Degrees of Diaphragma Sellae Descent during Transsphenoidal Pituitary Adenoma Resection:Predictive Factors and Effect on Outcome

This study is aimed to classify degrees of diaphragma sellae (DS) descent into sella turcica according to the surgical field block caused by the descent and to construct predictive imaging criteria for the degree of descent,and in addition,to determine whether there is any correlation between the degree of DS descent and the operative outcome (in the form of cerebrospinal fluid leak and/or presence of residual tumor).Totally,72 patients were enrolled in our study.Their clinical and radiological data as well as the high definition videos of operations were retrospectively reviewed.The degree of DS descent during the operation was classified into five degrees according to surgical field block caused by the descent.We investigated the correlation between these five degrees and the clinical findings,radiological findings as well as the surgical outcomes.We found that the most important determining factors of DS descent degree were the volume and the height of the tumor portion above diaphragma opening.On the other hand,the total tumor volume,the maximum tumor height and the morphological pattern according to Wilson's system (modified from Hardy) had no statistically significant correlation with DS degree of descent.Presence of residual tumor on postoperative magnetic resonance images was significantly correlated with Wilson's classification and with supradiaphragmatic tumor height.On the other hand,cerebrospinal fluid leak showed no statistically significant difference between variable degrees of DS descent.Volumetric data of the tumor portion above the diaphragma opening are more important than morphological data for prediction of surgical field block caused by descended DS.While DS prolapse significantly increases the difficulty of the operative procedure,residual tumor presence is mainly dependent on morphological classification,especially cavernous sinus invasion.

Tuberculum Sellae Meningiomas: Nuances in Treatment

Tuberculum sellae meningiomas (TSMs) represent special surgical challenge for neurosurgeons. In this review, we summarize the most common clinical manifestations, diagnostic images, surgical approaches and prognostic factors for outcome at single tertiary care teaching hospitals. Material and Methods: Prospective study was done between January 2010 and January 2017 (Minimum 24-month follow-up). Imaging and clinical data of 31 consecutive patients with TSMs were collected and analyzed. There were no exclusion criteria. Result: The majority of patients were >40 years old (22 patients;71%). There was a female preponderance 74%: 23 cases (M/F ratio was 1:3). The most common clinical presentation was visual impairment (24;77%). The mean tumor size was 3.3 cm. Thirty-one patients underwent surgical excision by different approaches. The overall visual improvement was 29% (9 of 31 patients) however visual deterioration occurred in 6.4% (2 of 31 patients). Favorable prognosis was found in patients with short preoperative visual affection (less than 6 months). This finding was statistically significant (P ≤ 0.05). Also, visual outcome had significant correlations with edema surrounded tumor: arterial encasement by the tumor and brain-tumor interface. Two patients died 3 weeks postoperatively from brain stem infarction (overall incidence of mortality 6%) while the overall incidence of morbidity was 19% (6 of 31 patients). Conclusion: The most common symptom of Tuberculum sellae meningioma is visual affection. The favorable prognosis was found in patients with short preoperative visual affection (less than 6 months). Also;visual prognosis had significant correlations with peritumoral edema, arterial encasement by the tumor, and brain-tumor interface.

Tuberculum Sellae Meningiomas: Transcranial Approaches Results and Complications

Objective: Tuberculum sellae meningiomas constitute about 5% - 10% of intracranial meningiomas. They are difficult to treat, owing to their close association with the optic nerves, chiasma, and major cerebral arteries. This retrospective study aims to report on the clinical outcome after transcranial approach for treatment of tuberculem sellae meningiomas at our hospital. Patients and Methods: We reviewed patients with tuberculem sellae meningiomas and underwent transcranial surgical approaches for their lesions at Sohag university hospitals over a 4 years period starting from January 2018. The patients’ clinical and radiological data, operative details, degrees of tumor removal, outcomes and complications were reported. Results: There were 17 patients with tuberculem sellae meningiomas with a mean age of 46.3 years. Female patients constituted 70% of cases. Pterional approach was used in 59% of cases and unilateral subfrontal approach was used in 41% of cases. Gross total tumor removal was achieved in 82% of cases. Visual acuity improved in 47%, remained unchanged in 41%, and worsened in 5.9% of patients. Transient post-operative diabetes inspidus and post-operative haematoma in tumor bed each occurred in 5.9% of patients. Conclusion: Transcranial removal of tuberculum sellae meningioma is still considered the standard approach, with high rate of gross total resection and better visual outcome and low mortality and morbidity.

Surgical Indications of Exploring Optic Canal and Visual Prognostic Factors in Neurosurgical Treatment of Tuberculum Sellae Meningiomas

Background： Tuberculum sellae meningiomas （TSMs） present a special symptom because of the adherence and compression to the optic nerve, optic artery, and the chiasm. A significant number of patients with TSMs appear visual deficits. This study aimed to investigate the surgical indications of exploring the optic canal and visual prognostic factors in the neurosurgical treatment of TSMs. Methods： Totally 21 patients with TSM, who were operated from September 2007 to August 2011 in the Department of Neurosurgery, Tongren Hospital were enrolled in this study. Results of orbital computed tomography （CT） and magnetic resonance imaging （MRI）, visual acuity, Goldmann visual field test, orbital color Doppler flow imaging （CDI） test in these patients were retrospectively analyzed. Results： Visual deficit and optic canal involvement （OCI） were detected in all the 21 patients. Fourteen patients had bone proliferation within the area of the optic canal. After the operation, visual outcomes were improved in 13 patients, unchanged in 7 patients, and deteriorated in 1 patient. All the 21 patients performed orbital CDI test preoperatively, the results showed that if the peak systolic velocity （PSV） of central retinal artery （CRA） value was 〈8 cm/s, the visual outcome would be better. Conclusions： The surgical indications of exploring optic canal in TSM cases included： （1） The neuroimaging evidences of OCI （CT and/ or MR/）; （2） PSV of CRA in orbital CDI test was ≤8 cm/s; （3） visual acuity was below 0.1 ; （4） visual field deficit. The PSV of CRA in CDI test could be a prognostic factor for visual outcomes of TSMs.

Optimal microsurgical treatment of dorsum sellae meningioma

Background There are few reports of microsurgical treatment of dorsum sellae meningiomas--which, because of location, size, and differences in growth direction, clinical presentations, degree of surgical difficulty, have varied posttreatment sequelae. In pursuit of an optimal microsurgical treatment option for dorsum sellae meningioma patients, we performed a retrospective analysis of eight microsurgery-treated patients in our set up. Methods Clinical data of eight microsurgery-treated dorsum sellae meningioma patients were analyzed. Dorsum sellae meningiomas were classified into 2 types based on tumor location, size, and direction of growth. Type Ⅰ tumors （dorsum sellae-inferior third ventricle type, four cases） were resected by craniotomy via the frontotemporal or orbitozygomatic approach. Type Ⅱ tumors （dorsum sellae-third ventricle type, 4 cases） were resected by frontal craniotomy via the transcallosal-interforniceal approach. Results Complete tumor resection was achieved in all the eight patients. In Type Ⅰ tumor patients, the only postoperative complication was oculomotor nerve palsy. In Type Ⅱ tumor patients, the postoperative complications included hyperthermia, electrolyte imbalances, endocrinologic disturbances, and hydrocephalus. The mean follow-up was 2.1 years. Four patients returned to normal life and found a job, two were able to live independently, one required assistance, while one died. Conclusions Dorsum sellae meningioma surgery is challenging, and resection of Type Ⅱ tumors is more difficult than Type Ⅰ tumors. The selection of a suitable microsurgical approach based on tumor type, and the active treatment of postoperative complications are important means of increasing therapeutic efficacy.

Persistent postoperative hypotension caused by subclinical empty sella syndrome after a simple surgery:A case report

BACKGROUND Empty sella is an anatomical and radiological finding of the herniation of the subarachnoid space into the pituitary fossa leading to a flattened pituitary gland.Patients with empty sella may present with various symptoms,including headache due to intracranial hypertension and endocrine symptoms related to the specific pituitary hormones affected.Here,we report a female patient who developed persistent postoperative hypotension caused by subclinical empty sella syndrome after a simple surgery.CASE SUMMARY A 47-year-old woman underwent vocal cord polypectomy under general anesthesia with endotracheal intubation.She denied any medical history,and her vital signs were normal before the surgery.Anesthesia and surgery were uneventful.However,she developed dizziness,headache and persistent hypotension in the ward.Thus,intravenous dopamine was started to maintain normal blood pressure,which improved her symptoms.However,she remained dependent on dopamine for over 24 h without any obvious anesthesia-and surgery-related complications.An endocrine etiology was then suspected,and further examination showed a high prolactin level,a low normal adrenocorticotropic hormone level and a low cortisol level.Magnetic resonance imaging of the brain revealed an empty sella.Therefore,she was diagnosed with empty sella syndrome and secondary adrenal insufficiency.Her symptoms disappeared one week later after daily glucocorticoid supplement.CONCLUSION Endocrine etiologies such as pituitary and adrenal-related dysfunction should be considered in patients showing persistent postoperative hypotension when anesthesia-and surgery-related factors are excluded.

带血管蒂鼻中隔黏膜瓣颅底重建技术

过去十几年中，鼻内镜外科技术成熟和发展，对经鼻内镜入路的解剖学认识显著提高，结合器械和影像技术的进步，促进了鼻颅底外科技术的发展和逐渐成熟。经鼻完成颅底和硬脑膜内病灶的暴露和切除，成为近期最具活力的医学进展。鼻内镜手术技术应用领域由延伸（extended）到扩大（expanded），即expanded endoscopic approach（EEA），是一种完全经鼻内镜径路的手术，提供了一种进人整个腹侧颅底的路径。但是，手术后蛛网膜下腔与鼻腔鼻窦之间屏障的重建仍然是个挑战，也是EEA应用和接受度的障碍。

空泡蝶鞍综合征3例报道

空泡蝶鞍综合征(empty-sella,syndrome,ESS)指蛛网膜下腔伸展至蝶鞍内,并使蝶鞍内充满脑脊液,致垂体受压缩小、蝶鞍窝扩大,而引起相应临床症状。目前诊断空泡蝶鞍综合征的最佳手段是MRI[1],临床上按影像特点分为完全性空泡蝶鞍及部分性空泡蝶鞍。头痛是ESS常见症状,约占62%[2],无特定位置和规律。空泡蝶鞍分级与头痛程度之间无明确关系,

Rare empty sella syndrome found after postoperative hypotension and respiratory failure:A case report

BACKGROUND Empty sella syndrome is a condition in which the pituitary gland shrinks or flattens. Patients with empty sella syndrome often present with headache,hypertension, obesity, visual disturbances, cerebrospinal fluid(CSF) rhinorrhoea,or endocrine dysfunction. Herein, we report a rare case of empty sella syndrome discovered after the patient experienced postoperative hypotension and respiratory failure.CASE SUMMARY A 60-year-old man was admitted for further workup of left shoulder pain. He was assessed by the orthopaedics team and booked for internal fixation of the left clavicle. General anaesthesia with a nerve block was administered. His blood pressure continued to decrease post-operation. Endocrine tests were performed,with the results supporting a diagnosis of hypopituitarism with hypocortisolism and hypothyroidism. Brain magnetic resonance imaging demonstrated that the sella was enlarged and filled with CSF, confirming a diagnosis of empty sella syndrome. The patient was started on endocrine replacement therapy. The patient regained consciousness and spontaneous breath finally.CONCLUSION This case highlights the importance of considering pituitary hormone insufficiency in the context of respiratory and hemodynamic failure during the perioperative period.

Ocular Symptoms of Tumors at Sella Turcica Region

Background: The sella tumors were found in 15% of intracranial tumors. The sella turcica region locates in the base of skull, so the carcinoma patients in early stage often showed no intracranial hypertension and other positive signs of neural system. However, the patients presented visual field defect and hypopsia, and often went to see the doctor of ophthalmology, which resulted from that the tumor often compressed optic nerve and chiasm. We analysed the symptomatic changes of the visual organs in order to provide a diagnositic basis for sellar tumor in oph-thalmological department.Clinical materials: Of the 407 cases of sellar tumors, 296 were pituitary adenoma, 52 were craniopharyngioma, 43 were meningioma, and the rest 16 were other kinds of sellar tumors. We analysed their ocular changes of the sellar tumors and the characteristics of the tumors.Results: The sellar tumor in its early stage is mainly symptomized as visual field changes. Visual field defect was found in 92. 9% of pituitary adenoma,

Cerebrospinal fluid flow in empty sella syndrome and normal sellar regions measured by phase-contrast quantitative magnetic resonance

We used MRI to examine 38 healthy females and 38 female patients with empty sella syndrome. Cerebrospinal fluid flow was examined in six regions of interest, including the anterior clinoid processes, posterior clinoid processes, and 1.0 mm, 1.0 mm, 2.0 mm, --2.0 mm from the midpoint of the line between the anterior and posterior clinoid processes. The results revealed no significant differences in cerebrospinal fluid flow velocity and discharge in a single cardiac cycle, or indicators of cardiac cycles in the control group, indicating that the cerebrospinal fluid flow was relatively steady in the saddle area of the normal brain. In the empty sella syndrome group, cerebrospinal fluid hernia into the saddle area triggered a fluctuation of the anterior and posterior clinoid processes in the saddle area, while the flow in other regions in the saddle area was relatively steady this resulted in significant differences in cerebrospinal fluid flow velocity and discharge, as well as the cardiac cycle.

Empty Sella [Presenting as Hypopituitarism] and Platybasia Secondary to Essential Fatty Acids Deprived Diet. Proof of Basic Concept Study by Retrospective Analysis

Background: Universal concern is an increased prevalence of morbidity, mortality;with improper comprehension, the globe has implemented, non evidence-based medical practice, without therapeutic indication, therapeutic protocols, policies-contraception, abortion, annihilating human race by therapy, destroying germ cells with consecutive systemic inflammatory response syndrome, associated with decreased androgen oestrogen resulting in metabolic syndrome, increased neoplasms—due to lacuna of this comprehension—cholesterol was blamed, resulting in essential fatty acids deprived diet, promoting sunflower seed oil, refined oil, lipid-lowering agents prescription like water, for the past >40 years;the tragedy of this false concept of refined oil, essential fatty acids deprived diet, [against God-ordained marvelous cell metabolism, from cholesterol] resulting in degenerative diseases, defaulted genomic repertoire, as cause and effect phenomenon in the two following morbid, fatal case presentations;contraception, abortion is the culprit and not cholesterol which is the basic life moiety of cell membrane, cell metabolism governing steroid hormones-androgen oestrogen derived from cholesterol. Case 1: 76-year-old male, vegetarian, presented with lethargy, hypotension, unexplained hyponatremia, on fludrocortisone for 2 years. MRI detected empty sella;hence hypopituitarism with cortisol deficiency, resulting in hyponatremia was considered and with hydrocortisone replacement, patient improved. Low levels of LDL, HDL, suggested chronic [>40 years] deprivation of diet containing essential fatty acids had resulted in degenerative—empty sella status with hypopituitarism. Case 2: 17-year-old girl presented with headache, vomiting, feeble pulse;6 months prior platybasia had been diagnosed and she had undergone corrective neurosurgery, to widen bilaterally, narrowed, base of skull foramina, to prevent compression on the exiting neurovascular bundles;urgent CT scan of brain confirmed significant narrowing of foramen magnum, compressing brainstem;she expired within 30 minutes secondary to brainstem edema. Low levels of HDL, LDL confirmed, long term [~16 years] deprivation of essential fatty acids intake, leading to decreased steroid hormone synthesis—including oestrogen—the surveilling hormone for cell metabolism, including skull base, having resulted in progressive Platybasia, compressing brainstem. Conclusion: Though both patients belonged to affluent society it was the sincere adherence to the false detrimental concept of essential fatty acids deprived diet, which was the cause and effect phenomenon of degenerative empty sella syndrome, ineffectual cell-bone metabolism presenting as platybasia.

Empty Sella Syndrome: A Case Report and Literature Review

An empty sella occurs due to herniation of the arachnoid through an incompetent diaphragma sellae. Over time, cerebrospinal fluid (CSF) pulsations may enlarge the sella and compress the gland against the floor of the sella. Empty sella syndrome is considered as a less common entity and is usually asymptomatic and an incidental finding. However, it can be a manifestation of increased intracranial pressure and can be occasionally severe. Compression of the pituitary gland may affect function, or traction on the optic chiasm and nerves may cause visual symptoms. An empty sella may be classified as primary when this occurs in persons who have not received pituitary radiation or pituitary surgery, while an empty sella discovered following such procedures is classified as secondary empty sella. In this report, we presented a 41-year-old multiparous patient who presented to us with symptoms of headache and left sided hemi-sensory disturbance. Examination was unrevealing except for the fact that she was obese. On evaluation, she was detected to have impaired blood sugars, dyslipidemia and vitamin insufficiency. MRI brain revealed presence of Empty Sella. Further hormonal analysis was normal. She was treated conservatively and regular follow-up was advised.

Isolated gonadotropin deficiency with primary empty sella: Causal or casual association?

Empty sella is a radiological-anatomical entity characterised by a sella turcica filled partially or completely with cerebrospinal fluid, leading to varying degrees of pituitary flattening. Literature reports a 5% - 20% incidence of empty sella in unselected autopsies leading many to argue that its an extreme normal variant. Endocrine dysfunction varies from 8% - 25% with primary empty sella with growth hormone deficiency being most common. However isolated gonadotropin deficiency with normal sized primary empty sella are rare if any. We are reporting a case of isolated gonadotropin deficiency with primary empty sella unable to confirm or refute the association as causal or casual.

A decade without diagnosis: Sheehan’s syndrome

Sheehan’s Syndrome (SS) occurs as a result of ischemic pituitary necrosis due to severe post-partum hemorrhage. We report a 41-year-old woman with a history of severe postpartum hemorrhage 18 years prior to presentation. During this period of time, she experienced severe fatigue. Three months prior to being admitted to our hospital, the patient started to notice alopecia, generalized edema and cognitive impairment. After proper investigation, laboratory tests and clinical findings indicated panhypopituitarism. In addition to neuroimaging and past medical history, SS was diagnosed and treatment started. We emphasize the importance of thorough investigation, further diagnosis and management of this condition (especially in third world countries), since SS is a neurological and endocrinological emergency and potentially life threatening.

A Unified Management for Spontaneous CSF Leak

Background: Spontaneous CSF leak represents less frequent cause of CSF leak, but cases are more difficult to control, with the highest failure rate and recurrence despite adequate repair. The problems in these cases might be related to an underlying undiagnosed associated intracranial hyper-tension. Recognition and long-term treatment of elevated ICP is therefore critical to the successful management of these patients. Objective: To evaluate the CSF pressure in cases of spontaneous CSF rhinorrhea and to describe our same setting combined protocol to the repair of the leak, measurement and management of CSF pressure. Patients and Methods: All patients presenting to Ain Shams University Hospitals, Cairo, Egypt, with spontaneous CSF leak were included prospectively in the study. Clinical and radiologic data were collected to suspect elevated intracranial pressure. After CSF repair, CSF pressure was measured and if found to be more than 20 cmH2O, a lumboperitoneal shunt was used. Results: Twenty-seven cases, 23 women and 4 men, presented with spontaneous CSF leak. 23 patients had BMI above 30. All patients had empty sella syndrome (100%), and a meningoencephalocele was found in 13 cases (48%). CSF pressure ranged from 5 to 39 cmH2O (mean = 28.7). A pressure above 21 cmH2O was found in19 patients (70%) and subsequently had lumboperitoneal shunt in the same setting. No recurrence occurred in this subset of patients with 6 - 60 months follow-up period. Conclusion: A selective and specific same setting protocol can result in a better diagnosis and control of the accompanying elevated ICP in cases of spontaneous CSF leak. It avoids a second operative intervention, and shortens the hospital stay, with an increase in the success rate. In the same time, the smaller number of patients with normal ICP can avoid further drainage.

Empty Sella Turcica Syndrome: About a Case Revealed by Adrenal Insufficiency

Background: Empty sella turcica corresponds to an arachnocele which may be complete or partial, primary or secondary. The primary form is rarer. Its cause is unknown, but etiological factors have been identified. The prevalence of this condition is variable, depending on techniques of diagnosis. It may be detected fortuitously on imaging or in the presence of neurological, ocular or endocrine manifestations. Aim: We aim to report a case of empty sella turcica syndrome revealed by adrenal insufficiency in a young African black woman. Case presentation: It was an overweight young woman with signs of intracranial hypertension associated with central adrenal insufficiency. The diagnosis of empty sella was confirmed by magnetic resonance imaging. Secondarily, she developed a hypo metabolism syndrome and biology confirmed central hypothyroidism. After correction of the adrenal cortical deficit, the treatment of the thyroid deficit was administered. Evolution was favourable clinically and biologically. Conclusion: The empty sella turcica is rare and its revelation by a central adrenal insufficiency is even more. The case we report is a perfect illustration.

Tumor

930177 Ganglioglioma.BAO Weiming(鲍伟民),et al.Dept Neurosurg,Huashan Hosp,Shanghai Med Univ,200040.Chin J Nerv &Ment Dis 1992;18(3):143-145.Fourteen cases with ganglioglioma verified bysurgery and pathology were reported.Amongthem,12 cases were in cerebral hemisphere,1 inthalamus,and 1 anterior to the third ventricle.Their age range was from 6 to 64 years,and 10of them were below thirty.The durations ofChina Medical Abstracts(Internal Medicine)