Venous angioma of the facial nerve: a case report.

BACKGROUND: Lower motor neurone type facial nerve palsy is a common condition that is very rarely caused by a neoplastic lesion. CASE DESCRIPTION: This case report describes a progressive facial palsy in a 62-year-old man because of a vascular tumor of the facial nerve. Histologic examination confirmed it to be a venous angioma. CONCLUSION: Meticulous imaging of the facial nerve is required to diagnose cases of progressive facial nerve palsy caused by a neoplastic lesion.

Complications after trans-sphenoidal surgery: our experience and a review of the literature.

The incidence of surgical complications after trans-sphenoidal surgery for pituitary lesions is low. The influence of size of the lesion and its pathology on the incidence of different types of complications and the remission rate of functioning adenomas are addressed in this retrospective study. Between 1996 and 2001, 126 trans-sphenoidal operations were performed on 108 patients with pituitary pathologies. Diabetes insipidus (DI) was the commonest (23%) and the incidence was higher with microadenomas and in those with Cushing's disease (p < 0.05). Other important complications were: postoperative hypopituitarism 22%, CSF leak 13%, meningitis 5.5%, pneumocephalus 2.4%, visual deterioration 1.5%, haematoma 0.8% and 30-day mortality rate of 0.8%. Other complications encountered were subdural haematoma, epistaxis, SIADH, sphenoid abscess, deep vein thrombosis, thalamic infarct and hydrocephalus. No vascular injuries were encountered. The overall remission rate for acromegaly and Cushing's disease (22 patients each) was 77 and 81%, respectively. The remission rate was 100% for microadenomas, 89% for both acromegaly and Cushing's disease. More aggressiveness towards complete tumour removal increases the biochemical cure rate of functioning adenomas and on the other hand results in higher incidence of CSF leak and hypopituitarism.

Subdural haematoma after trans-sphenoidal surgery.

We report a patient with pituitary adenoma who developed a subdural haematoma following trans-sphenoidal surgery and conservative management of a postoperative CSF leak with a lumbar drain. The possible causes and methods of treatment are discussed and the neurosurgeon is alerted to the possibility of its development in similar situations.

Transsphenoidal surgery for acromegaly in wales: results based on stringent criteria of remission.

We retrospectively analyzed 90 patients who underwent transsphenoidal surgery (performed by three surgeons) in our center as initial therapy for acromegaly. We used a combination of modern, evidence-based remission criteria including mean day curve GH less than 2.5 micro g/liter (5 mU/liter), a nadir GH less than 1.0 micro g/liter (2 mU/liter) after an oral glucose tolerance test, and normal age-related IGF-I levels (where available). Fifty-seven of 90 (63%) patients remained in remission after surgery. Seventy-nine percent of patients with microadenomas but only 56% of patients with macroadenomas achieved remission (P < 0.001). Eighty-six percent of patients with preoperative GH levels below 10 micro g/liter (day profile or after oral glucose tolerance test) went into remission, compared with 51% of patients with GH levels above 25 micro g/liter at diagnosis (P < 0.002). The remission rate was also related to the period of surgery that was significantly higher in 1998-2001 (76%; P < 0.05) compared with 1990-1997 (54%) and 1980-1989 (63%). There were no recurrences or perioperative deaths. Meningitis occurred in 3% of patients, cerebrospinal fluid rhinorrhea in 7%, and permanent diabetes insipidus in 15%. The proportion of patients who developed new anterior pituitary hormone deficiencies and panhypopituitarism was significantly less in the period 1998-2001 (P < 0.001) when compared with the periods from 1990-1997 and 1980-1989. Transsphenoidal surgery is a safe and effective treatment for acromegaly, and our results compare favorably with those from published series. The presence of an intrasellar lesion and low preoperative GH levels is a good predictor of remission in the long term, but historically in our center this can only be achieved in a significant proportion of patients at the expense of some degree of hypopituitarism. However, surgical outcome in our center, including a reduced frequency of hypopituitarism, has improved significantly over time, coincident with the arrival of a dedicated pituitary neurosurgeon and the use of selective adenomectomy as the preferred surgical approach wherever possible.

Long-term follow-up results of transsphenoidal surgery for Cushing's disease in a single centre using strict criteria for remission.

OBJECTIVE: Transsphenoidal selective adenomectomy (TSA) is widely accepted as the treatment of choice for Cushing's disease but not all patients are cured by this procedure. The success of surgery depends on the skill and experience of the surgeon but the criteria used to define remission are highly variable. We have analysed the outcome following surgery in our centre using the stringent requirement of a postoperative serum cortisol of < 50 nmol/l as our definition of remission and assessed whether changes in surgical policy, including a greater emphasis on selective procedures and the move in recent years to a single surgeon undertaking all pituitary surgery, have improved complication and remission rates. PATIENTS AND METHODS: The case notes, histology and pituitary imaging of 54 consecutive patients (42 females, mean age 41 years) with pituitary-dependent Cushing's syndrome who had undergone transsphenoidal surgery between January 1980 and November 2000 were reviewed. Follow-up was for a median of 6 years (range 6 months to 21 years). RESULTS: One patient died within 1 week of surgery (1.9%) and major morbidity occurred in eight patients (15%). Clinical and biochemical remission was achieved in 41 patients (77%) with only two recurrences (5%) to date. Success was related to tumour size with 37 (86%) of 43 intrasellar lesions successfully resected compared with only four (40%) of 10 extrasellar adenomas. Twenty-four (59%) of those in remission developed partial or complete hypopituitarism compared with four (33%) of those not in remission. The extent of surgical exploration predicted the development of hypopituitarism (88% total hypophysectomy, 33% hemihypophysectomy, 14% selective adenomectomy) but not remission (75% total hypophysectomy, 87% hemihypophysectomy, 71% selective adenomectomy). Among complications, an excess of venous thromboembolic disease was noted, with three patients (6%) developing deep venous thrombosis or pulmonary embolism postoperatively. Comparison of the data for individual surgeons revealed an improvement in outcome over time, with 100% remission of microadenomas, 29% hypopituitarism and 12% complications following the move to a single surgeon undertaking all pituitary surgery. CONCLUSION: Transsphenoidal surgery is a safe and effective treatment for Cushing's disease and our results compare favourably with those from published series, the majority of which comprise relatively small numbers. The presence of an intrasellar lesion and postoperative serum cortisol < 50 nmol/l are good predictors of remission in the long term but historically in our centre this can only be achieved in a significant number of patients at the expense of some degree of hypopituitarism. However, the surgical outcome for Cushing's disease, including a reduced frequency of hypopituitarism, can be improved if patients are operated on by a single pituitary surgeon, using selective adenomectomy as the preferred surgical approach wherever possible.

Spontaneous thrombosis of a giant internal carotid aneurysm in a patient who presented with hypopituitarism.

This case report describes a 66-year-old woman who initially presented with features of hypopituitarism secondary to a giant intra-cavernous internal carotid aneurysm. She represented a year later with features suggestive of a subarachnoid haemorrhage, but repeat CT showed no change from the one performed previously. A repeat angiogram, however, showed complete spontaneous thrombosis of the aneurysm including the parent artery.

Aseptic meningitis after posterior fossa surgery treated by pseudomeningocele closure.

Aseptic meningitis is a recognised complication after posterior fossa surgery. It is often self limiting but occasionally runs a protracted course requiring repeated CSF examination to exclude infection, and treatment with systemic steroids. A patient is described with aseptic meningitis after posterior fossa surgery who underwent posterior fossa re-exploration nearly 3 years after the initial operation. This disclosed a pseudomeningocele, which was closed. The patient remains symptom free almost 2 years after closure. In this case of chronic aseptic meningitis after posterior fossa surgery, closure of the pseudomeningocele found at exploratory surgery led to resolution of the symptoms.

Cerebral tuberculoma.

Intracranial tuberculoma has become a rarity. It remains a curable lesion that responds well to medical therapy. Although diagnosis in developed countries is often made only postoperatively, early and effective treatment can be instituted if a high index of suspicion is maintained and diagnostic criteria are looked for. A case is presented which illustrates the difficulties in reaching a diagnosis, and a review of the literature is given.