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

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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Delayed Cranial Nerve Palsy After Coiling of Carotid Cavernous Sinus Aneurysms

Neurosurgery ◽

10.1227/01.neu.0000369194.13994.62 ◽

2010 ◽

Vol 66 (6) ◽

pp. E1215-E1216 ◽

Cited By ~ 11

Author(s):

David S. Xu ◽

Michael C. Hurley ◽

H. Hunt Batjer ◽

Bernard R. Bendok

Keyword(s):

Cavernous Sinus ◽

Cranial Nerve ◽

Clinical Presentation ◽

Cranial Neuropathy ◽

Aneurysm Neck ◽

Post Procedure ◽

Cranial Nerve Palsies ◽

Endovascular Coils ◽

Healthy Females

Abstract OBJECTIVE Detachable endovascular coils have become a common treatment strategy for carotid cavernous sinus aneurysms (CCAs), but previously unrecognized postprocedure complications may emerge as longer follow-up data are accumulated. In this report, the authors document the first known cases of delayed cranial neuropathy following CCA coiling in 3 patients, all of whom present at least a year postprocedure without aneurysm regrowth. The potential mechanisms underlying this syndrome are discussed as well as their implications on the selection and optimal endovascular management of CCA patients. CLINICAL PRESENTATION Three previously healthy females aged 50, 60, and 62 underwent CCA coiling at our institution and subsequently developed ipsilateral cranial nerve palsies at 56, 28, and 14 months, respectively, post-procedure. At presentation, all 3 patients had a new, recurrent area of flow in their CCA without changes in aneurysm size. INTERVENTION One patient declined further treatment. In the other 2 patients, a stent was placed across the aneurysm neck, and one patient underwent additional coiling. Unfortunately, all 3 patients remained symptomatic at their latest follow-up. Conclusion Because of the intimate anatomic environment of the cavernous sinus, neural elements within it may be particularly susceptible to persistent mass or dynamic effects exacerbated by remnant or recurrent flow across the neck of a coiled aneurysm. These 3 cases prompted the authors to advocate for more aggressive efforts to achieve and maintain CCA occlusion. Furthermore, when such efforts are unsuccessful, consideration of traditional carotid occlusion strategies with or without bypass is warranted.

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Radiosurgical Management of Benign Cavernous Sinus Tumors: Dose Profiles and Acute Complications

Neurosurgery ◽

10.1097/00006123-200105000-00011 ◽

2001 ◽

Vol 48 (5) ◽

pp. 1022-1032 ◽

Cited By ~ 33

Author(s):

Joseph C.T. Chen ◽

Steven L. Giannotta ◽

Cheng Yu ◽

Zbigniew Petrovich ◽

Michael L. Levy ◽

...

Keyword(s):

Surgical Treatment ◽

Pituitary Adenoma ◽

Radiation Dose ◽

Cavernous Sinus ◽

Cranial Nerve ◽

Cranial Nerve Palsy ◽

Nerve Palsy ◽

Tumor Volume ◽

Grade Iii

Abstract OBJECTIVE Radiosurgery has emerged as an alternative treatment modality for cranial base tumors in patients deemed not suited for primary surgical extirpation, patients with recurrent or residual tumor after open surgery, or patients who refuse surgical treatment. We review our short-term experience with radiosurgical management of cavernous sinus region tumors with the Leksell gamma knife. METHODS From August 1994 to February 1999, 69 patients with cavernous sinus lesions were treated in 72 separate treatment sessions. The tumor type distribution was 29 pituitary adenomas, 35 meningiomas, 4 schwannomas, and 1 paraganglioma. The median follow-up was 122 weeks. Lesions were stratified according to a five-level surgical grade. The grade distribution of the tumors was as follows: Grade I, 13; Grade II, 21; Grade III, 19; Grade IV, 12; Grade V, 4. Median tumor volume was 4.7 cm3. The median radiation dose was 15 Gy to the 50% isodose line. Median maximal radiation dose was 30 Gy. RESULTS Analysis of tumor characteristics and radiation dose to optic nerve and pontine structures revealed a significant correlation between distance and dose. Much lower correlation coefficients were found between tumor volume and dose. One lesion in this series had evidence of transient progression and later regression on follow-up radiographic studies. No other lesions in this series were demonstrated to have exhibited progression. Complications after radiosurgical treatment were uncommon. Two patients had cranial nerve deficits after treatment. One patient with a surgical Grade III pituitary adenoma had VIth cranial nerve palsy 25 months after radiosurgical treatment that spontaneously resolved 10 months later. A patient with a bilateral pituitary adenoma experienced bilateral VIth cranial nerve palsy 3 months after treatment that had not resolved at 35 months after treatment. Six patients with preoperative cranial nerve deficits experienced resolution or improvement of their deficits after treatment. One patient with a prolactin-secreting adenoma experienced normalization of endocrine function with return of menses. CONCLUSION Radiosurgical treatment represents an important advance in the management of cavernous sinus tumors, with low risk of neurological deficit in comparison with open surgical treatment, even in patients with high surgical grades.

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Combination of microsurgery and Gamma Knife surgery for the treatment of intracranial chondrosarcomas

Journal of Neurosurgery ◽

10.3171/sup.2006.105.7.18 ◽

2006 ◽

Vol 105 (Supplement) ◽

pp. 18-25 ◽

Cited By ~ 13

Author(s):

Petter Förander ◽

Tiit Rähn ◽

Lars Kihlström ◽

Elfar Ulfarsson ◽

Tiit Mathiesen

Keyword(s):

Gamma Knife ◽

Cranial Nerve ◽

Residual Tumor ◽

Local Tumor Control ◽

Gamma Knife Surgery ◽

Long Term Results ◽

Tumor Control ◽

Low Grade ◽

Cranial Nerve Palsies ◽

Tumor Volume Reduction

ObjectIntracranial chondrosarcomas have a high risk of recurrence after surgery. This retrospective study of patients with intracranial chondrosarcoma was conducted to determine the long-term results of microsurgery followed by Gamma Knife surgery (GKS) for residual tumor or recurrence.MethodsThe authors treated nine patients whose median age was 36 years. Seven patients had low-grade chondrosarcomas (LGCSs), whereas mesenchymal chondrosarcomas (MCSs) were diagnosed in two. Radiosurgery was performed in eight patients, whereas one patient declined further surgical intervention and tumor-volume reduction necessary for the GKS.The patients were followed up for 15 to 173 months (median 108 months) after diagnosis and 3 to 166 months (median 88 months) after GKS. Seven patients had residual tumor tissue after microsurgery, and two operations appeared radical. In the two latter cases, tumors recurred after 25 and 45 months. Thus, definite tumor control was not achieved after surgery alone in any patient, whereas the addition of radiosurgery allowed tumor control in all six patients with LGCSs. Two of these patients experienced an initial tumor regrowth after GKS; in both cases the recurrences were outside the prescribed radiation field. The patients underwent repeated GKS, and subsequent tumor control was observed. An MCS was diagnosed in the remaining two patients. Complications after microsurgery included diplopia, facial numbness, and paresis. After GKS, one patient had radiation necrosis, which required microsurgery, and two patients had new cranial nerve palsies.Conclusions Tumor control after microsurgery alone was not achieved in any patient, whereas adjuvant radiosurgery provided local tumor control in six of eight GKS-treated patients. Tumor control was not achieved in the two patients with MCS. Similar to other treatments for intracranial chondrosarcoma, morbidity after micro- and radiosurgical combination therapy was high and included severe cranial nerve palsies.

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Surgical treatment of pulmonary artery sarcoma: a report of 17 cases

Pulmonary Circulation ◽

10.1177/2045894020986394 ◽

2021 ◽

Vol 11 (1) ◽

pp. 204589402098639

Author(s):

Wu Song ◽

Long Deng ◽

Jiade Zhu ◽

Shanshan Zheng ◽

Haiping Wang ◽

...

Keyword(s):

Pulmonary Artery ◽

Survival Rates ◽

Tumor Resection ◽

Long Term Results ◽

Pulmonary Endarterectomy ◽

Pulmonary Artery Sarcoma ◽

The Mean ◽

Operative Findings

Pulmonary artery sarcoma (PAS) is a rare and devastating disease. The diagnosis is often delayed, and optimal treatment remains unclear. The aim of this study is to report our experience in the surgical management of this disease. Between 2000 and 2018, 17 patients underwent operations for PAS at our center. The medical records were retrospectively reviewed to evaluate the clinical characteristics, operative findings, the postoperative outcomes, and the long-term results. The mean age at operation was 46.0 ± 12.4 years (range, 26–79 years), and eight (47.1%) patients were male. Six patients underwent tumor resection alone, whereas the other 11 patients received pulmonary endarterectomy (PEA). There were two perioperative deaths. Follow-up was completed for all patients with a mean duration of 23.5 ± 17.6 months (1–52 months). For all 17 patients, the median postoperative survival was 36 months, and estimated cumulative survival rates at 1, 2, 3, and 4 years were 60.0%, 51.4%, 42.9%, and 21.4%, respectively. The mean survival was 37.0 months after PEA and 14.6 months after tumor resection only ( p = 0.046). Patients who had no pulmonary hypertension (PH) postoperatively were associated with improved median survival (48 vs. 5 months, p = 0.023). In conclusion, PAS is often mistaken for chronic pulmonary thromboembolism. The prognosis of this very infrequent disease remains poor. Early detection is essential for prompt and best surgical approach, superior to tumor resection alone, and PEA surgery with PH relieved can provide better chance of survival.

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RARE-31. TREATMENT OUTCOME OF CHILDREN WITH PLEOMORPHIC XANTHOASTROCYTOMA: RETROSPECTIVE ANALYSIS – A SINGLE INSTITUTION EXPERIENCE

Neuro-Oncology ◽

10.1093/neuonc/noz175.954 ◽

2019 ◽

Vol 21 (Supplement_6) ◽

pp. vi228-vi228

Author(s):

Ossama Maher ◽

Toba Niazi ◽

Ziad Khatib ◽

John Ragheb

Keyword(s):

Local Recurrence ◽

Retrospective Analysis ◽

Malignant Transformation ◽

Cranial Nerve ◽

Pleomorphic Xanthoastrocytoma ◽

Braf V600e ◽

Biological Behavior ◽

High Local Recurrence Rate ◽

Cranial Nerve Palsies

Abstract BACKGROUND Pleomorphic xanthoastrocytoma (PXA) and anaplastic pleomorphic xanthoastrocytoma (APXA) are two types of rare astrocytomas in pediatrics. There is limited literature reporting their outcomes. METHODS A retrospective analysis of pediatric patients with diagnosis of PXA and APXA treated at Nicklaus Children’s Hospital was conducted using descriptive measures. RESULTS A chart review of patients with brain tumors from 2001 to 2019 revealed that 13 patients (median age 6 years, range 2–17 years) were diagnosed with non-metastatic PXA (n=12) and APXA (n=1). Six patients (46%) were male. Clinical presentation included seizures (n=8), headaches (n=2) cranial nerve palsies (n=2). Diagnostic imaging showed tumor in the temporal lobe (n=5), parietal lobe (n=2), temporoparietal lobe (n=2), frontal lobe (n=1), occipital lobe (n=1), others (n=2). BRAF V600E mutation were identified in three of five analyzed tumors including PXA (n=4) and APXA (n=1). Surgical intervention consisted of gross total resection (n=8) and near/subtotal resection (n=5). Ten patients (76%) required a second surgery (median 2; range 1–4) due to local recurrence. The median time to recurrence was 3 years (range 6 months - 7 years). Three patients (23%) had malignant transformation of PXA, which occurred three to eight years from the initial surgery; one of them also had extensive spinal metastasis. Focal radiation was given to six patients (46%) due to multiple recurrence (n=2), malignant transformation (n=3), APXA (n=1). At a median follow up of 8 years (range 3 to 20 years), eight patients remain alive, three patients had lost to follow up, two patients died from progressive disease. Long-term sequelae varied as follows; seizures (n=5), motor weakness (n=4), cranial nerve palsies (n=2), and learning disability (n=1). CONCLUSION PXA is associated with high local recurrence rate and uncommonly malignant transformation to APXA in pediatrics, which requires close follow-up due to unpredictable biological behavior of these tumors.

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Pediatric Mandibular Resection and Reconstruction: Long-Term Results with Autogenous Rib Grafts

Craniomaxillofacial Trauma & Reconstruction ◽

10.1055/s-0030-1249371 ◽

2010 ◽

Vol 3 (1) ◽

pp. 25-32 ◽

Cited By ~ 14

Author(s):

André M. Eckardt ◽

Enno-Ludwig Barth ◽

Johannes Berten ◽

Nils-Claudius Gellrich

Keyword(s):

Tumor Resection ◽

Three Dimensional ◽

Bone Defects ◽

Long Term Results ◽

Benign Tumors ◽

Tumor Surgery ◽

Bone Augmentation ◽

Facial Skeleton ◽

Computed Tomographic

Reconstruction of mandibular defects following tumor resection in infants is a particular challenge. Although autogenous rib grafts have no relevance in the restoration of mandibular bone defects occurring after ablative tumor surgery due to limited bone stock and the availability of other donor areas, they are a useful surgical alternative following tumor surgery in infants. We here report on a 2, 5, 8, and 15-year follow-up of four children who were diagnosed with benign tumors of the mandible with osseous destruction at the age of 4, 6, 15, and 18 months, respectively. Histologic diagnoses were melanotic neuroectodermal tumor ( n=2), hemangioendothelioma of the mandible ( n=1), and ameloblastoma ( n=1). Following continuity resection of the mandible, lateromandibular bone defects were restored using autogenous rib grafts. Both clinical and radiologic follow-up visits were performed for all children to assess growth of the facial skeleton and the mandible. One child was already further reconstructed using bone augmentation at the age of 15 years. Cephalometric measurements on panorex films and three-dimensional computed tomographic scans revealed a slight vertical growth excess and transversal growth inhibition of the reconstructed mandible compared with the nonoperated side. Although further growth of rib grafts is difficult to predict and occlusal disharmony may occur due to physiologic maxillary growth and growth of the unaffected mandible, we believe that autogenous rib grafts can be ideally used for the restoration of mandibular continuity defects in newborns and young children. Clinical follow-up visits on a yearly basis and orthodontic controls are useful for early orthodontic treatment of growth deficits. Further corrective surgery with bone augmentation or osseous distraction is required following completion of growth of the facial skeleton.

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A Rare Case of Tolosa-Hunt-Like Syndrome in a Poorly Controlled Diabetes Mellitus

Case Reports in Medicine ◽

10.1155/2016/9763621 ◽

2016 ◽

Vol 2016 ◽

pp. 1-4 ◽

Cited By ~ 1

Author(s):

Glenmore Lasam ◽

Sakshi Kapur

Keyword(s):

Diabetes Mellitus ◽

Cavernous Sinus ◽

Cranial Nerve ◽

Rare Case ◽

Tight Glycemic Control ◽

Eighth Cranial Nerve ◽

Diagnostic Investigation ◽

Hunt Syndrome ◽

Cranial Nerve Palsies ◽

The Right

We report a case of a 50-year-old female with diabetes mellitus who presented with progressive second, third, fifth, sixth, and eighth cranial nerve palsy. Diagnostic investigation revealed hyperglycemic state, and brain imaging showed a right cavernous sinus enhancement suggestive of and consistent with Tolosa-Hunt syndrome. The patient was started on steroids with tight glycemic control for eight weeks; subsequently, the cranial nerve palsies resolved as well as documented resolution of the right cavernous sinus enhancement.

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Transsphenoidal approach to infrasellar tumors involving the cavernous sinus

Journal of Neurosurgery ◽

10.3171/jns.1990.73.4.0513 ◽

1990 ◽

Vol 73 (4) ◽

pp. 513-517 ◽

Cited By ~ 43

Author(s):

Nobuo Hashimoto ◽

Haruhiko Kikuchi

Keyword(s):

Cavernous Sinus ◽

Cranial Nerve ◽

Cranial Nerves ◽

Transsphenoidal Approach ◽

Skull Base Tumors ◽

Content Type ◽

Operating Field ◽

Cranial Nerve Palsies ◽

Operative Complications ◽

Fine Print

✓ The authors review their 2-year experience with a rhinoseptal transsphenoidal approach to skull-base tumors of various pathologies involving both the sphenoid and cavernous sinuses. Eight patients with cranial nerve palsies attributable to compression of the contents of the cavernous sinus and/or optic canal are included in this report. Among these patients, a total of 17 cranial nerves were affected. Postoperative normalization was achieved in eight nerves, significant improvement in seven nerves, and no improvement in two nerves. There were no operative complications of aggravation of cranial nerve palsies in this series. In spite of the limited operating field, the results demonstrate the effectiveness and safety of this approach. The authors recommend that this approach be considered before more aggressive surgery is undertaken.

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Tolosa-Hunt Syndrome: A Case Report and Review of the Literature

Bangladesh Journal of Neuroscience ◽

10.3329/bjn.v29i2.56182 ◽

2013 ◽

Vol 29 (2) ◽

pp. 130-133

Author(s):

Md Rafiqul Islam ◽

Hasan Zahidur Rahman ◽

Akm Anwar Ullah ◽

Md Amir Hossain ◽

- Md Ziauddin

Keyword(s):

Cavernous Sinus ◽

Trigeminal Nerve ◽

Cranial Nerve ◽

Motor Nerve ◽

Pathological Process ◽

Sensory Loss ◽

Oral Steroid ◽

Superior Orbital Fissure ◽

Hunt Syndrome ◽

Cranial Nerve Palsies

Tolosa-Hunt Syndrome is a painful ophthalmoplegia which is characterized by periorbital or hemicranial pain, with ipsilateral ocular motor nerve palsies, oculosympathetic paralysis, sensory loss in the distribution of the ophthalmic and occasionally the maxillary division of the trigeminal nerve. Various combinations of these cranial nerve palsies may occur, localising the pathological process to the region of the cavernous sinus/superior orbital fissure. We report the case of a patient presented with severe pain in the right side of face which was periorbital with ipsilateral 3rd,4th, 6th cranial nerve palsies along with ophthalmic and maxillary division of trigeminal nerve involvement. MRI of orbit showed hypo-intense lesion in right cavernous sinus extending to right superior orbital fissure (suggestive of granulomatous infiltration). After taking oral steroid her pain was relieved quickly and cranial nerve palsies reversed within one week. Azathioprin was added and she was completely cured of within next three months. Bangladesh Journal of Neuroscience 2013; Vol. 29 (2) : 130-133

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

Case Reports in Otolaryngology ◽

10.1155/2020/9584090 ◽

2020 ◽

Vol 2020 ◽

pp. 1-5

Author(s):

Zaid Shareef ◽

Connor Kerndt ◽

Trevor Nessel ◽

Devin Mistry ◽

Bryan Figueroa

Keyword(s):

Pituitary Adenoma ◽

Histopathological Examination ◽

Past History ◽

Third Ventricle ◽

Tumor Resection ◽

Optic Chiasm ◽

Collision Tumor ◽

Fat Graft ◽

Csf Leak ◽

Graft Harvest

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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