 patients with acromegaly in a single centre.

OBJECTIVES: Acromegaly is a rare disease with increased mortality rate. The aim was to present our centre experience in the diagnosis and treatment of a series of patients suffering from acromegaly. METHODS: 130 patients (55 men, 75 women) aged 19-84 years presenting with clinical and hormonal features of acromegaly, attending Department of Endocrinology and Out-patient Clinic between 1990 and 2004 were studied. They were analyzed their GH and IGF-1 levels, CT and MRI scans, and they were administered medical therapy, neurosurgery and radiotherapy. RESULTS: We have observed 106 macro-, 16 microadenomas and 1 case of ectopic GHRH. 115 patients were operated, as cured were recognized 74 of them. Pituitary irradiation was applied to 11 patients, in 4 of them it did not cure the disease. Medical therapy was efficacious in 12% patients treated with bromocriptine, 73% with long-acting lanreotide and 58% with long-acting octreotide. In 7 patients other malignant neoplasm were detected. 11 patients died during the follow-up. CONCLUSIONS: There is possible underdiagnosis of acromegaly in our region, especially in males. We have observed better diagnostic opportunities in recent years when MRI was available. It was accompanied by better outcome of surgical and pharmacological treatment and better control of the complications of the disease.

[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.

[Severe cardiovascular complications due to the pituitary adenoma with acromegaly. An interdisciplinary approach to the treatment. A case report]. / Ciezkie powiklania sercowo-naczyniowe w przebiegu guza przysadki powodujacego akromegalie. Propozycja równoczesnego wielospecjalistycznego leczenia. Opis przypadku.

Acromegaly reduces life expectancy and leads to 3-5-fold increase in mortality. The main causes are cardiovascular, pulmonary and enhanced prevalence of deaths from malignancy. Successful therapy ought to normalize GH, IGF-I secretion, remove the adenoma mass and its local pressure effects and preserve pituitary functions intact to improve systemic morbidity and normalize mortality. The primary therapy for most patients with acromegaly is still transsphenoidal adenomectomy. The authors present a 64-year-old woman with diagnosed GH-secreting pituitary macroadenoma suffering from severe coronary heart disease and diabetes mellitus. Somatostatin analogue therapy was ineffective in our patient. She was unfit for transsphenoidal adenomectomy. The patient was qualified for coronary artery bypass grafting after cardiological investigation. We have decided to carry out the bypass grafting and transsphenoidal adenomectomy during one anaesthesia. Both surgical procedures and postoperative time were uncomplicated. Our patient feels well and she is in outpatient follow-up.

[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.

[Surgical treatment for Rathke cleft cysts]. / Leczenie chirurgiczne torbieli kieszonki Rathke'go.

Surgical treatment for Rathke cleft cysts--Intrasellar and suprasellar cysts are often lesions observed in the neuroradiological examinations. The majority of them (craniopharyngioma, cystic pituitary adenoma) are histologically neoplasmic. The others originate from the remnants of the embryonic diverticulum which arise from the roof of the stomodeum. Rathke cleft cyst is the most common cystic developmental lesion of the pituitary gland. It is located within the sella turcica as well as over the diaphragm, near the stalk. Occasionally, they may become large enough to cause typical symptoms and signs headaches, adenohypophysis disfunction, diabetes insipidus and visual field defects. Asymptomatic Rathke cleft cyst should be observed (detailed endocrinological and radiological examination of the pituitary gland). Magnetic resonance imaging (MRI) is the preferred neurodiagnostic study in evaluating the Rathke cleft cyst. Aspiration of cyst contents and cyst wall biopsy or it's total removal are the operative treatment of the symptomatic cysts. Transsphenoidal approach is usually effective. Reccurence of Rathke cleft cyst after surgical treatment is rare. The authors present 16 cases of Rathke cleft cysts operated on during the period from January 1996 to December 2002. We observed 12 intrasellar cysts and 4 suprasellar lesions. Fourteen patients underwent transsphenoidal procedure and four patients were operated on via transcranial route. Histological examination confirmed Rathke cleft cyst. There were no serious complications in our group. Follow-up examination comprises periodic endocrinological and radiological investigations.

La llamada depresión mayor en el curso de la enfermedad de cáncer diseminado con metástasis numerosas / The call major depression in the course of the disseminated cancer with multiple metastases

Muchos autores demuestran, sobre los ejemplos de sus pacientes, que sertralina es una medicación más eficaz y mejor tolerada en el tratamiento de la "depresión mayor" en el curso de las enfermedades de cáncer con metástasis. Presentamos el caso de una entrenadora de gimnasia.

La llamada depresión mayor en el curso de la enfermedad de cáncer diseminado con metástasis numerosas / The call major depression in the course of the disseminated cancer with multiple metastases

Muchos autores demuestran, sobre los ejemplos de sus pacientes, que sertralina es una medicación más eficaz y mejor tolerada en el tratamiento de la "depresión mayor" en el curso de las enfermedades de cáncer con metástasis. Presentamos el caso de una entrenadora de gimnasia. (AU)

[Radionuclide cisternography in the diagnosis of normal pressure hydrocephalus]. / Cysternografia radioizotopowa w rozpoznawaniu wodoglowia z prawidlowym cisnieniem plynu mózgowo-rdzeniowego.

An overview of significant research results of the last four decades as well as the author's own experience have served as a basis for the presentation of the radioisotope method and the radiopharmaceuticals in the diagnostics of normal pressure hydrocephalus (NPH). Also the physiology of the formation of PM-R its flow and absorption have shortly been discussed. Hydrocephalus is a major clinical, diagnostic and therapeutical problem. In the initial diagnosis of that pathology, methods like CT and MRI play an important role, which has also been the subject of this article. A clear and useful classification of hydrocephalus has been presented as well as NPH in adults as a clinical pathological syndrome together with its etiology, diagnostics and the differentiation in relation to other forms of hydrocephalus. Hydrocephalus and the atrophy of the brain have been illustrated by images taken by the author. In the assessment of the NPH in terms of a patient's qualification for a shunting operation a number of diagnostic factors are of particular importance. These are: the infusion test using PM-R pressure measurement of the ventricle system or the subarachnoid space on the spinal cord level, the neuropsychological evaluation as well as the brain imaging using emission tomography SPECT or the measuring of the brain metabolism by PET technique. None of these methods has been universal in diagnostic terms. Radionuclide cisternography seems to be the most physiological method that allows to gain more direct insight into the dynamics and the PM-R flow and its absorption. The results of the radioisotope examination turn out to be the most reliable criterion in the diagnostics of NPH.

[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.

Hydrogen-1 MR spectroscopy of the peritumoral zone in patients with cerebral glioma: assessment of the value of the method.

RATIONALE AND OBJECTIVES: The determination of tumor boundaries, especially in high-grade glioma, is critically important for the proper planning of treatment, but the standard diagnostic imaging methods do not enable precise delimitation of the extent of tumor cell infiltration into the surrounding tissue. The objective of this study was to assess the usefulness of hydrogen-1 (H-1) magnetic resonance (MR) spectroscopy for determining the extent of gliomatous infiltrate in the "uncertain zone'--the peritumoral area that appears unchanged on standard diagnostic MR images. MATERIALS AND METHODS: The study group consisted of 64 patients with cerebral glioma scheduled for tumor resection and subsequent radiation therapy. All patients were examined prior to resection with MR imaging and MR spectroscopy. MR spectra were obtained from examination of the solid part of the tumor and from two peritumoral volumes of interest located approximately along the axis of surgical access to the tumor. MR spectra obtained from a group of 32 healthy volunteers were used as control data. RESULTS: Analysis of the consequent voxels in the peritumoral zone revealed statistically significant differences in lipid/creatine and lactate/creatine metabolite ratios between patient subgroups with recurrent malignant lesions and without recurrent lesions. Significant differences also were found between the patient group and the control group in most metabolite ratios assessed. CONCLUSION: H-1 MR spectroscopic demonstration of metabolic changes in the peritumoral zone can guide treatment for cerebral glioma, enabling the physician to identify patients who have a high risk of recurrence.

[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.