Challenging Knosp high-grade pituitary adenomas

OBJECTIVEParasellar growth is one of the most important prognostic variables of pituitary adenoma surgery, with adenomas regarded as not completely resectable if they invade the cavernous sinus (CS) but potentially curable if they displace CS structures. This study was conducted to correlate surgical treatment options and outcomes to the different biological behaviors (invasion vs displacement) of adenomas with parasellar extension into the superior or inferior CS compartments or completely encasing the carotid artery (Knosp high grades 3A, 3B, and 4).METHODSThis was a retrospective cohort analysis of 106 consecutive patients with Knosp high-grade pituitary adenomas with parasellar extension who underwent surgery via a primary endoscopic transsphenoidal approach between 2003 and 2017. Biological tumor characteristics (surgical status of invasiveness and tumor texture, 2017 WHO classification, proliferation rate), extent of resection, and complication rate were correlated with parasellar extension grades 3A, 3B, and 4 on preoperative MRI studies.RESULTSInvasiveness was significantly less common in grade 3A (44%) than in grade 3B (72%, p = 0.037) and grade 4 (100%, p < 0.001) adenomas. Fibrous tumor texture was significantly more common in grade 4 (52%) compared to grade 3A (20%, p = 0.002), but not compared to grade 3B (28%) adenomas. Functioning macroadenomas had a significantly higher rate of invasiveness than nonfunctioning adenomas (91% vs 55%, p = 0.002). Mean proliferation rate assessed by MIB-1 was > 3% in all groups but without significant difference between the groups (grade 3A, 3.2%; 3B, 3.9%; 4, 3.7%). Rates of endocrine remission/gross-total resection were significantly higher in grade 3A (64%) than in grade 3B (33%, p = 0.021) and grade 4 (0%, p < 0.001) adenomas. In terms of complication rates, no significant difference was observed between grades.CONCLUSIONSAccording to the authors’ data, the biological behavior of pituitary adenomas varies significantly between parasellar extension patterns. Adenomas with extension into the superior CS compartment have a lower rate of invasive growth than adenomas extending into the inferior CS compartment or encasing the carotid artery. Consequently, a significantly higher rate of remission can be achieved in grade 3A than in grade 3B and grade 4 adenomas. Therefore, the distinction into grades 3A, 3B, and 4 is of importance for prediction of adenoma invasion and surgical treatment considerations.

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Endonasal endoscopic pituitary surgery in the elderly

Journal of Neurosurgery ◽

10.3171/2016.11.jns162286 ◽

2018 ◽

Vol 128 (2) ◽

pp. 429-436 ◽

Cited By ~ 11

Author(s):

Peter J. Wilson ◽

Sacit B. Omay ◽

Ashutosh Kacker ◽

Vijay K. Anand ◽

Theodore H. Schwartz

Keyword(s):

Elderly Patients ◽

Complication Rate ◽

Pituitary Adenomas ◽

Statistical Tests ◽

The Elderly ◽

Medical Complications ◽

Tumor Diameter ◽

Complication Rates ◽

Pseudoaneurysm Formation ◽

Significant Difference

OBJECTIVEPituitary adenomas are benign, slow-growing tumors that cause symptoms either through mass effect or hormone overproduction. The decision to operate on a healthy young person is relatively straightforward. In the elderly population, however, the risks of complications may increase, rendering the decision more complex. Few studies have documented the risks of surgery using the endonasal endoscopic approach in a large number of elderly patients. The purpose of this study was to audit a single center's data regarding outcomes of purely endoscopic endonasal transsphenoidal resection of pituitary adenomas in elderly patients and to compare them to the current literature.METHODSA retrospective review of a prospectively acquired database of all endonasal endoscopic surgeries done by the senior authors was queried for patients aged 60–69 years and for those aged 70 years or older. Demographic and radiographic preoperative data were reviewed. Outcomes with respect to extent of resection and complications were examined and compared with appropriate statistical tests.RESULTSA total of 135 patents were identified (81 aged 60–69 years and 54 aged 70 years or older [70+]). The average tumor diameter was slightly larger for the patients in the 70+ age group (mean [SD] 25.7 ± 9.2 mm) than for patients aged 60–69 years (23.1 ± 9.8 mm, p = 0.056). There was no significant difference in intraoperative blood loss (p > 0.99), length of stay (p = 0.22), or duration of follow-up (p = 0.21) between the 2 groups. There was a 7.4% complication rate in patients aged 60–69 years (3 nasal and 3 medical complications) and an 18.5% complication rate in patients older than 70 years (4 cranial, 3 nasal, 1 visual, and 2 medical complications; p = 0.05 overall and 0.013 for cranial complications). Cranial complications in the 70+ age category included 2 postoperative hematomas, 1 pseudoaneurysm formation, and 1 case of symptomatic subdural hygromas.CONCLUSIONSEndonasal endoscopic surgery in elderly patients is safe, but there is a graded increase in complication rates with increasing age. The decision to operate on an asymptomatic or mildly symptomatic patient in these age groups should take this increasing complication rate into account. The use of a lumbar drain or lumbar punctures should be weighed against the risk of subdural hematoma in patients with preexisting atrophy.

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The clinical application of a scoring protocol to select endarterectomy or stenting for carotid artery stenosis

10.21203/rs.3.rs-20272/v1 ◽

2020 ◽

Author(s):

Joonho Chung ◽

Jung-Jae Kim ◽

Yong Bae Kim ◽

Sang Hyun Suh ◽

Kyung-Yul Lee

Keyword(s):

Clinical Practice ◽

Surgical Treatment ◽

Carotid Artery ◽

Clinical Setting ◽

Carotid Artery Stenosis ◽

Treatment Options ◽

Artery Stenosis ◽

Related Complication ◽

Symptomatic Stenosis ◽

Selection Of

Abstract Background Our group previously described the protocol-based decision for choosing the proper surgical treatment option for carotid artery stenosis. The objective of this study is to describe our experiences of using this scoring protocol in the selection of endarterectomy or stenting for carotid artery stenosis. Methods Between October 2014 and March 2018, the scoring protocol was applied to a total of 105 consecutive patients. Eighty (76.2%) patients had symptomatic stenosis ≥50%, and 25 (23.8%) patients had asymptomatic stenosis ≥80%. We also speculated about how effectively the protocol worked in the real clinical setting. Results Stenting was performed in 73 patients and endarterectomy in 32 patients. Overall, 98 (93.3%) patients were treated according to the protocol, while the protocol was violated in seven (6.7%) patients. Sixty-one (58.1%) patients received treatments that were decided by the protocol. There were 37 (35.2%) patients who had the same score for both treatment options. Among these patients, 28 patients underwent stenting and nine patients underwent endarterectomy. In the stenting cases, 90.4% of the patients followed the protocol and violations occurred in 9.6%. In the endarterectomy cases, all of the patients followed the protocol. Overall, one patient had a procedure-related complication without morbidity. During the 12-month follow-ups, there were no restenoses or major strokes. Minor strokes were diagnosed in three (2.8%) patients. Conclusion In patients with carotid artery stenosis, stenting and endarterectomy should be considered simultaneously together, not against each other. Our scoring protocol can be used to weigh these options and applied in clinical practice.

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Surgical treatment of hemorrhoids: a critical appraisal of the current options

ABCD Arquivos Brasileiros de Cirurgia Digestiva (São Paulo) ◽

10.1590/s0102-67202014000100016 ◽

2014 ◽

Vol 27 (1) ◽

pp. 66-70 ◽

Cited By ~ 12

Author(s):

Marlise Mello CERATO ◽

Nilo Luiz CERATO ◽

Patrícia PASSOS ◽

Alberto TREIGUE ◽

Daniel C. DAMIN

Keyword(s):

Surgical Treatment ◽

Postoperative Pain ◽

Treatment Options ◽

Surgical Techniques ◽

Postoperative Recurrence ◽

Long Term Results ◽

Published Data ◽

Complication Rates ◽

Recurrence Rates

Introduction : Surgical treatment of hemorrhoids is still a dilemma. New techniques have been developed leading to a lower rate of postoperative pain; however, they are associated with a greater likelihood of recurrence. Aim : To review current indications as well as the results and complications of the main techniques currently used in the surgical treatment of hemorrhoidal disease. Methods : A systematic search of the published data on the options for treatment of hemorrhoids up to December 2012 was conducted using Medline/PubMed, Cochrane, and UpToDate. Results : Currently available surgical treatment options include procedure for prolapse and hemorrhoids (PPH), transanal hemorrhoidal dearterialization (THD), and conventional hemorrhoidectomy techniques. Excisional techniques showed similar results regarding pain, time to return to normal activities, and complication rates. PPH and THD were associated with less postoperative pain and lower complication rates; however, both had higher postoperative recurrence rates. Conclusion : Conventional surgical techniques yield better long-term results. Despite good results in the immediate postoperative period, PPH and THD have not shown consistent long-term favorable results.

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High-Grade Adult Isthmic L5–S1 Spondylolisthesis: A Report of Intraoperative Slip Progression Treated with Surgical Reduction and Posterior Instrumented Fusion

Global Spine Journal ◽

10.1055/s-0032-1307257 ◽

2012 ◽

Vol 2 (2) ◽

pp. 119-123 ◽

Cited By ~ 2

Author(s):

Mark M. Mikhael ◽

Gary S. Shapiro ◽

Jeffrey C. Wang

Keyword(s):

Patient Outcome ◽

Surgical Treatment ◽

Lumbar Spine ◽

Bone Graft ◽

Treatment Options ◽

High Grade ◽

Isthmic Spondylolisthesis ◽

Instrumented Fusion ◽

Surgical Reduction ◽

Posterior Instrumented Fusion

Adult isthmic spondylolisthesis most commonly occurs at the L5–S1 level of the lumbar spine. Slip progression is relatively rare in adults with this condition and slippage is typically associated with advanced degeneration of the disk below the pars defect. When symptomatic, radiculopathy is the typical complaint in adults with isthmic spondylolisthesis. When considering options for surgical treatment of adult isthmic spondylolisthesis, the surgeon must consider several different options, such as decompression, fusion, instrumentation, reduction, and type of bone graft to be used. All of these decisions must be individualized as deemed appropriate for each particular patient. This report presents a case of intraoperative slip progression of a L5–S1 adult isthmic spondylolisthesis to a high-grade slip, which was treated with complete surgical reduction and posterior instrumented fusion. This case demonstrates the potential instability of this condition in adults and has not been previously reported. The case details and images are reviewed and the intraoperative decisions, treatment options, and patient outcome are discussed.

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Differentiated approach to surgical treatment of atherosclerotic lesions of supra-aortic arteries

Galician Medical Journal ◽

10.21802/gmj.2016.3.3 ◽

2016 ◽

Vol 23 (3) ◽

Author(s):

I. Kopolovets ◽

P. Berek ◽

V. Sihotsky ◽

M. Kubikova ◽

N. Torma ◽

...

Keyword(s):

Surgical Treatment ◽

Mortality Rate ◽

Carotid Artery ◽

Cerebrovascular Disease ◽

Elective Surgery ◽

Surgical Reconstruction ◽

Atherosclerotic Lesions ◽

Group I ◽

Brachiocephalic Trunk ◽

Significant Difference

Atherosclerotic lesions of the supra-aortic arteries are mainly localized in the carotid artery bifurcations – 57%, the subclavian artery – 18%, the vertebral arteries – 14%, the brachiocephalic trunk and the common carotid artery – 11%.Objective. Theobjective of the research was to systematize the principles of surgical treatment of patients with atherosclerotic lesions of the supra-aortic arteries taking into consideration their polymorbidity and the multicentricity of atherosclerosis.Materials and methods. The results of surgical reconstruction of the supra-aortic arteries in 468 patients were analyzed.All the patients were divided into two groups.Group I included 276 (59%) patients with previous surgical or endovascular intervention on any vascular territory for treatment of atherosclerotic lesions being admitted to the hospital for elective surgery on the extracranial arteries.Group II included 192 (41%) patients without previous surgical and invasive treatments of arterial pathology being hospitalized for surgery on the supra-aortic arteries.Results. In Group I, according to the objective and clinical methods of examination, the patients’ condition was more critical due to somatic and intraoperative risk. When analyzing the results of postoperative complications there was no statistically significant difference between both groups (p<0.05).The overall rate for serious complications (acute cerebrovascular disease and myocardial infarction) in both groups was 3.4%; the mortality rate was 1.1%.Conclusions. 1. Approximately 87% of surgical reconstructions of the aortic arch branches are aimed at the prevention of acute cerebrovascular disease. 2. Surgical treatment of atherosclerotic lesions of the supra-aortic arteries allows us to achieve good postoperative results (the overall rate for serious complications – 3.4%, the mortality rate –1.1%).

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Abstract WP155: The Safety And Efficacy Of Carotid Artery Stenting In A High Grade Stenosis More Than 80% Under Proximal Protection With Flow-reversal System.

Stroke ◽

10.1161/str.44.suppl_1.awp155 ◽

2013 ◽

Vol 44 (suppl_1) ◽

Author(s):

Rie Yako ◽

Osamu Masuo ◽

Hiroyuki Matsumoto ◽

Naoyuki Nakao ◽

Tomoaki Terada ◽

...

Keyword(s):

Carotid Artery ◽

Carotid Artery Stenting ◽

Reverse Flow ◽

Clinical Results ◽

High Grade ◽

Protection Device ◽

Safety And Efficacy ◽

Significant Difference ◽

Ischemic Complication ◽

Distal Protection

Background: Different embolic protection devices in carotid artery stenting(CAS) have been developed to prevent procedural cerebral embolization. Proximal flow reverse protection has theoretically advantages from the view point of prevention of distal embolism, compared with distal protection. On the other hand, there is a disadvantage that this system is complexity. Purpose: we evaluated the safety and efficacy of proximal reverse flow protection for CAS in patients with high-grade stenosis. Methods: Distal protection has mainly been used as protection device in our institute. In case that there was high possibility of distal embolism, proximal reverse flow protection has been used. These cases treated with proximal flow reverse protection were included in this study. A total of 75 patients(71 men, mean age 71.9 years) with a high grade stenosis≧80% were treated between September 2003 and March 2012. 72% (n=54) of the patients were symptomatic.The primary endpoint was death and stroke rate at 30 days. The outcome was also compared to data from 386 patients with a high-grade stenosis who were treated under only distal protection device in the same period. Results: The procedure was technically successful in all cases. In 2 cases out of proximal reverse flow protection group, intracerebral hemorrhage was occurred. However, there was no ischemic complication. In distal protection group, the incidence of complication occurred in 11 cases (7 ischemic, 4 otheres). The stroke/death rate at 30 days was 2.6% (n=2) in proximal reverse flow protection group compared to 2.8% (n=11) in the distal protection group. There was no significant difference. However, the incidence of ischemic complication in the proximal reverse flow protection group tended to be lower than that of distal protection group. Conclusion: In selected patients with large atherosclerotic plaques, the clinical results of CAS with proximal reverse flow protection is safe and feasible. Especially, the incidence of ischemic stroke was lower than that of distal protection.

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Impact of Medical and Surgical Treatment of Endometriosis on the Cure of Endometriosis and Pain

BioMed Research International ◽

10.1155/2014/264653 ◽

2014 ◽

Vol 2014 ◽

pp. 1-9 ◽

Cited By ~ 15

Author(s):

Liselotte Mettler ◽

R. Ruprai ◽

Ibrahim Alkatout

Keyword(s):

Surgical Treatment ◽

Hormonal Therapy ◽

Treatment Options ◽

Combined Treatment ◽

Treatment Strategies ◽

Outcome Data ◽

Deep Infiltrating Endometriosis ◽

Cure Rate ◽

Significant Difference ◽

Group 2

This endometriosis study evaluates three different treatment strategies (hormonal medication, surgical, or combined treatment) and discusses the influence of endometriosis on the cure of this disease and pain relief. Four hundred and fifty patients with genital endometriosis, aged 18–44 years, were randomly distributed to three treatment groups at the first laparoscopy. They were reevaluated at a second-look laparoscopy (D 426/10), one to two months after the three-month hormonal therapy for groups 1 and 3 and five to six months later for group 2 (surgical treatment alone). Outcome data focussed on the recurrence of symptoms and pain. The three treatment options independent of the initial endoscopic endometriosis classification (EEC) stage including deep infiltrating endometriosis (DIE) achieved an overall cure rate of 50% or higher. The highest cure rate of 60% was achieved by the combined treatment, 55% by the exclusively hormonal therapy, and 50% by the exclusively surgical treatment. An overall pregnancy rate between 55% and 65% was achieved with no significant difference in relation to the therapeutical option.

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The Biological Behavior of High-Grade Glioma in H3K27M Mutant Circumscribed Midline Gliomas

10.21203/rs.3.rs-1184553/v1 ◽

2021 ◽

Author(s):

Hainan Li ◽

Jieyun Tan ◽

Mingyao Lai ◽

Wendan Chen ◽

Minting Liu ◽

...

Keyword(s):

High Grade Glioma ◽

Clinicopathological Characteristics ◽

Biological Behavior ◽

High Grade ◽

Who Grade ◽

Significant Difference ◽

Prognostic Stratification ◽

Grade 3 ◽

Elder Adults ◽

H3k27m Mutation

Abstract Purpose Due to the prognosis of circumscribed middle gliomas（CMGs）with H3K27M mutation is still unclear. This study explored the prognostic stratification of （CMGs） with H3K27M mutation.Methods: One hundred and sixty middle gliomas（MGs）were identified over 10 years. Immunohistochemistry was done for H3K27M, ATRX, IDH1, and P53, and Sanger sequencing performed for IDH and H3 genes. The clinicopathological characteristics were reviewed and survival analysis performed.Results: 1. H3K27M mutation was associated with a poor prognosis (p = 0.00017) for brainstem gliomas, but not for thalamic gliomas (p = 0.3). In the elder adults (≥40 years), there was no correlation between H3K27M mutation and the prognosis for MGs (p = 0.49).2. For H3K27M mutant MGs, there was no difference in prognosis between diffuse midline gliomas (DMGs) and CMGs (p = 0.211), also between the CNS WHO grades.3. The prognosis of H3K27M mutant CMGs of CNS WHO grade 1 was worse than that of H3K27M wild-type CMGs (p = 0.0024), even worse than of DMGs without H3K27M mutation of CNS WHO grade 2(p = 0.0066). There was no significant difference in prognosis from DMGs with histological grades CNS WHO grade 3 and 4 (p = 0.46).Conclusions: The weight value of H3K27M affecting prognosis is affected by location and age. CMGs with H3K27M mutation have biological behavior similar to high-grade gliomas. It is recommended that Treatment management was referenced to high-grade glioma for CMGs with H3K27 mutation.

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Complication-Specific In-Hospital Costs After Carotid Endarterectomy vs Carotid Artery Stenting

Journal of Endovascular Therapy ◽

10.1177/1526602818781580 ◽

2018 ◽

Vol 25 (4) ◽

pp. 514-521 ◽

Cited By ~ 1

Author(s):

Hanaa Dakour-Aridi ◽

Besma Nejim ◽

Satinderjit Locham ◽

Husain Alshaikh ◽

Tammam Obeid ◽

...

Keyword(s):

Carotid Artery ◽

Incremental Cost ◽

Carotid Endarterectomy ◽

Carotid Artery Stenting ◽

Logistic Models ◽

Complication Rates ◽

Healthcare Database ◽

Asymptomatic Patients ◽

Significant Difference ◽

Hospitalization Costs

Purpose: To quantify and compare the incremental cost associated with in-hospital stroke, death, and myocardial infarction (MI) after carotid endarterectomy (CEA) vs carotid artery stenting (CAS). Methods: A retrospective analysis was performed of 100,185 patients (mean age 70.7±9.5 years; 58.3% men) who underwent CEA (n=86,035) or CAS (n=14,150) between 2009 and 2015 and were entered into the Premier Healthcare Database. Multivariate logistic models and generalized linear models were used to analyze binary outcomes and hospitalization costs, respectively. Outcomes are presented as the adjusted odds ratio (aOR) and 95% confidence interval (CI). Results: CAS was associated with 1.6 times higher adjusted odds of stroke [aOR 1.55 (95% CI 1.36 to 1.77), p<0.001] and with 2.6 times higher odds of death [aOR 2.60 (95% CI 2.14 to 3.17), p<0.001] compared with CEA. There was no significant difference in MI risk between the 2 procedures. The adjusted incremental cost of death and MI were similar between the 2 procedures. However, the adjusted incremental cost of stroke was significantly higher in CEA compared with CAS by an estimated $2000. When stratified with respect to symptomatic status, the increased adjusted incremental cost of stroke in CEA was mainly seen in asymptomatic patients ($5284 vs $2932, p<0.01). Conclusion: The incremental cost of in-hospital stroke is relatively higher in CEA compared to CAS. However, CEA remains a more cost-effective carotid intervention due to lower complication rates and baseline costs compared with CAS. Long-term cost-effectiveness studies are needed before definite conclusions are made.

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Ultrasound Doppler examination in the surgical treatment of pituitary adenomas with cavernous sinus extension

Ukrainian Neurosurgical Journal ◽

10.25305/unj.222868 ◽

2021 ◽

Vol 27 (1) ◽

pp. 29-33

Author(s):

Ruslan V. Aksyonov ◽

Orest I. Palamar ◽

Andrii P. Huk ◽

Dmytro I. Okonskyi ◽

Dmytro S. Teslenko

Keyword(s):

Surgical Treatment ◽

Carotid Artery ◽

Internal Carotid Artery ◽

Doppler Ultrasound ◽

Cavernous Sinus ◽

Pituitary Adenomas ◽

Internal Carotid ◽

Gross Total Resection ◽

Total Resection ◽

Endoscopic Endonasal

Objective: To determine the effectiveness of intraoperative Doppler ultrasound in the surgical treatment of pituitary adenomas with invasive parasellar growth into the cavernous sinus Knosp 3 and Knosp 4. Material and Methods. During 2009–2017, 71 patients with pituitary adenomas (PA) with extension into the cavernous sinus Knosp 3 and Knosp 4 were retrospectively reviewed. According to the size PA were divided into pituitary macroadenomas, (from 10 to 40 mm) in 45 (63.4%) patients, and giant PA (over 40 mm) – in 26 (36.6%) patients. Cavernous sinus invasion Knosp 3 and 4 was identified in 47 (66.2%) and 24 (33.8%) patients respectively. Non-secreting PA - 43 (60.5%) patients and hormone-secreting PA - 28 patients (39.4%). Endoscopic endonasal trassphenoidal (EET) approach was used in all cases. Laterally expanded EET (LEEET) approach was used in 29 cases. Intraoperative Doppler ultrasound (IDUS) was used in 36 (51%) cases. Results. Intraoperative Doppler ultrasound was used in cases of Knosp 3 extension in 23 (32.4%) cases and in Knosp 4 - in 13 (18.3%) cases. Gross total resection, including extension into the cavernous sinus using IDUS was achieved in 22 (62.7%) patients. In cases where IDUS was not used, gross total resection was achieved in 19 (52.7%) cases. In cases where the IDUS was not used, recurrence rate was 7.3%, with IDUS - 5%. Biochemical remission was achieved in 22 (78.6%) cases. Liquorrhea nasalis after surgery was observed in 6 (8.4%) cases, meningoencephalitis - in 1 (1.4%) case, oculomotor palsy -3 (4.2%) cases. Conclusions. Intraoperative Doppler ultrasound is an informative method that provides safe resection of pituitary adenomas with cavernous sinus extension with a low level of possible postoperative complications. Parasellar extension of Pituitary adenomas into the cavernous sinus Knosp 4 significantly reduces the possibility of gross total resection. However, the use of intraoperative ultrasound makes it possible to determine safe boundaries for manipulation both medially and laterally from the internal carotid artery, increasing the level of radicality and the duration of clinical remission. Intraoperative Doppler ultrasound during endoscopic endonasal transsphenoidal surgery of pituitary adenomas with parasellar extension allows to identify the internal carotid artery in the tumor stroma with the existing changed skull base anatomy. Dura incision under intraoperative Doppler ultrasound reduces the risk of internal carotid artery injury.

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