Background
Five-aminolevulinic acid (Gliolan, medac, Wedel, Germany, 5-ALA) is approved for fluorescence-guided resections of adult malignant gliomas. Case reports indicate that 5-ALA can be used for ...children, yet no prospective study has been conducted as of yet. As a basis for a study, we conducted a survey among certified European Gliolan users to collect data on their experiences with children.
Methods
Information on patient characteristics, MRI characteristics of tumors, histology, fluorescence qualities, and outcomes were requested. Surgeons were further asked to indicate whether fluorescence was “useful”, i.e., leading to changes in surgical strategy or identification of residual tumor. Recursive partitioning analysis (RPA) was used for defining cohorts with high or low likelihoods for useful fluorescence.
Results
Data on 78 patients <18 years of age were submitted by 20 centers. Fluorescence was found useful in 12 of 14 glioblastomas (85 %), four of five anaplastic astrocytomas (60 %), and eight of ten ependymomas grades II and III (80 %). Fluorescence was found inconsistently useful in PNETs (three of seven; 43 %), gangliogliomas (two of five; 40 %), medulloblastomas (two of eight, 25 %) and pilocytic astrocytomas (two of 13; 15 %). RPA of pre-operative factors showed tumors with supratentorial location, strong contrast enhancement and first operation to have a likelihood of useful fluorescence of 64.3 %, as opposed to infratentorial tumors with first surgery (23.1 %).
Conclusions
Our survey demonstrates 5-ALA as being used in pediatric brain tumors. 5-ALA may be especially useful for contrast-enhancing supratentorial tumors. These data indicate controlled studies to be necessary and also provide a basis for planning such a study.
Aim of the Study:
Based on our past 5 years of experience in central skull base tumor operations, we mostly use supraorbital minimal craniotomy in transcranial or extended endoscopic way in ...transsphenoidal approach.
Methods:
Using transcranial approach in this period we have operated 58 pituitary adenomas, 50 meningiomas, 33 craniopharyngiomas, 16 third ventricle extended tumors, 7 arachnoid cysts, and 7 other lesions. In the same period using transsphenoidal approach, we have operated 10 parasellar or suprasellar giant pituitary adenomas, 1 adenoma associated with sphenoidal plate meningoma, 8 cysts (Rathke or arachnoidal), 10 meningiomas, 4 parasellar metastasis, 8 craniopharyngiomas, 6 upper clival chordomas, 2 clival cysts. Surgical approach was determined by the localization, extension and type of the tumors, depending on MRI, MSCT and MSCT-angiography. 56% females and 44% males were included in the study, from 18 to 75 years of age. The follow-up period was from 3 months to 4 years.
Results:
In the first group postoperative complications were CSF leakage in 6 cases, postoperative visual impairment in 13 cases, infection in 17 cases, and 7 cases of frontal nerve palsy. Recurrence tumors appeared in 11 pituitary tumors, 2 meningiomas, 7 craniopharyngiomas, and 4 third ventricle tumors. In the second group, all tumor margins could be visualized except parasellar ones because of their attachment to ACI. In six cases, postoperative hormone status was normal or improved. Vision field decreased in 15 cases. Postoperative complications included rhinoliquorrhea in six cases and four infections. Recurrence tumors appeared in 10 cases, which were mostly malignant tumors treated with radiosurgical approach or with conventional radiotherapy.
Conclusion:
In our opinion, not depending on their size, most sellar and suprasellar tumors which are positioned in the middle are operable in transsphenoidal way. We operate tumors which are extended to lateral parasellar region or sphenoidal plate using transcranial approach mostly by supraorbital minimal craniotomy. In our experience, the use of combined techniques reduces the operative trauma and improves the accuracy in planning the access, angle and extension of tumor removal.
Endoskopske operacije prakticiraju se u našoj klinici od 1996. godine kao pripomoć u mikroneurokirurškim operacijama. Na sličan način upotrebljavao se i endoskop u transsfenoidalnoj hipofiznoj ...kirurgiji, ali od početka 2004. godine počeli smo operirati tumore hipofize potpuno endoskopskim putem. Želimo prikazati svoja iskustva kod prvih devedeset pacijenata, kao i svoju operacijsku tehniku. Endoskopska hipofizna kirurgija radi se kroz nosnicu bez incizije kože. Četirimilimetarski endoskop uvodi se kroz nosnice u sfenoidalni sinus i tumor se uklanja specijalno dizajniranim kirurškim instrumentima. Postoperacijska je njega minimalna i bolesnici su otpuštani kući treći postoperacijski dan. Prva kontrola je mjesec dana nakon operacije. Imali smo osamnaest recidiva tumora.
Paranasal sinus osteomas are mostly asymptomatic; however, secondary mucocele can develop if they impede the natural sinus drainage. Such a mucocele can destroy the bone and extend into the adjacent ...structures. We report on an unusual case of frontal sinus osteoma in a 27-year-old patient, complicated by large secondary mucocele that eroded the bone and extended into the frontal lobe of the brain. Unexpectedly, the patient did not report any visual or other symptoms attributable to central nervous system deficit. The mucocele was completely resected through bifrontobasal osteoplastic craniotomy, whereas osteoma was evacuated in its entirety by both drilling and mobilizing. Open surgical approach remains the main treatment for complicated paranasal sinus osteoma, and radical removal of intracranial mucocele is mandatory to prevent the development of life-threatening infections. Although intradural extension of a secondary mucocele is extremely unusual, head and neck surgery specialists should take this severe complication in consideration.
From September 1991 to December 1992, during the war in Croatia, the General Hospital in Slavonski Brod served as an evacuation centre. During that period 197 patients with war-related penetrating ...craniocerebral injuries were admitted. They were analyzed according to wound characteristics, operability, mortality, operative and post-operative complications, and their condition after hospital discharge and follow-up. A less aggressive surgical approach was accepted in our surgical strategy, recommended in recent studies, followed by an aggressive intensive management. All patients received antibiotics (“war scheme”) and anticonvulsants. Early results of treatment do not differ significantly from other recent studies (Vietnam, Israel) in respect to both mortality and complications. Follow-up was difficult. Most of the patients were Bosnia and Herzegovina citizens who were refugees and banished to foreign countries; thus their addresses were unknown. They are consequently lost to follow-up. A less aggressive surgical approach proved to be justified. Routine use of antibiotics and anticonvulsants lowered the infection rate and early seizure incidence to an acceptable level. Late seizure incidence is similar to those previously reported.
Pituitary metastasis of renal cell carcinoma: a case report Background. Solitary metastasis of renal cell carcinoma in the pituitary gland is extremely rare and only in 7% of cases it is symptomatic. ...Case report. We report the case of a 52 year old man presenting with visual disturbance and headache after three years of treatment due to the metastatic renal cell carcinoma. Magnetic resonance imaging (MRI) showed tumour mass in supraselar region compressing optic chiasm with no other brain metastatic lesions. The trans-sphenoidal reduction of the tumour was performed. Pathology and imunohistology revealed metastasis of clear cell renal carcinoma. Conclusions. This is the 25th case of symptomatic pituitary metastases of renal cell carcinoma reported in literature.
Objective: To review our experience with endoscopic endonasal skull base reconstruction.
Materials and Methods: A retrospective review of a single-institution endoscopic endonasal patient database ...from 2014-2019. The CSF leaks were graded based on defect size from 0 (no leak) to 2. The reconstruction method was documented for all patients.
Results: There were in total 341 endoscopic endonasal operations for performed parasellar pathology. The pathology was: pituitary adenomas (85%), craniopharyngioma (1.1%), meningioma (2.9%), malignant tumors (0.5%) and other (9.9%). The total postoperative CSF leaks rates were 8.7%, and meningitis rates were 4.4%. The vast majority of CSF leaks were in the first 2 years of endoscopic endonasal skull base surgery. The flaps that were used: nasoseptal flap, middle turbinate flap (vascularized), free mucosal graft, fat graft and fat plug and the combination of these matherials.
Conclusion: Reconstruction of skull base defects is of uttermost importance in the prevention of meningitis. There is a slow learning curve in achieving the surgical skills for endoscopic endonasal skull base surgery. The nasoseptal flap is the “work-horse” for anterior skull base reconstruction.
Cerebrospinal fluid (CSF) fistula as a consequence of brain missile injury and following infectious complications has been recognized for years. Different methods of treatment have been advocated. ...Missiles used in war cause extensive destruction of the skull and brain as a result of their high kinetic energy. On its transfer through the skull, such high kinetic energy causes fractures called "discontinuous fractures," which are distant from the entry wound and not related to the fracture of the vault. The role of the timely diagnosis of CSF fistulas and their early repair in the management of these wounds is emphasized. Data on 312 patients with missile injuries of the brain inflicted during the war in Croatia were retrieved and analyzed, with special reference to the complications of CSF fistulas and infection. Forty-five patients developed CSF fistula, 15 (33%) of them at the wound site, 23 (51%) as CSF rhinorrhea, and seven (15%) as CSF otorrhea. Six patients developed infectious complications. The presented strategy and operative approach resulted in a low incidence of infectious complications in the study series.
Aim of the Study:
The concept of the minimally invasive keyhole approach in neurosurgery has been increasingly used in past years. The approach is different from standard craniotomy because of the ...smaller size of the skin incision and bone window; distinct microneurosurgical technique; and instrumentation, including endoscopic assistance. It involves a small supraorbital craniotomy of 2.5 cm × 1.5 cm, with the skin incision in the eyebrow. It is most suitable for tumors in the sellar region, especially for tuberculum sellae meningiomas.
Patients and Methods:
Between 1996 and 2010, we operated on 78 patients with tuberculum sellae meningiomas using this approach. There were 48 (61.5%) women and 30 (38.5 %) men with an age range of 28 to 76 years. Preoperative and postoperative CT scans and MRI were performed, as well as angiography if there were main vessels incorporated in tumor. The tumor sizes were from 1.8 cm to 5.6 cm. The follow-up period was from 6 months to 6 years.
Results:
In all operations, the keyhole approach was sufficient for complete exposure of the tumor layer. In 69 cases, gross total resection was successfully performed. Five residual tumors were treated by gamma knife radiosurgery. In two cases, gamma knife radiosurgery was not indicated because the tumor was adherent to the optic nerve so reoperation was performed using the existing craniotomy. Two recurrent tumors needed reoperation, both by pterional craniotomy. Postoperative complications were CSF leakage in five cases, visual impairment in eight cases, local infection in five cases, meningitis in four cases, and seven cases of supraorbital nerve palsies.
Conclusion:
Comparing the keyhole and standard approaches, we believe that the in-depth manipulative space is identical but there is less opportunity in the former to change the angle of approach during the procedure, so good preoperative planning and the use of endoscope is necessary. This approach has practically replaced pterional craniotomy in patients with this kind of tumor. Therefore, it can be considered to have certain advantages over standard craniotomy, particularly in terms of less brain exposure, shorter operation time, faster recovery, shorter hospitalization, and better cosmetic result.
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