Neuroendoscopy

Craniopharyngioma endoscopic endonasal approach

Craniopharyngioma endoscopic endonasal approach

Latest Craniopharyngioma endoscopic endonasal approach PubMed-related Articles

Indications

Craniopharyngioma endoscopic endonasal approach Indications.

Systematic reviews

The endoscopic endonasal approach (EEA) for craniopharyngiomas has proven to be a safe option for extensive tumor resection, with minimal or no manipulation of the optic nerves and excellent visualization of the superior hypophyseal artery branches when compared to the Transcranial Approach (TCA). However, there is an ongoing debate regarding the criteria for selecting different approaches. To explore the current results of EEA and discuss its role in the management of craniopharyngiomas, Figueredo et al. performed MEDLINE, Embase, and LILACS searches from 2012 to 2022. Baseline characteristics, the extent of resection, and clinical outcomes were evaluated. Statistical analysis was performed through an X2 and Fisher exact test, and a comparison between quantitative variables through a Kruskal-Wallis and verified with post hoc Bonferroni. The tumor volume was similar in both groups (EEA 11.92 cm3, -TCA 13.23 cm3). The mean follow-up in months was 39.9 for EEA and 43.94 for TCA, p = 0.76). The EEA group presented a higher visual improvement rate (41.96% vs. 25% for TCA, p < 0.0001, OR 7.7). Permanent DI was less frequent with EEA (29.20% vs. 67.40% for TCA, p < 0.0001, OR 0.2). CSF Leaks occurred more frequently with EEA (9.94% vs. 0.70% for TCA, p < 0.0001, OR 15.8). Recurrence rates were lower in the EEA group (EEA 15.50% vs. for TCA 21.20%, p = 0.04, OR 0.7). The results demonstrate that, in selected cases, EEA for resection of craniopharyngiomas is associated with better results regarding visual preservation and extent of tumor resection. Postoperative cerebrospinal fluid fistula rates associated with EEA have improved compared to the historical series. The decision-making process should consider each person’s characteristics; however, it is noticeable that recent data regarding EEA justify its widespread application as a first-line approach in centers of excellence for skull base surgery 1).

Qiao et al., conducted a systematic review and meta-analysis. They conducted a comprehensive search of PubMed to identify relevant studies. Pituitary, hypothalamus functions and recurrence were used as outcome measures. A total of 39 cohort studies involving 3079 adult patients were included in the comparison. Among these studies, 752 patients across 17 studies underwent endoscopic transsphenoidal resection, and 2327 patients across 23 studies underwent transcranial resection. More patients in the endoscopic group (75.7%) had visual symptoms and endocrine symptoms (60.2%) than did patients in the transcranial group (67.0%, p = 0.038 and 42.0%, p = 0.016). There was no significant difference in hypopituitarism and pan-hypopituitarism after surgery between the two groups: 72.2% and 43.7% of the patients in endoscopic group compared to 80.7% and 48.3% in the transcranial group (p = 0.140 and p = 0.713). We observed same proportions of transient and permanent diabetes insipidus in both groups. Similar recurrence was observed in both groups (p = 0.131). Pooled analysis showed that neither weight gain (p = 0.406) nor memory impairment (p = 0.995) differed between the two groups. Meta-regression analysis revealed that gross total resection contributed to the heterogeneity of recurrence proportion (p < 0.001). They observed similar proportions of endocrine outcomes and recurrence in both endoscopic and transcranial groups. More recurrences were observed in studies with lower proportions of gross total resection 2).

Komotar et al performed a systematic review of the available published reports after endoscope-assisted endonasal approaches and compared their results with transsphenoidal purely microscope-based or transcranial microscope-based techniques.

The endoscopic endonasal approach is a safe and effective alternative for the treatment of certain craniopharyngiomas. Larger lesions with more lateral extension may be more suitable for an open approach, and further follow-up is needed to assess the long-term efficacy of this minimal access approach 3)

Nowadays, an endoscopic endonasal approach (EEA) provides an “easier” way for CPs resection allowing a direct route to the tumor with direct visualization of the surrounding structures, diminishing inadvertent injuries, and providing a better outcome for the patient 4).

Historically, aggressive surgical resection was the treatment goal to minimize the risk of tumor recurrence via open transcranial midline, anterolateral, and lateral approaches, but could lead to clinical sequela of visual, endocrine, and hypothalamic dysfunction. However, recent advances in the endoscopic endonasal approach over the last decade have mostly supplanted transcranial surgery as the optimal surgical approach for these tumors. With viable options for adjuvant radiation therapy, targeted medical treatment, and alternative minimally invasive surgical approaches, the management paradigm for craniopharyngiomas has shifted from aggressive open resection to more minimally invasive but maximally safe resection, emphasizing quality of life issues, particularly in regards to visual, endocrine, and hypothalamic function. 5).

Craniopharyngioma surgery has evolved over the last two decades. Traditional transcranial microsurgical approaches were the only option until the advent of the endoscopic endonasal approach 6).

The endoscopic endonasal approach for craniopharyngiomas is increasingly used as an alternative to microsurgical transsphenoidal or transcranial approaches. It is a step forward in treatment, providing improved resection rates and better visual outcome. Especially in retrochiasmatic tumors, this approach provides better lesion access and reduces the degree of manipulations of the optic apparatus. The panoramic view offered by endoscopy and the use of angulated optics allows the removal of lesions extending far into the third ventricle avoiding microsurgical brain splitting. Intensive training is required to perform this surgery 7).

The highest priority of current surgical craniopharyngioma treatment is to maximize tumor removal without compromising the patients’ long-term functional outcome. Surgical damage to the hypothalamus may be avoided or at least ameliorated with a precise knowledge regarding the type of adherence for each case.

Endoscopic endonasal approach, has been shown to achieve higher rates of hypothalamic preservation regardless of the degree of involvement by tumor 8) 9).

Extended endoscopic transsphenoidal approach have gained interest. Surgeons have advocated for both approaches, and at present there is no consensus whether one approach is superior to the other.

With the widespread use of endoscopes in endonasal surgery, the endoscopic transtuberculum transplanum approach have been proposed as an alternative surgical route for removal of different types of suprasellar tumors, including solid craniopharyngiomas in patients with normal pituitary function and small sella.

As part of a minimally disruptive treatment paradigm, the extended endoscopic transsphenoidal approach has the potential to improve rates of resection, improve postoperative visual recovery, and minimize surgical morbidity 10).

Corridors

The endoscopic endonasal approach has become a valid surgical technique for the management of craniopharyngiomas. It provides an excellent corridor to infra- and supradiaphragmatic midline craniopharyngiomas, including the management of lesions extending into the third ventricle chamber. Even though indications for this approach are rigorously lesion based, the data confirm its effectiveness in a large patient series 11).

The endoscopic endonasal approach offers advantages in the management of craniopharyngiomas that historically have been approached via the transsphenoidal approach (i.e., purely intrasellar or intra-suprasellar infradiaphragmatic, preferably cystic lesions in patients with panhypopituitarism).

Use of the extended endoscopic endonasal approach overcomes the limits of the transsphenoidal route to the sella enabling the management of different purely suprasellar and retrosellar cystic/solid craniopharyngiomas, regardless of the sellar size or pituitary function 12).

They provide acceptable results comparable to those for traditional craniotomies. Endoscopic endonasal surgery is not limited to adults and actually shows higher resection rates in the pediatric population 13).

Infrachiasmatic corridor

Infrachiasmatic corridor

Complications

Craniopharyngioma endoscopic endonasal approach complications.

Case series

see Craniopharyngioma endoscopic endonasal approach case series.

References

1)

Figueredo LF, Martínez AL, Suarez-Meade P, Marenco-Hillembrand L, Salazar AF, Pabon D, Guzmán J, Murguiondo-Perez R, Hallak H, Godo A, Sandoval-Garcia C, Ordoñez-Rubiano EG, Donaldson A, Chaichana KL, Peris-Celda M, Bendok BR, Samson SL, Quinones-Hinojosa A, Almeida JP. Current Role of Endoscopic Endonasal Approach for Craniopharyngiomas: A 10-Year Systematic Review and Meta-Analysis Comparison with the Open Transcranial Approach. Brain Sci. 2023 May 23;13(6):842. doi: 10.3390/brainsci13060842. PMID: 37371322.
2)

Qiao N. Endocrine outcomes of endoscopic versus transcranial resection of craniopharyngiomas: A system review and meta-analysis. Clin Neurol Neurosurg. 2018 Apr 7;169:107-115. doi: 10.1016/j.clineuro.2018.04.009. [Epub ahead of print] Review. PubMed PMID: 29655011.
3)

Komotar RJ, Starke RM, Raper DM, Anand VK, Schwartz TH. Endoscopic endonasal compared with microscopic transsphenoidal and open transcranial resection of craniopharyngiomas. World Neurosurg. 2012 Feb;77(2):329-41. doi: 10.1016/j.wneu.2011.07.011. Epub 2011 Nov 1. Review. PubMed PMID: 22501020.
4)

Aragón-Arreola JF, Marian-Magaña R, Villalobos-Diaz R, López-Valencia G, Jimenez-Molina TM, Moncada-Habib JT, Sangrador-Deitos MV, Gómez-Amador JL. Endoscopic Endonasal Approach in Craniopharyngiomas: Representative Cases and Technical Nuances for the Young Neurosurgeon. Brain Sci. 2023 Apr 28;13(5):735. doi: 10.3390/brainsci13050735. PMID: 37239207; PMCID: PMC10216292.
5)

Hong CS, Omay SB. The Role of Surgical Approaches in the Multi-Modal Management of Adult Craniopharyngiomas. Curr Oncol. 2022 Feb 24;29(3):1408-1421. doi: 10.3390/curroncol29030118. PMID: 35323318; PMCID: PMC8947636.
6)

Fong RP, Babu CS, Schwartz TH. Endoscopic endonasal approach for craniopharyngiomas. J Neurosurg Sci. 2021 Apr;65(2):133-139. doi: 10.23736/S0390-5616.21.05097-9. PMID: 33890754.
7)

Baldauf J, Hosemann W, Schroeder HW. Endoscopic Endonasal Approach for Craniopharyngiomas. Neurosurg Clin N Am. 2015 Jul;26(3):363-75. doi: 10.1016/j.nec.2015.03.013. Epub 2015 May 26. PMID: 26141356.
8)

Tan TSE, Patel L, Gopal-Kothandapani JS, Ehtisham S, Ikazoboh EC, Hayward R, et al: The neuroendocrine sequelae of paediatric craniopharyngioma: a 40-year meta-data analysis of 185 cases from three UK centres. Eur J Endocrinol 176:359–369, 2017
9)

Yokoi H, Kodama S, Kogashiwa Y, Matsumoto Y, Ohkura Y, Nakagawa T, et al: An endoscopic endonasal approach for early-stage olfactory neuroblastoma: an evaluation of 2 cases with minireview of literature. Case Rep Otolaryngol 2015:541026, 2015
10)

Zacharia BE, Amine M, Anand V, Schwartz TH. Endoscopic Endonasal Management of Craniopharyngioma. Otolaryngol Clin North Am. 2016 Feb;49(1):201-12. doi: 10.1016/j.otc.2015.09.013. Review. PubMed PMID: 26614838.
11)

Cavallo LM, Frank G, Cappabianca P, Solari D, Mazzatenta D, Villa A, Zoli M, D’Enza AI, Esposito F, Pasquini E. The endoscopic endonasal approach for the management of craniopharyngiomas: a series of 103 patients. J Neurosurg. 2014 May 2. [Epub ahead of print] PubMed PMID: 24785324.
12)

Cavallo LM, Solari D, Esposito F, Villa A, Minniti G, Cappabianca P. The Role of the Endoscopic Endonasal Route in the Management of Craniopharyngiomas. World Neurosurg. 2014 Dec;82(6S):S32-S40. doi: 10.1016/j.wneu.2014.07.023. Review. PubMed PMID: 25496633.
13)

Koutourousiou M, Gardner PA, Fernandez-Miranda JC, Tyler-Kabara EC, Wang EW, Snyderman CH. Endoscopic endonasal surgery for craniopharyngiomas: surgical outcome in 64 patients. J Neurosurg. 2013 Nov;119(5):1194-207. doi: 10.3171/2013.6.JNS122259. Epub 2013 Aug 2. PubMed PMID: 23909243.

Pituitary apoplexy

Pituitary apoplexy

Definition

Pituitary apoplexy (PA) is a clinical condition characterized by a sudden increase in pituitary gland volume secondary to ischemia and/or necrosis.

Key concepts

● due to the expansion of a pituitary neuroendocrine tumor from hemorrhage or necrosis

● typical presentation: paroxysmal H/A with endocrinologic and/or neurologic deficit (usually ophthalmoplegia or visual loss)

● management: immediate administration of glucocorticoids, and transsphenoidal decompression within 7 days in most cases.

Epidemiology

Pituitary apoplexy epidemiology.

Classification

It is important to note that pituitary apoplexy may be divided into hemorrhagic or ischemic, each with unique neuroimaging findings.

Etiology

Pituitary apoplexy etiology.

Pathophysiology

Some postulate that a gradual enlarging pituitary tumor becomes impacted at the diaphragmatic notch, compressing and distorting the hypophyseal stalk and its vascular supply. This deprives the anterior pituitary gland and the tumor itself of its vascular supply, apoplectically causing ischemia and subsequent necrosis.

Another theory stipulates that rapid expansion of the tumor outstrips its vascular supply, resulting in ischemia and necrosis. This explanation is doubtful, since most tumors that undergo apoplexy are slow growing.

Cerebral ischemia due to pituitary apoplexy is very rare. It may be caused by vasospasm or direct compression of cerebral vessels by the tumor.

Clinical features

Pituitary apoplexy clinical features.

Diagnosis

Pituitary apoplexy diagnosis.

Differential diagnosis

Seung et al., present an unusual case of bitemporal hemianopsia caused by a large anterior communicating artery aneurysm.

A 41-year-old woman was admitted to our neurosurgical department with a sudden-onset bursting headache and visual impairment. On admission, her vision was decreased to finger counting at 30 cm in the left eye and 50 cm in the right eye, and a severe bitemporal hemianopsia was demonstrated on visual field testing. A brain computed tomography scan revealed a subarachnoid hemorrhage at the basal cistern, and conventional cerebral catheter angiography of the left internal carotid artery demonstrated an 18×8 mm dumbbell-shaped aneurysm at the ACoA. Microscopic aneurysmal clipping was performed. An ACoA aneurysm can produce visual field defects by compressing the optic chiasm or nerves.

Seung et al., emphasize that it is important to diagnose an aneurysm through cerebrovascular study to prevent confusing it with pituitary apoplexy 1).

A 52-year-old woman, previously diagnosed with asymptomatic Rathke cleft cyst (RCC), came with a severe headache, along with visual dysfunction and symptoms of pituitary insufficiency. Fluid-attenuated inversion recovery magnetic resonance imaging demonstrated diffuse hyperintensity in the cerebral cisterns, whereas watery clear cerebrospinal fluid was obtained by lumbar puncture. Surgery performed 1 month after onset revealed a nonhemorrhagic lesion, with a final diagnosis of nonhemorrhagic RCC rupture.

Yokota et al., conclude that nonhemorrhagic RCC rupture and subsequent leakage of the contents into subarachnoid space were the underlying pathogenesis in the present case of RCC resembling apoplexy 2).

Treatment

Pituitary apoplexy treatment.

Outcome

see Pituitary apoplexy outcome.

Case series

Pituitary apoplexy case series.

Case reports

Pituitary apoplexy case reports.

Pituitary apoplexy in Dogs

Nineteen cases of suspected Pituitary apoplexy were included. The majority of dogs showed behavioural abnormalities (11/19). Neurological signs more frequently identified were obtundation (7/19), vestibular signs (7/19) and epileptic seizures (6/19). The onset of neurological signs was per-acute in 14 out of 19 cases. Data regarding CT and MRI were available in 18 and 9 cases, respectively. Neurological signs resolved in less than 24 h in seven patients. The short-term prognosis was defined as favourable in the majority of the study population. The median survival time was of 7 months from the time of PA diagnosis. This is the first description of neurological signs, imaging findings and outcome in a large group of dogs with PA 3).

References

1)

Seung WB, Kim DY, Park YS. A Large Ruptured Anterior Communicating Artery Aneurysm Presenting with Bitemporal Hemianopsia. J Korean Neurosurg Soc. 2015 Sep;58(3):291-3. doi: 10.3340/jkns.2015.58.3.291. Epub 2015 Sep 30. PubMed PMID: 26539276; PubMed Central PMCID: PMC4630364.
2)

Yokota H, Ida Y, Wajima D, Nishimura F, Nakase H. Rathke Cleft Cyst with Evidence of Rupture into Subarachnoid Space. World Neurosurg. 2016 Oct 21. pii: S1878-8750(16)31061-0. doi: 10.1016/j.wneu.2016.10.072. [Epub ahead of print] PubMed PMID: 27777166.
3)

Galli G, Bertolini G, Dalla Serra G, Menchetti M. Suspected Pituitary Apoplexy: Clinical Presentation, Diagnostic Imaging Findings and Outcome in 19 Dogs. Vet Sci. 2022 Apr 15;9(4):191. doi: 10.3390/vetsci9040191. PMID: 35448689.

Pituitary neuroendocrine tumor

Pituitary neuroendocrine tumor

Latest Pubmed Related Articles

History

Pituitary neuroendocrine tumor history

Risk factors

Pituitary tumors have very few known risk factors, and these are related to genetics. There are no known environmental or lifestyle-related risk factors for pituitary tumors. Though science has suggested that people who are overweight or obese might be at increased risk.

Youn et al. discovered that a 3’untranslated region (3’UTR) variant, rs181031884 of CDKN2B (Asian-specific variant), had significant association with the risk of pituitary neuroendocrine tumor (PA) (Odds ratio = 0.58, P = 0.00003). Also, rs181031884 appeared as an independent causal variant among the significant variants in CDKN2A and CDKN2B, and showed dose-dependent effects on PA.

Although further studies are needed to verify the impact of this variant on pituitary neuroendocrine tumor susceptibility, the results may help to understand CDKN2B polymorphism and the risk of pituitary neuroendocrine tumor 1).

Epidemiology

Pituitary neuroendocrine tumor epidemiology.

Classification

Pituitary neuroendocrine tumor classification.

Natural History

Pituitary Neuroendocrine Tumor Natural History.

Genetic syndromes

Multiple endocrine neoplasia type 1

Multiple endocrine neoplasia type 4

McCune-Albright syndrome

Carney complex

Pathogenesis

Pituitary neuroendocrine tumor pathogenesis.

Clinical features

Pituitary neuroendocrine tumor clinical features.

Diagnosis

pituitary neuroendocrine tumor Diagnosis.

Treatment

Pituitary neuroendocrine tumor treatment

Outcome

Pituitary Neuroendocrine Tumor Outcome.

Case series

Pituitary neuroendocrine tumor case series

Case reports

A 45-year-old woman who suffered from limb edema for 2 months. Dong et al. focused on tumor recurrence and other common potential diseases based on the pituitary neuroendocrine tumor history. However, none of the examinations showed any abnormality. Later, her continuous complaints about the family relationship and depressed mood came into sight, and a psychiatry consultation was arranged. Following that, she was diagnosed with major depressive disorder. After several days of Melitracen and tandospirone treatment, the patient’s limb edema dramatically subsided. This is the first case of limb edema associated with depression. This highlights the importance of awareness of mental illness for non-psychiatrists, especially in patients with severe somatic symptoms, but with negative results 2).

Recurrence

Pituitary neuroendocrine tumor recurrence

Pituitary neuroendocrine tumor General University Hospital of Alicante Cases

A 39-year-old woman reports visual loss (blurred vision) in both eyes for 2 months, the left worse than the right. Refers to headache (twice a week) that subsides with paracetamol In the last 15 days, he has woken up at night several days due to headaches.

Migraines under control by Neurology

Antiphospholipid syndrome antibody/hypercoagulability in follow-up by Hematology

APA is positive at low titer.

Bilateral superior external quadrantanopia

Treatment with Zolmitriptan

Computed tomography

Suprasellar mass is observed that occupies and expands the sella turcica, difficult to define, which produces a break in the continuity of the floor of the sella turcica and a complete occupation of the sphenoid sinus, which also presents an expansion of the same and thinning of its bony walls. It has maximum measurements of 3.5 x 2.8 x 1.2 cm (craniocaudal by transverse by anteroposterior). These findings seem compatible with an aggressive pituitary neuroendocrine tumor

The mass ascends through the sellar diaphragm and compresses the optic chiasm, and in the lateral areas, it completely encompasses both intracavernous carotid arteries and both cavernous sinuses bilaterally.

Brain MRI

A large sellar lesion with a marked isointense suprasellar extension on T1 and heterogeneous on T2 with multiple hyperintense foci on T2, especially the cystic-necrotic suprasellar portion in relation to macroadenoma. The lesion measures approximately 4 cm in diameter craniocaudal, 3.9 anteroposterior, and 4.2 cm transverse. It extends to both cavernous sinuses and surrounds the right internal carotid artery for more than 180° and the left for approximately 180°. It causes a mass effect on the optic chiasm, displacing it superiorly. The pituitary stalk seems to be located anterior to the lesion with a slight right lateralization, although it is difficult to locate it due to the large size of the lesion.

HORMONES

FREE T4 1.7 ng/dL

FSH 5.3 U/L

LH 3.4 U/L

PROLACTIN 8.3ng/mL

ESTRADIOL 32.0 pg/mL

CORTISOL MORNING 10.9 µg/dL

IGF-1 231 ng/mL

Under general anesthesia, orotracheal intubation, and antibiotic prophylaxis with cefazolin 2 gr IV. Supine position with neutral head resting on a donut-type pillow. Preoperative topical intranasal oxymetazoline was applied with lectins.

nasal phase: Right middle turbinate resection. Preparation of a nasoseptal flap with mucosa from the right septum. It is left lodged in the right choana. Posterior septostomy and communication of both nostrils. In the ostium, a tumor is visualized that completely occupies the sphenoid sinus. Wide anterior sphenoidotomy with the help of a laminotome and cutting burr. Profuse bleeding throughout the nasal phase comes from the tumor. Part of the left paramedian septum that was encompassed by the tumor was removed.

Excision phase: Excision of the tumor part contained in the sphenoid sinus until the bony limits of the sella turcica were visualized. With the help of neuronavigation and Doppler, both ICAs were located. Clivus partly eroded. In the most inferior and posterior part, a bone area corresponding to the posterior clinoid is observed, which is moth-eaten and loose, encompassed by a tumor. Intracapsular excision of the tumor is started by way of debulking, and sending tumor samples for AP analysis. The tumor shows a friable consistency and a purplish color compatible with a pituitary neuroendocrine tumor. Central excision until visualizing gradual descent of sellar and arachnoid diagrams in the sellar cavity with contained low-flow fistula. Exeresis in the posterior region until observing the dura mater of the posterior fossa. Excision of the lateral walls and part of the cavernous sinus. Hemostasis with Floseal.

Reconstruction phase: Tachosil is placed covering the arachnoid in the area of ​​the contained fistula. A nasoseptal flap is placed in contact with the bone defect around the sellar opening. The flap is fixed with surgicel and tissucol. Rapid -Rhino binasal tires are left. The free mucosa of the middle turbinate is left covering the part of the septum from which the flap has been removed.

1)

Youn BJ, Cheong HS, Namgoong S, Kim LH, Baek IK, Kim JH, Yoon SJ, Kim EH, Kim SH, Chang JH, Kim SH, Shin HD. Asian-specific 3’UTR variant in CDKN2B associated with risk of pituitary neuroendocrine tumor. Mol Biol Rep. 2022 Sep 12. doi: 10.1007/s11033-022-07796-1. Epub ahead of print. PMID: 36097105.
2)

Dong X, Fang S, Li W, Li X, Zhang S. Deanxit and tandospirone relieved unexplained limb edema in a depressed pituitary neuroendocrine tumor survivor: A case report. Front Psychiatry. 2022 Nov 10;13:965495. doi: 10.3389/fpsyt.2022.965495. PMID: 36440410; PMCID: PMC9685525.

ShuntScope

ShuntScope

Autoclavable reusable SHUNTSCOPE® is designed to facilitate the endoscopic ventricular drainage placement during shunt surgery.

Case series

A retrospective analysis of all pediatric patients undergoing ventricular catheter placement using the ShuntScope from 01/2012 to 01/2022 in the Department of Neurosurgery, Saarland University Medical Center, Homburg was performed. Demographic, clinical, and radiological data were evaluated. The visualization quality of the intraoperative endoscopy was stratified into the categories of excellent, medium, and poor and compared to the postoperative catheter tip placement. Follow-up evaluation included the surgical revision rate due to proximal catheter occlusion.

A total of 65 ShuntScope-assisted surgeries have been performed on 51 children. The mean age was 5.1 years. The most common underlying pathology was a tumor- or cyst-related hydrocephalus in 51%. Achieved image quality was excellent in 41.5%, medium in 43%, and poor in 15.5%. Ideal catheter placement was achieved in 77%. There were no intraoperative ventricular catheter placement complications and no technique-related morbidity associated with the ShuntScope. The revision rate due to proximal occlusion was 4.61% during a mean follow-up period of 39.7 years. No statistical correlation between image grade and accuracy of catheter position was observed (p-value was 0.290).

The ShuntScope can be considered a valuable addition to standard surgical tools in pediatric hydrocephalus treatment. Even suboptimal visualization contributes to high rates of correct catheter placement and, thereby, to a favorable clinical outcome 1).

The purpose of the study is to compare the accuracy of catheter placement and the complication and revision rates between SG and freehand (FH) techniques.

A retrospective study based on a prospectively acquired database of patients who underwent VC placement between September 2018 and July 2021. The accuracy of catheter placement was graded on postoperative imaging using a three-point Hayhurst grading system. Complication and revision rates were documented and compared between both groups with an average follow-up period of 20.84 months.

Results: Fifty-seven patients were included. SG technique was used in 29 patients (mean age was 6.3 years, 1.4 -27.7 years, 48.1% females), and FH technique was used in 28 patients (mean age was 26.7 years, 0.83 – 79.5 years, 67.9% female). The success rate for the optimal placement of the VC with a grade I on the Hayhurst scale was significantly higher in the SG group (93.1%) than in the FH group (60.7%), P = 0.012. The revision rate was higher in the FH group with 35.7% vs. 20.7% of in the SG group, P = 0.211.

Conclusion: VC placement using the SG technique is a safe and effective procedure, which enabled a significantly higher success rate and lower revision and complication rate. Accordingly, we recommend using the SG technique especially in patients with difficult anatomy 2)

The experience of shuntscope-guided ventriculoperitoneal shunt in 9 cases done from June 2015 to April 2016. Shuntscope is a 1 mm outer diameter semi-rigid scope from Karl Storz with 10000 pixels of magnification. It has a fiber optic lens system with a camera and light source attachment away from the scope to make it lightweight and easily maneuverable.

Results: In all cases, VC was placed in the ipsilateral frontal horn away from choroid plexuses, septae, or membranes. Septum pellucidum perforation and placement to the opposite side of the ventricle was identified with shunt scope assistance and corrected.

Conclusion: Although our initial results are encouraging, larger case series would be helpful. Complications and cost due to shunt dysfunction can thus be reduced to a great extent with shuntscope 3)

The semi-rigid ShuntScope (Karl Storz GmbH & Co.KG, Tuttlingen, Germany) with an outer diameter of 1.0 mm and an image resolution of 10,000 pixels was used in a series of 27 children and adolescents (18 males, 9 females, age range 2 months-18 years). Indications included catheter placement in aqueductal stenting (n = 4), first-time shunt placement (n = 5), burr hole reservoir insertion (n = 4), catheter placement after endoscopic procedures (n = 7) and revision surgery of the ventricle catheter (n = 7).

ShuntScope-guided precise catheter placement was achieved in 26 of 27 patients. In one case of aqueductal stenting, the procedure had to be abandoned. One single wound healing problem was noted as a complication. Intraventricular image quality was always sufficient to recognize the anatomical structures. In the case of catheter removal, it was helpful to identify adherent vessels or membranes. Penetration of small adhesions or thin membranes was feasible. Postoperative imaging studies demonstrated catheter tip placements analogous to the intraoperative findings.

Misplacements of shunt catheters are completely avoidable with the presented intra-catheter technique including slit ventricles or even aqueductal stenting. Potential complications can be avoided during revision surgery. The implementation of the ShuntScope is recommended in pediatric neurosurgery 4).

Latest articles

1)

Prajsnar-Borak A, Teping F, Oertel J. Image quality and related outcomes of the ShuntScope for catheter implantation in pediatric hydrocephalus-experience of 65 procedures. Childs Nerv Syst. 2022 Dec 2. doi: 10.1007/s00381-022-05776-1. Epub ahead of print. PMID: 36459211.
2)

Issa M, Nofal M, Miotik N, Seitz A, Unterberg A, El Damaty A. ShuntScope®-Guided Versus Free Hand Technique for Ventricular Catheter Placement: A Retrospective Comparative Study of Intra-Ventricular Catheter Tip Position and Complication Rate. J Neurol Surg A Cent Eur Neurosurg. 2022 Feb 10. doi: 10.1055/a-1768-3892. Epub ahead of print. PMID: 35144299.
3)

Agrawal V, Aher RB. Endoluminal Shuntscope-Guided Ventricular Catheter Placement: Early Experience. Asian J Neurosurg. 2018 Oct-Dec;13(4):1071-1073. doi: 10.4103/ajns.AJNS_98_17. PMID: 30459870; PMCID: PMC6208226.
4)

Senger S, Antes S, Salah M, Tschan C, Linsler S, Oertel J. The view through the ventricle catheter – The new ShuntScope for the therapy of pediatric hydrocephalus. J Clin Neurosci. 2018 Feb;48:196-202. doi: 10.1016/j.jocn.2017.10.046. Epub 2017 Nov 6. PubMed PMID: 29102235.

Ventriculostomy related infection risk factors

Ventriculostomy related infection risk factors

Ventriculostomy related infection risk factors include prior brain surgery, cerebrospinal fluid fistula, and insertion site dehiscence. Walek et al. from Rhode Island Hospital found no significant association between infection risk and duration of external ventricular drainage placement 1).

A total of 15 supposed influencing factors includes: age, age & sex interactions, coinfection, catheter insertion outside the hospital, catheter type, CSF leakage, CSF sampling frequency, diagnosis, duration of catheterization, ICP > 20 mmHg, irrigation, multiple catheter, neurosurgical operation, reduced CSF glucose at catheter insertion and sex 2).

In a large series of patients, ventriculostomy related infection (VRI) was associated with a longer ICU stay, but its presence did not influence survival. A longer duration of ventriculostomy catheter monitoring in patients with VRI might be due to an increased volume of drained CSF during infection. Risk factors associated with VRIs are SAH, IVH, craniotomy, and coinfection 3).

A retrospective cohort study strengthens a growing body of works suggesting the importance of inoculation of skin flora as a critical risk factor in ventriculostomy related infections, underscoring the importance of drain changes only when clinically indicated and, that as soon as clinically permitted, catheters should be removed 4).

Associated with a longer ICU stay, but its presence did not influence survival. A longer duration of ventriculostomy catheter monitoring in patients with VAI might be due to an increased volume of drained CSF during infection. Risk factors associated with VAIs are subarachnoid hemorrhage (SAH), intraventricular hemorrhage IVH, craniotomy, and coinfection 5).

The risk of infection increases with increasing duration of catheterization and with repeated insertions. The use of local antibiotic irrigation or systemic antibiotics does not appear to reduce the risk of VAI. Routine surveillance cultures of CSF were no more likely to detect infection than cultures obtained when clinically indicated. These findings need to be considered in infection control policies addressing this important issue 6).

An increased risk of infection has been observed in patients with subarachnoid or intraventricular hemorrhage, in patients with concurrent systemic infections as well as with longer duration of catheterization, cerebrospinal (CSF) leakage, and frequent manipulation of the EVD system 7) 8) 9).

Many studies have been conducted to identify risk factors of EVD-related infections. However, none of these risk factors could be confirmed in a cohort of patients. Furthermore they not show any difference in infection rates between patients who were placed in single- or multibed rooms, respectively 10).

Interestingly no risk factor for EVD-related infection could be identified in a retrospective single center study 11).

References

1)

Walek KW, Leary OP, Sastry R, Asaad WF, Walsh JM, Horoho J, Mermel LA. Risk factors and outcomes associated with external ventricular drain infections. Infect Control Hosp Epidemiol. 2022 Apr 26:1-8. doi: 10.1017/ice.2022.23. Epub ahead of print. PMID: 35471129.
2)

Sorinola A, Buki A, Sandor J, Czeiter E. Risk Factors of External Ventricular Drain Infection: Proposing a Model for Future Studies. Front Neurol. 2019 Mar 15;10:226. doi: 10.3389/fneur.2019.00226. eCollection 2019. Review. PubMed PMID: 30930840; PubMed Central PMCID: PMC6428739.
3)

Bota DP, Lefranc F, Vilallobos HR, Brimioulle S, Vincent JL. Ventriculostomy-related infections in critically ill patients: a 6-year experience. J Neurosurg. 2005 Sep;103(3):468-72. PubMed PMID: 16235679.
4)

Katzir M, Lefkowitz JJ, Ben-Reuven D, Fuchs SJ, Hussein K, Sviri G. Decreasing external ventricular drain related infection rates with duration-independent, clinically indicated criteria for drain revision: A retrospective study. World Neurosurg. 2019 Aug 2. pii: S1878-8750(19)32121-7. doi: 10.1016/j.wneu.2019.07.205. [Epub ahead of print] PubMed PMID: 31382072.
5)

Bota DP, Lefranc F, Vilallobos HR, Brimioulle S, Vincent JL. Ventriculostomy-related infections in critically ill patients: a 6-year experience. J Neurosurg. 2005 Sep;103(3):468-72. PubMed PMID: 16235679.
6)

Arabi Y, Memish ZA, Balkhy HH, Francis C, Ferayan A, Al Shimemeri A, Almuneef MA. Ventriculostomy-associated infections: incidence and risk factors. Am J Infect Control. 2005 Apr;33(3):137-43. PubMed PMID: 15798667.
7)

Camacho E. F., Boszczowski Í., Basso M., Jeng B. C. P., Freire M. P., Guimarães T., Teixeira M. J., Costa S. F. Infection rate and risk factors associated with infections related to external ventricular drain. Infection. 2011;39(1):47–51. doi: 10.1007/s15010-010-0073-5.
8)

Kim J.-H., Desai N. S., Ricci J., Stieg P. E., Rosengart A. J., Hrtl R., Fraser J. F. Factors contributing to ventriculostomy infection. World Neurosurgery. 2012;77(1):135–140. doi: 10.1016/j.wneu.2011.04.017.
9)

Mayhall C. G., Archer N. H., Lamb V. A., Spadora A. C., Baggett J. W., Ward J. D., Narayan R. K. Ventriculostomy-related infections. A positive epidemiologic study. The New England Journal of Medicine. 1984;310(9):553–559. doi: 10.1056/NEJM198403013100903.
10)

Hagel S, Bruns T, Pletz MW, Engel C, Kalff R, Ewald C. External Ventricular Drain Infections: Risk Factors and Outcome. Interdiscip Perspect Infect Dis. 2014;2014:708531. Epub 2014 Nov 17. PubMed PMID: 25484896; PubMed Central PMCID: PMC4251652.
11)

Hagel S, Bruns T, Pletz MW, Engel C, Kalff R, Ewald C. External ventricular drain infections: risk factors and outcome. Interdiscip Perspect Infect Dis. 2014;2014:708531. doi: 10.1155/2014/708531. Epub 2014 Nov 17. PubMed PMID: 25484896; PubMed Central PMCID: PMC4251652.

Lactotroph adenoma treatment

Lactotroph adenoma treatment

Dopamine agonists such as bromocriptine and cabergoline have been found to be an effective treatment for hyperprolactinemia, not only inducing adenoma shrinkage but also lowering serum prolactin levels. Among known dopamine agonists, cabergoline is the drug of choice due to its enhanced tolerability compared with bromocriptine 1).

Surgical intervention may resurface as an alternative first-line treatment. When used in combination with cabergoline, surgery offers a higher disease remission rate than either drug or operation alone 2)

Lactotroph Adenoma Surgery is safe and efficient. It is particularly suitable for enclosed prolactinomas. The patient should be well informed of the pros and cons of the treatment options, which include dopamine agonist (DA) and transsphenoidal microsurgery, and the patient’s preference should be taken into account during decision-making 3).

In the absence of visual deficits, pituitary apoplexy in lactotroph adenomas is the only type of pituitary tumor for which medical therapy (Dopamine agonists) may be the primary treatment.

Issues and questions to be addressed in this approach to long-term management of prolactinomas include the frequency of radiographic monitoring, effect of pregnancy and menopause, safety of estrogen in women taking oral contraceptives, and the potential for discontinuation of dopamine agonist therapy 4).

Lactotroph adenoma Medical Therapy

see Dopamine agonist for Lactotroph adenoma.

Lactotroph Adenoma Surgery

see Lactotroph Adenoma Surgery

Controversies

Although transsphenoidal surgery (TSS) is an option for prolactinoma treatment, it is less effective than medical management, carries considerably more risk, and is more expensive. The benefit/risk ratio for DA therapy compared to TSS actually becomes increasingly more favorable as tumor size increases. Therefore DA should remain the clear treatment of choice for essentially all patients with prolactinomas, reserving TSS as a second-line option for the very small number of patients that do not tolerate or are completely resistant to DA therapy 5).

Radiosurgery

Lactotroph adenoma radiosurgery.

Serial imaging

The underlying decision to perform serial imaging in prolactinoma patients should be individualized on a case-by-case basis. Future studies should focus on alternative imaging methods and/or contrast agents 6).

References

1)

Krysiak R, Okopien B. Different Effects of Cabergoline and Bromocriptine on Metabolic and Cardiovascular Risk Factors in Patients with Elevated Prolactin Levels. Basic Clin Pharmacol Toxicol. 2014 Aug 13. doi: 10.1111/bcpt.12307. [Epub ahead of print] PubMed PMID: 25123447.
2)

Chen TY, Lee CH, Yang MY, Shen CC, Yang YP, Chien Y, Huang YF, Lai CM, Cheng WY. Treatment of Hyperprolactinemia: A Single-Institute Experience. J Chin Med Assoc. 2021 Jul 13. doi: 10.1097/JCMA.0000000000000584. Epub ahead of print. PMID: 34261980.
3)

Giese S, Nasi-Kordhishti I, Honegger J. Outcomes of Transsphenoidal Microsurgery for Prolactinomas – A Contemporary Series of 162 Cases. Exp Clin Endocrinol Diabetes. 2021 Jan 18. doi: 10.1055/a-1247-4908. Epub ahead of print. PMID: 33461233.
4)

Schlechte JA. Long-term management of prolactinomas. J Clin Endocrinol Metab. 2007 Aug;92(8):2861-5. Review. PubMed PMID: 17682084.
5)

Bloomgarden E, Molitch ME. Surgical treatment of prolactinomas: cons. Endocrine. 2014 Aug 12. [Epub ahead of print] PubMed PMID: 25112227.
6)

Varlamov EV, Hinojosa-Amaya JM, Fleseriu M. Magnetic resonance imaging in the management of prolactinomas; a review of the evidence. Pituitary. 2019 Oct 28. doi: 10.1007/s11102-019-01001-6. [Epub ahead of print] Review. PubMed PMID: 31659622.

Esthesioneuroblastoma

Esthesioneuroblastoma (ENB)

Esthesioneuroblastoma (ENB), originally described in 1924, AKA olfactory neuroblastoma, AKA olfactory esthesioneuroblastoma, AKA esthesioneurocytoma, AKA olfactory placode tumor 1).

Malignant tumor of sinonasal origin.

Epidemiology

A rare nasal neoplasm with an incidence of 0.4 per 1,000,000 people. 2).

Believed to arise from the olfactory neural crest cells in the upper nares, it is considered to be malignant. These tumors occur over a wide age range (3 to 90 years), with a bimodal peak between the second and third decade and a second peak in the sixth and seventh decades.

Classification

Esthesioneuroblastoma classification.

Clinical features

These tumors typically present with unilateral nasal obstruction and epistaxis.

Diagnosis

Diagnosis is confirmed on biopsy.

MRI: isointense with the brain on T1-weighted imaging and intermediate to high signal intensity on T2- weighted imaging and enhance heterogeneously with gadolinium. Signal characteristics may mimic meningioma. For higher stage lesions, the cribriform plate may be eroded; better seen on thin-cut CT. The most important factor determining resectability is an intracranial extension. Magnetic resonance aids in the distinction between extradural tumors, dural invasion, or parenchymal brain invasion. None of these are specific to this tumor.

Endoscopic biopsy is typically performed in the otolaryngology office prior to surgery. A clinical oncology exam should be performed, and if there is suspicion for metastatic disease a PET scan, which is sensitive for metastatic disease, should be ordered.

Differential diagnosis

Includes SNUC, nasal melanoma, nasal squamous cell carcinoma, and meningioma.

Treatment

see Esthesioneuroblastoma treatment.

Outcome

Esthesioneuroblastoma outcome.

Case series

Esthesioneuroblastoma case series.

Case reports

Esthesioneuroblastoma case reports.

References

1)

Berger L, Luc G, Richard D. L’Esthesioneuroepitheliome Olfactif. Bull Assoc Franc Etude Cancer. 1924; 13: 410–421
2)

Theilgaard SA, Buchwald C, Ingeholm P, et al. Esthesioneuroblastoma: a Danish demographic study of 40 patients registered between 1978 and 2000. Acta Otolaryngol. 2003; 123:433–439

Sphenoid sinus mucosal thickening

Sphenoid sinus mucosal thickening

In pituitary apoplexy etiology, there are reports on the appearance of sphenoid sinus mucosal thickening (SSMT) 1) 2). 3).

SSMT is otherwise uncommon with an incidence of up to 7% in asymptomatic individuals. The etiology of SSMT in pituitary apoplexy is unclear and may reflect inflammatory and/or infective changes 4).

The mechanism of thickening of the para sellar dura mater and sphenoid sinus mucosa have been considered to be caused by congestion of dural blood flow because of increased cavernous and circular sinus pressure due to a sudden increase in intrasellar pressure.

A study revealed that age, tumor size, and thickened sphenoid sinus mucosa were strongly related to the occurrence of internal carotid artery stenosis in pituitary apoplexy. Among these factors, age had the potential of being an independent predictor of the condition 5).

Two magnetic resonance imaging (MRI) signs of pituitary apoplexy are the “pituitary ring sign” and “sphenoid sinus mucosal thickening”. The occurrence of both these MRI signs together in patients with ischaemic pituitary apoplexy was investigated. A literature review searching the terms “pituitary ring sign” and “sphenoid sinus mucosal thickening” in the context of pituitary apoplexy from 1990 until the present was performed. To be included in the study, each case had to have ischaemic pituitary apoplexy defined as the acute expansion of a pituitary adenoma or, less commonly, in a non-adenomatous gland, from infarction without hemorrhage or very little hemorrhage and a T1-weighted MRI of the brain with contrast that displayed both “sphenoid sinus mucosal thickening” and a “pituitary ring sign” either on an actual study (the author’s cases) or in a figure in an article from the literature that could be reviewed and clearly illustrate these two signs. Twelve cases of ischaemic pituitary apoplexy were found, all with MRI images that showed both of these signs. Ten cases from the literature (3 of which were published by this author) plus an additional 2 recently evaluated in our hospital, totaled the 12 cases. Thus, 5 of the total 12 cases were evaluated by this author. Of these 12 patients, both headache and visual loss were present in 5 patients, headache alone was indicated in 5 patients (10 of the 12 presented with headache), and no initial symptoms identified in 2 patients (incidentally found non-functioning pituitary adenomas on MRI). These findings indicate that each sign (“pituitary ring sign” and “sphenoid sinus mucosal thickening”) may exist alone with or without pituitary apoplexy, yet both signs together in the appropriate clinical context is a strong predictor of pituitary apoplexy 6).

Arita et al. treated two patients with pituitary apoplexy in whom magnetic resonance (MR) images were obtained before and after the episode. Two days after the apoplectic episodes, MR imaging demonstrated marked thickening of the mucosa of the sphenoid sinus that was absent in the previous studies. The relevance of this change in the sphenoid sinus was investigated. Retrospective evaluations were performed using MR images obtained in 14 consecutive patients with classic pituitary apoplexy characterized by acute onset of severe headache. The mucosa of the sphenoid sinus had thickened predominantly in the compartment just beneath the sella turcica, in nine of 11 patients, as ascertained on MR images obtained within 7 days after the onset of apoplectic symptoms. This condition improved spontaneously in all four patients who did not undergo transsphenoidal surgery. The sphenoid sinus mucosa appeared to be normal on MR images obtained from three patients at the chronic stage (> 3 months after onset). The incidence of sphenoid sinus mucosal thickening during the acute stage was significantly higher in the patients with apoplexy than that in the 100 patients without apoplexy. A histological study conducted in four patients who underwent transsphenoidal surgery during the early stage showed that the subepithelial layer of the sphenoid sinus mucous membrane was obviously swollen. The sphenoid sinus mucosa thickens during the acute stage of pituitary apoplexy. This thickening neither indicates infectious sinusitis nor rules out the choice of the transsphenoidal route for surgery 7).

References

1)

Agrawal B, Dziurzynski K, Salamat MS, Baskaya M. The temporal association of sphenoid sinus mucosal thickening on MR imaging with pituitary apoplexy. Turk Neurosurg. 2012;22(6):785-90. doi: 10.5137/1019-5149.JTN.4273-11.1. PMID: 23208917.
2)

Liu JK, Couldwell WT. Pituitary apoplexy in the magnetic resonance imaging era: clinical significance of sphenoid sinus mucosal thickening. J Neurosurg. 2006 Jun;104(6):892-8. doi: 10.3171/jns.2006.104.6.892. PMID: 16776332.
3) , 7)

Arita K, Kurisu K, Tominaga A, Sugiyama K, Ikawa F, Yoshioka H, Sumida M, Kanou Y, Yajin K, Ogawa R. Thickening of sphenoid sinus mucosa during the acute stage of pituitary apoplexy. J Neurosurg. 2001 Nov;95(5):897-901. doi: 10.3171/jns.2001.95.5.0897. PMID: 11702884.
4)

Waqar M, McCreary R, Kearney T, Karabatsou K, Gnanalingham KK. Sphenoid sinus mucosal thickening in the acute phase of pituitary apoplexy. Pituitary. 2017 Aug;20(4):441-449. doi: 10.1007/s11102-017-0804-z. PMID: 28421421; PMCID: PMC5508043.
5)

Teramoto S, Tahara S, Kondo A, Morita A. Key Factors Related to Internal Carotid Artery Stenosis Associated with Pituitary Apoplexy. World Neurosurg. 2021 Feb 7:S1878-8750(21)00186-8. doi: 10.1016/j.wneu.2021.02.005. Epub ahead of print. PMID: 33567365.
6)

Vaphiades MS. Pituitary Ring Sign Plus Sphenoid Sinus Mucosal Thickening: Neuroimaging Signs of Pituitary Apoplexy. Neuroophthalmology. 2017 Aug 9;41(6):306-309. doi: 10.1080/01658107.2017.1349807. PMID: 29344069; PMCID: PMC5764063.

May 2, Webinar Topic: Endoscopic Ant Fossa Meningioma Excision/ Intraventricular Tumor Management

IFNE/ WFNS Endoscopy Weekend Update 3
Topic: Endoscopic Ant Fossa Meningioma Excision/ Intraventricular Tumor Management

Time: May 2, 2020
08:00 AM (Ohio GMT -4)
02:00 PM (Italy GMT +2)
12:00 PM (GMT +0)
05:00 PM (Pakistan Time GMT +5)

Join Zoom Meeting
https://zoom.us/j/93802030387
Meeting ID: 938 0203 0387