Suprasellar and intrasellar paragangliomas.

Neoplasms of the sellar region are entities with a large differential diagnosis. Although paraganglionic cells have not been demonstrated in the pituitary or adjacent structures, the existence of sellar region paragangliomas is well-documented. To elucidate, in this area the nature of these unusual tumors is relatively difficult. Clinical history, physical examination, radiographic investigation as well as intraoperative gross observation are the same as those of sellar meningioma or pituitary adenoma. Immunohistochemistry, using neuroendocrine markers and electron microscopy are the two definitive diagnostic methods to differentiate among these entities. The clinical management, the possible pathogenesis of the tumor, the importance of immunohistochemistry in making the diagnosis and the clinical outcome of these patients are discussed.

Resection of giant meningiomas of the anterior cranial fossa using orbital osteotomies.

AIM: The challenge in large cranial base meningiomas is total resection of the tumor with the least possible mortality and morbidity. During the last two decades the technical approaches for anterior skull base tumors have shown a considerable progress, providing a wide exposure with minimal brain retraction. The purpose of this study is to present our experience with these approaches for treatment of giant anterior cranial fossa meningiomas. METHODS: A retrospective analysis was performed in 20 patients with giant meningiomas (diameter >4.5 cm) of the anterior cranial fossa, which were treated surgically in our department, between January 1992 and January 2002. There were 5 men and 15 women with an average age of 48,3 years. Mental and visual disturbances were the most common presenting symptoms. We used the extended subfrontal approach for 16 patients and the fronto-orbito-zygomatic approach for 4 patients. The follow-up period ranged from 3 to 10 years. RESULTS: In all patients, total resection of the tumor (Simpson grade I, 12 patients, Simpson grade II, 8 patients) was accomplished. Significant improvement occurred by the time of follow-up examination in all but three patients. No evidence of recurrence was observed in 19 of the 20 patients. CONCLUSIONS: The extended anterior skull base approaches, using orbital osteotomies, for giant meningiomas of the anterior cranial fossa have improved the extent of radical tumor removal with minimal neurological morbidity. Furthermore a long term prevention of recurrence was achieved.

Internuclear ophthalmoplegia following minor head injury: a case report.

Internuclear ophthalmoplegia (INO) is a common sign of multiple sclerosis in young patients and of vascular diseases in older people. Traumatic bilateral internuclear ophthalmoplegia following severe head injuries may occur. We present the unusual case of a young patient suffered from bilateral INO as an isolated finding after a minor head injury, without other signs of brain stem or cortical injury. The ophthalmoplegia has persisted for 22 months.

Intrathecal granuloma after implantation of a morphine pump: case report and review of the literature.

BACKGROUND: Intrathecal morphine pumps are being increasingly used in patients with benign pain who have a longer life expectancy than cancer patients. Newer complications may be encountered. CLINICAL PRESENTATION: We report a complication that occurred in a 48-year-old woman who presented with intractable lower back pain 18 months after morphine pump implantation. Magnetic resonance imaging of the lumbosacral spine revealed an intrathecal mass around the catheter. At surgery, an inflammatory mass was found without any evidence of neoplasia or infection. This is a very unusual complication of intrathecal morphine pumps. (Related animal and human studies are reviewed in this article.) CONCLUSION: Long-term use of implantable pumps may carry increased risks that are not observed during the short-term experience of cancer patients. Reimaging is important in evaluating patients who have developed uncontrollable pain and new neurologic findings.

Saphenous vein graft bypass of the sigmoid sinus and jugular bulb during the removal of glomus jugulare tumors. Report of two cases.

Glomus jugulare tumors always invade the jugular bulb and sigmoid sinus, making it difficult to resect these tumors totally without sacrificing the involved sinus. Although the sinus can be sacrificed safely in most patients, a few patients will have serious consequences. Reconstruction of the jugular bulb using a saphenous vein graft may enable tumor resection in these patients without complications. The authors describe two cases of saphenous vein grafting used to bypass the sigmoid sinus. The first case is that of a 61-year-old man with a glomus jugulare tumor that invaded the dominant sigmoid sinus, which was poorly collateralized. Temporary occlusion of the sinus during surgery caused a 15-mm Hg increase in intrasinus pressure, without brain swelling or changes in evoked potentials. A saphenous vein graft was used to bypass the sigmoid sinus and jugular bulb and to allow for total tumor removal. The patient had a good outcome. The second case is that of a 41-year-old man with a left glomus jugulare tumor and another smaller tumor on the opposite, dominant sinus. The left glomus jugulare tumor was resected via a two-stage procedure. A saphenous vein graft was used to reconstruct the left sigmoid sinus because of the presence of contralateral disease, with the potential for bilateral sigmoid sinus occlusion. An evaluation of the venous collateral circulation during jugular foramen surgery and the prevention of complications are also discussed.

Craniofacial osteotomies to facilitate resection of large tumours of the anterior skull base.

Large tumours of the anterior cranial fossa can be a major challenge to the neurosurgeon or the maxillofacial surgeon. However, skull base approaches facilitate their resection. We describe our experience with the extended subfrontal approach in treating tumours of the anterior cranial base. This approach was performed on 29 patients with large tumours of the anterior skull base. The final outcome in all 29 patients was favourable in terms of total resection of the tumour with minimal subsequent neurological deficit. Two patients developed transient oedema of the frontal lobes without persistent neurological sequelae. Another patient developed a postoperative cerebrospinal fluid fistula that was successfully repaired. The patients were followed for a period ranging from 6 to 28 months. There was no recurrence. The operative technique is described. En bloc removal of the roofs of the orbits and part of the anterior cranial fossa permits wide exposure of the lesion with minimal brain retraction. Reconstruction of the anterior cranial base should be meticulous to avoid cerebrospinal fluid leaks and subsequent meningitis. Loss of smell is a sequel to this approach. The possible risks and some important technical details are highlighted.