Trepanation, Trephining and Craniotomy History and Stories

Trepanation, Trephining and Craniotomy History and Stories

by José M González-Darder (Author)

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This book takes readers on a journey around the world and through time, accompanied by a modern neurosurgeon who reviews historical techniques and instruments used for cranial opening. The author draws on original medical and surgical books to provide a comprehensive history of these techniques and tools.

To complement the general overview and offer readers a more ‘hands-on’ sense of context and atmosphere, extensive historical references, stories, media news, and illustrative cases have been included for each historical and geographical scenario. In addition, original illustrations and plates of these archaic instruments and techniques are supplied.

Neurosurgical surgeons, nurses, technicians, medical historiographers, paleo-pathologists and researchers interested in surgical techniques for cranial opening will find the volume a valuable guide, intended to increase the historical and cultural awareness of this core topic in neurological surgery.

Pituitary Adenoma Natural History

Pituitary Adenoma Natural History

Pituitary adenomas (PAs) are often detected as incidentalfindings. However, the natural history remains unclear. The objective of a study of Hwang et al., was to evaluate the natural history and growth pattern of untreated PAs.

Between 2003 and 2014, 59 PAs were managed with clinico-radiological follow up for longer than 12 months without any kind of therapeutic interventionTumor volumes were calculated at initial and last follow-up visit, and tumor growth during the observation period was determined. Data were analyzed according to clinical and imaging characteristics.

The mean initial and last tumor volume and diameter were 1.83±2.97 mL and 13.77±6.45 mm, 2.85±4.47 mL and 15.75±8.08 mm, respectively. The mean annual tumor growth rate was 0.33±0.68 mL/year during a mean observation period of 46.8±32.1 months. Sixteen (27%) PAs showed tumor growth. The initial tumor size (HR, 1.140; 95% confidence interval, 1.003-1.295; p=0.045) was the independent predictive factor that determined the tumor growth. Six patients (11%) of 56 conservatively managed non-symptomatic PAs underwent resection for aggravating visual symptoms with mean interval of 34.5 months from diagnosis. By Cox regression analysis, PAs of last longest diameter over 21.75 mm were a significant prognostic factor for eventual treatment.

The initial tumor size of PAs was independently associated with the tumor growth. Six patients (11%) of conservatively managed PAs were likely to be treated eventually. PAs of last follow-up longest diameter over 21.75 mm were a significant prognostic factor for treatment. Further studies with a large series are required to determine treatment strategy 1).


Despite the relatively high prevalence of pituitary incidentalomas (PIs)/nonfunctioning pituitary adenomas (NFPAs), the evidence on the natural history of these entities is scarce and of low quality. PIs/NFPAs seem to have fairly rare complications that may be more common when lesions are large (>10 mm) and solid 2).


The ‘watch and wait’ policy seems reasonable for microadenomas but is probably not a safe approach for macroadenomas, which appear to have a significant growth potential; in these cases, given the lack of established medical treatment, the decision for surgical intervention should balance the presence of significant comorbidities and the anaesthetic/peri-operative risks at presentation against the probability of tumour enlargement and its consequences, as well as the possible loss of advantages associated with early operation 3).

References

1)

Hwang K, Kwon T, Park J, Joo JD, Han JH, Oh CW, Kim CY. Growth Pattern and Prognostic Factors of Untreated Nonfunctioning Pituitary Adenomas. J Korean Neurosurg Soc. 2019 Mar;62(2):256-262. doi: 10.3340/jkns.2018.0153. Epub 2019 Feb 27. PubMed PMID: 30840981.
2)

Fernández-Balsells MM, Murad MH, Barwise A, Gallegos-Orozco JF, Paul A, Lane MA, Lampropulos JF, Natividad I, Perestelo-Pérez L, Ponce de León-Lovatón PG, Erwin PJ, Carey J, Montori VM. Natural history of nonfunctioning pituitary adenomas and incidentalomas: a systematic review and metaanalysis. J Clin Endocrinol Metab. 2011 Apr;96(4):905-12. doi: 10.1210/jc.2010-1054. Review. PubMed PMID: 21474687.
3)

Karavitaki N, Collison K, Halliday J, Byrne JV, Price P, Cudlip S, Wass JA. What is the natural history of nonoperated nonfunctioning pituitary adenomas? Clin Endocrinol (Oxf). 2007 Dec;67(6):938-43. Epub 2007 Aug 13. PubMed PMID: 17692109.

Chiari type 1 deformity Natural History

2 patients with Chiari type 1 deformity progressed in the degree of tonsillar herniation, whereas increasing in prolapse of tonsillar herniation after diagnosis is extremely uncommon.

The first patient aged 17 years was diagnosed with CM-1 in 2009 and was operated due to progression of 5 mm radiologically and worsening symptoms in 2014. The second 5-month-old patient initially showed just low-settled tonsillar localization at the borderline, then it descended by 2 cm when the patient reached 3 years of age, yet could not be operated because of parents’ objection.

Due to lack of reports on increasing tonsillar descent in the literature, these case reports will contribute to natural history and management of CM-1 1).


The natural history of mild symptomatic and asymptomatic CM-1 in adults is relatively benign and nonprogressive; the decision to perform surgical decompression should be based on severity and duration of a patient’s symptoms at presentation. It is reasonable to observe a patient with mild or asymptomatic symptoms even in the presence of significant tonsillar descent or syringomyelia 2).


Strahle et al., identified 147 patients in whom CM-I was diagnosed on MR imaging, who were not offered surgery at the time of diagnosis, and in whom at least 1 year of clinical and MR imaging follow-up was available after the initial CM-I diagnosis. These patients were included in an outcome analysis.

Patients were followed clinically and by MR imaging for a mean duration of 4.6 and 3.8 years, respectively. Of the 147 patients, 9 had new symptoms attributed to the CM-I during the follow-up interval. During this time, development of a spinal cord syrinx occurred in 8 patients; 5 of these patients had a prior diagnosis of a presyrinx state or a dilated central canal. Spontaneous resolution of a syrinx occurred in 3 patients. Multiple CSF flow studies were obtained in 74 patients. Of these patients, 23 had improvement in CSF flow, 39 had no change, and 12 showed worsening CSF flow at the foramen magnum. There was no significant change in the mean amount of cerebellar tonsillar herniation over the follow-up period. Fourteen patients underwent surgical treatment for CM-I. There were no differences in initial cerebellar tonsillar herniation or CSF flow at the foramen magnum in those who ultimately underwent surgery compared with those who did not.

In patients with CM-Is that are selected for nonsurgical management, the natural history is usually benign, although spontaneous improvement and worsening are occasionally seen 3).


Chiari type 1 deformity was incidentally detected on MR images in 11 of 22 patients. The remaining 11 patients had minimal clinical signs at presentation that were not regarded as necessitating immediate surgical treatment. Seventeen patients (77.3%) showed progressive improvement in their symptoms or remained asymptomatic at the last follow-up whereas 5 patients (22.7%) experienced worsening, which was mild in 2 cases and required surgical correction in the remaining 3 cases. On MR imaging a mild reduction in tonsillar herniation was appreciated in 4 patients (18.18%), with complete spontaneous resolution in 1 of these. In 16 patients, tonsillar herniation remained stable during follow-up.

Data confirm the common impression that in both asymptomatic and slightly symptomatic patients with CM-I, a conservative approach to treatment should be adopted with periodic clinical and radiological examinations 4).

References

1)

Börcek AÖ, Aslan A. Unexpected Progression of Tonsillar Herniation in Two Pediatric Cases with Chiari Malformation Type I and Review of the Literature. Pediatr Neurosurg. 2018 Dec 21:1-6. doi: 10.1159/000495066. [Epub ahead of print] PubMed PMID: 30580335.
2)

Langridge B, Phillips E, Choi D. Chiari Malformation Type 1: A Systematic Review of Natural History and Conservative Management. World Neurosurg. 2017 Aug;104:213-219. doi: 10.1016/j.wneu.2017.04.082. Epub 2017 Apr 21. Review. PubMed PMID: 28435116.
3)

Strahle J, Muraszko KM, Kapurch J, Bapuraj JR, Garton HJ, Maher CO. Natural history of Chiari malformation Type I following decision for conservative treatment. J Neurosurg Pediatr. 2011 Aug;8(2):214-21. doi: 10.3171/2011.5.PEDS1122. PubMed PMID: 21806365.
4)

Novegno F, Caldarelli M, Massa A, Chieffo D, Massimi L, Pettorini B, Tamburrini G, Di Rocco C. The natural history of the Chiari Type I anomaly. J Neurosurg Pediatr. 2008 Sep;2(3):179-87. doi: 10.3171/PED/2008/2/9/179. PubMed PMID: 18759599.
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