Evidencia insuficiente de la círugía guíada por imágen

La cirugía guiada por imágen, utiliza una variedad de herramientas y tecnologías (todas ellas muy caras) para ayudar a lograr una resección amplia de tumores.
Según el estudio de la Cochrane hay poca evidencia y de muy baja calidad (según criterios GRADE) de que la tecnología de resonancia intraoperatoria, cirugía guiada por fluorescencia o la neuronavegación aumenten la proporción de pacientes con glioma de alto grado con resección completa del tumor.
Existe preocupación teórica de que la maximización de la resección pueda conducir a situaciones adversas más frecuentes, pero esto se publica de manera deficiente en los estudios incluidos.
Por tanto los efectos de la cirugía guiada por imagen sobre la calidad de vida (QoL) no están claros.
Instan a tratar este tema con más rigor, incluyendo estudios comparativos con la cirugía guiada por ultrasonidos (menos costosa) ((Barone DG, Lawrie TA, Hart MG. Image guided surgery for the resection of brain tumours. Cochrane Database Syst Rev. 2014 Jan 28;1:CD009685. [Epub ahead of print] PubMed PMID: 24474579.)).

Se publica el mayor análisis retrospectivo de los aneurismas cerebrales rotos en la población China

El artículo es gratuito
Enlace
Analiza 1256 pacientes entre el 2006-2013
784 mujeres y 472 hombres, con una relación mujer / hombre de 1,66.
Esta relación se ve reducida a 0,50 para los pacientes menores de 35 años.
La ruptura del aneurisma fue más común en la franja de edad de 50-59 años.
Los aneurismas rotos eran en su mayoría de 2 mm-5 mm de tamaño (47,1%), seguido de 5 mm-10 mm (39,7%).
La rotura de un aneurisma cerebral único en circulación anterior en 95,0% de los casos, y el 5,0% en la circulación posterior.
La rotura de aneurisma mas frecuente ocurrió en la arteria comunicante posterior (34,9%) y la arteria comunicante anterior (29,5%).
183 casos (14,6%) tenían aneurismas múltiples.

Pituitary corticotroph adenoma surgery

Pituitary corticotroph adenoma surgery

Transsphenoidal surgery is the treatment of choice for most (medical therapy is inadequate as initial therapy since there is no effective pituitary suppressive medication). Cure rates are ≈ 85% for microadenomas, but are lower for larger tumors.

see Corticotroph adenoma medical treatment.

The surgical management of Pituitary corticotroph adenoma is often complicated by difficulties detecting the adenoma.

Various diagnostic modalities are used when conventional magnetic resonance imaging (MRI) is negative or inconclusive. Potts et al. sought to analyze the use of two such modalities in the surgical management of Cushing’s disease: (1) Cavernous/Inferior petrosal sinus sampling(central venous sampling, CVS) for adrenocorticotropic hormone and (2) dynamic MRI (dMRI).

Potts et al. conducted a single-center, retrospective review of all patients with Cushing’s disease treated by a single neurosurgeon with endonasal transsphenoidal surgery. Accuracy of adenoma localization with CVS and dMRI was analyzed. Ninety-one consecutive patients were included. Pathology confirmed an adenoma in 66. Preoperative dMRI and CVS were performed in 40 and 37 patients, respectively, with 20 undergoing both studies. Surgical pathology was positive for adenoma in 31 dMRI patients, 25 CVS patients, and 13 who underwent both. Among patients with pathology confirming an adenoma, dMRI identified a lesion in 96.8 % and correctly lateralized the lesion in 89.7 %, while CVS correctly lateralized in 52.2-65.2 % (depending on location of sampling). Among patients with both studies, dMRI and CVS correctly lateralized in 76.9 and 61.5-69.2 %, respectively. Accuracy of CVS improved if only patients with symmetric venous drainage were considered. In this mixed population of Cushing’s disease patients, dMRI was more accurate than CVS at localizing adenomas, supporting the use of advance MRI techniques in the work-up of Cushing’s disease. CVS, however, remains an important tool in the workup of Cushing’s syndrome 1).


In 2002 Perrin et al., published the technical aspects and surgical strategy for removal 2).

see Pituitary adenoma surgery.


Even with microadenomas, hemihypophysectomy on the side of the tumor is usually required for cure (the tumor is diffcult to completely extirpate) with attendant increased risk of CSF leak. If this fails, consideration should then be for total hypophysectomy. Failure of total hypophysectomy prompts consideration for bilateral adrenalectomy (total hypophysectomy virtually eliminates risk of Nelson’s syndrome following adrenalectomy).


If no tumor is identified on pre-op MRI:

● Intraoperative ultrasound may help localize tumor in ≈ 70% of cases 3) but a specialized U/S probe is required

● if Inferior petrosal sinus sampling (IPS) sampling showed a lateralizing ACTH gradient: start with a paramedian incision on the side of the higher ACTH gradient; if no adenoma is encountered, the contralateral paramedian and then midline incisions are used to explore the pituitary gland

● if IPS sampling and MRI do not suggest tumor location: the gland is explored sequentially with 2 paramedian incisions and then a midline incision

● if the adenoma cannot be found, a hemihypophysectomy is performed on the side of higher ACTH levels if IPS sampling shows a lateralizing gradient, or on the side with more suspicious tissue on frozen section. Total hypophysectomy is not routinely performed 4).

References

1)

Potts MB, Shah JK, Molinaro AM, Blevins LS, Tyrrell JB, Kunwar S, Dowd CF, Hetts SW, Aghi MK. Cavernous and inferior petrosal sinus sampling and dynamic magnetic resonance imaging in the preoperative evaluation of Cushing’s disease. J Neurooncol. 2014 Jan 8. [Epub ahead of print] PubMed PMID: 24398617.
2)

Perrin G, Stevenaert A, Jouanneau E. [Technical aspects and surgical strategy for removal of corticotroph pituitary adenoma]. Neurochirurgie. 2002 May;48(2-3 Pt 2):186-214. Review. French. PubMed PMID: 12058125.
3)

Watson JC, Shawker TH, Nieman LK, et al. Localiza- tion of Pituitary Adenomas by Using Intraoperative Ultrasound in Patients with Cushing’s Disease and No Demonstrable Pituitary Tumor on Magnetic Res- onance Imaging. JNeurosurg. 1998; 89:927–932
4)

Esposito F, Dusick JR, Cohan P, et al. Early morning cortisol levels as a predictor of remission after transsphenoidal surgery for Cushing’s disease. J Clin Endocrinol Metab. 2006; 91:7–13
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