Collision Tumor in the Pituitary, Concurrent Pituitary Adenoma, and Craniopharyngioma

Collision tumors are two independent, distinct tumors occupying the same anatomical space. This case presents a pituitary adenoma-craniopharyngioma collision tumor presenting with hemianopsia. A 60-year-old with a past history of a nonsecretory pituitary adenoma presented with progressive headaches, bitemporal hemianopsia, and nausea. Previously, in 2008, his adenoma was effectively treated with nasal septal flap and transsphenoidal pituitary resection. A magnetic resonance imaging (MRI) was ordered for concern of recurrence, given his history and neurologic complaints. The MRI revealed a suprasellar mass extending into the third ventricle with displacement of the hypothalamus and optic chiasm. Laboratory testing revealed no indicators of endocrinopathy. The neurosurgical and otolaryngologic teams were elected to perform tumor resection given the ongoing symptoms. An image-guided transsphenoidal tumor resection with abdominal fat graft harvest and septal mucosal flap CSF leak repair was performed. Histopathological examination revealed two tumor components within the resection including an adamantinomatous craniopharyngioma and recurrent pituitary adenoma.

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Microsurgical Resection of a C1-C2 Dumbbell and Ventral Cervical Schwannoma: 2-Dimensional Operative Video

Operative Neurosurgery ◽

10.1093/ons/opaa138 ◽

2020 ◽

Vol 19 (4) ◽

pp. E407-E408 ◽

Cited By ~ 1

Author(s):

Vincent N Nguyen ◽

Nickalus R Khan ◽

Kenan I Arnautović

Keyword(s):

Spinal Cord ◽

Evoked Potential ◽

Tumor Resection ◽

Motor Evoked Potential ◽

Senior Author ◽

Neurological Function ◽

Fat Graft ◽

Csf Leak ◽

Pin Fixation ◽

Microsurgical Resection

Abstract Dumbbell schwannoma of the cervical spine is a known entity,1-5 and should be radically resected with the preservation or improvement of neurological function. However, to our knowledge, an operative video of a C1-C2 cervical dumbbell schwannoma with ventral extension and dorsal spinal cord compression has not been reported previously. This tumor resection video performed by the senior author (KIA) includes details of dural opening, and techniques for microsurgical resection and for postoperative closure to avoid cerebrospinal fluid (CSF) leak and pseudomeningocele formation. Fat grafting was performed through a small paraumbilical incision. The patient was prone in MAYFIELD 3-point pin fixation (Integra LifeSciences, Plainsboro Township, New Jersey). Intraoperative neurophysiological electrodes were placed for somatosensory evoked potential (SSEP) and motor evoked potential (MEP) monitoring. Stealth neuronavigation was used to aid in tumor localization. A small suboccipital craniectomy and C1 laminectomy were performed before opening the dura. Using a microsurgical technique, the dura was opened in the form of the letter “Y.” The right-sided dentate ligament was cut to aid in the mobilization of the tumor away from the spinal cord. After dividing the tumor at the dumbbell isthmus, the ventral tumor component was removed, with attention paid to the division of a perforator coming from the vertebral artery. Intraforaminal tumor debulking was performed with a cavitron ultrasonic surgical aspirator (CUSA) and resected. High cervical dumbbell schwannoma should be radically resected while preserving and improving preoperative neurological function. Avoidance of CSF leak and formation of pseudomeningocele should be planned at the beginning, utilizing fascia and fat graft to avoid this feared complication. The patient provided written consent and permission to publish her image.

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Endoscopic endonasal transplanum transtuberculum approach for resection of retrochiasmatic craniopharyngioma

Neurosurgical FOCUS ◽

10.3171/2012.v2.focus11299 ◽

2012 ◽

Vol 32 (Suppl1) ◽

pp. E2 ◽

Cited By ~ 4

Author(s):

James K. Liu ◽

Jean Anderson Eloy

Keyword(s):

Third Ventricle ◽

Tumor Resection ◽

Radical Resection ◽

Optic Chiasm ◽

Cranial Base ◽

Surgical Morbidity ◽

Endoscopic Endonasal ◽

Retrochiasmatic Region ◽

Brain Retraction ◽

Neurovascular Structures

Retrochiasmatic craniopharyngiomas are formidable cranial base tumors to resect because of their intimate relationship with neighboring critical neurovascular structures, particularly the undersurface of the optic chiasm and hypothalamus. Radical resection offers the best chance of minimizing tumor recurrence, although this may be associated with significant surgical morbidity. Although various transcranial approaches have been utilized (transbasal subfrontal, frontobasal interhemispheric, pterional, orbitozygomatic, and petrosal) for resection of retrochiasmatic craniopharyngiomas, each is associated with some degree of brain retraction, and direct visualization of the retrochiasmatic region is often incomplete, therefore resulting in blind dissection. The endoscopic endonasal transplanum transtuberculum approach provides the most direct route to the retrochiasmatic region while affording unmatched visualization of the undersurface of the optic chiasm, third ventricle, and hypothalamus. This advantage allows for direct bimanual tumor dissection off of these critical structures by using microsurgical principles. The endonasal route also has the advantage of avoiding brain retraction and risk of cerebral edema that can be associated with transcranial approaches. In this operative video atlas report, the authors demonstrate their step-by-step techniques for resection of a suprasellar retrochiasmatic craniopharyngioma using a purely endoscopic endonasal transplanum transtuberculum approach. They describe and illustrate the operative nuances and surgical pearls to safely and efficiently perform the approach, tumor resection, and multilayered reconstruction of the cranial base defect. The video can be found here: http://youtu.be/ZIbJvAyRxYU.

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Symptomatic Primary Tethered Optic Chiasm: Technical Case Report

Operative Neurosurgery ◽

10.1093/ons/opaa093 ◽

2020 ◽

Vol 19 (4) ◽

pp. E440-E445 ◽

Cited By ~ 1

Author(s):

Nika Byrne ◽

Ryan B Kochanski ◽

Bobby Tajudeen ◽

Richard W Byrne

Keyword(s):

Clinical Presentation ◽

Visual Fields ◽

Optic Chiasm ◽

Abdominal Fat ◽

Empty Sella ◽

Fat Graft ◽

Endoscopic Endonasal ◽

Empty Sella Syndrome ◽

Graft Harvest ◽

Magnetic Resonance Imaging Mri

Abstract BACKGROUND AND IMPORTANCE Symptomatic tethering of the optic nerves and chiasm is a rare occurrence and has been reported following both surgical and medical treatment of pituitary adenoma. Here we present a case of primary optic chiasm tethering in a patient with empty sella syndrome. CLINICAL PRESENTATION The patient was a 61-yr-old female who presented with progressively worsening bitemporal hemianopsia. Magnetic resonance imaging (MRI) brain revealed an empty sella with herniation of the optic chiasm into the sella. The patient underwent an endoscopic, endonasal/trans-sphenoidal approach to the sella, where the optic chiasm was then detethered via lysis of arachnoid adhesions and ultimately buttressed with an abdominal fat graft. Postoperatively, the patient did well with subjective and objective improvements in her visual fields. CONCLUSION We report a rare case of primary tethered optic chiasm, which was successfully treated via an endoscopic, endonasal approach with abdominal fat graft harvest.

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Combined simultaneous endoscopic endonasal and microscopic transventricular surgery using a port retractor system for giant pituitary adenoma: A technical case report

Surgical Neurology International ◽

10.25259/sni_826_2020 ◽

2021 ◽

Vol 12 ◽

pp. 90

Author(s):

Erika Yamada ◽

Hiroyoshi Akutsu ◽

Hiroyoshi Kino ◽

Shuho Tanaka ◽

Hidetaka Miyamoto ◽

...

Keyword(s):

Pituitary Adenoma ◽

Obstructive Hydrocephalus ◽

Third Ventricle ◽

Tumor Resection ◽

Endoscopic Endonasal Surgery ◽

Endonasal Surgery ◽

Endoscopic Endonasal ◽

Giant Pituitary Adenoma ◽

The Third ◽

Memory Disturbance

Background: We report a case of a giant pituitary adenoma with marked extension into the third ventricle that was successfully removed using combined simultaneous endoscopic endonasal surgery (EES) and microscopic transventricular port surgery. Case Description: A 47-year-old woman, who complained of memory disturbance, had a giant pituitary adenoma with marked extension into the third ventricle that was causing obstructive hydrocephalus. She underwent combined EES and microscopic transventricular surgery using a port retractor system. Most of the tumor was resected from the EES side with assistance from the transcranial side with minimum cortical trajectory damage. The tumor was completely excised without any complications. Conclusion: For giant pituitary adenoma with marked extension into the third ventricle, combined simultaneous EES and transventricular surgery using a port retractor system is effective to maximize the extent of tumor resection while also preventing complications. Using port surgery on the transcranial side, microscopic secure dissection is possible with minimum additional cortical damage.

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Extended Endonasal Solo Endoscopic Approach for the Resection of Craniopharyngiomas

Bangladesh Journal of Neuroscience ◽

10.3329/bjn.v29i2.56179 ◽

2013 ◽

Vol 29 (2) ◽

pp. 108-114

Author(s):

Samsul Alam ◽

A N Wakil Uddin ◽

Anis Ahmed ◽

Moshiur Rahman Mojumder ◽

Kamrunnessa Hossain ◽

...

Keyword(s):

Visual Acuity ◽

Pituitary Adenoma ◽

Diabetes Insipidus ◽

Bacterial Infections ◽

Third Ventricle ◽

Endoscopic Approach ◽

Transsphenoidal Approach ◽

Csf Leak ◽

Endoscopic Endonasal ◽

Extended Transsphenoidal Approach

Background: Extended endonasal solo endoscopic approach for the non-pituitary lesions of the sellar and suprasellar regions are not new in the field of neurosurgery. Following endoscopic surgical approach of the pituitary adenoma, endoscopic neurosurgeon is eager to develop the skill for non-pituitary sellar & suprasellar lesions. Common sellar & suprasellar lesions are pituitary adenoma, craniopharyngioma, tuberculumselle meningioma and suprasellar germinoma. Objective: Traditional transsphenoidal approach gives exposure to the pituitary fossa, whereas extended approach provides exposure to the optic nerve, chiasm, acom complex and basal frontal lobe ,mammillary body, mid brain and laterally to the cavernous sinuses. Material & method: From November 2007 to March 2012, 12 cases of done by extended endonasal solo endoscopic approach among 12 cases of craniopharyngiomas. Patient’s history, clinical findings, pre-operative and post-operative visual acuity, visual field and radiological data were collected and analyzed. All patients underwent solo endoscopic extended transsphenoidal approach with or without nasoseptal flap technique for closure. Most of the patients were given lumbar drain as a treatment for CSF leak. Result: All patients were of age group of 10 to 60 years. Male were 8 (66.67%), female were 4 (33.33%) in number. Gross total removals were done in 7 cases out of 12 (58.33%) craniopharyngiomas and subtotal removal done in 5 (41.67%) cases. Visual acuity and field of vision were improved in all cases of craniopharyngiomas. One case (8.33%) of craniopharyngioma had prolong period of unconsciousness probably from hypothalamic disturbance. CSF leak developed in 2 (16.67%) cases. Patients with craniopharyngioma were required thyroxin and cortisol for replacement. Permanent diabetes insipidus developed in 5 cases (41.67%). Three patients required permanent CSF diversion via a ventriculoperitoneal shunt after documentation of postoperative HCP. There was one case of chemical meningitis, and two cases confirmed bacterial infections. Craniopharyngioma can be successfully resected via a purely endoscopic, endonasal approach. Craniopharyngioma have a higher rate of perioperative hydrocephalus and postoperative CSF leak compared with other tumor types in the same area. Conclusion: Extended transsphenoidal approach is an excellent alternative of skull base approach for the removal of most of the craniopharyngioma.The endoscopic endonasal route provides a good exposure, especially of the sub-chiasmatic and retro-chiasmatic areas, as well as of the stalk– infundibulum axis and the third ventricle chamber. It gives better visualization, improved postoperative visual outcome for less manipulation and low complication then craniotomy. However CSF leak and diabetes insipidus is common known complications which have to be manage promptly and appropriately. Bangladesh Journal of Neuroscience 2013; Vol. 29 (2) : 108-114

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Nonfunctioning Ectopic Pituitary Adenoma Presenting as Epistaxis: A Report of Two Cases

Otorhinolaryngology Clinics - An International Journal ◽

10.5005/jp-journals-10003-1175 ◽

2014 ◽

Vol 6 (3) ◽

pp. 130-133

Author(s):

Aparna Govindan ◽

Premkumar Sasi ◽

Suma Radhakrishnan ◽

Jacob Paul Alapatt ◽

KP Aravindan

Keyword(s):

Pituitary Adenoma ◽

Pituitary Adenomas ◽

Sphenoid Sinus ◽

Histopathological Examination ◽

Third Ventricle ◽

Correct Diagnosis ◽

Final Diagnosis ◽

Extensive Literature ◽

Ectopic Pituitary Adenoma ◽

Suprasellar Region

ABSTRACT Ectopic pituitary adenomas are uncommon lesions and are found along the migratory pathway of the Rathke's pouch. Sites reported include suprasellar region, clivus, sphenoid sinus, nasopharynx, third ventricle, petrous temporal bone, hypo thalamus, etc. Compared to intrasellar adenomas, a higher proportion of the ectopic examples are functional and most commonly produce adenocorticotropic hormone (ACTH). The authors report two cases of ectopic pituitary adenoma in the sphenoid sinus in two male patients 36 and 40 years old, presenting with epistaxis. Both the patients did not have any endocrine abnor malities. The clinical and imaging findings were suggestive of sinonasal malignancy. The final diagnosis was made after histopathological examination and immunohistochemistry for cytokeratin, chromogranin and pituitary hormones. The diagnosis of ectopic pituitary adenomas is difficult especially in those tumors that are nonfunctioning. After extensive literature search, we could find only six cases of nonfunctioning adenomas reported in the sphenoid sinus and in all these cases the correct diagnosis could be made only by histopathology. How to cite this article Govindan A, Sasi P, Radhakrishnan S, Alapatt JP, Aravindan KP. Nonfunctioning Ectopic Pituitary Adenoma Presenting as Epistaxis: A Report of Two Cases. Int J Otorhinolaryngol Clin 2014;6(3):130133.

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Collagen Matrix With Mucoperiosteum Graft as an Effective Fatless Flapless Reconstruction After Endoscopic Pituitary Adenoma Resection

Operative Neurosurgery ◽

10.1093/ons/opaa212 ◽

2020 ◽

Author(s):

Mostafa Shahein ◽

Alaa S Montaser ◽

Juan M Revuelta Barbero ◽

Guillermo Maza ◽

Alexandre B Todeschini ◽

...

Keyword(s):

Pituitary Adenoma ◽

Skull Base ◽

Collagen Matrix ◽

Leak Rate ◽

Fat Graft ◽

Csf Leak ◽

Endoscopic Endonasal ◽

Skull Base Reconstruction ◽

Group A ◽

Group B

Abstract BACKGROUND Proper skull base reconstruction after endoscopic endonasal pituitary surgery is of great importance to decrease the rate of complications. OBJECTIVE To assess the safety and efficacy of reconstruction with materials other than fat graft and naso-septal flaps (NSF) to avoid their associated morbidities. METHODS The authors’ institutional database for patients who underwent endoscopic endonasal approach for pituitary adenoma was reviewed. Exclusion criteria included recurrence, postradiation therapy, and reconstruction by fat graft or NSF. They were divided into group A, where collagen matrix (CM) (DuraGen® Plus Matrix, Integra LifeSciences Corporation, Plainsboro, New Jersey) alone was used; group B, where CM and simple mucoperiosteum graft were used and group C, which included cases without CM utilization. RESULTS The study included 252 patients. No age, gender, or body mass index statistically significant difference between groups. Group B included the largest tumor size (23.0 mm) in comparison to groups A (18.0 mm) and C (13.0 mm). Suprasellar extension was more frequently present (49.4%) in comparison to groups A (29.8%, P = .001) and C (21.2%, P < .001). Postoperative cerebrospinal fluid (CSF) leak rate was 0%, 2.9%, and 6% in groups A, B, and C, respectively. In group B, the CSF leak rate decreased from 45.9% intraoperatively to 2.9% postoperatively (P < .001). In group A, the CSF leak reduction rate was almost statistically significant (P = .06). CONCLUSION Utilization of CM and simple mucosperiosteal graft in skull base reconstruction following pituitary adenoma surgery is an effective method to avoid the morbidities associated with NSF or fat graft.

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Endoscopic endonasal trans-sphenoid surgery of pituitary adenoma

Journal of Neurosciences in Rural Practice ◽

10.4103/0976-3147.102615 ◽

2012 ◽

Vol 03 (03) ◽

pp. 328-337 ◽

Cited By ~ 20

Author(s):

YR Yadav ◽

S Sachdev ◽

V Parihar ◽

H Namdev ◽

PR Bhatele

Keyword(s):

Pituitary Adenoma ◽

Operating Time ◽

Tumor Resection ◽

Empty Sella ◽

Endocrine Function ◽

Csf Leak ◽

High Definition ◽

Endoscopic Endonasal ◽

Operative Care ◽

Proper Patient Selection

ABSTRACTEndoscopic endonasal trans-sphenoid surgery (EETS) is increasingly used for pituitary lesions. Pre-operative CT and MRI scans and peroperative endoscopic visualization can provide useful anatomical information. EETS is indicated in sellar, suprasellar, intraventricular, retro-infundibular, and invasive tumors. Recurrent and residual lesions, pituitary apoplexy and empty sella syndrome can be managed by EETS. Modern neuronavigation techniques, ultrasonic aspirators, ultrasonic bone curette can add to the safety. The binostril approach provides a wider working area. High definition camera is much superior to three-chip camera. Most of the recent reports favor EETS in terms of safety, quality of life and tumor resection, hospital stay, better endocrinological, and visual outcome as compared to the microscopic technique. Nasal symptoms, blood loss, operating time are less in EETS. Various naso-septal flaps and other techniques of CSF leak repair could help reduce complications. Complications can be further reduced after achieving the learning curve, good understanding of limitations with proper patient selection. Use of neuronavigation, proper post-operative care of endocrine function, establishing pituitary center of excellence and more focused residency and endoscopic fellowship training could improve results. The faster and safe transition from microscopic to EETS can be done by the team concept of neurosurgeon/otolaryngologist, attending hands on cadaveric dissection, practice on models, and observation of live surgeries. Conversion to a microscopic or endoscopic-assisted approach may be required in selected patients. Multi-modality treatment could be required in giant and invasive tumors. EETS appears to be a better surgical option in most pituitary adenoma.

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The medial wall of the cavernous sinus. Part 2: Selective medial wall resection in 50 pituitary adenoma patients

Journal of Neurosurgery ◽

10.3171/2018.5.jns18595 ◽

2019 ◽

Vol 131 (1) ◽

pp. 131-140 ◽

Cited By ~ 5

Author(s):

Salomon Cohen-Cohen ◽

Paul A. Gardner ◽

Joao T. Alves-Belo ◽

Huy Q. Truong ◽

Carl H. Snyderman ◽

...

Keyword(s):

Pituitary Adenoma ◽

Cavernous Sinus ◽

Cranial Nerve ◽

Tumor Resection ◽

Medial Wall ◽

Long Term Results ◽

Fat Graft ◽

Cranial Nerve Palsies ◽

Remission Rates

OBJECTIVEPituitary adenomas often invade the medial wall of the cavernous sinus (CS), but this structure is generally not surgically removed because of the risk of vascular and cranial nerve injury. The purpose of this study was to report the surgical outcomes in a large series of cases of invasive pituitary adenoma in which the medial wall of the CS was selectively removed following an anatomically based, stepwise surgical technique.METHODSThe authors’ institutional database was reviewed to identify cases of pituitary adenoma with isolated invasion of the medial wall, based on an intraoperative evaluation, in which patients underwent an endoscopic endonasal approach with selective resection of the medial wall of the CS. Cases with CS invasion beyond the medial wall were excluded. Patient complications, resection, and remission rates were assessed.RESULTSFifty patients were eligible for this study, 15 (30%) with nonfunctional adenomas and 35 (70%) with functional adenomas, including 16 growth hormone–, 10 prolactin-, and 9 adrenocorticotropic hormone (ACTH)–secreting tumors. The average tumor size was 2.3 cm for nonfunctional and 1.3 cm for functional adenomas. Radiographically, 11 cases (22%) were Knosp grade 1, 23 (46%) Knosp grade 2, and 16 (32%) Knosp grade 3. Complete tumor resection, based on intraoperative impression and postoperative MRI, was achieved in all cases. The mean follow-up was 30 months (range 4–64 months) for patients with functional adenomas and 16 months (range 4–30 months) for those with nonfunctional adenomas. At last follow-up, complete biochemical remission (using current criteria) without adjuvant treatment was seen in 34 cases (97%) of functional adenoma. No imaging recurrences were seen in patients who had nonfunctional adenomas. A total of 57 medial walls were removed in 50 patients. Medial wall invasion was histologically confirmed in 93% of nonfunctional adenomas and 83% of functional adenomas. There were no deaths or internal carotid artery injuries, and the average blood loss was 378 ml. Four patients (8%) developed a new, transient cranial nerve palsy, and 2 of these patients required reoperation for blood clot evacuation and fat graft removal. There were no permanent cranial nerve palsies.CONCLUSIONSThe medial wall of the CS can be removed safely and effectively, with minimal morbidity and excellent resection and remission rates. Further follow-up is needed to determine the long-term results of this anatomically based technique, which should only be performed by very experienced endonasal skull base teams.

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Management and Implications of Intraoperative Cerebrospinal Fluid Leak in Transnasoseptal Transsphenoidal Microsurgery

Operative Neurosurgery ◽

10.1227/neu.0b013e318207b3fc ◽

2011 ◽

Vol 68 (suppl_1) ◽

pp. ons144-ons151 ◽

Cited By ~ 5

Author(s):

George J. Kaptain ◽

Adam S. Kanter ◽

David K. Hamilton ◽

Edward R. Laws

Keyword(s):

Cerebrospinal Fluid ◽

Visual Function ◽

Transsphenoidal Surgery ◽

Visual Loss ◽

Fat Graft ◽

Csf Leak ◽

Csf Rhinorrhea ◽

Graft Harvest ◽

Additional Surgery ◽

Sellar Reconstruction

Abstract BACKGROUND: Nonvascularized autologous grafts used for sellar reconstruction in transseptal transsphenoidal surgery are commonly applied in the setting of intraoperative cerebrospinal fluid (CSF) leak and have been shown to be effective in preventing postoperative complications. OBJECTIVE: To assess the clinical implications of intraoperative CSF leak, to evaluate the efficacy of repair techniques using autologous nonvascularized materials, and to analyze the nature and timing of failures. These data may serve as a basis for assessing the utility of innovations in techniques and implant technologies. METHODS: A review was conducted of 257 consecutive patients who underwent transsphenoidal surgery that was complicated by intraoperative CSF leak from 1995 to 2001. Sellar reconstruction was performed with autologous materials except in reoperations in which septal materials were not available; lumbar drain catheters were used selectively. RESULTS: Six of the 257 patients (2.3%) developed postoperative CSF rhinorrhea occurring an average of 6.6 days after surgery. All 6 underwent reoperation, with 5 of 6 managed with operative lumbar drainage. Bacterial meningitis developed in 3 of 257 (1.2%). Worsening in visual function occurred in 8 of 257 (3.1%), with 1 of 257 (0.3%) suffering from permanent worsening of visual function. Additional surgery was performed in 2 of these patients, resulting in successful reversal of visual loss. Ten of 257 patients (3.9%) developed a subcutaneous hematoma at the fat graft harvest site, with 1 patient requiring surgical re-exploration. CONCLUSIONS: Watertight closure of the sella with autologous materials is effective in preventing postoperative rhinorrhea. Complications specific to the technique include graft site hematoma (4%) and rare instances of visual loss caused by optic nerve compression.

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